Large-scale genome-wide association study of coronary artery disease in genetically diverse populations.

We report a genome-wide association study (GWAS) of coronary artery disease (CAD) incorporating nearly a quarter of a million cases, in which existing studies are integrated with data from cohorts of white, Black and Hispanic individuals from the Million Veteran Program. We document near equivalent heritability of CAD across multiple ancestral groups, identify 95 novel loci, including nine on the X chromosome, detect eight loci of genome-wide significance in Black and Hispanic individuals, and demonstrate that two common haplotypes at the 9p21 locus are responsible for risk stratification in all populations except those of African origin, in which these haplotypes are virtually absent. Moreover, in the largest GWAS for angiographically derived coronary atherosclerosis performed to date, we find 15 loci of genome-wide significance that robustly overlap with established loci for clinical CAD. Phenome-wide association analyses of novel loci and polygenic risk scores (PRSs) augment signals related to insulin resistance, extend pleiotropic associations of these loci to include smoking and family history, and precisely document the markedly reduced transferability of existing PRSs to Black individuals. Downstream integrative analyses reinforce the critical roles of vascular endothelial, fibroblast, and smooth muscle cells in CAD susceptibility, but also point to a shared biology between atherosclerosis and oncogenesis. This study highlights the value of diverse populations in further characterizing the genetic architecture of CAD.

Variation in contrast-associated acute kidney injury prophylaxis for percutaneous coronary intervention: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) program.

BACKGROUND: Contrast-Associated Acute Kidney Injury (CA-AKI) is a serious complication associated with percutaneous coronary intervention (PCI). Patients with chronic kidney disease (CKD) have an elevated risk for developing this complication. Although CA-AKI prophylactic measures are available, the supporting literature is variable and inconsistent for periprocedural hydration and N-acetylcysteine (NAC), but is stronger for contrast minimization. METHODS: We assessed the prevalence and variability of CA-AKI prophylaxis among CKD patients undergoing PCI between October 2007 and September 2015 in any cardiac catheterization laboratory in the VA Healthcare System. Prophylaxis included periprocedural hydration with normal saline or sodium bicarbonate, NAC, and contrast minimization (contrast volume to glomerular filtration rate ratio ≤ 3). Multivariable hierarchical logistic regression models quantified site-specific prophylaxis variability. As secondary analyses, we also assessed CA-AKI prophylaxis measures in all PCI patients regardless of kidney function, periprocedural hydration in patients with comorbid CHF, and temporal trends in CA-AKI prophylaxis. RESULTS: From 2007 to 2015, 15,729 patients with CKD underwent PCI. 6928 (44.0%) received periprocedural hydration (practice-level median rate 45.3%, interquartile range (IQR) 35.5-56.7), 5107 (32.5%) received NAC (practice-level median rate 28.3%, IQR 22.8-36.9), and 4656 (36.0%) received contrast minimization (practice-level median rate 34.5, IQR 22.6-53.9). After adjustment for patient characteristics, there was significant site variability with a median odds ratio (MOR) of 1.80 (CI 1.56-2.08) for periprocedural hydration, 1.95 (CI 1.66-2.29) for periprocedural hydration or NAC, and 2.68 (CI 2.23-3.15) for contrast minimization. These trends were similar among all patients (with and without CKD) undergoing PCI. Among patients with comorbid CHF (n = 5893), 2629 (44.6%) received periprocedural hydration, and overall had less variability in hydration (MOR of 1.56 (CI 1.38-1.76)) compared to patients without comorbid CHF (1.89 (CI 1.65-2.18)). Temporal trend analysis showed a significant and clinically relevant decrease in NAC use (64.1% of cases in 2008 (N = 1059), 6.2% of cases in 2015 (N = 128, p = < 0.0001)) and no significant change in contrast-minimization (p = 0.3907). CONCLUSIONS: Among patients with CKD undergoing PCI, there was low utilization and significant site-level variability for periprocedural hydration and NAC independent of patient-specific risk. This low utilization and high variability, however, was also present for contrast minimization, a well-established measure. These findings suggest that a standardized approach to CA-AKI prophylaxis, along with continued development of the evidence base, is needed.

