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WASHINGTON (Oct 05, 2017) -
Data from the American College of Cardiology’s National Cardiovascular Data Registry was the source of several published studies in recent months, including a study on predicting 30-day readmission rates for patients undergoing percutaneous coronary intervention and a study that found women were less likely to use oral anticoagulants to treat atrial fibrillation.
What Factors Most Affect Rhythm Control Treatment Decisions in Patients With AFib?
Rhythm control is a cornerstone of therapy for nonvalvular atrial fibrillation (AFib) and it can significantly improve AFib symptoms. However, this treatment may be underused in outpatient centers across the U.S., and there is substantial practice variation, according to a randomized clinical trial recently published in the American Heart Journal. Anil K. Gehi, MD, et al., used data from ACC's PINNACLE Registry to analyze treatment decisions for 511,958 patients who were diagnosed with nonvalvular AFib between May 2008 and December 2014. Results showed that only 1 in 5 AFib patients received rhythm control, while only 1 in 50 received catheter ablation, the most recent innovation in AFib treatment. The study assessed patient (age, gender, race, insurance type and more) and practice (number of providers, area type and practice region) factors associated with rhythm control treatment. Read more.
NCDR-Based Study Finds Similar One-Year Rates of Death, Stroke in TAVR and SAVR Patients
No difference was found in one-year rates of death, stroke and days alive out of hospital between patients who underwent transcatheter aortic valve replacement (TAVR) and those who had surgical aortic valve replacement (SAVR), according to a nationally representative real-world cohort study published July 17 in the Journal of the American College of Cardiology. J. Matthew Brennan, MD, et al., used data from the STS/ACC TVT Registry, a partnership of the ACC and The Society of Thoracic Surgeons, and the STS National Database. By linking this data to Medicare administrative claims, they analyzed 9,464 patients with severe aortic stenosis, half of whom underwent TAVR, half who had SAVR. While researchers discovered no difference in one-year rates of death (17.3 percent vs. 17.9 percent), stroke (4.2 percent vs. 3.3 percent) or days alive out of hospital (hazard ratio 1.00), they discovered differences in procedure outcomes. Read more.
Development of Risk Model to Predict 30-Day Readmission in PCI Patients
A simple risk score model could help identify the risk of 30-day readmission in patients undergoing PCI, according to a recent study published in Catheterization and Cardiovascular Interventions. Led by Karl E. Minges, PhD, MPH, et al., the study linked data on 388,078 PCI patients (≥65 years), who were treated at a hospital participating in ACC's CathPCI Registry, to Medicare fee-for-service claims made between January 2007 and December 2009. The researchers randomly assigned patients to either a development cohort (n = 194,179) or a validation cohort (n = 193,899) and found similar mean 30-day unplanned readmission rates for both cohorts (11.35 percent vs. 11.36 percent respectively). Clinical and demographic characteristics were also similar across both groups. Of the 19 total variables associated with the risk of 30-day readmission, 14 variables were included to identify high and low risk of 30-day readmission with a point system ranging from one to six. Read more.
NCDR Studies Examine PCI Process and Outcome Measures, Risk of Adverse Events After Discharge
Two studies using the NCDR's CathPCI Registry provide new insights into hospital performance for PCI process and outcomes measures, as well as the impact of acute kidney injury (AKI) after PCI on adverse clinical events. A cross-sectional analysis published in the Journal of the American Heart Association found that median hospital performance for many PCI process measures exceeded 90 percent, demonstrating minimal opportunity for improvement. Philip W. Chui, MD, et al., analyzed 1,268,860 PCIs performed between January 2010 and December 2011 across 1,331 hospitals. The results show strong correlations between medication-specific process measures but weak correlations between the newly proposed PCPI process measures and established process measures.
In another study, the largest evaluation of a contemporary cohort of PCI patients using a standardized definition of AKI, found that AKI was significantly associated with increased risk of death, myocardial infarction, bleeding and recurrent kidney injury after discharge. Most of these events occurred within the first 30 days, but the risk continued out to one year. The study was published in Circulation: Cardiovascular Interventions. Led by Javier A. Valle, MD, et al., the study linked patient data from the CathPCI Registry to Center for Medicare and Medicaid Services billing data between Nov. 29, 2004, and Dec. 31, 2009. Of the 453,475 patients who underwent a PCI, 8.8 percent developed in-hospital AKI post PCI. Read more.
