Kevin L. Thomas

Use of Cardiac Resynchronization Therapy in Patients Hospitalized With Heart Failure

Background— The frequency and characterization of patients receiving cardiac resynchronization therapy (CRT) are largely unknown since the publication of pivotal clinical trials and subsequent incorporation of CRT into the American College of Cardiology/American Heart Association guidelines for heart failure. Methods and Results— We analyzed 33 898 patients admitted from January 2005 through September 2007 to 228 hospitals participating in the American Heart Association’s Get With the Guidelines–Heart Failure program. There were 4201 patients (12.4%) discharged alive with CRT, including 811 new implants. Patients discharged with CRT were older (median age, 75 versus 72 years) and had lower median left ventricular ejection fraction (30% versus 38%), more frequent ischemic cardiomyopathy (58% versus 45%), more history of atrial fibrillation (38% versus 27%), and higher rates of &bgr;-blocker and aldosterone antagonist use (P<0.0001 for all) than those without CRT. We found that 4.8% of patients with left ventricular ejection fraction ≤35% were discharged with a new CRT implant, which varied greatly by hospital. Ten percent of patients discharged with a new CRT implant had a left ventricular ejection fraction >35%. Major factors associated with lower rates of new CRT placement were treatment in the northeast (odds ratio, 0.40; 95% confidence interval, 0.30 to 0.53), black race (odds ratio, 0.45; 95% confidence interval, 0.36 to 0.57), increasing left ventricular ejection fraction per 10% (odds ratio, 0.56; 95% confidence interval, 0.52 to 0.60), and increasing age per 10 years in those >70 years of age (odds ratio, 0.56; 95% confidence interval, 0.48 to 0.65). Conclusions— Although CRT is a recent evidence-based therapy for heart failure, patterns of use differ significantly from clinical trials and published guidelines. Important variations also exist for CRT therapy based on race, geographic region, comorbidities, and age and need to be addressed through further study and/or quality-of-care initiatives.

Trends in Use of Implantable Cardioverter-Defibrillator Therapy Among Patients Hospitalized for Heart Failure Have the Previously Observed Sex and Racial Disparities Changed Over Time?

Background— Prior studies have demonstrated low use of implantable cardioverter defibrillators (ICDs) as primary prevention, particularly among women and blacks. The degree to which the overall use of ICD therapy and disparities in use have changed is unclear. Methods and Results— We examined 11 880 unique patients with a history of heart failure and left ventricular ejection fraction ⩽35% who were ≥65 years old and enrolled in the Get With the Guidelines–Heart Failure (GWTG-HF) program from January 2005 through December 2009. We determined the rate of ICD use by year for the overall population and for sex and race groups. From 2005 to 2007, overall ICD use increased from 30.2% to 42.4% and then remained unchanged in 2008 to 2009. After adjustment for potential confounders, ICD use increased significantly in the overall study population during 2005 to 2007 (odds ratio, 1.28; 95% confidence interval, 1.11–1.48 per year; P=0.0008) and in black women (odds ratio, 1.82; 95% confidence interval, 1.28–2.58 per year; P=0.0008), white women (odds ratio, 1.30; 95% confidence interval, 1.06–1.59 per year; P=0.010), black men (odds ratio, 1.54; 95% confidence interval, 1.19–1.99 per year; P=0.0009), and white men (odds ratio, 1.25; 95% confidence interval, 1.06–1.48 per year; P=0.0072). The increase in ICD use was greatest among blacks. Conclusions— In the GWTG-HF quality improvement program, a significant increase in ICD therapy use was observed over time in all sex and race groups. The previously described racial disparities in ICD use were no longer present by the end of the study period; however, sex differences persisted.

Association of race/ethnicity with clinical risk factors, quality of care, and acute outcomes in patients hospitalized with heart failure

BACKGROUND Black and Hispanic populations are at increased risk for developing heart failure (HF) at a younger age and experience differential morbidity and possibly differential mortality compared with whites. Yet, there have been insufficient data characterizing the clinical presentation, quality of care, and outcomes of patients hospitalized with HF as a function of race/ethnicity. METHODS We analyzed 78,801 patients from 257 hospitals voluntarily participating in the American Heart Associations Get With The Guidelines-HF Program from January 2005 thru December 2008. There were 56,266 (71.4%) white, 17,775 (22.6%) black, and 4,760 (6.0%) Hispanic patients. In patients hospitalized with HF, we sought to assess clinical characteristics, adherence to core and other guideline-based HF care measures, and in-hospital mortality as a function of race and ethnicity. RESULTS Relative to white patients, Hispanic and black patients were significantly younger (median age 78.0, 63.0, 64.0 years, respectively), had lower left ventricular ejection fractions, and had more diabetes mellitus and hypertension. With few exceptions, the provision of guideline-based care was comparable for black, Hispanic, and white patients. Black and Hispanic patients had lower in-hospital mortality than white patients: black/white odds ratio 0.69, 95% CI 0.62-0.78, P < .001 and Hispanic/white odds ratio 0.81, 95% CI 0.67-0.98, P = .03. CONCLUSIONS Hispanic and black patients hospitalized with HF have more cardiovascular risk factors than white patients; however; they have similar or better in-hospital mortality rates. Within the context of a national HF quality improvement program, HF care was equitable and improved in all racial/ethnic groups over time.