Same-day discharge among patients undergoing elective PCI: Insights from the VA CART Program.

BACKGROUND: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System. METHODS: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30 days. RESULTS: Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (P < .001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, P = .24; mortality: 0% vs. 0.07%, P = .99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250). CONCLUSIONS: Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes.

Medical Therapy Utilization and Long-Term Outcomes Following Percutaneous Coronary Intervention: Five-Year Results From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program.

BACKGROUND: Optimal medical therapy is endorsed by national guidelines in the management of ischemic heart disease; however, few studies have examined its long-term utilization following percutaneous coronary intervention (PCI) and association with clinical outcomes. We sought to assess longitudinal trends in medical therapy use after PCI and its prognostic significance. METHODS AND RESULTS: From the Veteran Affairs Clinical Assessment, Reporting, and Tracking System Program, we retrospectively identified 57 900 Veteran's Affairs patients undergoing PCI from January 2005 to May 2014. Using prescription fill dates, the utilization of 4 classes of medical therapy including statins, ß-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, P2Y12 inhibitors, and their composites were assessed at discharge, 6 months, 1, 3, and 5 years post-PCI. Multivariable Cox regression models were developed to assess the association between medical therapy status and major adverse cardiovascular events, defined as all-cause mortality, rehospitalization for myocardial infarction, rehospitalization for stroke, or repeat revascularization. At discharge following PCI, 58.3% of patients received all 4 classes of medical therapy. Utilization of statins, ß-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers decreased from 89%, 84.9%, and 72.2% on discharge, respectively, to 72.7%, 67.9%, and 57.9% at 5 years. Prescription refills of P2Y12 inhibitors declined from 96.5% on discharge to 28.3% at 5 years, driven by a large decline in P2Y12 inhibitor use after 1 year. Use of each class of medical therapy, and its composite use, was associated with a significant reduction in major adverse cardiovascular events at 5 years, with the largest effect size seen by the use of statins (HR, 0.77; 95% CI, 0.75-0.79; P<0.0001) and P2Y12 inhibitors (HR, 0.82; 95% CI, 0.79-0.85; P<0.0001). CONCLUSIONS: Consistent declines in medical therapy use following PCI were observed over time, which is associated with worse outcomes. Further efforts are needed to promote long-term adherence to secondary prevention therapies after revascularization.

Association of Coronary Anatomical Complexity With Clinical Outcomes After Percutaneous or Surgical Revascularization in the Veterans Affairs Clinical Assessment Reporting and Tracking Program.

Importance: Anatomical scoring systems for coronary artery disease, such as the SYNTAX (Synergy Between Percutaneous Coronary Intervention [PCI] With Taxus and Cardiac Surgery) score, are well established tools for understanding patient risk. However, they are cumbersome to compute manually for large data sets, limiting their use across broad and varied cohorts. Objective: To adapt an anatomical scoring system for use with registry data, allowing facile and automatic calculation of scores and association with clinical outcomes among patients undergoing percutaneous or surgical revascularization. Design, Setting, and Participants: This cross-sectional observational cohort study involved procedures performed in all cardiac catheterization laboratories in the largest integrated health care system in the United States, the Veterans Affairs (VA) Healthcare System. Patients undergoing coronary angiography in the VA Healthcare System followed by percutaneous or surgical revascularization within 90 days were observed and data were analyzed from January 1, 2010, through September 30, 2017. Main Outcomes and Measures: An anatomical scoring system for coronary artery disease complexity before revascularization was simplified and adapted to data from the VA Clinical Assessment, Reporting, and Tracking Program. The adjusted association between quantified anatomical complexity and major adverse cardiovascular and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and repeat revascularization, was assessed for patients undergoing percutaneous or surgical revascularization. Results: A total of 50 226 patients (49 359 men [98.3%]; mean [SD] age, 66 [9] years) underwent revascularization during the study period, with 34 322 undergoing PCI and 15 904 undergoing coronary artery bypass grafting (CABG). After adjustment, the highest tertile of anatomical complexity was associated with increased hazard of MACCEs (adjusted hazard ratio [HR], 2.12; 95% CI, 2.01-2.23). In contrast, the highest tertile of anatomical complexity among patients undergoing CABG was not independently associated with overall MACCEs (adjusted HR, 1.04; 95% CI, 0.92-1.17), and only repeat revascularization was associated with increasing complexity (adjusted HR, 1.34; 95% CI, 1.06-1.70) in this subgroup. Conclusions and Relevance: These findings suggest that an automatically computed score assessing anatomical complexity can be used to assess longitudinal risk for patients undergoing revascularization. This simplified scoring system appears to be an alternative tool for understanding longitudinal risk across large data sets.

