Catheter Ablation for Atrial Fibrillation in Adult Congenital Heart Disease: An International Multicenter Registry Study.

BACKGROUND: Data on atrial fibrillation (AF) ablation and outcomes are limited in patients with congenital heart disease (CHD). We aimed to investigate the characteristics of patients with CHD presenting for AF ablation and their outcomes. METHODS: A multicenter, retrospective analysis was performed of patients with CHD undergoing AF ablation between 2004 and 2020 at 13 participating centers. The severity of CHD was classified using 2014 Pediatric and Congenital Electrophysiology Society/Heart Rhythm Society guidelines. Clinical data were collected. One-year complete procedural success was defined as freedom from atrial tachycardia or AF in the absence of antiarrhythmic drugs or including previously failed antiarrhythmic drugs (partial success). RESULTS: Of 240 patients, 127 (53.4%) had persistent AF, 62.5% were male, and mean age was 55.2±13.3 years. CHD complexity categories included 147 (61.3%) simple, 68 (28.3%) intermediate, and 25 (10.4%) severe. The most common CHD type was atrial septal defect (n=78). More complex CHD conditions included transposition of the great arteries (n=14), anomalous pulmonary veins (n=13), tetralogy of Fallot (n=8), cor triatriatum (n=7), single ventricle physiology (n=2), among others. The majority (71.3%) of patients had trialed at least one antiarrhythmic drug. Forty-six patients (22.1%) had reduced systemic ventricular ejection fraction <50%, and mean left atrial diameter was 44.1±8.2 mm. Pulmonary vein isolation was performed in 227 patients (94.6%); additional ablation included left atrial linear ablations (40%), complex fractionated atrial electrogram (19.2%), and cavotricuspid isthmus ablation (40.8%). One-year complete and partial success rates were 45.0% and 20.5%, respectively, with no significant difference in the rate of complete success between complexity groups. Overall, 38 patients (15.8%) required more than one ablation procedure. There were 3 (1.3%) major and 13 (5.4%) minor procedural complications. CONCLUSIONS: AF ablation in CHD was safe and resulted in AF control in a majority of patients, regardless of complexity. Future work should address the most appropriate ablation targets in this challenging population.

Mortality Among Patients With Early-Onset Atrial Fibrillation and Rare Variants in Cardiomyopathy and Arrhythmia Genes.

Importance: Patients with early-onset atrial fibrillation (AF) are enriched for rare variants in cardiomyopathy and arrhythmia genes. The clinical significance of these rare variants in patients with early-onset AF is unknown. Objective: To assess the association between rare variants in cardiomyopathy and arrhythmia genes detected in patients with early-onset AF and time to death. Design, Setting, and Participants: This prospective cohort study included participants with AF diagnosed before 66 years of age who underwent whole-genome sequencing through the National Heart, Lung and Blood Institute's Trans-Omics for Precision Medicine program. Participants were enrolled from November 23, 1999, to June 2, 2015. Data were analyzed from February 26 to September 19, 2021. Exposures: Rare variants identified in a panel of 145 genes that are included in cardiomyopathy and arrhythmia panels used by commercial clinical genetic testing laboratories. Main Outcomes and Measures: The primary study outcome was time to death and was adjudicated from medical records and the National Death Index. Multivariable Cox proportional hazards regression was used to evaluate the association of disease-associated variants with risk of death after adjustment for age at AF diagnosis, sex, race, body mass index, left ventricular ejection fraction, and an interaction term of age at AF diagnosis and disease-associated variant status. Results: Among 1293 participants (934 [72%] male; median age at enrollment, 56.0 years; IQR, 48.0-61.0 years), disease-associated (pathogenic or likely pathogenic) rare variants were found in 131 (10%). During a median follow-up of 9.9 years (IQR, 6.9-13.2 years), 219 participants (17%) died. In univariable analysis, disease-associated variants were associated with an increased risk of mortality (hazard ratio, [HR], 1.5; 95% CI, 1.0-2.1; P = .05); the association remained significant in multivariable modeling when adjusted for age at AF diagnosis, sex, race, body mass index, left ventricular ejection fraction, and an interaction term between disease-associated variant status and age at AF diagnosis. The interaction demonstrated that disease-associated variants were associated with a significantly higher risk of mortality compared with no disease-associated variant when AF was diagnosed at a younger age (P = .008 for interaction). Higher body mass index (per IQR: HR, 1.4; 95% CI, 1.2-1.6; P < .001) and lower left ventricular ejection fraction (per IQR: HR, 0.8; 95% CI, 0.7-0.8; P < .001) were associated with higher mortality risk. There were 73 cardiomyopathy-related deaths, 40 sudden deaths, and 10 stroke-related deaths. Mortality among patients with the most prevalent genes with disease-associated variants was 26% (10 of 38 patients) for TTN, 33% (6 of 18) for MYH7, 22% (2 of 9) for LMNA, 0% (0 of 10) for MYH6, and 0% (0 of 8) for KCNQ1. Conclusions and Relevance: The findings suggest that rare variants in cardiomyopathy and arrhythmia genes may be associated with increased risk of mortality among patients with early-onset AF, especially those diagnosed at a younger age. Genetic testing may provide important prognostic information for patients with early-onset AF.

