Behnood Bikdeli

Trends in Hospitalization Rates and Outcomes of Endocarditis among Medicare Beneficiaries

OBJECTIVES The aim of this study was to determine the hospitalization rates and outcomes of endocarditis among older adults. BACKGROUND Endocarditis is the most serious cardiovascular infection and is especially common among older adults. Little is known about recent trends for endocarditis hospitalizations and outcomes. METHODS Using Medicare inpatient Standard Analytic Files, we identified all fee-for-service beneficiaries age ≥65 years with a principal or secondary diagnosis of endocarditis from 1999 to 2010. We used Medicare Denominator Files to report hospitalizations per 100,000 person-years. Rates of 30-day and 1-year mortality were calculated using Vital Status Files. We used mixed-effects models to calculate adjusted rates of hospitalization and mortality and to compare the results before and after 2007, when the American Heart Association revised their recommendations for endocarditis prophylaxis. RESULTS Overall, 262,658 beneficiaries were hospitalized with endocarditis. The adjusted hospitalization rate increased from 1999 to 2005, reaching 83.5 per 100,000 person-years in 2005, and declined during 2006 to 2007. After 2007, the decline continued, reaching 70.6 per 100,000 person-years in 2010. Adjusted 30-day and 1-year mortality rates ranged from 14.2% to 16.5% and from 32.6% to 36.2%, respectively. There were no consistent changes in adjusted rates of 30-day and 1-year mortality after 2007. Trends in rates of hospitalization and outcomes were consistent across demographic subgroups. Adjusted rates of hospitalization and mortality declined consistently in the subgroup with a principal diagnosis of endocarditis. CONCLUSIONS Our study highlights the high burden of endocarditis among older adults. We did not observe an increase in adjusted rates of hospitalization or mortality associated with endocarditis after publication of the 2007 guidelines.

Pathophysiology of Aortocoronary Saphenous Vein Bypass Graft Disease

Aortocoronary saphenous vein bypass grafting relieves anginal pain in patients with coronary artery disease. However, its effectiveness is limited due to graft failure; the 10-year patency rate is 50%–60%. Early, 1-year and late graft failure may be due to thrombosis, fibrointimal hyperplasia and atherosclerosis, respectively. There is general agreement that vein graft atherosclerosis differs from arterial lesions in terms of temporal and histological changes. Vein graft atherosclerosis is more rapid, with diffuse concentric changes and a less noticeable fibrous cap, making venous plaques more vulnerable to rupture and subsequent thrombus formation. Despite progress in understanding the pathophysiology, some aspects of vein graft atherosclerosis need to be clarified. This review focuses on the pathophysiologic aspects of this widespread, costly and disabling disease, with emphasis on late graft occlusion and distinctions between arterial and venous atherosclerosis in terms of histology, pathophysiology and risk factors.

Vena Caval Filter Utilization and Outcomes in Pulmonary Embolism: Medicare Hospitalizations From 1999 to 2010

BACKGROUND Inferior vena caval filters (IVCFs) may prevent recurrent pulmonary embolism (PE). Despite uncertainty about their net benefit, patterns of use and outcomes of these devices in contemporary practice are unknown. OBJECTIVES The authors determined the trends in utilization rates and outcomes of IVCF placement in patients with PE and explored regional variations in use in the United States. METHODS In a national cohort study of all Medicare fee-for-service beneficiaries ≥65 years of age with principal discharge diagnoses of PE between 1999 and 2010, rates of IVCF placement per 100,000 beneficiary-years and per 1,000 patients with PE were determined. The 30-day and 1-year mortality rates after IVCF placement were also investigated. RESULTS Among 556,658 patients hospitalized with PE, 94,427 underwent IVCF placement. Between 1999 and 2010, the number of PE hospitalizations with IVCF placement increased from 5,003 to 8,928, representing an increase in the rate per 100,000 beneficiary-years from 19.0 to 32.5 (p < 0.001 for both). As the total number of PE hospitalizations increased (from 31,746 in 1999 to 54,392 in 2010), the rate of IVCF placement per 1,000 PE hospitalizations did not change significantly (from 157.6 to 164.1, p = 0.11). Results were consistent across demographic subgroups, although IVCF use was higher in blacks and patients ≥85 years of age. IVCF utilization varied widely across regions, with the highest rate in the South Atlantic region and the lowest rate in the Mountain region. CONCLUSIONS In a period of increasing PE hospitalizations among Medicare fee-for-service beneficiaries, IVCF placement increased as utilization rates in patients with PE remained greater than 15%. Mortality associated with PE hospitalizations is declining, regardless of IVCF use.

