Hoang V. Tran

Underuse of Effective Cardiac Medications Among Women, Middle-Aged Adults, and Racial/Ethnic Minorities With Coronary Artery Disease (from the National Health and Nutrition Examination Survey 2005 to 2014)

Given the proven effectiveness of several cardiac medications for patients with coronary artery disease (CAD), we examined the national use of 4 classes of effective medications, overall and by age, sex, and race/ethnicity in 2005 to 2014. We used data from the National Health and Nutrition Examination Survey, including a self-reported diagnosis of CAD and independently verified medication use. Weighting procedures extrapolated our data to the adult US population with CAD. Analyses included 1,789u2009US adults aged ≥45 years with a history of CAD. The average age of this population was 68 years; 40% were women and 79% were non-Hispanic whites. In 2005 to 2014, 53.2% (standard error [SE]u2009=u20091.5) reported use of angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, 58.5% (SEu2009=u20091.5) β blockers, and 67.2% (SEu2009=u20091.4) statins. Two of these medications were used by 64.1% (SEu2009=u20091.5) of the study population and all 3 by 29.1% (SEu2009=u20091.3). In 2011 to 2014, 68.5% (SEu2009=u20092.4) of American adults with a history of CAD reported use of aspirin. The use of statins increased from 63.1% in 2005/2006 to 76.8% in 2013/2014. Adults aged 45 to 64 years old, women, and racial/ethnic minorities had lower use of effective cardiac medications compared with older adults, men, and non-Hispanic whites. In conclusion, the use of statins, but not other medications, has increased over the past 10 years among American adults with previously diagnosed CAD. Continued targeted efforts are needed to increase the receipt of effective cardiac medications among all US adults with CAD, especially those aged 45 to 64 years, women, and racial/ethnic minorities.

Trends in Length of Hospital Stay and the Impact on Prognosis of Early Discharge After a First Uncomplicated Acute Myocardial Infarction

Few studies have examined recent trends in the length of stay (LOS) among patients hospitalized with a first uncomplicated acute myocardial infarction (AMI) and the impact of early hospital discharge on various short-term outcomes in these low-risk patients. We used data from 1,501 residents hospitalized with a first uncomplicated AMI from all central Massachusetts medical centers on a biennial basis between 2001 and 2011. The association between hospital LOS and subsequent hospital readmission or death was examined using logistic regression modeling. The average age of the study population was 63.7 years, 63.0% were men, and 91.4% were non-Hispanic whites. The average hospital LOS declined from 4.1 days in 2001 to 2.9 days in 2011. During the years under study, the average 30-day hospital readmission rate was 11.9%, whereas the 30- and 90-day death rates were 1.5% and 2.9%, respectively. The multivariable adjusted odds ratio of a 30-day hospital readmission (odds ratio [OR]u2009=u20090.81, 95% confidence interval [CI]u2009=u20090.52 to 1.41), or 30-day (ORu2009=u20090.93, 95% CIu2009=u20090.29 to 2.98) and 90-day (ORu2009=u20090.89, 95% CIu2009=u20090.36 to 2.20) death rates were not significantly different between patients who were discharged from central Massachusetts medical centers during the first 2 days as compared with those discharged thereafter. In conclusion, the average LOS in patients with a first uncomplicated AMI declined during the years under study, and early discharge from the hospital at day 2 or sooner of these low-risk patients does not appear to be associated with an increased risk of adverse events post discharge compared with those discharged at a later time.

Clinically significant ventricular arrhythmias and progression of depression and anxiety following an acute coronary syndrome

BACKGROUNDnDepression and anxiety are common and associated with worse clinical outcomes in patients who experience an acute coronary syndrome (ACS). We investigated the association between major ventricular arrhythmias (VAs) with the progression of depression and anxiety among hospital survivors of an ACS.nnnMETHODSnPatients were interviewed in hospital and by telephone up to 12u202fmonths after hospital discharge. The primary outcome was the presence of moderate/severe symptoms of depression and anxiety defined as a Patient Health Questionnaire (PHQ)-9 scoreu202f≥u202f10 and a Generalized Anxiety Disorder (GAD)-7 scoreu202f≥u202f10 at baseline and 1u202fmonth and PHQ-2u202f≥u202f3 and GAD-2u202f≥u202f3 at 3, 6, and 12u202fmonths. We used marginal models to examine the association between major VAs and the symptoms of depression or anxiety over time.nnnRESULTSnThe average age of the study population (nu202f=u202f2074) was 61.1u202fyears, 33.5% were women, and 78.3% were white. VAs developed in 105 patients (5.1%). Symptoms of depression and anxiety were present in 22.2% and 23.5% of patients at baseline, respectively, and declined to 14.1% and 12.6%, respectively, at 1-month post-discharge. VAs were not significantly associated with the progression of symptoms of depression (adjusted relative risk [aRR]u202f=u202f1.29, 95% confidence interval [CI]u202f=u202f0.94-1.77) and anxiety (aRRu202f=u202f1.22, 95% CIu202f=u202f0.86-1.72), or with change in average scores of PHQ-2 and GAD-2 over time, both before and after risk adjustment.nnnCONCLUSIONnThe prevalence of symptoms of depression and anxiety was high after an ACS but declined thereafter and may not be associated with the occurrence of major in-hospital VAs.