Association Between Chronic Kidney Disease and Rates of Transfusion and Progression to End-Stage Renal Disease in Patients Undergoing Transradial Versus Transfemoral Cardiac Catheterization-An Analysis From the Veterans Affairs Clinical Assessment Reporting and Tracking (CART) Program.

BACKGROUND: Patients with chronic kidney disease (CKD) are at increased risk for bleeding, transfusion, and dialysis after cardiac catheterization. Whether rates of these complications are increased in this high-risk population undergoing transradial access compared with transfemoral access is unknown. METHODS AND RESULTS: From the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking program, we identified 229 108 patients undergoing cardiac catheterization between 2007 and 2014, of which 48 155 (21.0%) had baseline glomerular filtration rate (GFR) between 15 and 59 mL/min. We used multivariable Cox modeling to determine the independent association between transradial access and postprocedure transfusion as well as progression to new dialysis by degree of renal dysfunction. Overall, 35 979 (15.7%) of patients underwent Transradial access. Transradial patients tended to be slightly younger, but, overall, had similar rates of CKD compared to transfemoral patients (24.3% vs 27.1%). Transradial patients had longer fluoroscopy times (7.2 vs 6.0 minutes; P<0.001), but lower contrast use (85.0 vs 100.0 mL; P<0.001). The estimated rate of blood transfusion within 48 hours was lower among transradial patients (0.85% vs 1.01%) as were rates of new dialysis at 1 year (0.58% vs 0.71%). After multivariable adjustment, transradial access was associated with lower rates of progression to dialysis at 1 year overall (hazard ratio [HR], 0.83; 95% CI, 0.70-0.98), with no trend of increased risk for dialysis by degree of CKD compared with transfemoral access. Transradial access was associated with greater reduction in transfusion rates with increasing degree of CKD (P value for trend=0.04: non-CKD: HR, 0.99; 95% CI, 0.73-1.34; GFR 45-59 mL/min: HR, 0.93; 95% CI, 0.70-1.23; GFR 30-44 mL/min: HR, 0.73; 95% CI, 0.51-1.03; GFR 15-29 mL/min: HR, 0.43; 95% CI, 0.20-0.90). CONCLUSIONS: Among patients undergoing cardiac catheterization in the VA health system, transradial access was associated with lower risk for postprocedure transfusion within 48 hours among patients with more-severe CKD, and with lower risk of progression to end-stage renal disease at 1 year compared with transfemoral access. These data provide additional evidence that transradial access may provide significant benefit in this high-risk population.

Percutaneous Coronary Intervention in Native Coronary Arteries Versus Bypass Grafts in Patients With Prior Coronary Artery Bypass Graft Surgery: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

