RESUMEN
Pressure loss recovery (PLR) is a hydrodynamic phenomenon that occurs when blood flow encounters a narrowing typified by aortic valve stenosis (AS). Multiple factors contribute to the magnitude of PLR including the volumetric rate of flow, the geometry of the entrance to the vena contracta (VC) or point of minimum dimension, including that of the left ventricular outflow tract and valve orifice, and the geometry of the proximal aorta. In the majority of clinical circumstances, PLR results in echocardiographic Doppler gradient estimates that are modestly, but generally not clinically important, greater than those derived from rigorously performed catheter measurements. The contribution of PLR to the echocardiographically-measured gradient may not differ significantly between currently available valve prostheses and is likely to be small in patients with mild AS following TAVR.
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Estenosis de la Válvula Aórtica , Válvula Aórtica , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Ecocardiografía Doppler , Hemodinámica , Humanos , Resultado del TratamientoRESUMEN
BACKGROUND: On May 20, 2016, US professional organizations in cardiology published joint treatment guidelines recommending the use of angiotensin-receptor neprilysin inhibitor (ARNI) for eligible patients with heart failure with reduced ejection fraction (HFrEF). Using data from the Get With The Guidelines-Heart Failure registry, we evaluated the early impact of this update on temporal trends in ARNI prescription. METHODS: We analyzed patients with HFrEF who were eligible for ARNI prescription (EF ≤40%, no contraindications) and hospitalized from February 20, 2016, through August 19, 2016-allowing for 13weeks before and after guideline publication. We quantified trends in ARNI use associated with guidelines publication with an interrupted time-series design using logistic regression and accounting for correlations within hospitals using general estimating equation methods. RESULTS: Of 7,200 eligible patient hospitalizations, 51.9% were discharged in the period directly preceding publication of the guidelines, and 48.1% were discharged after. Odds ratios of ARNI prescription at discharge were significantly higher in the postguideline period compared with the preguideline period in adjusted models (adjusted odds ratio 1.29, 95% CI 1.06-1.57, P=.01). However, there was no significant interaction between observed and expected ARNI use after guideline publication (Pinteraction=.14). Results were consistent using a 6-month before and after time frame. CONCLUSIONS: The model suggested a small increase in ARNI use in HF patients being discharged from the hospital immediately after guideline release. However, the publication of national guidelines recommending ARNI use seemed to have little influence on the adoption of this evidence-based medication in the first 3 to 6months.
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Antagonistas de Receptores de Angiotensina/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Edición , Anciano , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/metabolismo , Humanos , Difusión de la Información/métodos , Masculino , Neprilisina/antagonistas & inhibidores , Selección de Paciente , Volumen Sistólico/efectos de los fármacos , Encuestas y Cuestionarios , Factores de Tiempo , Estados UnidosRESUMEN
The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure to clinical personnel. While the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. ACC leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. "Optimal Use of Ionizing Radiation in Cardiovascular Imaging - Best Practices for Safety and Effectiveness" is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. "Part I: Radiation Physics and Radiation Biology" addresses radiation physics, dosimetry and detrimental biologic effects. "Part II: Radiologic Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection" covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy). For each modality, it includes the determinants of radiation exposure and techniques to minimize exposure to both patients and to medical personnel.
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Técnicas de Imagen Cardíaca/normas , Enfermedades Cardiovasculares/diagnóstico por imagen , Exposición Profesional/normas , Dosis de Radiación , Exposición a la Radiación/normas , Benchmarking/normas , Consenso , Medicina Basada en la Evidencia/normas , Humanos , Exposición Profesional/efectos adversos , Exposición Profesional/prevención & control , Seguridad del Paciente/normas , Valor Predictivo de las Pruebas , Exposición a la Radiación/efectos adversos , Exposición a la Radiación/prevención & control , Medición de Riesgo , Factores de RiesgoRESUMEN
The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure for clinical personnel. Although the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. The American College of Cardiology leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. Part I: Radiation Physics and Radiation Biology addresses the issue of medical radiation exposure, the basics of radiation physics and dosimetry, and the basics of radiation biology and radiation-induced adverse effects. Part II: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy) and will be published in the next issue of the Journal.