NCDR-Based Study Finds Women Less Likely to Use Oral Anticoagulants for AFib
Women with atrial fibrillation (AFib) are significantly less likely to use oral anticoagulants (OAC), across all levels of the CHA₂DS₂-VASc risk score, according to a study published July 19 in the Journal of the American Heart Association. Led by Lauren E. Thompson, MD, et al., the study used ACC's PINNACLE Registry to analyze patients diagnosed with AFib between May 2008 and December 2014. Of the 691,906 patients included in the analysis, 48.5 percent were women who were older and had a lower body mass index, a lower prevalence of coronary artery disease and a higher prevalence of many CHA₂DS₂-VASc risk factors. Results found that while 59 percent of the study population was prescribed an OAC, women were less likely than men to use any OAC overall (56.7 percent vs. 61 percent) and at all levels of the CHA₂DS₂-VASc score (adjusted risk ratio 9 percent to 33 percent lower). Overall OAC use increased for both sexes over the six-year study, with women seeing a slightly higher rate in non–vitamin-K OAC use than men (increase per year 56.2 percent vs. 53.6 percent) between 2010 and 2014. However, women remained less likely to receive any OAC throughout the study period. Read more.
Outcomes of Clopidogrel Reloading for MI Patients on Pre-Admissions Clopidogrel Therapy
Clopidogrel reloading occurs most frequently in patients with acute myocardial infarction (MI) who are already taking clopidogrel, particularly for STEMI. Results from a recent study published in the European Heart Journal has now found that clopidogrol reloading does not cause an increased risk of in-hospital major bleeding or mortality. Using data from ACC's ACTION Registry-GWTG, Jacob A. Doll, MD, et al., analyzed 51,524 patients who were admitted to 735 PCI-capable hospitals between July 2009 and December 2014. Approximately 39 percent of the study population presented with STEMI, while 61 percent presented with NSTEMI. Only 9 percent of STEMI patients used pre-admission P2Y12 inhibitors, whereas 19 percent of NSTEMI patients did. The authors note that "clopidogrel was the most common agent (91.9 percent), though rates of clopidogrel use declined slightly in later years in concert with increasing use of prasugrel and ticagrelor." In fact, they excluded 4,803 patients for switching to one of these two P2Y12 inhibitors during the study period. Of those taking clopidogrel, 38 percent were reloaded with a dose ≥300 mg upon presentation. Majority of STEMI patients (76 percent) received a loading dose, while only a quarter of NSTEMI patients were reloaded. Read more.
Association Between BMI and Long-Term Outcomes Among Older STEMI Patients
Older STEMI patients who fit into the World Health Organization's normal weight or extreme obesity body mass index (BMI) categories are more likely to have worse long-term outcomes than those who are mildly obese. The results of a study recently published in the European Heart Journal: Quality of Care & Clinical Outcomes address a knowledge gap in the obesity paradox and highlight the risks of an increasing aging population. After matching Centers for Medicare and Medicaid longitudinal administrative data to patient data in ACC's ACTION Registry-GWTG, Ian J. Neeland, MD, et al., analyzed the long-term outcomes of 19,499 patients (mean age of 74.8 years) who had an acute STEMI between January 2007 and December 2011. The majority of the patients were white (90 percent) and more than half were men (62 percent). When stratified by BMI, 30 percent were normal weight, 41 percent overweight, 19 percent mildly obese, 6 percent moderately obese and 3 percent extremely obese. Results showed an association between increasing BMI, higher left ventricular ejection fraction at presentation and less in-hospital cardiogenic shock. In regard to in-hospital major bleeding, the authors noted a U-shaped relationship, with rates highest at the extreme BMI categories. However, the study authors did not find significant differences based on BMI for cardiac arrest, provision of antiplatelet, anticoagulation, statin or reperfusion therapy, door to balloon time or cardiac rehabilitation referral. Read more.
