Registry Roundup: NCDR Data Optimizing Patient Care

High-quality real-world data is a cornerstone of clinical decision-making today. Evidence from ACC's NCDR registries provides the answers you need to deliver patient-centered care – fine-tuning care for the patient in front of you.

Here we bring you a roundup of evidence from analyses using data from two of the 10 registries.

Reports from the Chest Pain – MI Registry brings new insights about how cognitive impairment in STEMI and NSTEMI patients impacts the choice of treatment, contemporary utilization patterns of P2Y12 inhibitors and a possible predictive model for length of stay and postacute care.

From the STS/ACC TVT Registry come insights about the relation between operator experience and outcomes for transcatheter mitral valve repair and between institutional volume and outcomes for mitral valve surgery, and more.

STS/ACC TVT Registry: Experience Improves Outcomes For Mitral Valve Repair

Operator experience is a key factor in successfully obtaining better procedural outcomes when performing transcatheter mitral valve repair for the treatment of mitral regurgitation. The findings from an analysis of data from the STS/ACC TVT Registry were presented at TCT 2019 and simultaneously published in the Journal of the American College of Cardiology.

Transcatheter mitral valve repair using a MitraClip device has been performed in the U.S. since 2013 but is a complex and still relatively novel procedure. Adnan K. Chhatriwalla, MD, FACC, et al., reviewed data from 14,923 transcatheter mitral valve repair cases enrolled in the STS/ACC TVT Registry from November 2013 to March 2018. The cases were performed by 562 operators at 290 U.S. sites. Patient baseline characteristics were comparable for all three categories.

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Of the 562 operators, 549 performed 1-25 cases, 230 performed 26-50 cases and 116 performed more than 50 cases during the study period. Researchers found that procedural success improved across categories of operator experience while procedural time and complications decreased.

Optimal success, defined as ≤1+ residual mitral regurgitation without death or cardiac surgery, increased across the categories of operator experience (63.9 percent, 68.4 percent and 75.1 percent; p<0.001). Likewise, there was an increase for acceptable procedural success, defined as residual ≤2+ mitral regurgitation without death or cardiac surgery, with more operator experience (91.4 percent, 92.4 percent, and 93.8 percent, p<0.001).

Regarding the learning curve, at about 50 cases there was an evident improvement, with continuous improvement up to 200 cases.

"Increasing operator case experience was associated with improvements in procedural outcomes, including procedural success, procedure time and procedural complications," concluded the researchers "These findings suggest that a relatively greater attention to case selection may be important during the early operator experience. Further research is needed to understand the specific factors associated with operator and site experience that impact long-term clinical outcomes."

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NCDR: Presence of Cognitive Impairment in Older MI Patients Impacts Treatment Selection

Among older patients presenting with a myocardial infarction (MI), those with an NSTEMI are less likely to receive invasive treatment and those with STEMI are less likely to receive fibrinolysis. The presence of cognitive impairment was also associated with increased in-hospital mortality. These are among the findings of a study conducted using data from the NCDR Chest Pain – MI Registry and published in the Journal of the American Heart Association.

Akshay Bagai, MD, MHS, et al., examined data from 43,812 patients with STEMI and 90,904 patients with NSTEMI who were older than 65 years and enrolled in the NCDR Chest Pain – MI Registry between January 2015 and December 2016. For the study, chart-documented cognitive impairment was categorized as mild (3.9 percent of STEMI patients vs. 5.7 percent of NSTEMI patients) or moderate/severe (2.0 percent vs. 2.6 percent, respectively).

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Patients with STEMI with cognitive impairment were less frequently treated with cardiac medical therapies, including aspirin or a P2Y12 receptor inhibitor, within 24 hours or parenteral anticoagulation in-hospital compared with patients without cognitive impairment. There was a numerically small difference in the use of PCI among STEMI patients without cognitive impairment, mild impairment and moderate/severe impairment, respectively: 92.1 percent, 92.8 percent and 90.4 percent (p=0.003).

The use of thrombolytic therapy (excluding those treated with PCI or ineligible) was lower in STEMI patients with mild or moderate/severe cognitive impairment (27.4 percent and 24.3 percent) compared with those without (40.9 percent). The results also showed in STEMI patients a slightly longer time from first medical contact to device and a lower use of CABG, and a difference in discharge medications with a lower use of P2Y12 receptor inhibitors, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins.