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Técnicas de Imagen Cardíaca/normas , Enfermedades Cardiovasculares/diagnóstico por imagen , Dosis de Radiación , Exposición a la Radiación/normas , Benchmarking/normas , Consenso , Medicina Basada en la Evidencia/normas , Humanos , Seguridad del Paciente/normas , Valor Predictivo de las Pruebas , Exposición a la Radiación/efectos adversos , Exposición a la Radiación/prevención & control , Medición de Riesgo , Factores de RiesgoRESUMEN
BACKGROUND: Seasonal variation with winter preponderance of myocardial infarction incidence has been described decades ago, but only a few small studies have classified myocardial infarction based on ST-segment elevation. It is unclear whether seasonal and circadian variations are equally present in warmer and colder regions. We investigated whether seasonal and circadian variations in acute myocardial infarction (AMI) are more prominent in colder northern states compared with warmer southern states. We also investigated the peak time of admission to better understand the circadian rhythm. METHODS: Data from the GWTG-CAD database were used. We analyzed 82,971 consecutive acute myocardial infarction (AMI) patients treated at 276 US centers from 2003 to 2008. The country was geographically divided into warmer southern and colder northern states using latitude 35 degrees for this purpose. RESULTS: Overall, acute myocardial infarction (AMI) admissions varied across seasons (P < .01), and were higher in winter (winter vs. spring n = 21,483 vs. 20,291, respectively). When stratified based on type of AMI, non-ST-segment elevation myocardial infarction (NSTEMI) admissions varied across seasons (P < .01) and were highest in winter and lowest in spring. Seasonal variation was not significant in STEMI admissions (P = .30). Seasonal variation with winter predominance was noted in AMI patients in warmer southern states (P < .01), but not in colder states. The distributions of length of stay for AMI patients and door to balloon times for STEMI patients were minimally different across all four seasons (P < .01) with longest occurring in winter. Most patients with AMI presented during daytime with a peak close to 11 am and a nadir at approximately 4 am. CONCLUSIONS: Seasonal variation with winter predominance exists in AMI admissions and was significant in NSTEMI admissions but not in STEMI admissions. Seasonal variation was only significant in warmer southern states.
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Ritmo Circadiano , Sistema de Registros , Estaciones del Año , Anciano , Enfermedad de la Arteria Coronaria , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Masculino , Infarto del Miocardio/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: To evaluate and compare baseline characteristics, outcomes and compliance with guideline based therapy at discharge among diabetic and non-diabetic patients admitted with acute coronary syndromes (ACS). METHODS AND RESULTS: Study population consisted of 151,270 patients admitted with ACS from 2002 through 2008 at 411 sites participating in the American Heart Association's Get with the Guidelines (GWTG) program. Demographic variables, physical exam findings, laboratory data, left ventricular ejection fraction, length of stay, in-hospital mortality and discharge medications were compared between diabetic and non-diabetic patients. Temporal trends in compliance with guidelines directed therapy were evaluated. Of 151,270 patients, 48,938 (32%) had diabetes. Overall, diabetic patients were significantly older and more likely non-white. They had significantly more hypertension, atherosclerotic disease, CKD, and LV dysfunction and were more likely to present as NSTEMI. They had longer hospital stay and higher hospital mortality than non-diabetic patients. Diabetic patients were less likely to get LDL checks (65% vs 70%) and less frequently prescribed statins (85% vs 89%), RAAS blockers for LV dysfunction (80% vs 84%) and dual-antiplatelet therapy (69% vs 74%). Diabetic patients were less likely to achieve BP goals before discharge (75% vs 82%). Fewer diabetic patients met first medical contact to PCI time for STEMI (44% vs 52%). Temporal trends, however, showed continued progressive improvement in most performance measures from 2002 to 2008 (all P<.001). CONCLUSIONS: These data from a large cohort of ACS patients demonstrate gaps in compliance with guidelines directed therapy in diabetic patients but also indicate significant and continued improvement in most performance measures over time. Concerted efforts are needed to continue this positive trend.
