Boback Ziaeian

Epidemiology and aetiology of heart failure

Heart failure (HF) is a rapidly growing public health issue with an estimated prevalence of >37.7 million individuals globally. HF is a shared chronic phase of cardiac functional impairment secondary to many aetiologies, and patients with HF experience numerous symptoms that affect their quality of life, including dyspnoea, fatigue, poor exercise tolerance, and fluid retention. Although the underlying causes of HF vary according to sex, age, ethnicity, comorbidities, and environment, the majority of cases remain preventable. HF is associated with increased morbidity and mortality, and confers a substantial burden to the health-care system. HF is a leading cause of hospitalization among adults and the elderly. In the USA, the total medical costs for patients with HF are expected to rise from US

Comprehensive quality of discharge summaries at an academic medical center

20.9 billion in 2012 to

The Prevention of Hospital Readmissions in Heart Failure

53.1 billion by 2030. Improvements in the medical management of risk factors and HF have stabilized the incidence of this disease in many countries. In this Review, we provide an overview of the latest epidemiological data on HF, and propose future directions for reducing the ever-increasing HF burden.

Pre-existing Psychiatric Illness is Associated With Increased Risk of Recurrent Takotsubo Cardiomyopathy

BACKGROUND Discharge summaries are essential for safe transitions from hospital to home. OBJECTIVE To conduct a comprehensive quality assessment of discharge summaries. DESIGN Prospective cohort study. SUBJECTS Three hundred seventy-seven patients discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MEASURES Discharge summaries were assessed for timeliness of dictation, transmission of the summary to appropriate outpatient clinicians, and presence of key content including elements required by The Joint Commission and elements endorsed by 6 medical societies in the Transitions of Care Consensus Conference (TOCCC). RESULTS A total of 376 of 377 patients had completed discharge summaries. A total of 174 (46.3%) summaries were dictated on the day of discharge; 93 (24.7%) were completed more than a week after discharge. A total of 144 (38.3%) discharge summaries were not sent to any outpatient physician. On average, summaries included 5.6 of 6 The Joint Commission elements and 4.0 of 7 TOCCC elements. Summaries dictated by hospitalists were more likely to be timely and to include key content than summaries dictated by housestaff or advanced practice nurses. Summaries dictated on the day of discharge were more likely to be sent to outside physicians and to include key content. No summary met all 3 quality criteria of timeliness, transmission, and content. CONCLUSIONS Discharge summary quality is inadequate in many domains. This may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes. However, improving discharge summary timeliness may also improve content and transmission.

The 2013 ACC/AHA Cholesterol Treatment Guidelines: Applicability to Patients with Diabetes.

Heart failure (HF) is a growing healthcare burden and one of the leading causes of hospitalizations and readmission. Preventing readmissions for HF patients is an increasing priority for clinicians, researchers, and various stakeholders. The following review will discuss the interventions found to reduce readmissions for patients and improve hospital performance on the 30-day readmission process measure. While evidence-based therapies for HF management have proliferated, the consistent implementation of these therapies and development of new strategies to more effectively prevent readmissions remain areas for continued improvement.

Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults

BACKGROUND The increased prevalence of psychiatric illness among patients with takotsubo cardiomyopathy (TC) has been previously described. OBJECTIVES We sought to assess the effect of pre-existing psychiatric illness on clinical outcomes following the diagnosis of TC. METHODS Adults diagnosed with TC at Vanderbilt University Medical Center between 1999 and 2015 were included in the study. Medical records were retrospectively reviewed to identify any pre-existing mood, anxiety, or schizophrenia-spectrum illness before TC presentation. Multivariable logistic regression was used to test for independent association of pre-existing psychiatric illness with 30-day mortality and recurrent TC; Cox proportional hazard analysis was used to evaluate for association with long-term mortality. RESULTS Among 306 patients diagnosed with TC during the study period, 114 (37%) had a pre-existing psychiatric illness. In all, 43 (14%) and 88 (29%) patients died within 30 days of index diagnosis and as of last medical record review, respectively. Of the 269 who survived their index hospitalization, 19 (7%) had a confirmed recurrent episode of TC. In multivariable analyses, pre-existing psychiatric illness was not associated with increased 30-day (P = 0.320) or long-term (P = 0.621) mortality. Pre-existing psychiatric illness was associated with higher risk of recurrent TC (odds ratio = 7.44, 95% CI: 2.30-24.01, P < 0.001). CONCLUSIONS Pre-existing psychiatric illness was associated with an increased risk of recurrent TC. No significant association was noted between pre-existing psychiatric illness and survival.