Dominance of Furosemide for Loop Diuretic Therapy in Heart Failure: Time to Revisit the Alternatives?

To the Editor: Diuretics are a mainstay of treatment in both chronic and acute decompensated heart failure (HF). Studies during the 1990s and early 2000s show that roughly 90% of HF patients receive at least 1 class of diuretics, particularly a loop diuretic, for management of chronic ([1,2][1]) or

National Trends in Pulmonary Embolism Hospitalization Rates and Outcomes for Adults Aged ≥65 Years in the United States (1999 to 2010)

Little is known about national trends of pulmonary embolism (PE) hospitalizations and outcomes in older adults in the context of recent diagnostic and therapeutic advances. Therefore, we conducted a retrospective cohort study of 100% Medicare fee-for-service beneficiaries hospitalized from 1999 to 2010 with a principal discharge diagnosis code for PE. The adjusted PE hospitalization rate increased from 129/100,000 person-years in 1999 to 302/100,000 person-years in 2010, a relative increase of 134% (p <0.001). Black patients had the highest rate of increase (174 to 548/100,000 person-years) among all age, gender, and race categories. The mean (standard deviation) length of hospital stay decreased from 7.6 (5.7) days in 1999 to 5.8 (4.4) days in 2010, and the proportion of patients discharged to home decreased from 51.1% (95% confidence interval [CI] 50.5 to 51.6) to 44.1% (95% CI 43.7 to 44.6), whereas more patients were discharged with home health care and to skilled nursing facilities. The in-hospital mortality rate decreased from 8.3% (95% CI 8.0 to 8.6) in 1999 to 4.4% (95% CI 4.2 to 4.5) in 2010, as did adjusted 30-day (from 12.3% [95% CI 11.9 to 12.6] to 9.1% [95% CI 8.5 to 9.7]) and 6-month mortality rates (from 23.0% [95% CI 22.5 to 23.4] to 19.6% [95% CI 18.8 to 20.5]). There were no significant racial differences in mortality rates by 2010. There was no change in the adjusted 30-day all-cause readmission rate from 1999 to 2010. In conclusion, PE hospitalization rates increased substantially from 1999 to 2010, with a higher rate for black patients. All mortality rates decreased but remained high. The increase in hospitalization rates and continued high mortality and readmission rates confirm the significant burden of PE for older adults.

Place of Residence and Outcomes of Patients With Heart Failure Analysis From the Telemonitoring to Improve Heart Failure Outcomes Trial

Background—Recent studies show an association between neighborhood-level measures of socioeconomic status (SES) and outcomes for patients with heart failure. We do not know whether neighborhood SES has a primary effect or is a marker for individual SES. Methods and Results—We used the data from participants of the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) trial, recruited from 33 US internal medicine and cardiology practices and examined the association between neighborhood SES and outcomes of patients with heart failure. We used census tracts as proxies for neighborhoods and constructed summary SES scores that included information about wealth and income, education, and occupation. The primary end points were readmission and all-cause mortality at 6 months. We conducted patient interviews and medical chart reviews to obtain demographic information, clinical factors, therapies, and individual SES. We included 1557 patients: 524, 516, and 517 from low, medium, and high SES neighborhoods, respectively (mean age, 61.1±15.2 years; 42.2% women).Overall, 745 patients (47.8%) had ≥1 readmission and 179 patients (11.5%) died. When compared with patients in high SES neighborhoods, those living in low-SES neighborhoods were more likely to be readmitted (odds ratio, 1.35; 95% confidence interval, 1.01–1.82), but the mortality rates were not significantly different (odds ratio, 0.78; 95% confidence interval, 0.50–1.18). The results were consistent after multivariable adjustments for individual demographics, clinical factors, and individual SES. Conclusions—Among patients with heart failure, neighborhood SES was significantly associated with 6-month all-cause readmission even after adjusting for other patient-level factors, including individual SES. Greater number of events and longer follow-up is required to ascertain the potential effect of neighborhood SES on mortality. Clinical Trial Registration—URL: http://clinicaltrials.gov/. Unique identifier: NCT00303212.

Most Important Articles on Cardiovascular Disease Among Racial and Ethnic Minorities

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of cardiovascular disease among racial and ethnic minorities.

