From transthyretin cardiac amyloidosis diagnosis to tafamidis treatment: Association of drop-off with patient sociodemographic characteristics.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Compared to estimated population prevalence rates, relatively few patients at risk are diagnosed with and treated for transthyretin cardiac amyloidosis (ATTR-CA). Where along the clinical pathway patient drop-off occurs, as well as the association of drop-off with patient sociodemographic characteristics, remains unknown. METHODS: Using data from a healthcare system-wide cardiovascular imaging repository and specialty pharmacy, we characterized the clinical pathway from diagnosis with pyrophosphate scintigraphy (PYP) to tafamidis prescription, initiation, and adherence. Standardized differences (d values of ≥0.20, indicating at least a small effect size) were used to compare sociodemographics (age, sex, race, Area Deprivation Index) among patients with PYP-identified ATTR-CA by tafamidis prescription status and among patients prescribed tafamidis by initiation status. Tafamidis adherence was measured with the proportion of days covered (PDC). RESULTS: Of 97 patients with ATTR-CA, 58.8% were prescribed tafamidis, with 80.7% of those initiating therapy. Patients with ATTR-CA prescribed tafamidis were younger than those not prescribed tafamidis (d = -0.30). Utilization of a specialty pharmacy resulted in enrichment of treatment in subgroups traditionally undertreated in cardiovascular medicine, with higher rates of tafamidis initiation among women (100% initiation), patients of Black/African American race (d = 0.40), and those living in more economically disadvantaged areas (d ≥ 0.30). Adherence was high (PDC of >80%) in 88.4% of those initiating tafamidis. CONCLUSION: These findings highlight the tremendous opportunity for more robust ATTR-CA clinical programs, identifying potential patient subgroups that should be targeted to reduce disparities. For patients diagnosed with ATTR-CA, utilization of a specialty pharmacy process appears to ensure equitable provision of tafamidis therapy.

Post-9/11 deployment history and the incidence of breast cancer among women veterans.

PURPOSE: To determine if women Veterans who deployed in support of Operations Enduring Freedom/Iraqi Freedom (OEF/OIF) would show a greater likelihood of breast cancer (BC) than other women Veterans. METHODS: This was a retrospective cohort study of women aged <60 years who received Veterans Affairs medical center primary care, 2001-2021. The exposure was OEF/OIF deployment and the outcome was a BC diagnosis after entering Veterans Affairs care. Poisson models evaluated the association between deployment and BC incidence, covarying demographics, lifestyle factors, and hormonal contraceptive and hormone replacement therapy use. Analyses were also stratified by age and race, and a sensitivity analysis adjusted for healthcare utilization over the initial 2 years. RESULTS: Of 576,601 women, 24.6% (n = 141,935) deployed during post-9/11 conflicts. Across follow-up [median: 8.2 years], 1.2% women were diagnosed with BC. Those who deployed in support of OEF/OIF were 23% less likely to be diagnosed with BC than women who did not deploy (95% CI: 0.73, 0.86). The association remained in stratified models and when including healthcare utilization. CONCLUSIONS: Despite the exposures of OEF/OIF deployment, there was a significantly lower incidence of BC among women who deployed versus not, possibly due to a healthy soldier effect or to differences in screening.

Association of depression and anxiety disorders with outcomes after revascularization in chronic limb-threatening ischemia hospitalizations nationwide.