Toxin-Mediated Myocarditis From a Brown Recluse Spider Bite.

We describe a case of myocarditis associated with a brown recluse spider bite in a 31-year-old man. Cardiac magnetic resonance revealed late gadolinium enhancement in the lateral wall and inferior wall. There was also regional elevation of the myocardial T2 and extracellular volume indicative of myocardial edema. (Level of Difficulty: Intermediate.).

Early-Onset Atrial Fibrillation and the Prevalence of Rare Variants in Cardiomyopathy and Arrhythmia Genes.

Importance: Early-onset atrial fibrillation (AF) can be the initial manifestation of a more serious underlying inherited cardiomyopathy or arrhythmia syndrome. Objective: To examine the results of genetic testing for early-onset AF. Design, Setting, and Participants: This prospective, observational cohort study enrolled participants from an academic medical center who had AF diagnosed before 66 years of age and underwent whole genome sequencing through the National Heart, Lung, and Blood Institute's Trans-Omics for Precision Medicine program. Participants were enrolled from November 23, 1999, to June 2, 2015. Data analysis was performed from October 24, 2020, to March 11, 2021. Exposures: Rare variants identified in a panel of 145 genes that are included on cardiomyopathy and arrhythmia panels used by commercial clinical genetic testing laboratories. Main Outcomes and Measures: Sequencing data were analyzed using an automated process followed by manual review by a panel of independent, blinded reviewers. The primary outcome was classification of rare variants using American College of Medical Genetics and Genomics criteria: benign, likely benign, variant of undetermined significance, likely pathogenic, or pathogenic. Disease-associated variants were defined as pathogenic/likely pathogenic variants in genes associated with autosomal dominant or X-linked dominant disorders. Results: Among 1293 participants (934 [72.2%] male; median [interquartile range] age at enrollment, 56 [48-61] years; median [interquartile range] age at AF diagnosis, 50 [41-56] years), genetic testing identified 131 participants (10.1%) with a disease-associated variant, 812 (62.8%) with a variant of undetermined significance, 92 (7.1%) as heterozygous carriers for an autosomal recessive disorder, and 258 (20.0%) with no suspicious variant. The likelihood of a disease-associated variant was highest in participants with AF diagnosed before the age of 30 years (20 of 119 [16.8%; 95% CI, 10.0%-23.6%]) and lowest after the age of 60 years (8 of 112 [7.1%; 95% CI, 2.4%-11.9%]). Disease-associated variants were more often associated with inherited cardiomyopathy syndromes compared with inherited arrhythmias. The most common genes were TTN (n = 38), MYH7 (n = 18), MYH6 (n = 10), LMNA (n = 9), and KCNQ1 (n = 8). Conclusions and Relevance: In this cohort study, genetic testing identified a disease-associated variant in 10% of patients with early-onset AF (the percentage was higher if diagnosed before the age of 30 years and lower if diagnosed after the age of 60 years). Most pathogenic/likely pathogenic variants are in genes associated with cardiomyopathy. These results support the use of genetic testing in early-onset AF.