Rates of cardiopulmonary resuscitation training in the United States.

IMPORTANCE Prompt bystander cardiopulmonary resuscitation (CPR) improves the likelihood of surviving an out-of-hospital cardiac arrest. Large regional variations in survival after an out-of-hospital cardiac arrest have been noted. OBJECTIVES To determine whether regional variations in county-level rates of CPR training exist across the United States and the factors associated with low rates in US counties. DESIGN, SETTING, AND PARTICIPANTS We used a cross-sectional ecologic study design to analyze county-level rates of CPR training in all US counties from July 1, 2010, through June 30, 2011. We used CPR training data from the American Heart Association, the American Red Cross, and the Health & Safety Institute. Using multivariable logistic regression models, we examined the association of annual rates of adult CPR training of citizens by these 3 organizations (categorized as tertiles) with a countys geographic, population, and health care characteristics. EXPOSURE Completion of CPR training. MAIN OUTCOME AND MEASURES Rate of CPR training measured as CPR course completion cards distributed and CPR training products sold by the American Heart Association, persons trained in CPR by the American Red Cross, and product sales data from the Health & Safety Institute. RESULTS During the study period, 13.1 million persons in 3143 US counties received CPR training. Rates of county training ranged from 0.00% to less than 1.29% (median, 0.51%) in the lower tertile, 1.29% to 4.07% (median, 2.39%) in the middle tertile, and greater than 4.07% or greater (median, 6.81%) in the upper tertile. Counties with rates of CPR training in the lower tertile were more likely to have a higher proportion of rural areas (adjusted odds ratio, 1.12 [95% CI, 1.10-1.15] per 5-percentage point [PP] change), higher proportions of black (1.09 [1.06-1.13] per 5-PP change) and Hispanic (1.06 [1.02-1.11] per 5-PP change) residents, a lower median household income (1.18 [1.04-1.34] per

Preventing tomorrow's sudden cardiac death today: Dissemination of effective therapies for sudden cardiac death prevention

10 000 decrease), and a higher median age (1.28 [1.04-1.58] per 10-year change). Counties in the South, Midwest, and West were more likely to have rates of CPR training in the lower tertile compared with the Northeast (adjusted odds ratios, 7.78 [95% CI, 3.66-16.53], 5.56 [2.63-11.75], and 5.39 [2.48-11.72], respectively). CONCLUSIONS AND RELEVANCE Annual rates of US CPR training are low and vary widely across communities. Counties located in the South, those with higher proportions of rural areas and of black and Hispanic residents, and those with lower median household incomes have lower rates of CPR training than their counterparts. These data contribute to known geographic disparities in survival of cardiac arrest and offer opportunities for future community interventions.

Cloning, overexpression, purification, and immunobiology of an 85-kilodalton outer membrane protein from Haemophilus ducreyi

Because the burden of sudden cardiac death (SCD) is substantial, it is important to use all guideline-driven therapies to prevent SCD. Among those therapies is the implantable cardioverter defibrillator (ICD). When indicated, ICD use is beneficial and cost-effective. Unfortunately, studies suggest that most patients who have indications for this therapy for primary or secondary prevention of SCD are not receiving it. To explore potential reasons for this underuse and to propose potential facilitators for ICD dissemination, the Duke Center for the Prevention of SCD at the Duke Clinical Research Institute (Durham, NC) organized a think tank meeting of experts on this issue. The meeting took place on December 12 and 13, 2007, and it included representatives of clinical cardiology, cardiac electrophysiology, general internal medicine, economics, health policy, the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Health care Research and Quality, and the device and pharmaceutical industry. Although the meeting was funded by industry participants, this article summarizing the presentations and discussions that occurred at the meeting presents the expert opinion of the authors.