Evolution of Surgical Aortic Valve Replacement in the Era of Transcatheter Valve Technology

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide and the management of blood cholesterol is a cornerstone of medical therapy for the primary and secondary prevention of cardiovascular disease. Patients with diabetes represent an important high-risk group in whom clinicians should advocate the use of statins and lifestyle modification for the reduction of ASCVD. The recent 2013 ACC/AHA guidelines on managing blood cholesterol provide an important framework for the effective implementation of this important risk reduction strategy. The guidelines identify four groups of individuals who have been shown to benefit from statin therapy and update the dosing and monitoring recommendations based on evidence from published, large-scale randomized controlled trials (RCTs) with clinical hard endpoints. Primary care physicians and specialists play key roles in identifying populations at elevated ASCVD risk and providing effective care for patients, especially those with diabetes. This article will summarize the 2013 ACC/AHA guidelines on managing blood cholesterol and provide a practical management overview in order to facilitate implementation of these guidelines for patients with diabetes.

Psychiatric Illness in Takotsubo (Stress) Cardiomyopathy: A Review

Importance Advances in perioperative cardiac management and an increase in the number of endovascular procedures have made significant contributions to patients and postoperative myocardial infarction (POMI) risk following high-risk vascular procedures. Whether these changes have translated into real-world improvements in POMI incidence remain unknown. Objective To examine the temporal trends of myocardial infarction (MI) following high-risk vascular procedures. Design, Setting, and Participants A retrospective cohort study was performed using data collected from January 1, 2005, to December 31, 2013, in the American College of Surgeons National Surgery Quality Improvement Program database, to which participating hospitals across the United States report their preoperative, operative, and 30-day outcome data. A total of 90 303 adults who underwent a high-risk vascular procedure—open aortic surgery or infrainguinal bypass—during the study period were identified. Patients were divided into cohorts based on their year of operation, and their baseline cardiac risk factors and incidence of POMI were compared. Cases from 2005 to 2014 in the database were eligible for inclusion if one of their Current Procedural Terminology codes matched any of the operations identified as a high-risk vascular procedure. Data analysis took place from August 1, 2016, to November 15, 2016. Exposures The main exposure was the year of the operation. Other variables of interest included demographics, comorbidities, and other risk factors for MI. Main Outcomes and Measures Primary outcome of interest was the incidence of POMI. Results Of the 90 303 patients included in the study, 22 836 (25.3%) had undergone open aortic surgery and 67 467 (74.7%) had had infrainguinal bypass. The open aortic cohort comprised 16 391 men (71.9%), had a mean (SD) age of 69.1 (11.5) years, and was predominantly white (18 440 patients [80.8%] self-identified as white race/ethnicity). The infrainguinal bypass cohort included 41 845 men (62.1%), had a mean (SD) age of 66.7 (11.7) years, and had 51 043 patients (75.7%) who self-identified as white race/ethnicity. During the study period, patients who underwent open aortic procedures were more likely to be classified as American Society of Anesthesiologists class IV (7426 patients [32.6%] vs 15 683 [23.3%] for the infrainguinal bypass cohort) or class V (1131 [5.0%] vs 206 [0.3%]; P < .001) and to undergo emergency procedures (4852 [21.3%] vs 4954 [7.3%]; P < .001). The open aortic procedure cohort also experienced significantly higher actual incidence of POMI (464 [3.0%] vs 1270 [1.9%]; P < .001). From 2009 to 2014, the incidence of POMI demonstrated no substantial temporal change (2.7% in 2009 to 3.1% in 2014; P = .64 for trend). Postoperative MI was consistently associated with poor prognosis, with a 3.62-fold (95% CI, 2.25-5.82) to 11.77-fold (95% CI, 6.10-22.72) increased odds of cardiac arrest and a 3.01-fold (95% CI, 2.08-4.36) to 6.66-fold (95% CI, 4.66-9.52) increased odds of mortality. Conclusions and Relevance The incidence of MI did not significantly decrease in the past decade and has been consistently associated with worse clinical outcomes. Further inquiry into why advanced perioperative care did not reduce cardiac complications is important to quality improvement efforts.

Statins and the Prevention of Heart Disease

Author(s): Mantha, Aditya; Juo, Yen-Yi; Morchi, Ravi; Ebrahimi, Ramin; Ziaeian, Boback; Shemin, Richard J; Benharash, Peyman

Heart failure clinical trials: how do we define success?

BACKGROUND Takotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, has been increasingly described in relation to psychiatric illness. METHODS We performed a literature review to identify the key findings related to psychiatric illness in TC that may be relevant to the practice of mental health and other health care providers. RESULTS The association of psychiatric illness with TC in addition to the spectrum of psychiatric illness found in TC, the role of exacerbation or treatment of psychiatric illness in triggering TC, different modes of presentation, prognostic implications, and long-term management of psychiatric illness in TC are discussed. Additionally, we review the limitations of the pre-existing literature and suggest areas of future research. CONCLUSIONS There is a strong association between pre-existing psychiatric illness, particularly anxiety and mood spectrum disorders, and TC. Acute exacerbation of psychiatric illness, rapid uptitration or overdose of certain psychotropic agents, and electroconvulsive therapy may trigger TC. Further studies are needed to better evaluate the prognostic significance and long-term management of psychiatric illness in TC.