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Síndrome Coronario Agudo/terapia , Diabetes Mellitus/terapia , Angiopatías Diabéticas/terapia , Adhesión a Directriz , Guías de Práctica Clínica como Asunto , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/mortalidad , Anciano , Angiopatías Diabéticas/complicaciones , Angiopatías Diabéticas/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Resultado del TratamientoRESUMEN
BACKGROUND: Recent initiatives have focused on primary prevention to delay time to first myocardial infarction (MI). The aim of this study was to evaluate the change in risk factor profile over time in patients without known cardiovascular disease presenting with first MI. METHODS: In the American Heart Association's Get With The Guidelines-Coronary Artery Disease national registry, 100,884 patients without known cardiovascular disease presenting with acute MI from 408 hospitals were evaluated between 2002 and 2008. The time trends of the proportion of patients with cardiovascular risk factors (nonmodifiable: age >45 years for men or >55 years for women, male sex, modifiable: diabetes mellitus, hypertension, hyperlipidemia, tobacco use) were analyzed. Analyses were stratified by non-ST-segment elevation MI (NSTEMI) versus ST-segment elevation MI (STEMI). RESULTS: The proportion of patients with ≥3 of 6 traditional risk factors slightly decreased over time in the NSTEMI (69.5%-66.8%, P < .0001) and STEMI (68.9%-66.4%, P < .0001) cohorts. The proportion of patients with ≥2 of 4 modifiable risk factors increased from 52% to 59% and then declined to 52.1% (P < .0001) in the NSTEMI cohort but declined slightly in the STEMI cohort (50.9%-47.3%, P < .0001). After adjusting for age and gender, the time trend of proportion with diabetes mellitus, hypertension, and tobacco use declined in both cohorts. However, the proportion of patients with hyperlipidemia remained similar. CONCLUSIONS: Although risk factor profiles in patients presenting with first MI have shown improvements over time, the changes are modest.
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Electrocardiografía , Adhesión a Directriz , Infarto del Miocardio/prevención & control , Prevención Primaria/normas , Sistema de Registros , Medición de Riesgo/métodos , Factores de Edad , Anciano , Enfermedades Cardiovasculares , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Estados Unidos/epidemiologíaAsunto(s)
Técnicas de Imagen Cardíaca/normas , Enfermedades Cardiovasculares/diagnóstico por imagen , Dosis de Radiación , Exposición a la Radiación/normas , Benchmarking/normas , Consenso , Medicina Basada en la Evidencia/normas , Humanos , Seguridad del Paciente/normas , Valor Predictivo de las Pruebas , Exposición a la Radiación/efectos adversos , Exposición a la Radiación/prevención & control , Medición de Riesgo , Factores de RiesgoRESUMEN
The Society of Cardiovascular Angiography and Interventions present a practical approach to assist cardiac catheterization laboratories in establishing a radiation safety program. The importance of this program is emphasized by the appropriate concerns for the increasing use of ionizing radiation in medical imaging, and its potential adverse effects. An overview of the assessment of radiation dose is provided with a review of basic terminology for dose management. The components of a radiation safety program include essential personnel, radiation monitoring, protective shielding, imaging equipment, and training/education. A procedure based review of radiation dose management is described including pre-procedure, procedure and post-procedure best practice recommendations. Specific radiation safety considerations are discussed including women and fluoroscopic procedures as well as patients with congenital and structural heart disease.