OBJECTIVE: Patients with chronic limb-threatening ischemia (CLTI), the end stage of peripheral artery disease, often present with comorbid depression and anxiety disorders. The prevalence of these comorbidities in the inpatient context over time, and their association with outcomes after revascularization and resource usage is unknown. METHODS: Using the 2011 to 2017 National Inpatient Sample, two cohorts were created-CLTI hospitalizations with endovascular revascularization and CLTI hospitalizations with surgical revascularization. Within each cohort, the annual prevalence of depression and anxiety disorder diagnoses was determined, and temporal trends were evaluated using the Cochran-Mantel-Haenszel test. Hierarchical multivariable logistic and linear regression analyses were used to examine the association of depression and anxiety disorder diagnoses with inpatient major amputation, mortality, length of stay (LOS), and cost, adjusting for illness severity, comorbidities, and potential bias in the documentation of depression and anxiety disorder diagnoses stratified by patient sociodemographic data. RESULTS: Across the study period were a total of 245,507 CLTI-related hospitalizations with endovascular revascularization and 138,922 with surgical revascularization. Hospitalizations with a depression or anxiety disorder diagnosis increased from 10.8% in 2011 to 15.3% in 2017 in the endovascular revascularization cohort and from 11.7% in 2011 to 14.4% in 2017 in the surgical revascularization cohort (Ptrend < .001). In the endovascular revascularization cohort, depression was associated with higher odds of major amputation (odds ratio, 1.15; 95% confidence interval, 1.03-1.30). In addition, depression (9 vs 8 days [P < .001]; $105,754 vs $102,481 [P = .018]) and anxiety disorder (9 vs 8 days [P < .001]; $109,496 vs $102,324 [P < .001]) diagnoses were associated with a longer median LOS and higher median costs. In the surgical revascularization cohort, depression was associated with a higher odds of major amputation (odds ratio, 1.33; 95% confidence interval, 1.13-1.58) and a longer LOS (median, 9 vs 9 days; P = .004). CONCLUSIONS: Depression and anxiety disorder diagnoses have become increasingly prevalent among CLTI hospitalizations including revascularizations. When present, these psychiatric comorbidities are associated with an increased risk of amputation and greater resource usage.

Derivation and validation of a predictive model for chronic stress in patients with cardiovascular disease.

BACKGROUND: Chronic stress in patients with cardiovascular disease (CVD), including peripheral artery disease (PAD), is independently associated worse outcomes. A model that can reliably identify factors associated with risk of chronic stress in patients with CVD is needed. METHODS: In a prospective myocardial infarction (MI) registry (TRIUMPH), we constructed a logistic regression model using 27 patient demographic, socioeconomic, and clinical factors, adjusting for site, to identify predictors of chronic stress over 1 year. Stress at baseline and at 1-, 6- and 12-month follow-up was measured using the 4-item Perceived Stress Scale (PSS-4) [range 0-16, scores ≥6 depicting high stress]. Chronic stress was defined as at least 2 follow-up PSS-4 scores ≥6. We identified and validated this final model in another prospective registry of patients with symptomatic PAD, the PORTRAIT study. RESULTS: Our derivation cohort consisted of 4,340 patients with MI (mean age 59.1 ± 12.3 years, 33% females, 30% non-white), of whom 30% had chronic stress at follow-up. Of the 27 factors examined, female sex, current smoking, socioeconomic status, and economic burden due to medical care were positively associated with chronic stress, and ENRICHD Social Support Instrument (ESSI) score and age were inversely related to chronic stress. In the validation cohort of 797 PAD patients (mean age 68.6±9.7 years, 42% females, 28% non-white, 18% chronic stress) the c-statistic for the model was 0.77 and calibration was excellent. CONCLUSIONS: We can reliably identify factors that are independently associated with risk of chronic stress in patients with CVD. As chronic stress is associated with worse outcomes in this population, our work identifies potential targets for interventions to as well as the patients that could benefit from these.

Association of propofol induction dose and severe pre-incision hypotension among surgical patients over age 65.

