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

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

Functional Status and Survival in Older Nursing Home Residents With Advanced Non-Small-Cell Lung Cancer: A SEER-Medicare Analysis.

PURPOSE: Many older patients with advanced lung cancer have functional limitations and require skilled nursing home care. Function, assessed using activities of daily living (ADL) scores, may help prognostication. We investigated the relationship between ADL impairment and overall survival among older patients with advanced non-small-cell lung cancer (NSCLC) receiving care in nursing homes. METHODS: Using the SEER-Medicare database linked with Minimum Data Set assessments, we identified patients age 65 years and older with NSCLC who received care in nursing homes from 2011 to 2015. We used Cox regression and Kaplan-Meier survival curves to examine the relationship between ADL scores and overall survival among all patients; among patients who received systemic cancer chemotherapy or immunotherapy within 3 months of NSCLC diagnosis; and among patients who did not receive any treatment. RESULTS: We included 3,174 patients (mean [standard deviation] age, 77 [7.4] years [range, 65-102 years]; 1,664 [52.4%] of female sex; 394 [12.4%] of non-Hispanic Black race/ethnicity), 415 (13.1%) of whom received systemic therapy, most commonly with carboplatin-based regimens (n = 357 [86%] patients). The median overall survival was 3.1 months for patients with ADL score < 14, 2.8 months for patients with ADL score between 14 and 17, 2.3 months for patients with ADL score between 18-19, and 1.8 months for patients with ADL score 20+ (log-rank P < .001). The ADL score was associated with increased risk of death (hazard ratio [HR], 1.20; 95% CI, 1.16 to 1.25 per standard deviation). One standard deviation increase in the ADL score was associated with lower overall survival rate among treated (HR, 1.14; 95% CI, 1.02 to 1.27) and untreated (HR, 1.20; 95% CI, 1.15 to 1.26) patients. CONCLUSION: ADL assessment stratified mortality outcomes among older nursing home adults with NSCLC, and may be a useful clinical consideration in this population.

Risk of out-of-hospital cardiac arrest among sepsis survivors in Taiwan: analysis of a nationwide population-based cohort.

OBJECTIVES: There is minimal literature examining the association of sepsis with out-of-hospital cardiac arrest (OHCA). Using a large national database, we aimed to quantify the risk of OHCA among sepsis patients after hospital discharge. DESIGN: Population-based cohort study. SETTING: Nationwide sepsis cohort retrieved from the National Health Insurance Research Database of Taiwan between 2000 and 2013. PARTICIPANTS: We included 17 304 patients with sepsis. After hospital discharge, 144 patients developed OHCA within 30 days and 640 between days 31 and 365. PRIMARY AND SECONDARY OUTCOME MEASURES: The main outcomes were OHCA events following hospital discharge for sepsis. To evaluate the independent association between sepsis and OHCA after a sepsis hospitalisation, we constructed two non-sepsis comparison cohorts using risk set sampling and propensity score matching techniques (non-infection cohort, non-sepsis infection cohort). We plotted the daily number and daily risk of OHCA within 1 year of hospital discharge between sepsis and matched non-sepsis cohorts. We used Cox regression to evaluate the risk of early and late OHCA, comparing sepsis to non-sepsis patients. RESULTS: Compared with non-infected patients, sepsis patients had a higher rate of early (HR 1.66, 95% CI: 1.27 to 2.16) and late (HR 1.19, 95% CI: 1.06 to 1.33) OHCA events. This association was independent of age, sex or cardiovascular history. Compared with non-sepsis patients with infections, sepsis patients had a higher rate of both early (HR 1.28, 95% CI: 1.00 to 1.63) and late (HR 1.13, 95% CI: 1.01 to 1.27) OHCA events, especially among patients with cardiovascular disease (OR 1.35, 95% CI: 1.01 to 1.81). CONCLUSIONS: Sepsis patients had increased risk of OHCA compared with matched non-sepsis controls, which lasted up to 1 year after hospital discharge.

Into the Unknown: A Case of New-Onset Cardiomyopathy in a Patient Treated With Recently Approved Tyrosine Kinase Inhibitor, Pralsetinib.

With the rapid development and adoption of novel anti-cancer therapeutics, physicians commonly encounter cancer patients on regimens with recently approved drugs for which information about rare or long-term side effects may not be available. In this case, we present a young woman with cholangiocarcinoma who was treated with the rearranged during transfection (RET)-selective tyrosine kinase inhibitor (TKI), pralsetinib, and presented to the hospital with shortness of breath. We review her diagnosis of new-onset systolic dysfunction as a possible sequela of her TKI therapy to encourage ongoing efforts to enhance provider familiarity with the side effects of this important and increasingly prescribed drug class.

Multimodal Imaging for the Diagnosis of Isolated Cardiac Sarcoidosis.

We report a case of isolated cardiac sarcoidosis (CS) diagnosed using a multimodality imaging approach. A patient presented after an out-of-hospital, ventricular fibrillation-mediated cardiac arrest. The use of echocardiography, cardiac magnetic resonance, and fluorodeoxyglucose-positron emission tomography enabled the diagnosis of isolated CS. (Level of Difficulty: Beginner.).

Permanent His bundle pacing to replace biventricular pacing for cardiac resynchronization therapy.

INTRODUCTION: Cardiac resynchronization therapy (CRT) or biventricular pacing (BIVP) has become a common procedure for the treatment of ventricular dyssynchrony in patients with heart failure, particularly in those with bundle branch block patterns (QRS durations >150ms) on the electrocardiogram (ECG). However, a large group of non-responders are made up of patients with dyssynchrony and QRS duration below 130ms. Recent studies have introduced permanent His bundle pacing as another method for achieving normalization of the QRS duration even in a majority of patients with right or left bundle branch block pattern on the ECG. HYPOTHESES: We hypothesize 1. Biventricular pacing, (BIVP) performed as the standard procedure for CRT is inherently abnormal, spatially, at the right and left ventricular apex, and temporally, in regard to the timing of normal activation of the interventricular conduction system. Corollary 1. Permanent, selective, His bundle pacing (PHBP) is the most physiological form of ventricular pacing which replicates the normal activation of the interventricular conduction system. Corollary 2. An appropriately powered, prospective, crossover trial comparing PHBP with BIVP will show that the former is associated with the same benefits in patients with heart failure and QRS durations >130ms and would improve, rather than worsen, outcomes in heart failure patients with QRS duration <130ms. We present experimental and clinical evidence in support of these hypotheses.