Increase in white blood cell count is associated with the development of atrial fibrillation after an acute coronary syndrome

BACKGROUNDnEvidence linking an elevated white blood cell count (WBCC), a marker of inflammation, to the development of atrial fibrillation (AF) after an acute coronary syndrome (ACS) is limited. We examined the association between WBCC at hospital admission, and changes in WBCC during hospitalization, with the development of new-onset AF during hospitalization for an ACS.nnnMETHODSnDevelopment of AF was based on typical ECG changes in a systematic review of hospital medical records. Increase in WBCC was calculated as the difference between maximal WBCC during hospitalization and WBCC at hospital admission. Multiple logistic regression analysis was used to adjust for several potentially confounding demographic and clinical variables in examining the association between WBCC, and changes over time therein, with the occurrence of AF.nnnRESULTSnThe median age of study patients (nu202f=u202f1325) was 60u202fyears, 31.8% were women, and 80.1% were non-Hispanic whites. AF developed in 7.3% of patients with an ACS. Patients who developed AF, as compared with those who did not, had a similar WBCC at admission, but a greater increase in WBCC during hospitalization (6.0u202f×u202f109u202fcell/L vs. 2.7u202f×u202f109 cell/L, pu202f<u202f0.001). After adjusting for several potentially confounding factors, an increase in WBCC was associated with the development of AF. This association was observed in patients with different ACS subtypes, types of treatment received, and according to time of acute symptom onset.nnnCONCLUSIONnIncrease in the WBCC during hospitalization for an ACS should be further studied as a potentially simple predictor for new-onset AF in these patients.

Hyperglycemia and risk of ventricular tachycardia among patients hospitalized with acute myocardial infarction

BackgroundLittle is known about the association of hyperglycemia with the development of ventricular tachycardia (VT) in patients hospitalized with acute myocardial infarction (AMI) which we examined in the present study. The objectives of this community-wide observational study were to examine the relation between elevated serum glucose levels at the time of hospital admission for AMI and occurrence of VT, and time of occurrence of VT, during the patient’s acute hospitalization.MethodsWe used data from a population-based study of patients hospitalized with AMI at all central Massachusetts medical centers between 2001 and 2011. Hyperglycemia was defined as a serum glucose levelu2009≥u2009140xa0mg/dl at the time of hospital admission. The development of VT was identified from physicians notes and electrocardiographic findings by our trained team of data abstractors.ResultsThe average age of the study population was 70xa0years, 58.0% were men, and 92.7% were non-Hispanic whites. The mean and median serum glucose levels at the time of hospital admission were 171.4xa0mg/dl and 143.0, respectively. Hyperglycemia was present in 51.9% of patients at the time of hospital admission; VT occurred in 652 patients (15.8%), and two-thirds of these episodes occurred during the first 48xa0h after hospital admission (early VT). After multivariable adjustment, patients with hyperglycemia were at increased risk for developing VT (adjusted ORu2009=u20091.48, 95% CIu2009=u20091.23–1.78). The presence of hyperglycemia was significantly associated with early (multivariable adjusted ORu2009=u20091.39, 95% CIu2009=u20091.11–1.73) but not with late VT. Similar associations were observed in patients with and without diabetes and in patients with and without ST-segment elevation AMI.ConclusionsEfforts should be made to closely monitor and treat patients who develop hyperglycemia, especially early after hospital admission, to reduce their risk of VT.