Exploring the affective dimension of the life review process: Facilitators' interactional strategies for fostering personhood and social value among older adults with early dementia.

We employed an auto-ethnography approach to explore the affective dimension of life review sessions with community-dwelling older military veterans with minor cognitive impairment (MCI) and early dementia. Using researchers' analytic memos, we identified facilitators' interactional strategies that fostered the participant's sense of personal identity, dignity and social self-worth. Interaction among participant, caregiver, and facilitators evoked a range of emotional responses, offering a window into the affective world of MCI and early dementia. Positive emotional responses outnumbered negative emotional responses by a ratio of two-to-one in the life review sessions; however, negative emotions were more revelatory of current struggles with declines in health and function. Facilitators utilized two interactional strategies, in particular, to foster personhood and social value of participants: focusing on the participant and creating an empathic connection with the participant. Further work is needed to understand the role of emotions in research interactions and to examine the psychosocial mechanisms through which positive affect functions in promoting identity, personhood and social value among persons with MCI and early dementia.

The mouse B cell-specific mb-1 gene encodes an immunoreceptor tyrosine-based activation motif (ITAM) protein that may be evolutionarily conserved in diverse species by purifying selection.

The B-lymphocyte accessory molecule Ig-alpha (Ig-α) is encoded by the mouse B cell-specific gene (mb-1), and along with the Ig-beta (Ig-ß) molecule and a membrane bound immunoglobulin (mIg) makes up the B-cell receptor (BCR). Ig-α and Ig-ß form a heterodimer structure that upon antigen binding and receptor clustering primarily initiates and controls BCR intracellular signaling via a phosphorylation cascade, ultimately triggering an effector response. The signaling capacity of Ig-α is contained within its immunoreceptor tyrosine-based activation motif (ITAM), which is also a key component for intracellular signaling initiation in other immune cell-specific receptors. Although numerous studies have been devoted to the mb-1 gene product, Ig-α, and its signaling mechanism, an evolutionary analysis of the mb-1 gene has been lacking until now. In this study, mb-1 coding sequences from 19 species were compared using Bayesian inference. Analysis revealed a gene phylogeny consistent with an expected species divergence pattern, clustering species from the primate order separate from lower mammals and other species. In addition, an overall comparison of non-synonymous and synonymous nucleotide mutational changes suggests that the mb-1 gene has undergone purifying selection throughout its evolution.

Heart failure is a risk factor for incident driving cessation among community-dwelling older adults: findings from a prospective population study.

BACKGROUND: Heart failure (HF) patients often depend on driving for access to specialty care. We analyzed a public-use copy of the Cardiovascular Health Study (CHS) data to determine if HF is a risk factor for driving cessation and to identify other risk factors for driving cessation among those with HF. METHODS AND RESULTS: Of the 5,383 community-dwelling drivers aged ≥65 years (mean age 73 years, 55% women, 13% African American), 839 had HF: 246 had baseline prevalent HF and 593 developed incident HF before driving cessation during 9 years of follow-up. Incident driving cessation occurred at rates of 3,980 and 3,709 per 10,000 person-years of follow-up for those with and without HF, respectively (unadjusted hazard ratio [HR] associated with HF as a time-varying variable: 2.13, 95% confidence interval [CI] 1.83-2.47; P < .001). This association remained unchanged after multivariable risk adjustment (HR 1.43, 95% CI 1.21-1.68; P < .001). Among the 839 older drivers with HF, independent predictors for incident driving cessation were age ≥75 years (HR 1.99, 95% CI 1.44-2.73; P < .001), female gender (HR 1.93, 95% CI 1.37-2.74; P < .001), difficulty walking half a mile (HR 1.47 (1.04-2.08); P = .028), vision problems (HR 1.47, 95% CI 1.07-2.02; P = .018), and stroke as a time-varying covariate (HR 1.96, 95% CI 1.38-2.79; P < .001). CONCLUSIONS: HF is an independent risk factor for incident driving cessation among community-dwelling older drivers. Several patient characteristics predicted driving cessation in older HF patients, which may be targets for interventions to prevent driving cessation among these patients.