Racial differences in long-term survival among patients with coronary artery disease

ABSTRACT We have identified an 85-kDa outer membrane protein that is expressed by all tested strains of Haemophilus ducreyi. Studies of related proteins from other pathogenic bacteria, includingHaemophilus influenzae, Pasteurella multocida, Neisseria gonorrhoeae, Neisseria meningitidis, and Shigella dysenteriae, suggested a role for these proteins in pathogenesis and immunity. In keeping with the first such described protein fromHaemophilus influenzae type B, we termed the H. ducreyi protein D15. The gene encoding the H. ducreyiD15 protein was cloned and sequenced, and the deduced amino acid sequence was found to be most similar to sequences of the D15-related proteins from other Pasteurella spp. The arrangement of the flanking genes was similar to that of H. influenzae Rd and suggested that D15 was part of a multigene operon. Attempts to make a null mutation of the D15 gene were unsuccessful, paralleling results in other D15 gene studies. Overexpression of H. ducreyi D15 inEscherichia coli resulted in a source of recombinant D15 (rD15) from which it was readily purified. rD15 was immunogenic, and it was found that immunization of rabbits with an rD15 vaccine preparation conferred partial protection against a virulent challenge infection. Antisera to an N-terminal peptide recognized all tested strains ofH. ducreyi.

Extent of and Reasons for Nonuse of Implantable Cardioverter Defibrillator Devices in Clinical Practice Among Eligible Patients With Left Ventricular Systolic Dysfunction

BACKGROUND Cardiovascular disease is the leading cause of death among blacks and whites in the United States. Despite this, there are insufficient data on the long-term prognosis of black patients with coronary artery disease (CAD) as well as the major clinical related determinants of outcome. METHODS We studied 22,618 patients (3,314 black) having significant CAD findings at cardiac catheterization performed at Duke from January 1986 to December 2004 with follow-up through June 2006. Using Kaplan-Meier and Cox modeling, we compared unadjusted and adjusted long-term survival by patient race and gender (median follow-up 7.6 years, interquartile range 3.5-13.0) as well as identified major patient characteristics associated with survival. RESULTS Blacks with CAD were younger; were more often female; had lower median household incomes; and had more hypertension, diabetes mellitus, and heart failure. The number of coronary vessels with significant disease was similar by race. At 15-year follow-up, black women had the lowest survival and white men had the highest (41.5% vs 45.8%, P < .0001). Blacks were less likely to receive initial therapy with coronary revascularization (odds ratio 0.66, 95% CI 0.60-0.72, P < .0001). After adjusting for baseline clinical and demographic characteristics and initial treatment selection, black race remained an independent predictor of lower survival (hazard ratio 2.54, 95% CI 1.60-4.04, P < .0001). CONCLUSIONS Among patients with CAD, blacks have lower long-term survival compared with whites. The difference may be partially, but not fully, explained by differences in cardiovascular risk factors and 30-day revascularization rates.

Management of Postoperative Atrial Fibrillation and Subsequent Outcomes in Contemporary Patients Undergoing Cardiac Surgery: Insights From the Society of Thoracic Surgeons CAPS‐Care Atrial Fibrillation Registry

Background— Several studies that used claims and registry data have reported that 40% to 80% of patients eligible for an implantable cardioverter defibrillator (ICD) fail to receive one in clinical practice, and the rates are especially high among women and blacks. The extent and documented reasons for nonuse of ICDs among patients with left ventricular systolic dysfunction are unknown. Methods and Results— Using hospital claims and clinical data, we identified patients hospitalized with a heart failure diagnosis and left ventricular ejection fraction ⩽30% between January 1, 2007, and August 30, 2007, at a tertiary-care center. Using claims data, we determined placement of an ICD or cardiac resynchronization therapy with defibrillation device at any time up to 1 year after hospitalization. Medical records for patients without an ICD were abstracted to determine reasons for nonuse. Patients with an ICD were compared with patients without an ICD and also with patients without an ICD who did not have any contraindication for an ICD as identified through chart abstraction. Of the 542 potentially eligible patients identified, 224 (41%) did not have an ICD. In the initial adjusted analysis, female sex (odds ratio=1.90; 95% CI, 1.28 to 2.81) and increasing age (odds ratio=1.07; 95% CI, 1.04 to 1.11) were associated with a higher likelihood of not having an ICD. After detailed chart review, of the 224 patients without an ICD, 117 (52%) were ineligible for the device and 38 (17%) patients refused the device, resulting in only 69 (13%) patients eligible for an ICD who failed to receive one. In this subsequent adjusted analysis, remaining factors associated with a higher likelihood of not having an ICD were absence of ventricular arrhythmias (odds ratio=4.93; 95% CI, 2.56 to 9.50), noncardiology hospital service (odds ratio=3.73; 95% CI, 1.98 to 7.04), and lack of health insurance (odds ratio=3.10; 95% CI, 1.48 to 6.46). Conclusions— On the basis of a detailed chart review, the true rate of ICD underuse may be substantially lower than previous estimates. In addition, after accounting for ICD eligibility criteria, patient sex and age disparities in ICD therapy were no longer present.

Race and gender variation in the QT interval and its association with mortality in patients with coronary artery disease: Results from the Duke Databank for Cardiovascular Disease (DDCD)

Postoperative atrial fibrillation (POAF) is a well‐recognized complication of cardiac surgery; however, its management remains a challenge, and the implementation and outcomes of various strategies in clinical practice remain unclear.