STUDY OBJECTIVE: We aimed to study the association between propofol induction dose (mg/kg) and pre-incision severe hypotension (Mean Arterial Pressure (MAP) ≤ 55 mmHg) among patients ≥65 years of age. DESIGN: Retrospective Observational. SETTING: 40 centers participating in the Multicenter Perioperative Outcomes Group consortium. PATIENTS: Patients ≥65 years of age undergoing non-cardiac, non-vascular surgery who received propofol for general anesthetic induction prior to endotracheal intubation between January 2014 and December 2018. INTERVENTIONS: None. MEASUREMENTS: The primary exposure was total propofol induction dose in mg/kg, and the primary outcome was occurrence of severe hypotension (MAP≤55 mmHg) prior to surgical incision, stratified by non-invasive vs. invasive blood pressure monitoring type. MAIN RESULTS: Among 320,585 total patients, 22.6% experienced the outcome of pre-incision severe hypotension (MAP≤55 mmHg). When stratified by blood pressure monitoring type, 20.7% with non-invasive blood pressure measurements, and 35.0% with invasive blood pressure measurements had the outcome. After controlling for a variety of patient and procedural factors, there was a significant independent association between propofol induction dose and pre-incision hypotension (Non-invasive blood pressure cohort odds ratio (OR) 1.10; 95% confidence interval (CI) 1.07 to 1.13; p < 0.001; and Invasive blood pressure cohort OR 1.15; 95%CI 1.10 to 1.21; adjusted p < 0.001). The association was robust to alternative definitions of the outcome, including less severe hypotension (MAP≤65 mmHg) and blood pressure drop from baseline as a continuous measure. Although no threshold safe induction dose was identified at which hypotension was avoided, an analysis of propofol dose greater or less than 1.5 mg/kg (i.e. the maximum FDA-defined typical induction dose) demonstrated that doses in excess of the FDAs threshold were positively associated with odds of severe hypotension (Non-invasive cohort: OR 1.05; 95% CI 1.02 to 1.08; p < 0.001; Invasive cohort: OR 1.11; 95%CI 1.05 to 1.17; adjusted p < 0.001). CONCLUSIONS: In a multicenter cohort of geriatric surgical patients receiving propofol for general anesthetic induction and endotracheal intubation, severe pre-incision hypotension (MAP ≤55 mmHg) that has previously been associated with postoperative morbidity was common. The dose of propofol used was significantly associated with increased odds of this outcome after controlling for a number of clinically relevant factors. Future studies that are designed to test different approaches to anesthesia induction for reducing severe post induction pre-incision hypotension are warranted.

Feasibility of a randomized hypertension screening initiative in the perioperative setting.

OBJECTIVES: This study sought to assess feasibility of a randomized trial of blood pressure intervention (home blood pressure monitoring vs. counseling) in the preoperative clinic and the baseline rates of primary care follow-up after such interventions. METHODS: A prospective randomized feasibility study was performed at Yale New Haven Hospital Preadmission Testing Clinic. A sample of 100 adults, with elevated blood pressure, were recruited during their preadmission visit, and randomized 1:1 to receive brief BP counseling and an educational brochure versus additionally receiving a home BP monitor (HBPM) with a mailed report of their home readings. At 60-day post-surgery telephone follow-up, investigators asked whether participants had primary-care follow-up; had new/adjusted hypertension treatment; and felt satisfied with the study. RESULTS: There were 51 patients in the counseling group and 49 in the HBPM group. Of 46 patients in the HBPM group who returned their monitors, 36 (78%) were hypertensive at home. At 60 days post-surgery, 31 (61%) patients in the counseling group and 30 (61%) in the HBPM group were reached by telephone with the remaining followed by EHR. Thirty-six (71%) patients in the counseling group and 36 (73%) in the HBPM group had seen their primary care provider. Seventeen of 36 (47%) in the counseling group and 18 of 31 (58%) in the HBPM group received new or adjusted hypertension medications. Sixty-one participants answered questions regarding their satisfaction with the study with 52 (85%) reporting that they felt moderately to very satisfied. CONCLUSIONS: This feasibility study suggests that interventional blood pressure trials in the preoperative clinic are feasible, but telephone follow-up leads to significant gaps in outcome ascertainment. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03634813 . Registered 16 of August 2018.

Pain intensity and pain medication prescription patterns in Veterans with heart failure and back pain.