OBJECTIVES: The aim of this study was to examine the frequency, associations, and outcomes of native coronary artery versus bypass graft percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (CABG) in the Veterans Affairs (VA) integrated health care system. BACKGROUND: Patients with prior CABG surgery often undergo PCI, but the association between PCI target vessel and short- and long-term outcomes has received limited study. METHODS: A national cohort of 11,118 veterans with prior CABG who underwent PCI between October 2005 and September 2013 at 67 VA hospitals was examined, and the outcomes of patients who underwent native coronary versus bypass graft PCI were compared. Logistic regression with generalized estimating equations was used to adjust for correlation between patients within hospitals. Cox regressions were modeled for each outcome to determine the variables with significant hazard ratios (HRs). RESULTS: During the study period, patients with prior CABG represented 18.5% of all patients undergoing PCI (11,118 of 60,171). The PCI target vessel was a native coronary artery in 73.4% and a bypass graft in 26.6%: 25.0% in a saphenous vein graft and 1.5% in an arterial graft. Compared with patients undergoing native coronary artery PCI, those undergoing bypass graft PCI had higher risk characteristics and more procedure-related complications. During a median follow-up period of 3.11 years, bypass graft PCI was associated with significantly higher mortality (adjusted HR: 1.30; 95% confidence interval: 1.18 to 1.42), myocardial infarction (adjusted HR: 1.61; 95% confidence interval: 1.43 to 1.82), and repeat revascularization (adjusted HR: 1.60; 95% confidence interval: 1.50 to 1.71). CONCLUSIONS: In a national cohort of veterans, almost three-quarters of PCIs performed in patients with prior CABG involved native coronary artery lesions. Compared with native coronary PCI, bypass graft PCI was significantly associated with higher incidence of short- and long-term major adverse events, including more than double the rate of in-hospital mortality.

Patient access and 1-year outcomes of percutaneous coronary intervention facilities with and without on-site cardiothoracic surgery: insights from the Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking (CART) program.

BACKGROUND: The safety of percutaneous coronary intervention (PCI) at medical facilities without on-site cardiothoracic (CT) surgery has been established in clinical trials. However, the comparative effectiveness of this strategy in real-world practice, including impact on patient access and outcomes, is uncertain. The Veterans Affairs (VA) health care system has used this strategy, with strict quality oversight, since 2005, and can provide insight into this question. METHODS AND RESULTS: Among 24,387 patients receiving PCI at VA facilities between October 2007 and September 2010, 6616 (27.1%) patients underwent PCI at facilities (n=18) without on-site CT surgery. Patient drive time (as a proxy for access), procedural complications, 1-year mortality, myocardial infarction, and rates of subsequent revascularization procedures were compared by facility. Results were stratified by procedural indication (ST-segment-elevation myocardial infarction versus non-ST-segment-elevation myocardial infarction/unstable angina versus elective) and PCI volume. With the inclusion of PCI facilities without on-site CT surgery, median drive time for patients treated at those facilities decreased by 90.8 minutes (P<0.001). Procedural need for emergent coronary artery bypass graft and mortality rates were low and similar between facilities. Adjusted 1-year mortality and myocardial infarction rates were similar between facilities (hazard ratio in PCI facilities without relative to those with on-site CT surgery, 1.02; 95% confidence interval, 0.87-1.2), and not modified by either PCI indication or PCI volume. Subsequent revascularization rates were higher at sites without on-site CT surgery facilities (hazard ratio, 1.21; 95% confidence interval, 1.03-1.42). CONCLUSIONS: This study suggests that providing PCI facilities without on-site CT surgery in an integrated health care system with quality oversight improves patient access without compromising procedural or 1-year outcomes.

Quantitative assessment of the conformational change in the femoropopliteal artery with leg movement.

BACKGROUND: The unique physical forces exerted on the femoropopliteal (FP) artery during movement have been implicated in the high rates of restenosis and stent fracture in this artery. Conformational changes in the FP artery during movement are important surrogates of these forces. This study sought to quantify the conformational change in the FP artery between the straight-leg (SL) and crossed-leg (CL) positions. METHODS: Using paired angiographic images of overlapping segments of the FP artery in SL and CL positions from patients with peripheral arterial disease, 3-D models of individual segments were generated and subsequently fused to create a 3-D model of the entire FP artery in both leg positions. Based on these 3-D models, the following parameters in the SL and CL positions were quantitatively assessed for the superficial femoral artery (SFA), popliteal artery (PA), and FP artery (i.e., SFA and PA): length, curvature, torsion, twist angle, and development of new flexion angles = 15 degrees. RESULTS: In nine male patients with a mean age of 57 +/- 10.2 years, angiography was performed in 10 FP arteries, with successful generation of 3-D models for all vessels. Movement from the SL to the CL position for the SFA, PA, and FP artery was associated with (a) a mean shortening of 18.2 mm (P = 0.002), 32.2 mm (P < 0.001), and 50.3 mm (P < 0.001), respectively; (b) a mean increase in curvature of 0.04 cm(-1) (P = 0.012), 0.2 cm(-1) (P < 0.001), and 0.11 cm(-1) (P < 0.001), respectively; (c) and small absolute changes in mean torsion of 0.034 cm(-1) (P = 0.48), 0.006 cm(-1) (P < 0.001), and 0.057 cm(-1) (P < 0.001), respectively. The same leg movement was associated with a mean twist angle of 45.6 degrees +/- 27.9 degrees (range of 17.4 degrees-103.4 degrees ) and 61.1 degrees +/- 31.9 degrees (range of 20.5 degrees-101.1 degrees ) for the SFA and PA, respectively. Compared to the SL position, the CL position induced a single flexion point (FxP) =15 degrees in the SFA in two patients, and a mean of 2.4 FxPs =15 degrees (range 1-5) in the PA. CONCLUSIONS: Significant changes in length, curvature, and twist occur in the PA and significant but more modest changes in length and twist occur in the SFA during movement from the SL to the CL position. This data has important implications for endovascular therapies that are used to treat disease in the FP artery.