Risks Associated With Transcatheter PDA Occlusions in Lower Weight Infants
Transcatheter patent ductus arteriosus (PDA) occlusion is one of the safest interventional cardiac procedures among adults and children. However, major adverse events are five to 10 times greater among infants who weigh less than 6 kilograms, according to a study published August 16 in JACC: Cardiovascular Interventions. Using ACC's IMPACT Registry, Carl H. Backes, MD, et al., identified 747 infants weighing less than 6 kilograms who underwent transcatheter PDA occlusion between January 2011 and March 2015. Across 73 hospitals, the procedural success rate was 94.3 percent, and 96 percent of cases required less than two hours in the catheterization suite. Regarding the study population, researchers examined differences by grouping the infants into three weight categories: extremely low weight (ELW, <2 kilograms), very low weight (VL, 2-<4 kilograms) and low weight (LW, 4-<6 kilograms). At catheterization, the median age was 4.3 months and most were LW (4.6 kilograms). While the majority of attempted PDA closures were successful, approximately 13 percent of the infants experienced major adverse events (MAEs). "In the present cohort of infants <6 kg, procedural success rates for transcatheter PDA closure are similar to those in more mature counterparts, but rates of MAE were 5-10 fold greater," note the study authors. Read more.
Real-World Implications of the AATAC Trial in Patients With AFib and HFrEF
Application of the findings from the AATAC randomized clinical trial may potentially lead to an increased use of catheter ablation in patients with atrial fibrillation (AFib) and heart failure with reduced ejection fraction (HFrEF), suggested Jehu S. Mathew, MD, et al., in an analysis using NCDR data published August 11 in the Journal of the American Heart Association. The study is part of ACC's Research to Practice (R2P) initiative, which identifies impactful cardiovascular research and analyzes its implications for contemporary clinical practice by facilitating rapid analysis of NCDR registry data. In this case, researchers used ACC's PINNACLE Registry to understand the impact of the AATAC trial, which showed catheter ablation to be beneficial in appropriately selected HFrEF patients. Study authors identified 8,483 patients between 2013 and 2014 who met AATAC enrollment criteria and compared their patterns of antiarrhythmic drugs (AADs) and procedural use with the AATAC trial population. Compared with the AATAC trial population, PINNACLE Registry patients eligible for AATAC were older (mean age, 71.2 ± 11.2 years vs. 61 ± 11 years), had greater comorbidity (hypertension 82.4 percent, coronary artery disease 79.2 percent and diabetes 31.8 percent) and were on more medical therapy (all patients were taking an angiotensin-converting enzyme inhibitor and beta-blocker). While all patients in the AATAC trial had persistent AFib, within this PINNACLE Registry analysis only 16.7 percent of patients had persistent or permanent AFib. Read more.
Direct-Home Discharge and Readmission 30 Days After TAVR
There is no significant association between the hospital practice of direct-home discharge post-transcatheter aortic valve replacement (TAVR) and 30-day readmission, according to a study published Aug. 21 in the Journal of the American Heart Association. Using data from the STS/ACC TVT Registry, John A. Dodson, MD, MPH, FACC, et al., analyzed 18,568 TAVR patients between Nov. 9, 2011, and March 31, 2015. The 329 U.S. hospitals included in the study were divided into quartiles based on the percentage of patients discharged directly home. Overall, hospitals discharged 69 percent of patients home post-TAVR. Hospitals in the highest quartile typically had fewer female patients (44.6 percent vs. 51.8 percent) and more nonwhite patients (7 percent vs. 3.5 percent) compared with hospitals in the lowest quartile. Additionally, hospitals in the highest quartile were more likely to use femoral access (75.2 percent vs. 60 percent) and had fewer patients receiving a transfusion (26.4 percent vs. 40.9 percent). The median 30-day readmission rate was 17.9 percent. However, even after multivariable adjustment, researchers did not find a significant difference in 30-day readmissions or mortality within 30 days among the hospital quartiles. "Based on this finding it appears that factors other than discharge disposition predominate in determining readmission risk," the study authors said. Of all the results, the most surprising was the regional variation across the U.S. in skilled nursing facility (SNF) use. For example, the authors note that “hospitals in the highest quartile of direct home discharge were, on average, most likely to be in the Southern United States and least likely to be in the Northeast United States.” Read more.
Comparison of Conscious Sedation Versus General Anesthesia for TAVR
Transcatheter aortic valve replacement (TAVR) with conscious sedation is associated with lower in-hospital and 30-day mortality and a shorter length of stay compared to TAVR with general anesthesia, according to a recent study published in Circulation. Matthew C. Hyman, MD, PhD, et al., used the STS/ACC TVT Registry to analyze the outcomes of 10,997 patients at 314 hospitals who underwent elective percutaneous transfermoral TAVR between April 2014 and June 2015. Approximately 15.8 percent were treated with conscious sedation, of whom 102 converted from conscious sedation to general anesthesia. Over the study period, the percentage of national TAVR cases performed under conscious sedation per quarter rose 9 percentage points (11 percent to 20 percent), as did the number of sites utilizing conscious sedation for at least one TAVR case. While intraprocedural success was similar, those who underwent TAVR with conscious sedation were less likely to suffer in-hospital (1.6 percent vs. 2.5 percent) and 30-day (2.9 percent vs. 4.1 percent) death than those treated with general anesthesia. Additionally, further analysis showed conscious sedation patients had a briefer ICU and hospital length of stay than general anesthesia patients. They were also more likely to be discharged directly home. Read more.