Understanding the reasons for the underuse of pneumococcal vaccination by community-dwelling older African Americans.

OBJECTIVES: To understand the potential roles of various patient and provider factors in the underuse of pneumococcal vaccination in Medicare-eligible older African Americans. DESIGN: The Cardiovascular Health Study. SETTING: Four U.S. states. PARTICIPANTS: Seven hundred ninety-five pairs of community-dwelling Medicare-eligible African-American and white adults aged 65 and older, balanced according to age and sex. MEASUREMENTS: Data on self-reported race, receipt of pneumococcal vaccination, and other important sociodemographic and clinical variables were collected at baseline. RESULTS: Participants had a mean age ± standard deviation of 73 ± 6; 63% were female. Pneumococcal vaccination rates were 22% for African Americans and 28% for whites (unadjusted odds ratios (OR) for African Americans=0.75; 95% confidence interval (CI)=0.60-0.94; P=.01). This association remained significant despite adjustment for sociodemographic and clinical confounders, including education, income, chronic obstructive pulmonary disease, and prior pneumonia (OR=0.74, 95% CI=0.56-0.97; P=.03), but the association was no longer significant after additional adjustment for the receipt of influenza vaccination (OR=0.79, 95% CI=0.59-1.06; P=.12). Receipt of influenza vaccination was associated with higher odds of receiving pneumococcal vaccination (unadjusted OR=6.43, 95% CI=5.00-8.28; P<.001), and the association between race and pneumococcal vaccination lost significance when adjusted for influenza vaccination alone (OR=0.81, 95% CI=0.63-1.03; P=.09). CONCLUSION: The strong association between receipt of influenza and pneumococcal vaccinations suggests that patient and provider attitudes toward vaccination, rather than traditional confounders such as education and income, may help explain the underuse of pneumococcal vaccination in older African Americans.

Predictors of in-hospital mortality among hospitalized nursing home residents: an analysis of the National Hospital Discharge Surveys 2005-2006.

OBJECTIVE: To determine the demographic and clinical predictors of in-hospital mortality among hospitalized nursing home (NH) residents. DESIGN: Retrospective analysis of the public-use copies of the 2005-2006 National Hospital Discharge Survey (NHDS) datasets. SETTING: Non-federal acute-care, short-stay hospitals in all 50 states and the District of Columbia. PARTICIPANTS: Participants were 1904 and 1752 NH residents, 45 years or older, hospitalized in 2005 and 2006, respectively. MEASUREMENTS: In-hospital mortality. METHODS: A multivariable logistic regression model was developed to determine independent predictors of in-hospital mortality using the 2005 dataset. The model was then applied to the 2006 dataset to determine the generalizability of the predictors. RESULTS: Significant independent predictors of in-hospital mortality in 2005 included age 85 years or older (adjusted odds ratio [OR], 2.53; 95% confidence interval [CI], 1.21-5.30; P=.013), acute respiratory failure (adjusted OR, 5.67; 95% CI, 3.51-9.17; P < .0001), septicemia (adjusted OR, 4.63; 95% CI, 3.08-6.96; P < .0001), and acute renal failure (adjusted OR, 2.11; 95% CI, 1.30-3.41; P=.002). The following baseline characteristics also predicted in-hospital mortality in 2006: age 85 years or older (adjusted OR, 2.45; 95% CI, 1.31-4.59; P=.005), acute respiratory failure (adjusted OR, 7.11; 95% CI, 4.46-11.33; P < .0001), septicemia (adjusted OR, 3.91; 95% CI, 2.64-5.80; P < .0001), and acute renal failure (adjusted OR, 2.75; 95% CI, 1.82-4.15; P < .0001). Chronic morbidities were not associated with in-hospital mortality. CONCLUSION: Among hospitalized NH residents, age 85 years or older and several acute conditions, but not chronic morbidities, predicted in-hospital mortality. Elderly NH residents at risk of developing these acute conditions may benefit from palliative care.

