Percutaneous coronary intervention in patients with stable coronary artery disease and left ventricular systolic dysfunction: insights from the VA CART program.

BACKGROUND: Revascularization of ischemic cardiomyopathy by coronary artery bypass grafting has been shown to improve survival among patients with left ventricular ejection fraction (LVEF) ≤35%, but the role of percutaneous coronary intervention (PCI) in this context is incompletely described. This study sought to evaluate the effect of PCI on mortality and hospitalization among patients with stable coronary artery disease and reduced left ventricular ejection fraction. METHODS: We performed a retrospective analysis comparing PCI with medical therapy among patients with ischemic cardiomyopathy in the Veterans Affairs Health Administration. Patients with angiographic evidence of 1 or more epicardial stenoses amenable to PCI and LVEF ≤35% were included in the analysis. Outcome data were determined by VA and non-VA data sources on mortality and hospital admission. RESULTS: From 2008 through 2015, a study sample of 4,628 patients was identified, of which 1,322 patients underwent ad hoc PCI. Patients were followed to a maximum of 3 years. Propensity score weighted landmark analysis was used to evaluate the primary and secondary outcomes. The primary outcome of all-cause mortality was significantly lower in the PCI cohort compared with medical therapy (21.6% vs 30.0%, P <.001). The secondary outcome of all-cause rehospitalization or death was also lower in the PCI cohort (76.5% vs 83.8%, P <.001). CONCLUSIONS: In this retrospective analysis of patients with ischemic cardiomyopathy with coronary artery disease amenable to PCI and LVEF ≤35%, revascularization by PCI was associated with decreased all-cause mortality and decreased all-cause death or rehospitalization.

Trends in Treatment for Patients Hospitalized with Heart Failure with Preserved Ejection Fraction Before and After Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT).

The TOPCAT trial investigated spironolactone vs placebo in patients with heart failure with preserved ejection fraction (HFpEF). Although the primary endpoint was not statistically significant, treatment with spironolactone did reduce heart failure hospitalizations compared with placebo. TOPCAT's impact on prescribing patterns in the United States is not well-characterized. We performed a retrospective analysis of discharge prescribing data in the Get With The Guidelines-Heart Failure Registry among patients with left ventricular ejection fraction ≥50% discharged between January 2009 and December 2016 to assess prescribing trends upon dissemination of TOPCAT results. Of 142,201 patients included in the study, 18,581 (13.1%) were prescribed mineralocorticoid receptor antagonists (MRAs) at discharge. Compared with those not prescribed MRAs, patients discharged on MRAs were generally younger (75 vs 78 years), and report white race (76.7% vs 72.0%), more likely to have had prior heart failure hospitalizations (75.5% vs 65.7%), lower brain natriuretic peptide levels (492 vs 545 pg/mL), but similar serum creatinine levels (1.2 vs 1.2 mg/dL) upon admission. MRA prescribing modestly increased over time (p <0.0001), without significant change in the overall trend of prescribing rate for MRAs after TOPCAT results were presented (p =0.17). In conclusion, our findings suggest that for patients with HFpEF, the use of MRAs at hospital discharge is low, with only modest increases over time and no discernible change in the rate of MRA use after the TOPCAT results were released. There remains an important need for more clinical trials to better establish the efficacy and safety of MRAs for the treatment of HFpEF.

Testing for Coronary Artery Disease in Older Patients With New-Onset Heart Failure: Findings From Get With The Guidelines-Heart Failure.

BACKGROUND: Current guidelines recommend evaluation for underlying heart disease and reversible conditions for patients with new-onset heart failure (HF). There are limited data on contemporary testing for coronary artery disease (CAD) in patients with new-onset HF. METHODS: We performed an observational cohort study using the Get With The Guidelines-Heart Failure registry linked to Medicare claims. All patients were aged ≥65 and hospitalized for new-onset HF from 2009 to 2015. We collected left ventricular ejection fraction (LVEF), prior HF history, and in-hospital CAD testing from the registry, as well as testing for CAD using claims from 90 days before to 90 days after index HF hospitalization. RESULTS: Among 17 185 patients with new-onset HF, 6672 (39%) received testing for CAD, including 3997 (23%) during the index hospitalization. Testing for CAD differed by LVEF: 53% in HF with reduced EF (LVEF ≤40%), 42% in HF with borderline EF (LVEF, 41%-49%), and 31% in HF with preserved EF (LVEF ≥50%). After multivariable adjustment, patients who received testing for CAD, compared with those who did not, were younger and more likely to be male, have a smoking history, have hyperlipidemia, and have HF with reduced ejection fraction or HF with borderline ejection fraction (all P<0.05). CONCLUSIONS: The majority of patients hospitalized for new-onset HF did not receive testing for CAD either during the hospitalization or in the 90 days before and after. The rates of testing for CAD were higher in patients with LVEF ≤40% though remained low. These data highlight an opportunity to improve care by identifying appropriate candidates for optimal CAD medical therapy and revascularization.

Out-of-hospital medication errors among young children in the United States, 2002-2012.

OBJECTIVE: To investigate out-of-hospital medication errors among young children in the United States. METHODS: Using data from the National Poison Database System, a retrospective analysis of out-of-hospital medication errors among children <6 years old from 2002 through 2012 was conducted. RESULTS: During 2002-2012, 696,937 children <6 years experienced out-of-hospital medication errors, averaging 63,358 episodes per year, or 1 child every 8 minutes. The average annual rate of medication errors was 26.42 per 10,000 population. Cough and cold medication errors decreased significantly, whereas the number (42.9% increase) and rate (37.2% increase) of all other medication errors rose significantly during the 11-year study period. The number and rate of medication error events decreased with increasing child age, with children <1 year accounting for 25.2% of episodes. Analgesics (25.2%) were most commonly involved in medication errors, followed by cough and cold preparations (24.6%). Ingestion accounted for 96.2% of events, and 27.0% of medication errors were attributed to inadvertently taking or being given medication twice. Most (93.5%) cases were managed outside of a health care facility; 4.4% were treated and released from a health care facility; 0.4% were admitted to a non-critical care unit; 0.3% were admitted to a critical care unit; and 25 children died. CONCLUSIONS: This is the first comprehensive study to evaluate the epidemiologic characteristics of out-of-hospital medication errors among children <6 years of age on a national level. Increased efforts are needed to prevent medication errors, especially those involving non-cough and cold preparations, among young children.