NCDR Data Depicts Outcomes With Contemporary BAV in Congenital Aortic Stenosis
Researchers found balloon aortic valvuloplasty (BAV) may be an effective treatment for patients with congenital aortic stenosis (AS), according to a study published Sept. 4 in JACC: Cardiovascular Interventions. Led by Brian A. Boe, MD, FACC, et al., the study used ACC's IMPACT Registry to analyze 1,026 BAV procedures performed between January 2011 and March 2015, of which 710 were successful. In terms of patient population, neonates (less than a month) and infants (1 to 11 months) made up the majority of the patient population (27.4 percent and 25.2 percent, respectively), followed by adolescents (11 to 17 years, 18.6 percent). Most patients had noncritical AS (n = 916) and underwent elective BAV (71.8 percent) in an outpatient setting (68.8 percent). Researchers found low rates of mortality and adverse events for patients with congenital AS, while those with critical AS had higher risk for procedure-related adverse events. When stratified by AS type, patients with noncritical AS had a 70.9 percent success rate, whereas those with critical AS had a slightly lower success rate at 62.7 percent. Adverse events were more frequent in BAV procedures performed on critical vs. non-critical AS patients (30 percent vs. 14.1 percent), and occurred in 15.8 percent of the total procedures analyzed. Read more.
New Risk-Standardization Model Validated for IMPACT Registry
The creation of a risk-standardization model for adverse outcomes following congenital cardiac catheterization will lay another brick in the path towards quality improvement for participants in ACC's IMPACT Registry, according to a study published Sept. 7 in Circulation. Natalie Jayaram, MD, MSB, FACC, et al., note that the IMPACT Registry collects data on over 200 different types of interventional procedures. Given the lack of feasibility to adjust for each procedure individually, a committee of eight subject matter experts was convened to review the IMPACT case report form and determine the adverse events that constituted a major adverse event (MAE). Cardiac arrest requiring CPR, embolic stroke within 72 hours of cardiac catheterization and subsequent cardiac catheterization due to complication were among the more than 15 defined events. Using the IMPACT Registry, researchers identified 39,725 patients who underwent cardiac catheterization at 74 centers in the United States between January 2011 and March 2014. They randomly selected 70 percent of the total study population for the derivation cohort and 30 percent for the validation cohort. The mean patient age was 9.7 years and the most common comorbidity was chronic lung disease (6 percent of patients). One in 10 had a reportable genetic condition, while 1 in 5 had single ventricle physiology. The study authors note that a MAE occurred in 7 percent of cases, and a similar occurrence rate was found in both derivation and validation cohorts (7.1 percent vs. 7.2 percent). Results showed the most common events were bleeding (1.4 percent), an arrhythmia requiring antiarrhythmic medication (1 percent) and death during hospital admission following cardiac catheterization (2 percent). Neonates were more likely to experience a MAE compared with children or adults (22.2 percent vs. 4.3 percent), as were those with a genetic condition compared with those without a documented syndrome (10 percent vs. 6.8 percent). Read more.
NCDR data was also used in studies previously highlighted during this time period. Read more:
The American College of Cardiology is the professional home for the entire cardiovascular care team. The mission of the College and its more than 52,000 members is to transform cardiovascular care and to improve heart health. The ACC leads in the formation of health policy, standards and guidelines. The College operates national registries to measure and improve care, offers cardiovascular accreditation to hospitals and institutions, provides professional medical education, disseminates cardiovascular research and bestows credentials upon cardiovascular specialists who meet stringent qualifications. For more, visit acc.org.
The Journal of the American College of Cardiology ranks among the top cardiovascular journals in the world for its scientific impact. JACC is the flagship for a family of journals—JACC: Cardiovascular Interventions, JACC: Cardiovascular Imaging, JACC: Heart Failure, JACC: Clinical Electrophysiology and JACC: Basic to Translational Science—that prides themselves in publishing the top peer-reviewed research on all aspects of cardiovascular disease. Learn more at JACC.org.