BACKGROUND: Pain and heart failure are highly comorbid. OBJECTIVES: The purpose of this study was to examine differences in pain intensity and pain medication prescriptions among Veterans with comorbid heart failure and pain and those with pain alone. METHODS: The Musculoskeletal Disorder (MSD) cohort includes 5,237,763 Veteran diagnosed with a musculoskeletal disorder between 2000 and 2013. Veterans with comorbid heart failure and back pain (heart failure+, n = 3,950, Mage = 70.5 ± 12) were compared to those with back pain alone (heart failure-, n = 165,290, Mage = 52.1 ± 17.5). RESULTS: In multivariate adjusted models, heart failure+ was associated with a higher likelihood of moderate/severe pain (OR = 1.12; 95% CI 1.04-1.21), a higher likelihood of opioids (OR = 1.63; CI = 1.52-1.75) and/or gabapentin prescriptions (OR = 1.18; CI = 1.02-1.36), but a lower likelihood of NSAID prescriptions (OR = 0.57; CI = 0.50-0.66). CONCLUSIONS: Comorbid cardiovascular and pain conditions present a challenge in clinical management that warrants further study.

Variation in propofol induction doses administered to surgical patients over age 65.

BACKGROUND/OBJECTIVES: Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery. DESIGN: Retrospective observational study using the Multicenter Perioperative Outcomes Group data set. SETTING: Thirty-six institutions across the United States. PARTICIPANTS: A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018. INTERVENTION: None. MEASUREMENTS: Total induction bolus dose of propofol administered. RESULTS: The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among patients aged 80 and older. CONCLUSION: The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.

Modifiable lifestyle factors in women with Takotsubo syndrome: A case-control study.

BACKGROUND: There is limited information on the relationship between modifiable lifestyle factors and Takotsubo syndrome (TS). OBJECTIVES: To determine the association of physical activity, smoking, alcohol use, and caffeinated coffee consumption with TS. METHODS: This case-control study enrolled women with newly diagnosed TS (n = 45), women post-myocardial infarction (MI; n = 32), and healthy women volunteers (HC; n = 30). Information on physical activity, smoking, alcohol use, and caffeinated coffee consumption was collected 1-month post-discharge for TS and MI, and 1-month post-enrollment for HC. RESULTS: TS women reported a higher prevalence of lifetime smoking and cigarette packs/day, greater coffee consumption, and less physical activity than HC. Associations with cigarette and coffee use remained significant in adjusted models. Physical activity, smoking, and coffee consumption were similar in TS and MI women. CONCLUSIONS: Use of psychostimulants (caffeine and cigarettes) may play a role in TS pathophysiology. These findings need to be confirmed in larger, fully powered studies.

Association of prescription opioids and incident cardiovascular risk factors among post-9/11 Veterans.

Reports indicate that long-term opioid therapy is associated with cardiovascular disease (CVD). Using VA electronic health record data, we measured the impact of opioid use on the incidence of modifiable CVD risk factors. We included Veterans whose encounter was between October 2001 to November 2014. We identified Veterans without CVD risk factors during our baseline period, defined as the date of first primary care visit plus 365 days. The main exposure was opioid prescriptions (yes/no, long-term (i.e. ≥90 days) vs no opioid, and long-term vs short-term (i.e. <90 days)), which was time-updated yearly from the end of the baseline period to February 2015. The main outcome measures were incident CVD risk factors (hypertension, dyslipidemia, diabetes, obesity, and current smoking). After excluding prevalent CVD risk factors, we identified 308,015 Veterans. During the first year of observation, 12,725 (4.1%) Veterans were prescribed opioids, including 2028 (0.6%) with long-term exposure. Compared to patients without opioid use, Veterans with opioid use were more likely to have CVD risk factors. Those with long-term exposure were at higher risk of having hypertension (adjusted average hazards ratio [HR] 1.45, 99% confidence interval [CI] 1.33-1.59), dyslipidemia (HR 1.45, 99% CI 1.35-156), diabetes (HR 1.30, 99% CI 1.07-1.57), current smoking status (HR 1.34, 99% CI 1.24-1.46), and obesity (HR 1.22, 99% CI 1.12-1.32). Compared to short-term exposure, long-term had higher risk of current smoking status (HR 1.12, 99% CI 1.01-1.24). These findings suggest potential benefit to screening and surveillance of CVD risk factors for patients prescribed opioids, especially long-term opioid therapy.