Barriers to Healthcare Access and to Improvements in Health-Related Quality of Life After an Acute Coronary Syndrome (From TRACE-CORE)

Little is known about how barriers to healthcare access affect health-related quality of life (HRQOL) after an acute coronary syndrome (ACS). In a large cohort of ACS survivors from 6 medical centers in Massachusetts and Georgia enrolled from 2011 to 2013, patients were classified as having any financial barriers, no usual source of care (USOC), or transportation barriers to healthcare based on their questionnaire survey responses. The principal study outcomes included clinically meaningful declines in generic physical and mental HRQOL and in disease-specific HRQOL from 1 to 6 months posthospital discharge. Adjusted relative risks (aRRs) for declines in HRQOL were calculated using Poisson regression models, controlling for several sociodemographic and clinical factors of prognostic importance. In 1,053 ACS survivors, 29.0% had a financial barrier, 14.2% had no USOC, and 8.7% had a transportation barrier. Patients with a financial barrier had greater risks of experiencing a decline in generic physical (aRR 1.48, 95% confidence interval [CI] 1.17, 1.86) and mental (aRR 1.36, 95% CI 1.07, 1.75) HRQOL at 6 months. Patients with 2 or more access barriers had greater risks of decline in generic physical (aRR 1.53, 95% CI 1.20, 1.93) and mental (aRR 1.50, 95% CI 1.17, 1.93) HRQOL compared with those without any healthcare barriers. There was a modest association between lacking a USOC and experiencing a decline in disease-specific HRQOL (aRR 1.46, 95% CI 0.96, 2.22). Financial and other barriers to healthcare access may be associated with clinically meaningful declines in HRQOL after hospital discharge for an ACS.

Decade Long Trends (2001-2011) in the Incidence Rates of Initial Acute Myocardial Infarction

Despite the magnitude and impact of acute coronary disease, there are limited population-based data in the United States describing relatively recent trends in the incidence rates of acute myocardial infarction (AMI). The objectives of this study were to describe decade long (2001-2011) trends in the incidence rates of initial hospitalized episodes of AMI, with further stratification of these rates by age, sex, and type of AMI, in residents of central Massachusetts hospitalized at 11 area medical centers. The study population consisted of 3,737 adults hospitalized with a first AMI at 11 medical centers in central Massachusetts on a biennial basis between 2001 and 2011. The median age of this study population was 70 years, 57% were men, and 90% were white. Patients hospitalized during the most recent study years (2009/11) were younger, more likely to be men, have more co-morbidities, and less in-hospital complications as compared with those in the earliest study years (2001/03). The overall age-adjusted hospital incidence rates (per 100,000 persons) of initial AMI declined (from 319 to 163), for men (from 422 to 219), women (from 232 to 120), for patients with a ST segment elevation (129 to 56), and for those with an non-ST segment elevation (190 to 107) between 2001 and 2011, respectively. In conclusion, the incidence rates of initial AMI declined appreciably in residents of central Massachusetts who were hospitalized with AMI during the years under study.

Is low iodine a risk factor for cardiovascular disease in Americans without thyroid dysfunction? Findings from NHANES

BACKGROUND AND AIMSnLow body iodine levels are associated with cardiovascular disease, in part through alterations in thyroid function. While this associationxa0suggested from animal studies, it lacks supportive evidence in humans. This study examined the association between urine iodine levels and presence of coronary artery disease (CAD) and stroke in adults without thyroid dysfunction.nnnMETHODS AND RESULTSnThis cross-sectional study included 2440 adults (representing a weighted nxa0=xa091,713,183) aged ≥40 years without thyroid dysfunction in the nationally-representative 2007-2012 National Health and Nutrition Examination Survey. The age and sex-adjusted urine iodine/creatinine ratio (aICR) was categorized into low (aICR<116xa0μg/day), medium (116xa0μg/dayxa0≤xa0aICRxa0<xa0370μg/day), and high (aICRxa0≥xa0370μg/day) based on lowest/highest quintiles. Stroke and CAD were from self-reported physician diagnoses. We examined the association between low urine aICR and CAD or stroke using multivariable logistic regression modeling. The mean age of this population was 56.0 years, 47% were women, and three quarters were non-Hispanic whites. Compared with high urine iodine levels, multivariable adjusted odds ratios aOR (95% confidence intervals) for CAD were statistically significant for low, aORxa0=xa01.97 (1.08-3.59), but not medium, aORxa0=xa01.26 (0.75-2.13) urine iodine levels. There was no association between stroke and low, aORxa0=xa01.12 (0.52-2.44) or medium, aORxa0=xa01.48 (0.88-2.48) urine iodine levels.nnnCONCLUSIONnThe association between low urine iodine levels and CAD should be confirmed in a prospective study with serial measures of urine iodine. If low iodine levels precede CAD, then this potential and modifiable new CAD risk factor might have therapeutic implications.