A pre-clinical assessment of an atlas-based automatic segmentation tool for the head and neck.

BACKGROUND AND PURPOSE: Accurate conformal radiotherapy treatment requires manual delineation of target volumes and organs at risk (OAR) that is both time-consuming and subject to large inter-user variability. One solution is atlas-based automatic segmentation (ABAS) where a priori information is used to delineate various organs of interest. The aim of the present study is to establish the accuracy of one such tool for the head and neck (H&N) using two different evaluation methods. MATERIALS AND METHODS: Two radiotherapy centres were provided with an ABAS tool that was used to outline the brainstem, parotids and mandible on several patients. The results were compared to manual delineations for the first centre (EM1) and reviewed/edited for the second centre (EM2), both of which were deemed as equally valid gold standards. The contours were compared in terms of their volume, sensitivity and specificity with the results being interpreted using the Dice similarity coefficient and a receiver operator characteristic (ROC) curve. RESULTS: Automatic segmentation took typically approximately 7min for each patient on a standard PC. The results indicated that the atlas contour volume was generally within +/-1SD of each gold standard apart from the parotids for EM1 and brainstem for EM2 that were over- and under-estimated, respectively (within +/-2SD). The similarity of the atlas contours with their respective gold standard was satisfactory with an average Dice coefficient for all OAR of 0.68+/-0.25 for EM1 and 0.82+/-0.13 for EM2. All data had satisfactory sensitivity and specificity resulting in a favourable position in ROC space. CONCLUSIONS: These tests have shown that the ABAS tool exhibits satisfactory sensitivity and specificity for the OAR investigated. There is, however, a systematic over-segmentation of the parotids (EM1) and under-segmentation of the brainstem (EM2) that require careful review and editing in the majority of cases. Such issues have been discussed with the software manufacturer and a revised version is due for release.

Self-reported health and driving cessation in community-dwelling older drivers.

BACKGROUND: Stopping driving has significant negative consequences for older adults, but there is no simple, reliable screening tool to predict driving cessation. We sought to determine if self-rated health (SRH) was an independent predictor of driving cessation among older adults. METHODS: Data on SRH (poor, fair, good, very good, or excellent), medical diagnoses, physical performance, visual acuity, driving status, and other relevant covariates were collected from 649 community-dwelling older Alabama drivers during in-home interviews. Using multivariable logistic regression analyses, we estimated the association of SRH with driving cessation 2 years later. RESULTS: Participants had a mean age of 74 years; 43% were women, 41% African American, and 48% rural. Overall, 36% reported poor to fair SRH at baseline, and 11% had stopped driving after 2 years. Compared to 8% of drivers with good to excellent SRH, 17% with poor to fair health stopped driving (adjusted odds ratio [OR], 1.93; 95% confidence interval [CI], 1.09-3.41; p=.025). Lower Short Physical Performance Battery (SPPB) scores (adjusted OR, 0.86; 95% CI, 0.78-0.95; p=.001) and older age (adjusted OR, 1.06 per year; 95% CI, 1.01-1.11; p=.010) were also associated with driving cessation. Receiver operating characteristics curves documented similar predictive discrimination (c statistics) for SRH (0.72), the SPPB (0.70), and a count of comorbidities based on the Charlson Comorbidity Index (0.73). CONCLUSIONS: Poor to fair SRH predicted incident driving cessation after 2 years in a cohort of older adults. SRH can be easily obtained during clinic visits to identify at-risk drivers.