Elevated preoperative blood pressures in adult surgical patients are highly predictive of elevated home blood pressures.

Blood pressure (BP) measurement during the presurgical assessment has been suggested as a way to improve longitudinal detection and treatment of hypertension. The relationship between BP measured during this assessment and home blood pressure (HBP), a better indicator of hypertension, is unknown. The purpose of the present study was to determine the positive predictive value of presurgical BP for predicting elevated HBP. We prospectively enrolled 200 patients at a presurgical evaluation clinic with clinic blood pressures (CBPs) ≥130/85 mm Hg, as measured using a previously validated automated upper-arm device (Welch Allyn Vital Sign Monitor 6000 Series), to undergo daily HBP monitoring (Omron Model BP742N) between the index clinic visit and their day of surgery. Elevated HBP was defined, per American Heart Association guidelines, as mean systolic HBP ≥135 mm Hg or mean diastolic HBP ≥85 mm Hg. Of the 200 participants, 188 (94%) returned their home blood pressure monitors with valid data. The median number of HBP recordings was 10 (interquartile range, 7-14). Presurgical CBP thresholds of 140/90, 150/95, and 160/100 mm Hg yielded positive predictive values (95% confidence interval) for elevated HBP of 84.1% (0.78-0.89), 87.5% (0.81-0.92), and 94.6% (0.87-0.99), respectively. In contrast, self-reported BP control, antihypertensive treatment, availability of primary care, and preoperative pain scores demonstrated poor agreement with elevated HBP. Elevated preoperative CBP is highly predictive of longitudinally elevated HBP. BP measurement during presurgical assessment may provide a way to improve longitudinal detection and treatment of hypertension.

The effect of race on postsurgical ambulatory medical follow-up among United States Veterans.

STUDY OBJECTIVE: To investigate the association between self-identified black or African American race and the presence of ambulatory internal medicine follow-up in the year after surgery. Our hypothesis was that among US Veterans who presented for surgery, black or African American race would be associated with a decreased likelihood to receive ambulatory internal medicine follow-up in the year after surgery. DESIGN: Retrospective observational. SETTING: All US Veterans Affairs hospitals. PATIENTS: A total of 236,200 Veterans undergoing surgery between 2006 and 2011 who were discharged within 10 days of surgery and survived the full 1-year exposure period. INTERVENTIONS: None. MEASUREMENTS: Attendance at an internal medicine follow-up appointment within 1 year after surgery. MAIN RESULTS: After controlling for year of surgery, age, age ≥65 years, sex, Hispanic ethnicity, and number of inpatient days, black or African American patients were 11% more likely to lack internal medicine follow-up after surgery (adjusted odds ratio, 1.11; 95% confidence interval, 1.06-1.16). When accounting for geographic region, this difference remained significant at the Bonferoni-corrected P < .007 level only in the Midwest United States where black or African American patients were 28% more likely to lack medical follow-up in the year after surgery (odds ratio, 1.28; 95% confidence interval, 1.16-1.42; P < .0001). CONCLUSIONS: The disparity in ambulatory medical follow-up following surgery among black or African American vs nonblack or non-African American Veterans in the Midwest region deserves further study and may lead to important quality improvement initiatives aimed specifically at this population.

Management of Patients on Abuse-Deterrent Opioids in the Ambulatory Surgery Setting.