Primary care provider turnover and quality in managed care organizations.

OBJECTIVES: To examine the association between primary care provider turnover in managed care organizations and measures of member satisfaction and preventive care. STUDY DESIGN: Retrospective cohort study of a national sample of 615 managed care organizations that reported HEDIS data to the National Committee for Quality Assurance from 1999 through 2001. METHODS: Multivariable hierarchical regression modeling was used to evaluate the association between health plan primary care provider turnover rate and member satisfaction and preventive care measures, including childhood immunization, well-child visits, cholesterol, diabetes management, and breast and cervical cancer screening, adjusting for patient and organizational characteristics, time, and repeated measures. RESULTS: The median primary care provider turnover rate was 7.1% (range, 0%-53.3%). After adjustment for plan characteristics, health plans with higher primary care provider turnover rates had significantly lower measures of member satisfaction, including overall rating of healthcare (P < .01). A 10% higher primary care provider turnover rate was associated with 0.9% fewer members rating high overall satisfaction with healthcare. Health plans with higher provider turnover rates also had lower rates of preventive care, including childhood immunization (P = .045), well-child visits (P = .002), cholesterol screening after cardiac event (P = .042), and cervical cancer screening (P = .024). For example, a 10% higher primary care provider turnover was associated with a 2.7% lower rate of child-members receiving well-child visits in the first 15 months of life. CONCLUSIONS: Primary care provider turnover is associated with several measures of care quality, including aspects of member satisfaction and preventive care. Future studies should evaluate whether interventions to reduce primary care provider turnover can improve quality of care and patient outcomes.

Exploring the volume-outcome relationship for off-pump coronary artery bypass graft procedures.

BACKGROUND: The relationship between the surgical case volume and risk-adjusted clinical outcomes has been examined for different surgical specialties. The purpose of this study was to explore the relationship between the off-pump coronary artery bypass graft procedure volumes (OPCABG) with risk-adjusted outcomes within the Department of Veterans Affairs (VA) 44 cardiac surgery programs. METHODS: Based on VA Continuous Improvement in Cardiac Surgery Program data, the results of 5,076 OPCABG surgical procedures performed between October 1998 and September 2003 were analyzed. Hierarchical logistic regression models evaluated the relationship between OPCABG procedure volume with risk-adjusted 30-day operative mortality, perioperative morbidity, and 180-day mortality. Both a hospital's average OPCABG volume per 6-month period and the hospital's most recent 6-month OPCABG volume were examined. RESULTS: Hospital OPCABG average volume in a 6-month period ranged from 0.2 to 47.4 procedures; whereas the most recent 6-month OPCABG hospital volume ranged from 0 to 76 OPCABG per site. No relationship between the volume measures and the outcome variables was found. CONCLUSIONS: We did not find an association between OPCABG volume with short-term mortality, perioperative morbidity, or intermediate-term (180-day) mortality.

Outcomes after acute coronary syndrome admission to primary versus tertiary Veterans Affairs medical centers: the Veterans Affairs Access to Cardiology study.