Focusing on patients presenting with NSTEMI, patients with cognitive impairment, compared with those without, were less likely to receive cardiac medical therapy within 24 hours, cardiac catheterization, or PCI and CABG procedures. In patients without, mild or moderate/severe cognitive impairment, the rates of catheterization were 84.7 percent, 50.3 percent and 24.6 percent (p<0.001) and the rates of PCI were 49.4 percent, 27.3 percent and 12.7 percent. The use of all discharge medications was lower for those with cognitive impairment.

Cognitive impairment was associated with higher in-hospital mortality for STEMI and NSTEMI patients. For patients with mild cognitive impairment, compared with those without, the adjusted odds ratio for in-hospital mortality was 2.2 for STEMI and 1.7 for NSTEMI. For those with moderate/severe cognitive impairment, the odds ratio was 1.3 for both STEMI and NSTEMI.

The authors note that one in 13 patients older than 65 years in the U.S. have cognitive impairment documented in their medical records. Cognitive impairment without dementia is more prevalent and varies from a spectrum of age-related cognitive issues to mild cognitive impairment. After MI, even mild cognitive impairment was associated with less invasive care and less referral to and participation in cardiac rehabilitation, with moderate to severe cognitive impairment associated with worse risk-adjusted one-year survival.

"Improving outcomes of this patient population requires understanding the MI presentation in context of other medical conditions and patient goals of care," researchers concluded. "It also requires addressing noncardiac risk for mortality during and after hospitalization. Additional studies are needed to determine an optimal approach to inform clinical decision-making for older patients with MI with cognitive impairment.

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Increasing Ticagrelor Use, Low-Dose Aspirin Post AMI: Chest Pain – MI Registry

Contemporary utilization patterns of P2Y12 inhibitors show a steady increase in prescription of ticagrelor at discharge after an acute myocardial infarction (AMI), according to a study using ACC's Chest Pain – MI Registry data. The study also found significant compliance with the ACC/AHA guideline recommendation of low-dose aspirin in patients treated with ticagrelor. The results were published in the Journal of the American Heart Association.

Sukhdeep S. Basra, MD, MPH, et al., ​evaluated temporal trends in P2Y12 prescriptions in 167,455 patients treated for AMI at 622 sites from October 2013 through December 2014. They found the prescription rate for ticagrelor increased from 12 percent to 16.7 percent, there was a decrease in the prescription of clopidogrel from 54.2 percent to 51.1 percent and in prasugrel from 15.7 percent to 13.9 percent (p<0.0001 for all).

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The independent factors associated with prescribing ticagrelor rather than clopidogrel included younger age, white race, home ticagrelor use, invasive management, and inhospital reinfarction and stroke (p<0.0001 for all). For prescribing ticagrelor over prasugrel, the independent factors included older age, female sex, prior stroke, home ticagrelor use and inhospital stroke (p<0.0001 for all).

Among the 21,262 patients discharged on ticagrelor plus aspirin, high-dose aspirin was prescribed for 3.1 percent. Independent factors associated with prescribing high-dose aspirin were home aspirin use, diabetes, previous MI, previous CABG, STEMI, cardiogenic shock and geographic region (p=0.01).

"Our contemporary report shows a modest but significant increase in the use of ticagrelor early and at discharge, with simultaneous decline in the use of clopidogrel and prasugrel in patients presenting with AMI," the authors concluded. In addition, an increased use of low-dose aspirin at discharge in patients treated with ticagrelor was demonstrated. Yet, the significant regional and hospital variability in ticagrelor prescription and aspirin dose at discharge "represent[s] important opportunities for future improvements in care of patients with AMI."

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Predictive Models For LOS, Postacute Care in AMI Developed From Chest Pain – MI Registry Data

Two predictive models created using ACC's Chest Pain – MI Registry data could predict length of stay (LOS) and discharge to a postacute facility after hospital admission for an acute myocardial infarction (AMI), according to a study published in Circulation: Cardiovascular Quality and Outcomes.