Two Decades of Cardiovascular Trials With Primary Surrogate Endpoints: 1990–2011

Background Surrogate endpoint trials test strategies more efficiently but are accompanied by uncertainty about the relationship between changes in surrogate markers and clinical outcomes. Methods and Results We identified cardiovascular trials with primary surrogate endpoints published in the New England Journal of Medicine, Lancet, and JAMA: Journal of the American Medical Association from 1990 to 2011 and determined the trends in publication of surrogate endpoint trials and the success of the trials in meeting their primary endpoints. We tracked for publication of clinical outcome trials on the interventions tested in surrogate trials. We screened 3016 articles and identified 220 surrogate endpoint trials. From the total of 220 surrogate trials, 157 (71.4%) were positive for their primary endpoint. Only 59 (26.8%) surrogate trials had a subsequent clinical outcomes trial. Among these 59 trials, 24 outcomes trial results validated the positive surrogates, whereas 20 subsequent outcome trials were negative following positive results on a surrogate. We identified only 3 examples in which the surrogate trial was negative but a subsequent outcomes trial was conducted and showed benefit. Findings were consistent in a sample cohort of 383 screened articles inclusive of 37 surrogate endpoint trials from 6 other high‐impact journals. Conclusions Although cardiovascular surrogate outcomes trials frequently show superiority of the tested intervention, they are infrequently followed by a prominent outcomes trial. When there was a high‐profile clinical outcomes study, nearly half of the positive surrogate trials were not validated. Cardiovascular surrogate outcome trials may be more appropriate for excluding benefit from the patient perspective than for identifying it.

Poorly Cited Articles in Peer-Reviewed Cardiovascular Journals from 1997 to 2007 Analysis of 5-Year Citation Rates

Background— The extent to which articles are cited is a surrogate of the impact and importance of the research conducted; poorly cited articles may identify research of limited use and potential wasted investments. We assessed trends in the rates of poorly cited articles and journals in the cardiovascular literature from 1997 to 2007. Methods and Results— We identified original articles published in cardiovascular journals and indexed in the Scopus citation database from 1997 to 2007. We defined poorly cited articles as those with ⩽5 citations in the 5 years following publication and poorly cited journals as those with >75% of journal content poorly cited. We identified 164 377 articles in 222 cardiovascular journals from 1997 to 2007. From 1997 to 2007, the number of cardiovascular articles and journals increased by 56.9% and 75.2%, respectively. Of all the articles, 75 550 (46.0%) were poorly cited, of which 25 650 (15.6% overall) had no citations. From 1997 to 2007, the proportion of poorly cited articles declined slightly (52.1%–46.2%, trend P<0.001), although the absolute number of poorly cited articles increased by 2595 (trend P<0.001). At a journal level, 44% of cardiovascular journals had more than three-fourths of the journal’s content poorly cited at 5 years. Conclusion— Nearly half of all peer-reviewed articles published in cardiovascular journals are poorly cited 5 years after publication, and many are not cited at all. The cardiovascular literature and the number of poorly cited articles both increased substantially from 1997 to 2007. The high proportion of poorly cited articles and journals suggests inefficiencies in the cardiovascular research enterprise.

Prophylaxis for venous thromboembolism: a great global divide between expert guidelines and clinical practice?

Our understanding of development and prevention of venous thromboembolism (VTE) has improved dramatically since Virchow described the triad of stasis, hypercoagulability, and endothelial dysfunction during the mid-1800s. A full arsenal of effective pharmacological and mechanical methods can help prevent VTE and many professional organizations have provided extensive evidence-based statements for VTE prophylaxis. Disappointingly, however, VTE has remained the major preventable cause of hospital death. Adherence rate to clinical guidelines is undesirably low. Many real-world patients have also been excluded from VTE prevention trials and hence practice guidelines recommendations. The comprehensive and repetitious formats of many available guidelines also limit their readability and applicability by nonthrombosis specialists. Moreover, some patients suffer from VTE despite complying with the contemporary prophylaxis regimens. Besides, significant heterogeneity exists in thromboprophylaxis practice and pitfalls between different countries. Last but not the least; although many at-risk patients are underprophylaxed, there is evidence to suggest that overprophylaxis (i.e., prescription of thromboprophylaxis in low-risk patients) comprises another important problem. We review the thromboprophylaxis practice and pitfalls around the world and provide recommendations on how the major obstacles can be overcome.