Asunto(s)
Cateterismo Cardíaco/efectos adversos , Laboratorios , Enfermedades Profesionales/prevención & control , Exposición Profesional , Dosis de Radiación , Traumatismos por Radiación/prevención & control , Protección Radiológica/métodos , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/educación , Benchmarking , Angiografía Coronaria/efectos adversos , Medicina Basada en la Evidencia , Femenino , Humanos , Laboratorios/organización & administración , Masculino , Enfermedades Profesionales/etiología , Objetivos Organizacionales , Guías de Práctica Clínica como Asunto , Desarrollo de Programa , Traumatismos por Radiación/etiología , Radiografía Intervencional/efectos adversos , Medición de Riesgo , Sociedades MédicasRESUMEN
Background Sacubitril/Valsartan has been highly efficacious in randomized trials of heart failure with reduced ejection fraction (HFrEF). However, the effectiveness of sacubitril/valsartan in older patients hospitalized for HFrEF in real-world US practice is unclear. Methods and Results This study included Medicare beneficiaries age ≥65 years who were hospitalized for HFrEF ≤40% in the Get With The Guidelines-Heart Failure registry between October 2015 and December 2018, and eligible for sacubitril/valsartan. Associations between discharge prescription of sacubitril/valsartan and clinical outcomes were assessed after inverse probability of treatment weighting and adjustment for other HFrEF medications. Overall, 1551 (10.9%) patients were discharged on sacubitril/valsartan. Of those not prescribed sacubitril/valsartan, 7857 (62.0%) were prescribed an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker. Over 12-month follow-up, compared with a discharge prescription of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, sacubitril/valsartan was independently associated with lower all-cause mortality (adjusted hazard ratio [HR], 0.82; 95% CI, 0.72-0.94; P=0.004) but not all-cause hospitalization (adjusted HR, 0.97; 95% CI, 0.89-1.07; P=0.55) or heart failure hospitalization (adjusted HR, 1.04; 95% CI, 0.91-1.18; P=0.59). Patients prescribed sacubitril/valsartan versus those without a prescription had lower risk of all-cause mortality (adjusted HR, 0.69; 95% CI, 0.60-0.79; P<0.001), all-cause hospitalization (adjusted HR, 0.90; 95% CI, 0.82-0.98; P=0.02), but not heart failure hospitalization (adjusted HR, 0.94; 95% CI, 0.82-1.08; P=0.40). Conclusions Among patients hospitalized for HFrEF, prescription of sacubitril/valsartan at discharge was independently associated with reduced postdischarge mortality compared with angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, and reduced mortality and all-cause hospitalization compared with no sacubitril/valsartan. These findings support the use of sacubitril/valsartan to improve postdischarge outcomes among older patients hospitalized for HFrEF in routine US clinical practice.
Asunto(s)
Aminobutiratos/uso terapéutico , Bloqueadores del Receptor Tipo 1 de Angiotensina II/uso terapéutico , Compuestos de Bifenilo/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Hospitalización , Inhibidores de Proteasas/uso terapéutico , Volumen Sistólico/efectos de los fármacos , Valsartán/uso terapéutico , Función Ventricular Izquierda/efectos de los fármacos , Anciano , Anciano de 80 o más Años , Aminobutiratos/efectos adversos , Bloqueadores del Receptor Tipo 1 de Angiotensina II/efectos adversos , Compuestos de Bifenilo/efectos adversos , Combinación de Medicamentos , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Medicare , Neprilisina/antagonistas & inhibidores , Alta del Paciente , Inhibidores de Proteasas/efectos adversos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Valsartán/efectos adversosRESUMEN
BACKGROUND: Systemic arterial hemodynamics play an important role in the assessment of the severity and hemodynamic consequences of aortic valve stenosis (AVS). METHODS AND RESULTS: Systemic vascular resistance, total arterial compliance, effective arterial elastance, and aortic characteristic impedance were derived from high-fidelity catheter recordings of ascending aortic pressure and blood flow velocity at rest and with supine bicycle exercise in 18 patients with AVS and 11 control subjects. Mean aortic pressure was similar between groups. At rest, systemic vascular resistance (AVS patients, 1426+/-318 dynes . s . cm(-5); control subjects, 107+/-228 dynes . s . cm(-5); P<0.01), arterial elastance (AVS patients, 1.38+/-0.36 mm Hg/mL; control subject, 0.99+/-0.15 mm Hg/mL; P<0.002), and aortic characteristic impedance (AVS patients, 107+/-23 dynes . s . cm(-5); control subjects, 76+/-30 dynes . s . cm(-5); P<0.01) were increased, whereas total arterial compliance was lower (AVS patients, 0.737+/-0.19x10(-3) cm(5)/dyne; control subjects, 1.155+/-0.27x10(-3) cm(5)/dyne; P<0.001) in