PURPOSE OF REVIEW: The use of prescription opioids for acute and chronic pain has become more prevalent than ever, and concurrent with the increased prescribing of opioids, there has been a steady increase in opioid abuse. Abuse is commonly associated with physical or chemical manipulation of the original opiate to provide more rapid onset of the active ingredient. RECENT FINDINGS: This growing national public health concern has led to the development of various abuse-deterring opioids with the intent of decreasing the diversion of opioids from their prescribed use. Given the ever-increasing percentage of surgeries performed in the ambulatory surgery setting, anesthesia providers will inevitably encounter more and more patients taking these new opioid formulations with abuse-deterring properties. Consequently, a thorough understanding of these medications is vital for optimal anesthetic management. This article reviews the scope of the problem of prescription opiate abuse, summarizes the currently available abuse-deterring opioids, and discusses the anesthetic management of patients who are taking these new medications in the outpatient setting.

Does intravenous induction dosing among patients undergoing gastrointestinal surgical procedures follow current recommendations: a study of contemporary practice.

STUDY OBJECTIVE: It is recommended to correct intravenous induction doses by up to 50% for patients older than 65 years. The objectives were to determine (a) the degree to which anesthesia providers correct induction doses for age and (b) additionally adjust for American Society of Anesthesiologists physical status (ASA-PS) class (severity of illness) and (c) whether postinduction hypotension is more common among patients aged >65. DESIGN: Retrospective chart review. SETTING: Academic medical center. PATIENTS: A total of 1869 adult patients receiving general anesthesia for GI surgical procedures from February 2013 to January 2014. MEASUREMENTS: Patients were divided into 3 age groups (age <65, 65-79, ≥80 years) and then further stratified into ASA-PS class (I/II vs III/IV). Multiple pairwise comparisons were conducted using Welch t tests for continuous variables to determine whether dosing was different for the older groups vs the younger group; separate analyses were performed within and across ASA-PS class. This approach was also used to determine differences in mean arterial pressure change in the older groups vs the younger group, whereas the rates of hypotension among different age groups were compared by Cochran-Armitage trend test. MAIN RESULTS: No significant decrease in dosing between age groups was observed for fentanyl and midazolam. For propofol, there was a significantly lower dosing for older patients: 17% for patients aged 65-79 and 29% for those aged >80, which was still in less than the recommendations. An inverse relationship was observed between propofol dosing and ASA-PS class, but no consistent relationship was noted for fentanyl and midazolam. There were a significantly larger drop in mean arterial pressure and a greater likelihood of hypotension following induction in patients aged 65-79 years and >80 years as compared with those aged <65 years. CONCLUSIONS: This study shows that the administered dose of anesthetic induction agents is significantly higher than that recommended for patients older than 65 years. This failure to age-adjust dose may contribute to hypotensive episodes.

Ambulatory Medical Follow-Up in the Year After Surgery and Subsequent Survival in a National Cohort of Veterans Health Administration Surgical Patients.

OBJECTIVES: Among a national cohort of surgical patients, the authors analyzed the association between medical follow-up during the first postsurgical year and survival during the second postsurgical year. DESIGN: Retrospective cohort study. SETTING: US Veterans Hospitals. PARTICIPANTS: The study included adults who received surgical care in any Veterans Health Administration facility from 2006 to 2011 who were discharged within 10 days of surgery and who survived for at least 1 year postoperatively. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between the receipt of nonsurgical ambulatory medical care during the first postoperative year and the hazard of death during postsurgical year 2 was measured. Among 236,200 veterans, 93.2% received a nonsurgical medical follow-up visit in postsurgical year 1; of those, 5.1% died during postsurgical year 2. This compares with 9.4% year-2 mortality among patients lacking year-1 medical follow-up (p<0.0001). After adjustment for confounders, medical follow-up in postoperative year 1 again was associated with a significantly lower hazard of death in postoperative year 2 (hazard ratio 0.71; 95% confidence interval 0.66-0.78). Sensitivity analyses examining patient subgroups stratified by procedural specialty demonstrated comparable findings. The results were robust under a variety of simulated scenarios of unmeasured confounding. CONCLUSIONS: Within a national cohort of US veterans who presented for surgery, those who received nonsurgical ambulatory follow-up during the first postoperative year demonstrated lower all-cause mortality in the subsequent postoperative year than those who did not receive the same type of follow-up care. Interventions focused on postoperative care coordination of outpatient medical follow-up may have the potential to improve long-term postoperative survival.