Jason H. Wasfy, MD, MPhil, FACC, et al., used an analysis cohort of 906,324 patients admitted with a STEMI or an NSTEMI to a hospital participating in ACC's Chest Pain – MI Registry between July 1, 2008 to March 31, 2017. Of these, 633,737 patients (70 percent) were included in the training cohort and 272,587 patients (30 percent) in the validation cohort.

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The authors developed hierarchical proportional models to predict LOS and hierarchical logistic regression models to predict discharge to postacute care (extended care, transitional care unit or rehabilitation).

After multivariable adjustment and stepwise elimination, factors independently associated with a longer LOS included: older age and at admission heart failure, higher heart rate, systolic blood pressure <150 mm Hg or >150 mm Hg, shock, diabetes, lower glomerular filtration rate, and lower hemoglobin.

After multivariable adjustment and stepwise elimination, factors independently associated with greater odds of discharge to a postacute facility included: older age and at admission heart failure, higher heart rate, shock, prior cerebrovascular disease and lower hemoglobin.

The authors write, "We have demonstrated that with clinical characteristics known at the time of initial hospitalization for AMI, both LOS and postacute utilization can be predicted with moderate and strong predictive accuracy, respectively."

They add, "We think that these models may substantially improve the ability of health care providers and health delivery organizations to improve performance in [episode payment models] and other types of payment mechanisms that incentivize judicious use of resources and costs, although further research into how best to use these models is needed."

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Very Few TAVR Patients Develop Complications Requiring Surgical Bailout

Just 1 percent of patients undergoing transcatheter aortic valve replacement (TAVR) have complications that require surgical bailout, according to a study published in JACC: Cardiovascular Interventions. Andres M. Pineda, MD, FACC, et al., used data from the STS/ACC TVT Registry.

Between November 2011 and September 2015, a total of 47,546 patients underwent TAVR. Surgical bailout during TAVR was performed in 1.17 percent of the cases (558 patients). The most frequent reasons for surgical bailout were valve dislodgement (22 percent), rupture of the ventricle (19.9 percent) and rupture of the aortic valve (14.2 percent).

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Results showed that TAVR patients who required surgical bailout had poor outcomes. Researchers found 50 percent of these patients had died within 30 days – more than 10-fold higher than patients who did not require surgical bailout during TAVR. Certain patients were at higher risk of requiring surgical bailout, including those undergoing emergency instead of elective TAVR procedures, and those whose catheter was not inserted through the femoral artery. Women and those with a higher ejection fraction were also at increased risk. The incidence of surgical bailout decreased over time – from 1.25 percent at the beginning of the study to 1.04 percent at the end.

"This excellent study reminds us… that we should thoroughly discuss the option of surgical bailout with every patient and the next of kin upfront before going into the procedure to avoid futile surgical bailout procedures prone to result in a disastrous outcome and therefore adds only further harm to the patients and their families," write Fabian Nietlispach, MD, PhD, and Osmund Bertel, MD, in an accompanying editorial comment. "Thoughtful patient selection is an issue not only for TAVR itself but also for surgical bailout when complications are met."

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Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Interventions and Structural Heart Disease, Sleep Apnea, Mitral Regurgitation

Keywords: ACC Publications, Cardiology Magazine, Adenosine, American Heart Association, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Aortic Valve, Aspirin, Cardiac Catheterization, Blood Pressure, Chest Pain, Cardiac Rehabilitation, Cardiac Surgical Procedures, Cognition, Cohort Studies, Dementia, Diabetes Mellitus, Femoral Artery, Glomerular Filtration Rate, Health Personnel, Fibrinolysis, Hemoglobins, Hospital Mortality, Heart Failure, Heart Rate, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Incidence, Learning Curve, Logistic Models, Mitral Valve, Mitral Valve Insufficiency, Length of Stay, Myocardial Infarction, Medical Records, Odds Ratio, Patient Care Planning, Patient Selection, Percutaneous Coronary Intervention, Patient-Centered Care, Referral and Consultation, Shock, Cardiogenic, Research Report, Registries, Stroke, Stroke Volume, Thrombolytic Therapy, Subacute Care, Transcatheter Aortic Valve Replacement, Thoracic Surgery, Ticlopidine, Transition to Adult Care


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