BACKGROUND: There is a concern that patients with acute coronary syndrome (ACS) admitted to primary care hospitals (without on-site cardiac procedures) may be at risk for worse outcomes compared with patients admitted to tertiary care hospitals. In addition to mortality, one way to assess patient outcomes is via health status and rehospitalization rates. We compared the health status and rehospitalization of patients with ACS admitted to primary versus tertiary care Veterans Affairs hospitals. METHODS: This was a cohort study of 2132 patients with ACS admitted to 21 Veterans Affairs hospitals (12 primary care and 9 tertiary care) from 1998 to 1999. Primary outcomes were 7-month health status as measured by the Seattle Angina Questionnaire and rehospitalization. Hierarchical multivariable regression was used to evaluate the association between admission to a primary (vs tertiary) care hospital and these outcomes. Discharge medications and 7-month cardiac procedure rates were also compared. RESULTS: There were no significant differences in discharge medication rates between primary and tertiary hospital patients. Forty-two percent of the patients admitted to a primary care hospital was transferred to a tertiary care hospital during index admission. Primary hospital patients had significantly lower 7-month rates of cardiac catheterization (36% vs 51%, P < .001) and percutaneous coronary intervention (11% vs 20%, P < .001), but there were no differences in coronary artery bypass graft surgery rates. After risk adjustment, there were no significant differences in 7-month angina frequency (odds ratio [OR] 0.98, 95% CI 0.78-1.22), physical limitation (OR 0.97, 95% CI 0.77-1.23), quality of life (OR 1.12, 95% CI 0.89-1.40), or rehospitalization (OR 1.07, 95% CI 0.54-2.14) between the 2 groups. CONCLUSIONS: These results suggest that an integrated health care system can achieve similar intermediate-term health status and rehospitalization outcomes for patients with ACS irrespective of the site of admission despite the lower rates of cardiac procedures for the primary care hospital patients.

Prescription-filling rates for key medications in Veterans Affairs patients after coronary artery bypass grafting.

PURPOSE: The six-month prescription-filling rates for key secondary-prevention drugs in Department of Veterans Affairs (VA) patients who had undergone coronary artery bypass grafting (CABG) were studied. METHODS: Patient records for elective CABG from April 2000 through March 2002 (divided into four six-month periods) were analyzed. The study population included 8925 CABG-only patients surviving to hospital discharge. For each six-month period and in aggregate, the primary study endpoint was the six-month prescription-filling rate. RESULTS: Across the four six-month periods, prescription-filling rates increased for all categories of medications studied. There were modest progressive increases for lipid-lowering agents, statins, -blockers, angiotensin-converting-enzyme Inhibitors, and angiotensin-receptor blockers. The antithrombotic-filling rate averaged 88.5%. Filling rates for aspirin were much higher than for aspirin alternatives. CONCLUSION: Prescription-filling rates for post-CABG medications in VA facilities were generally high and suggested compliance with guidelines for the prevention of cardiovascular events.

Impact of angina burden and other factors on treatment satisfaction after acute coronary syndromes.

PURPOSE: Although of great importance to clinicians, hospitals, and health care systems, little is known about factors that influence treatment satisfaction after acute coronary syndromes (ACS). The objective of this study was to identify potentially modifiable factors associated with treatment satisfaction 7 months after ACS. METHODS: The study population included 1957 patients with ACS who were enrolled in the multicenter, prospective Veterans' Health Administration Access to Cardiology Study. The primary outcome was treatment satisfaction 7 months after ACS as measured by the Seattle Angina Questionnaire. Multivariable regression models were developed to determine the association between treatment satisfaction and patient characteristics, physician-patient communication, and current angina frequency. RESULTS: Patient characteristics associated with reduced treatment satisfaction included a history of depression, atrial fibrillation, prior heart surgery, arthritis, hypertension, younger age, and a discharge diagnosis of unstable angina (as opposed to myocardial infarction). After adjusting for patient characteristics, patient-reported inability to reach one or more of their physicians (OR, 2.40; 95% CI, 1.47 to 3.91), being given confusing information (OR, 3.48; 95% CI, 2.08 to 5.83), and poor overall communication with one or more of their physicians (OR, 4.94; 95% CI, 2.93 to 8.34) were all associated with reduced satisfaction. Finally, after adjustment for both patient characteristics and physician communication, weekly (OR, 3.52; 95% CI, 2.28 to 5.45) and daily angina (OR, 3.88; 95% CI, 2.23 to 6.75) were associated with worse treatment satisfaction. CONCLUSIONS: Current angina symptoms and aspects of physician communication are independently associated with treatment satisfaction after ACS. These results suggest that treatment satisfaction may be improved through better communication and better control of angina symptoms.