AVS. With exercise, total arterial compliance increased in control subjects (rest, 1.155+/-0.27x10(-3) cm(5)/dyne; exercise, 1.421+/-0.49x10(-3) cm(5)/dyne; P<0.05) but did not change in AVS patients (rest, 0.737+/-0.19x10(-3) cm(5)/dyne; exercise, 0.769+/-0.21x10(-3) cm(5)/dyne; P=0.2). Arterial elastance increased on exercise in AVS patients (rest, 1.38+/-0.36 mm Hg/mL; exercise, 1.57+/-0.44; P<0.01). Aortic characteristic impedance remained elevated on exercise (AVS patients, 122+/-30 dynes . s . cm(-5); control subjects, 80+/-43 dynes . s . cm(-5); P=0.01). Stroke flow increased significantly in both AVS patients (rest, 229+/-69 mL/s; exercise, 256+/-78 mL/s; P<0.01) and control subjects (rest, 230+/-37 mL/s; exercise, 406+/-69 mL/s; P<0.001), although the increment was much attenuated in AVS. On multiple regression, the increase in stroke flow was related to the decrease in systemic vascular resistance (P=0.03), increase in total arterial compliance (P=0.03), and decrease in arterial elastance (P=0.02). CONCLUSIONS: These results indicate a pressure-independent increase in the steady and pulsatile components of the arterial load in patients with AVS under resting conditions. Persistent "stiffening" of the arterial system is an important contributor to the diminished stroke output response to exercise in AVS.
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Estenosis de la Válvula Aórtica/fisiopatología , Ejercicio Físico , Hemodinámica , Adulto , Anciano , Presión Sanguínea , Gasto Cardíaco , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Volumen SistólicoAsunto(s)
Enfermedad de la Arteria Coronaria/terapia , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/uso terapéutico , Trombosis Coronaria/prevención & control , Quimioterapia Combinada , Stents Liberadores de Fármacos/efectos adversos , Humanos , Inhibidores de Agregación Plaquetaria/efectos adversos , Medición de RiesgoRESUMEN
Importance: There are major gaps in use of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). Patient-reported data outlining patient goals and preferences associated with GDMT are not available. Objective: To survey patients with chronic HF to better understand their experiences and perceptions of living with HF, including their familiarity and concerns with important GDMT therapies. Design, Setting, and Participants: Study participants were recruited from the GfK KnowledgePanel, a probability-sampled online panel representative of the US adult population. English-speaking adults who met the following criteria were eligible if they were (1) previously told by a physician that they had HF; (2) currently taking medications for HF; and (3) had no history of left ventricular assist device or cardiac transplant. Data were collected between October and November 2018. Analysis began in December 2018. Main Outcomes and Measures: The survey included 4 primary domains: (1) relative importance of disease-related goals, (2) challenges associated with living with HF, (3) decision-making process associated with HF medication use, and (4) awareness and concerns about available HF medications. Results: Of 30â¯707 KnowledgePanel members who received the initial survey, 15â¯091 (49.1%) completed the screening questions, 440 were eligible and began the survey, and 429 completed the survey. The median (interquartile range) age was 68 (60-75) years and most were white (320 [74.6%]), male (304 [70.9%]), and had at least a high school education (409 [95.3%]). Most survey responders reported familiarity with ß-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. Overall, 107 (24.9%) reported familiarity with angiotensin receptor-neprilysin inhibitors or mineralocorticoid receptor antagonists. Overall, 136 patients (42.5%) reported have safety concerns regarding angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 133 (38.5%) regarding ß-blockers, 35 (37.9%) regarding mineralocorticoid receptor antagonists, 38 (36.5%) regarding angiotensin receptor-neprilysin inhibitors, and 123 (37.2%) regarding diuretics. Between 27.7% (n = 26) and 38.5% (n = 136) reported concerns regarding the effectiveness of ß-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists, or diuretics, while 41% (n = 132) were concerned with the effectiveness of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. Conclusions and Relevance: In this survey study, many patients were not familiar with GDMT for HF, with familiarity lowest for angiotensin receptor-neprilysin inhibitors and mineralocorticoid receptor antagonists. Among patients not familiar with these therapies, significant proportions questioned their effectiveness and/or safety. Enhanced patient education and shared decision-making support may be effective strategies to improve the uptake of GDMT for HF in US clinical practice.