Balancing Model Performance and Simplicity to Predict Postoperative Primary Care Blood Pressure Elevation.

BACKGROUND: Because of uncertainty regarding the reliability of perioperative blood pressures and traditional notions downplaying the role of anesthesiologists in longitudinal patient care, there is no consensus for anesthesiologists to recommend postoperative primary care blood pressure follow-up for patients presenting for surgery with an increased blood pressure. The decision of whom to refer should ideally be based on a predictive model that balances performance with ease-of-use. If an acceptable decision rule was developed, a new practice paradigm integrating the surgical encounter into broader public health efforts could be tested, with the goal of reducing long-term morbidity from hypertension among surgical patients. METHODS: Using national data from US veterans receiving surgical care, we determined the prevalence of poorly controlled outpatient clinic blood pressures ≥140/90 mm Hg, based on the mean of up to 4 readings in the year after surgery. Four increasingly complex logistic regression models were assessed to predict this outcome. The first included the mean of 2 preoperative blood pressure readings; other models progressively added a broad array of demographic and clinical data. After internal validation, the C-statistics and the Net Reclassification Index between the simplest and most complex models were assessed. The performance characteristics of several simple blood pressure referral thresholds were then calculated. RESULTS: Among 215,621 patients, poorly controlled outpatient clinic blood pressure was present postoperatively in 25.7% (95% confidence interval [CI], 25.5%-25.9%) including 14.2% (95% CI, 13.9%-14.6%) of patients lacking a hypertension history. The most complex prediction model demonstrated statistically significant, but clinically marginal, improvement in discrimination over a model based on preoperative blood pressure alone (C-statistic, 0.736 [95% CI, 0.734-0.739] vs 0.721 [95% CI, 0.718-0.723]; P for difference <0.0001). The Net Reclassification Index was 0.088 (95% CI, 0.082-0.093); P < 0.0001. A preoperative blood pressure threshold ≥150/95 mm Hg, calculated as the mean of 2 readings, identified patients more likely than not to demonstrate outpatient clinic blood pressures in the hypertensive range. Four of 5 patients not meeting this criterion were indeed found to be normotensive during outpatient clinic follow-up (positive predictive value, 51.5%; 95% CI, 51.0-52.0; negative predictive value, 79.6%; 95% CI, 79.4-79.7). CONCLUSIONS: In a national cohort of surgical patients, poorly controlled postoperative clinic blood pressure was present in >1 of 4 patients (95% CI, 25.5%-25.9%). Predictive modeling based on the mean of 2 preoperative blood pressure measurements performed nearly as well as more complicated models and may provide acceptable predictive performance to guide postoperative referral decisions. Future studies of the feasibility and efficacy of such referrals are needed to assess possible beneficial effects on long-term cardiovascular morbidity.

Preoperative depression symptom severity and its impact on adherence to preoperative beta-blocker therapy.

OBJECTIVES: To test the association among depression symptoms, distressed personality type, and preoperative beta-blocker nonadherence and to estimate the prevalence of untreated major depression in this population. DESIGN: Prospective observational study. SETTING: A veterans hospital. PARTICIPANTS: One hundred twenty patients on outpatient beta-blocker therapy presenting for surgery. INTERVENTIONS: The Patient Health Questionnaire (PHQ)-9, the D-Scale-14 (DS14), and Modified Morisky Scale (MMS) questionnaires. MEASUREMENTS AND MAIN RESULTS: Of 99 participants who presented for surgery, the incidence of preoperative nonadherence was 14.1% (95% confidence interval 7%-21%), consistent with prior research. Nonadherence was 9.5% among those with no depression, 27.8% among those with mild depression, and 28.6% among those with moderate-to-severe depression (Cochran-Armitage test for trend p = 0.03). Distressed personality type was found in 35% of the cohort (95% confidence interval 26-45%) and was not associated with beta-blocker nonadherence (Fisher's exact test, p = 0.24). Among participants with symptoms of major depressive disorder (n = 25, 25.3%), more than half (n = 14, 56%) had no indication of depression listed at their most recent primary care visit. CONCLUSIONS: Patients with symptoms of depression on chronic beta-blocker therapy are susceptible to medication nonadherence on the day of surgery. Most surgical patients with symptoms of major depression lack a diagnosis of depression. Preoperative depression screening may thus (1) identify a population at increased risk of beta-blocker withdrawal, and (2) identify patients who may benefit from anesthesiologist-initiated referral for this treatable condition.