Racial similarities and differences in predictors of mobility change over eighteen months.

OBJECTIVES: To define racial similarities and differences in mobility among community-dwelling older adults and to identify predictors of mobility change. DESIGN: Prospective, observational, cohort study. PARTICIPANTS: Nine hundred and five community-dwelling older adults. MEASURES: Baseline in-home assessments were conducted to assess life-space mobility, sociodemographic variables, disease status, geriatric syndromes, neuropsychological factors, and health behaviors. Disease reports were verified by review of medications, physician questionnaires, or hospital discharge summaries. Telephone interviews defined follow-up life-space mobility at 18 months of follow-up. RESULTS: African Americans had lower baseline life-space (LS-C) than whites (mean 57.0 +/- standard deviation [SD] 24.5 vs. 72.7 +/- SD 22.6; P < .001). This disparity in mobility was accompanied by significant racial differences in socioeconomic and health status. After 18 months of follow-up, African Americans were less likely to show declines in LS-C than whites. Multivariate analyses showed racial differences in the relative importance and strength of the associations between predictors and LS-C change. Age and diabetes were significant predictors of LS-C decline for both African Americans and whites. Transportation difficulty, kidney disease, dementia, and Parkinson's disease were significant for African Americans, while low education, arthritis/gout, stroke, neuropathy, depression, and poor appetite were significant for whites. CONCLUSIONS: There are significant disparities in baseline mobility between older African Americans and whites, but declines were more likely in whites. Improving transportation access and diabetes care may be important targets for enhancing mobility and reducing racial disparities in mobility.

Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care.

BACKGROUND: The appropriate roles for generalists and cardiologists in the care of patients with heart failure (HF) are unknown. The objective of this retrospective cohort study was to determine whether consultation between generalists and cardiologists was associated with better quality and outcomes of HF care. METHODS: We studied left ventricular function evaluation (LVFE) and angiotensin-converting enzyme inhibitor (ACEI) use and 90-day readmission and 90-day mortality rates in patients with HF who were hospitalized. Patient care was categorized into cardiologist (solo), generalist (solo), or consultative cares. The processes and outcomes of care were compared by care category using logistic regression analyses fit with generalized linear mixed models to adjust for hospital-related clustering. RESULTS: Of the 1075 patients studied, 13% received cardiologist care, 55% received generalist care, and 32% received consultative care. More patients who received consultative care (75%) received LVFE than patients who received generalist care (36%) and cardiologist care (53%; P <.001). Fewer patients who received solo care (54% each) received ACEI compared with 71% of patients who received consultative care (P <.001). After multivariable adjustment, consultative care was associated with higher odds of LVFE than generalist care (adjusted odds ratio [OR], 6.06; 95% CI, 3.97-9.26) or cardiologist care (adjusted OR, 2.96; 95% CI, 1.70-5.13) care. Consultation was also associated with higher odds of ACEI use compared with generalist (adjusted OR, 2.42; 95% CI, 1.42-4.12) or cardiologist (adjusted OR, 2.32; 95% CI, 1.14-4.72) care. Compared with patients who received generalist care, patients who received consultative care had lower odds of 90-day readmission (adjusted OR, 0.54; 95% CI, 0.34-0.86). CONCLUSION: Collaboration between generalists and cardiologists, rather than solo care by either, was associated with better HF processes and outcomes of care.

Racial variations in cardiology care among hospitalized older heart failure patients.