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Toma de Decisiones , Objetivos , Conocimientos, Actitudes y Práctica en Salud , Insuficiencia Cardíaca/terapia , Antagonistas Adrenérgicos beta/uso terapéutico , Anciano , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Diuréticos/uso terapéutico , Femenino , Grupos Focales , Humanos , Masculino , Persona de Mediana Edad , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Neprilisina/antagonistas & inhibidores , Encuestas y CuestionariosRESUMEN
Congestion is associated with adverse outcomes in heart failure (HF) patients. We characterized congestion in patients hospitalized for HF and examined the association between congestion severity at admission and postdischarge outcomes. Using the OPTIMIZE-HF registry linked to Medicare claims, we analyzed patients ≥65 years old hospitalized for HF from 2003 to 2004. Congestion severity was measured using a 15-point scale that scores dyspnea, orthopnea, fatigue, jugular venous pressure, rales, and edema. Patient characteristics and outcomes were described by congestion strata. Proportional hazards models were fit to examine associations between congestion and 1-year outcomes. Congestion scores for the 24,724 patients ranged from 0 to 14, with a median of 5 (Q1, Q3: 3, 7). At baseline, patients with the highest scores (≥7) had the highest rates of recent HF hospitalizations, EF ≤40%, and co-morbidities, including arrhythmias, diabetes mellitus, and renal insufficiency. Adjusting for patient characteristics, a 3-point congestion score increase was positively associated with mortality (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.03, 1.09), all-cause rehospitalization (HR 1.02, 95% CI 1.00, 1.04), and HF rehospitalization (HR 1.09, 95% CI 1.06, 1.12), but not emergency department visits (HR 0.99, 95% CI 0.97, 1.01). In conclusion, for patients hospitalized with HF, congestion was associated with rehospitalization and mortality.
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Disnea/epidemiología , Edema/epidemiología , Fatiga/epidemiología , Insuficiencia Cardíaca/fisiopatología , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Arritmias Cardíacas/epidemiología , Comorbilidad , Diabetes Mellitus/epidemiología , Disnea/etiología , Edema/etiología , Servicio de Urgencia en Hospital , Fatiga/etiología , Femenino , Insuficiencia Cardíaca/complicaciones , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Venas Yugulares , Masculino , Mortalidad , Postura , Pronóstico , Modelos de Riesgos Proporcionales , Insuficiencia Renal/epidemiología , Ruidos Respiratorios/etiología , Índice de Severidad de la Enfermedad , Presión VenosaRESUMEN
Background The angiotensin-receptor/neprilysin inhibitor ( ARNI ) sacubitril/valsartan reduces hospitalization and mortality for patients with heart failure with reduced ejection fraction. However, adoption of ARNI into clinical practice has been slow. Factors influencing use of ARNI have not been fully elucidated. Using data from the Get With The Guidelines-Heart Failure registry, Hospital Compare, Dartmouth Atlas, and the American Hospital Association Survey, we sought to identify hospital characteristics associated with patient-level receipt of an ARNI prescription. Methods and Results We analyzed patients with heart failure with reduced ejection fraction who were eligible for ARNI prescription (ejection fraction≤40%, no contraindications) and hospitalized from October 1, 2015 through December 31, 2016. We used logistic regression to estimate the associations between hospital characteristics and patient ARNI prescription at hospital discharge, accounting for clustering of patients within hospitals using generalized estimating equation methods and adjusting for patient-level covariates. Of 16 674 eligible hospitalizations from 210 hospitals, 1020 patients (6.1%) were prescribed ARNI at discharge. The median hospital-level proportion of patients prescribed ARNI was 3.3% (Q1, Q3: 0%, 12.6%). After adjustment for patient-level covariates, for-profit hospitals had significantly higher odds of ARNI prescription compared with not-for-profit hospitals (odds ratio, 2.53; 95% CI , 1.05-6.10; P=0.04), and hospitals located in the Western United States had lower odds of ARNI prescription compared with those in the Northeast (odds ratio, 0.33; 95% CI , 0.13-0.84; P=0.02). Conclusions Relatively few hospital characteristics were associated with ARNI prescription at hospital discharge, in contrast to what has been observed in early adoption in other disease areas. Additional evaluation of barriers to implementing new evidence into heart failure practice is needed.