Atenolol is associated with lower day-of-surgery heart rate compared to long- and short-acting metoprolol.

OBJECTIVES: The authors analyzed the association between outpatient ß-blocker type and day-of-surgery (DOS) heart rate in ambulatory surgical patients. They further investigated whether differences in DOS heart rate between atenolol and metoprolol could be explained by once-daily versus twice-daily dosing regimens. DESIGN: Retrospective observational study. SETTING: Veterans Administration hospital. PARTICIPANTS: Ambulatory surgical patients on long-term atenolol or metoprolol. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using a propensity-score-matched cohort, DOS heart rates were compared in patients prescribed atenolol versus metoprolol. Then, once-daily and twice-daily metoprolol formulations were differentiated and DOS heart rates were compared within a general linear model. DOS heart rates in patients prescribed atenolol versus any metoprolol formulation were slower by a mean of 5.1 beats/min (66.6 v 71.7; 95% confidence interval [CI] of difference, 1.9-8.3; p = 0.002), a difference that was not observed in preoperative primary care visits. The general linear model showed that patients prescribed atenolol (typically once-daily dosing) had a mean DOS heart rate 5.6 beats/min lower compared with patients prescribed once-daily metoprolol succinate (68.9 v 74.5; 95% CI of difference, -8.6 to -2.6; p < 0.001) and 3.8 beats/min lower compared with patients prescribed twice-daily metoprolol tartrate (68.9 v 72.7; 95% CI of difference, -6.1 to -1.6; p < 0.001). DOS heart rates were similar between different formulations of metoprolol (95% CI of difference, -1.0 to +4.6; p = 0.22). CONCLUSIONS: Atenolol is associated with a lower DOS heart rate versus metoprolol. The heart rate difference is specific to the day of surgery and is not explained by once-daily versus twice-daily dosing regimens.

The effect of enhanced depression care on adherence to risk-reducing behaviors after acute coronary syndromes: findings from the COPES trial.

BACKGROUND: The presence of depression after an acute coronary syndrome (ACS) is associated with worse prognosis and lower adherence to risk-reducing behaviors. We reported earlier that an enhanced depression care intervention reduces depression symptoms and major adverse cardiac events. This study evaluates the impact of the depression intervention on health behavior and blood pressure control. METHODS: Between 2005 and 2008, 157 patients who remained persistently depressed 3 months after ACS were randomized to a 6-month depression intervention (initial patient preference for problem-solving therapy and/or pharmacotherapy, followed by stepped care; 80 patients) or to usual care (77 patients). At randomization, and then 2, 4, and 6 months later, patients were asked if they (1) missed taking their aspirin; (2) followed a heart healthy diet; (3) exercised regularly; and (4) used tobacco products. Blood pressure was measured before randomization and 6 months later. RESULTS: At the end of the intervention, there was no significant improvement in the percentage of intervention compared to control group patients who adhered to aspirin (+3% versus -1%, P = .23), followed a healthy diet (+10% versus +8%, P = .39), exercised regularly (+5% versus +4%, P = .65), abstained from tobacco (-3% versus -1%, P = .77), or had controlled blood pressure (+6% versus +16%, P = .26). CONCLUSION: Despite improving depression, enhanced depression care after an ACS did not improve health behavior or blood pressure control compared to usual care. Research is needed to test whether adding an adherence intervention to enhanced depression care can improve adherence and cardiovascular prognosis in depressed patients post-ACS.