Health-related quality of life after percutaneous coronary intervention versus coronary bypass surgery in high-risk patients with medically refractory ischemia.

OBJECTIVES: We compared six-month health-related quality of life (HRQL) for high-risk patients with medically refractory ischemia randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery. BACKGROUND: Mortality rates after PCI and CABG surgery are similar. Therefore, differences in HRQL outcomes may help in the selection of a revascularization procedure. METHODS: Patients were enrolled in a Veterans Affairs multicenter randomized trial comparing PCI versus CABG for patients with medically refractory ischemia and one or more risk factors for adverse outcome; 389 of 423 patients (92%) alive six months after randomization completed an Short Form-36 (SF-36) health status survey. Primary outcomes were the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36. Multivariable analyses were used to evaluate whether PCI or CABG surgery was associated with better PCS or MCS scores after adjusting for over 20 baseline variables. RESULTS: There were no significant differences in either PCS scores (38.7 vs. 37.3 for PCI and CABG, respectively; p = 0.23) or MCS scores (45.5 vs. 46.1, p = 0.58) between the treatment arms. In multivariable models, there remained no difference in HRQL for post-PCI versus post-CABG patients (for PCS, absolute difference = 0.56 +/- standard error of 1.14, p = 0.63; for MCS, absolute difference = -1.23 +/- 1.12, p = 0.27). We had 97% power to detect a four-point difference in scores, where four to seven points is a clinically important difference. CONCLUSIONS: High-risk patients with medically refractory ischemia randomized to PCI versus CABG surgery have equivalent six-month HRQL. Therefore, HRQL concerns should not drive decision-making regarding selection of a revascularization procedure for these patients.

The impact of ethnicity on outcomes following coronary artery bypass graft surgery in the Veterans Health Administration.

OBJECTIVES: We evaluated the effect of African American (AA) and Hispanic American (HA) ethnicity on mortality and complications following coronary artery bypass graft (CABG) surgery in the Veterans Health Administration (VHA). BACKGROUND: Few studies have examined the impact of ethnicity on outcomes following cardiovascular procedures. METHODS: This study included all 29,333 Caucasian, 2,570 AA, and 1,525 HA patients who underwent CABG surgery at any one of the 43 VHA cardiac surgery centers from January 1995 through March 2001. We evaluated the relationship between ethnicity (AA vs. Caucasian and HA vs. Caucasian) and 30-day mortality, 6-month mortality, and 30-day complications, adjusting for a wide array of demographic, cardiac, and noncardiac variables. RESULTS: After adjustment for baseline characteristics, AA and Caucasian patients had similar 30-day (AA/Caucasian odds ratio [OR] 1.07; 95% confidence interval [CI] 0.84 to 1.35; p = 0.59) and 6-month mortality risk (AA/Caucasian OR 1.10; 95% CI 0.91 to 1.34; p = 0.31). However, among patients with low surgical risk, AA ethnicity was associated with higher mortality (OR 1.52, CI 1.10 to 2.11, p = 0.01), and AA patients were more likely to experience complications following surgery (OR 1.28; 95% CI 1.14 to 1.45; p < 0.01). In contrast, HA patients had lower 30-day (HA/Caucasian OR 0.70; 95% CI 0.49 to 0.98; p = 0.04) and 6-month mortality risk (HA/Caucasian OR 0.66; 95% CI 0.50 to 0.88; p < 0.01) than Caucasian patients. CONCLUSIONS: Ethnicity does not appear to be a strong risk factor for adverse outcomes following CABG surgery in the VHA. Future studies are needed to determine why AA patients have more complications, but ethnicity should not affect the decision to offer the operation.