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Aminobutiratos/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Hospitalización/tendencias , Cumplimiento de la Medicación/estadística & datos numéricos , Neprilisina/uso terapéutico , Sistema de Registros , Volumen Sistólico/fisiología , Tetrazoles/uso terapéutico , Anciano , Anciano de 80 o más Años , Antagonistas de Receptores de Angiotensina/uso terapéutico , Compuestos de Bifenilo , Combinación de Medicamentos , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Volumen Sistólico/efectos de los fármacos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiología , ValsartánRESUMEN
OBJECTIVE: To assess the effect of ischemic postconditioning on indices of coronary microvascular function during percutaneous coronary intervention (PCI) for acute ST segment elevation myocardial infarction (STEMI). BACKGROUND: Myocardial tissue level perfusion remains suboptimal in many patients with STEMI despite restoration of antegrade flow in the epicardial coronary artery. METHODS: Twenty-four patients with an evolving anterior STEMI were randomized to undergo a previously-validated ischemic postconditioning protocol or usual care during PCI. The extent of resolution of ST segment elevation along with Doppler-tip catheter velocimetry was used as indices of myocardial reperfusion and microvascular function, respectively. RESULTS: Postconditioned patients exhibited a greater, and therefore more rapid, extent of ST segment resolution (postconditioning, 70% +/- 15%; control, 48% +/- 16%; P = 0.0002) by the end of the procedure. Postconditioned patients also exhibited a greater hyperemic coronary vasodilator response at the completion of the procedure (coronary flow velocity reserve, CFVR: postconditioning, 2.2 +/- 0.1; control, 1.5 +/- 0.1; P < 0.0001). The end-procedure CFVR was directly related to the extent of the ST segment resolution (r = 0.85) but inversely related to the absolute magnitude of ST segment elevation at end procedure (r = -0.76). Peak serum creatine kinase was significantly lower in postconditioned patients (postconditioning, 1,524 +/- 435 IU/l; control, 1,862 +/- 561 IU/l; P = 0.03). CONCLUSIONS: Ischemic postconditioning, as described, can be expeditiously performed during PCI for STEMI. Concordant changes in coronary flow reserve and ST segment resolution, measures of microcirculatory function, and myocardial perfusion, were greater in postconditioned patients.