In this retrospective follow-up study, the authors examined the association between race and the receipt of cardiology care in 1062 Medicare beneficiaries 65 years of age and older who were hospitalized with heart failure. The primary outcome measure was receipt of care from a cardiologist (via admission or consultation). Using logistic regression analyses, crude and adjusted odds ratios (OR) and 95% confidence intervals (95%CI) of receipt of cardiology care were estimated for nonwhite versus white patients. Two hundred (19%) patients were nonwhites and 483 (46%) patients received care from cardiologists. Proportion of patients receiving cardiology care was lower among nonwhite patients (35% versus 48% among whites; P = 0.001), and nonwhite race was associated with a lower odds of receiving cardiology care (crude OR = 0.57; 95%CI = 0.42-0.79). After adjustment for various patient characteristics and process-of-care variables, the magnitude and precision of the association between nonwhite race and a lower odds of receiving care from a cardiologist remained unchanged (adjusted OR = 0.43; 95% CI = 0.30-0.62). These findings suggest that nonwhite elderly hospitalized heart failure patients are less likely to be cared for by cardiologists.

Survival benefits of angiotensin-converting enzyme inhibitors in older heart failure patients with perceived contraindications.

OBJECTIVES: To determine the association between angiotensin-converting enzyme (ACE) inhibitor therapy and survival of older heart failure patients with conditions perceived by physicians as contraindications to ACE inhibitors. SETTING: Hospital. DESIGN: Retrospective follow-up study. PARTICIPANTS: Hospitalized older heart failure patients with systolic blood pressure of 90 mmHg or less, serum creatinine of 2.5 mg/dL or more, serum potassium of 5.5 mmol/L or more, or severe aortic stenosis. MEASUREMENTS: One-year postdischarge mortality (with and without adjustment for various patient and care characteristics). Logistic regression analyses were used to estimate the effect of the perceived contraindications on subsequent use of ACE inhibitors. Using Cox proportional hazards models, crude and adjusted hazard ratios (HRs) of 1-year mortality with 95% confidence intervals (CIs) were estimated for patients discharged on ACE inhibitors and compared with those without. HRs were estimated for all patients and were repeated after stratifying patients based on the presence of perceived contraindications to ACE inhibitor use. RESULTS: Of the 295 subjects, 52 (18%) had conditions perceived as contraindications, 186 (63%) received ACE inhibitors, and 107 (40%) died within 1 year of discharge. Presence of a perceived contraindication was independently associated with underutilization of ACE inhibitors on discharge (adjusted OR = 0.35, 95% CI = 0.17-0.71). ACE inhibitor prescription at discharge was associated with lower 1-year mortality overall (HR = 0.58, 95% CI = 0.40-0.85) and for the groups of patients with (HR = 0.34, 95% CI = 0.14-0.81) and without (HR = 0.66, 95% CI = 0.42-1.02) perceived contraindications. CONCLUSIONS: ACE inhibitor use was associated with a significant survival benefit in this cohort of hospitalized older heart failure patients with perceived contraindications.

Coordination and advocacy for rural elders (CARE): a model of rural case management with veterans.

PURPOSE: To describe a pilot initiative sponsored by the Veterans Health Administration (VHA) to improve the health and community tenure of frail older veterans living in rural counties 50-100 miles from two host VHA medical centers. DESIGN AND METHODS: Veterans aged 75 and older who scored at risk of repeated hospital admission on the PRA-Plus telephone questionnaire were targeted and visited by evaluators who administered a comprehensive health questionnaire prior to being assessed at home by the Coordination and Advocacy for Rural Elders (CARE) program clinical teams. Guided by current state-of-the-art practices, the nurse-social worker teams performed in-home standardized assessments using the MDS-HC, developed patient-specific care plans, and mobilized family, community, and VHA resources to implement plans. RESULTS: On average, eight problems were identified for each patient, most commonly falls risk, social needs, pain, and needs related to IADL disability. As a result of initial assessment, two thirds of CARE participants received referral/linkage to formal services, more than half to medical providers. IMPLICATIONS: Through CARE, the VHA is learning more about the unmet needs of older rural veterans. Further development and evaluation should guide the VHA toward providing efficient, effective community-based services to all frail older veterans.