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Angioplastia Coronaria con Balón , Cateterismo , Circulación Coronaria , Electrocardiografía , Infarto del Miocardio/terapia , Anciano , Velocidad del Flujo Sanguíneo , Presión Sanguínea , Vasos Coronarios , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Reperfusión Miocárdica , Nitroglicerina/administración & dosificación , Stents , Vasodilatadores/administración & dosificaciónRESUMEN
BACKGROUND: Sex-based differences in acute coronary syndrome (ACS) mortality may attenuate with age due to better symptom recognition and prompt care. HYPOTHESIS: Age is a modifier of temporal trends in sex-based differences in ACS care. METHODS: Among 104 817 eligible patients with ACS enrolled in the AHA Get With the Guidelines-Coronary Artery Disease registry between 2003 and 2008, care and in-hospital mortality were evaluated stratified by sex and age. Temporal trends within sex and age groups were assessed for 2 care processes: percentage of STEMI patients presenting to PCI-capable hospitals with a DTB time ≤ 90 minutes (DTB90) and proportion of eligible ACS patients receiving aspirin within 24 hours. RESULTS: After adjustment for clinical risk factors and sociodemographic and hospital characteristics, 2276 (51.7%) women and 6276 (56.9%) men with STEMI were treated with DTB90 (adjusted OR: 0.85, 95% CI: 0.80-0.91, P < 0.0001 for women vs men). Time trend analysis showed an absolute increase ranging from 24% to 35% in DTB90 rates among both men and women (P for trend <0.0001 for each group), with consistent differences over time across the 4 age/sex groups (3-way P-interaction = 0.93). Despite high rate of baseline aspirin use (87%-91%), there was a 9% to 11% absolute increase in aspirin use over time, also with consistent differences across the 4 age/sex groups (all 3-way P-interaction ≥0.15). CONCLUSIONS: Substantial gains of generally similar magnitude existed in ACS performance measures over 6 years of study across sex and age groups; areas for improvement remain, particularly among younger women.
Asunto(s)
Síndrome Coronario Agudo/terapia , Aspirina/administración & dosificación , Enfermedad de la Arteria Coronaria/terapia , Adhesión a Directriz/tendencias , Disparidades en Atención de Salud/tendencias , Intervención Coronaria Percutánea/tendencias , Inhibidores de Agregación Plaquetaria/administración & dosificación , Pautas de la Práctica en Medicina/tendencias , Evaluación de Procesos, Atención de Salud/tendencias , Infarto del Miocardio con Elevación del ST/terapia , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/mortalidad , Factores de Edad , Anciano , American Heart Association , Distribución de Chi-Cuadrado , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Mejoramiento de la Calidad/tendencias , Indicadores de Calidad de la Atención de Salud/tendencias , Sistema de Registros , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/mortalidad , Factores Sexuales , Factores de Tiempo , Tiempo de Tratamiento/tendencias , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Surveys of patients with cardiovascular disease have suggested that "home-time"-being alive and out of any health care institution-is a prioritized outcome. This novel measure has not been studied among patients with heart failure (HF). OBJECTIVES: This study sought to characterize home-time following hospitalization for HF and assess its relationship with patient characteristics and traditionally reported clinical outcomes. METHODS: Using GWTG-HF (Get With The Guidelines-Heart Failure) registry data, patients discharged alive from an HF hospitalization between 2011 and 2014 and ≥65 years of age were identified. Using Medicare claims, post-discharge home-time over 30-day and 1-year follow-up was calculated for each patient as the number of days alive and spent outside of a hospital, skilled nursing facility (SNF), or rehabilitation facility. RESULTS: Among 59,736 patients, 57,992 (97.1%) and 42,153 (70.6%) had complete follow-up for home-time calculation through 30 days and 1 year, respectively. The mean home-time was 21.6 ± 11.7 days at 30 days and 243.9 ± 137.6 days at 1 year. Contributions to reduced home-time varied by follow-up period, with days spent in SNF being the largest contributor though 30 days and death being the largest contributor through 1 year. Over 1 year, 2,044 (4.8%) patients had no home-time following index hospitalization discharge, whereas 8,194 (19.4%) had 365 days of home-time. In regression models, several conditions were associated with substantially reduced home-time, including chronic obstructive pulmonary disease, renal insufficiency, and dementia. Through 1 year, home-time was highly correlated with time-to-event endpoints of death (tau = 0.72) and the composite of death or HF readmission (tau = 0.59). CONCLUSIONS: Home-time, which can be readily calculated from administrative claims data, is substantially reduced for many patients following hospitalization for HF and is highly correlated with traditional time-to-event mortality and hospitalization outcomes. Home-time represents a novel, easily measured, patient-centered endpoint that may reflect effectiveness of interventions in future HF studies.