Vikas Bhatia

Relation of Baseline Systolic Blood Pressure and Long-Term Outcomes in Ambulatory Patients With Chronic Mild to Moderate Heart Failure

We studied the impact of baseline systolic blood pressure (SBP) on outcomes in patients with mild to moderate chronic systolic and diastolic heart failure (HF) in the Digitalis Investigation Group trial using a propensity-matched design. Of 7,788 patients, 7,785 had baseline SBP data and 3,538 had SBP ≤ 120 mm Hg. Propensity scores for SBP ≤ 120 mm Hg, calculated for each of the 7,785 patients, were used to assemble a matched cohort of 3,738 patients with SBP ≤ 120 and >120 mm Hg who were well-balanced in 32 baseline characteristics. All-cause mortality occurred in 35% and 32% of matched patients with SBPs ≤ 120 and >120 mm Hg respectively, during 5 years of follow-up (hazard ratio [HR] when SBP ≤ 120 was compared to >120 mm Hg 1.10, 95% confidence interval [CI] 0.99 to 1.23, p = 0.088). HRs for cardiovascular and HF mortalities associated with SBP ≤ 120 mm Hg were 1.15 (95% CI 1.01 to 1.30, p = 0.031) and 1.30 (95% CI 1.08 to 1.57, p = 0.006). Cardiovascular hospitalization occurred in 53% and 49% of matched patients with SBPs ≤ 120 and > 120 mm Hg, respectively (HR 1.13, 95% CI 1.03 to 1.24, p = 0.008). HRs for all-cause and HF hospitalizations associated with SBP ≤ 120 mm Hg were 1.10 (95% CI 1.02 to 1.194, p = 0.017) and 1.21 (95% CI 1.07 to 1.36, p = 0.002). In conclusion, in patients with mild to moderate long-term systolic and diastolic HF, baseline SBP ≤ 120 mm Hg was associated with increased cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations that was independent of other baseline characteristics.

Beta-blocker use and 30-day all-cause readmission in medicare beneficiaries with systolic heart failure

BACKGROUND Beta-blockers improve outcomes in patients with systolic heart failure. However, it is unknown whether their initial negative inotropic effect may increase 30-day all-cause readmission, a target outcome for Medicare cost reduction and financial penalty for hospitals under the Affordable Care Act. METHODS Of the 3067 Medicare beneficiaries discharged alive from 106 Alabama hospitals (1998-2001) with a primary discharge diagnosis of heart failure and ejection fraction <45%, 2202 were not previously on beta-blocker therapy, of which 383 received new discharge prescriptions for beta-blockers. Propensity scores for beta-blocker use, estimated for each of the 2202 patients, were used to assemble a matched cohort of 380 pairs of patients receiving and not receiving beta-blockers who were balanced on 36 baseline characteristics (mean age 73 years, mean ejection fraction 27%, 45% women, 33% African American). RESULTS Beta-blocker use was not associated with 30-day all-cause readmission (hazard ratio [HR] 0.87; 95% confidence interval [CI], 0.64-1.18) or heart failure readmission (HR 0.95; 95% CI, 0.57-1.58), but was significantly associated with lower 30-day all-cause mortality (HR 0.29; 95% CI, 0.12-0.73). During 4-year postdischarge, those in the beta-blocker group had lower mortality (HR 0.81; 95% CI, 0.67-0.98) and combined outcome of all-cause mortality or all-cause readmission (HR 0.87; 95% CI, 0.74-0.97), but not with all-cause readmission (HR 0.89; 95% CI, 0.76-1.04). CONCLUSIONS Among hospitalized older patients with systolic heart failure, discharge prescription of beta-blockers was associated with lower 30-day all-cause mortality and 4-year combined death or readmission outcomes without higher 30-day readmission.

Impact of Atrial Fibrillation and Heart Failure, Independent of Each Other and in Combination, on Mortality in Community-Dwelling Older Adults

Atrial fibrillation (AF) and heart failure (HF), common in older adults, are associated with poor outcomes. However, little is known about their impact, independent of each other. We studied 5,673 community-dwelling adults aged ≥ 65 years in the Cardiovascular Health Study. Baseline prevalent AF and HF were centrally adjudicated, and 116 patients had AF only, 219 had HF only, 39 had both, and 5,263 had neither. The Cox proportional hazards model was used to estimate age-gender-race-adjusted hazard ratio (aHR) and 95% confidence intervals (CIs) for all-cause, cardiovascular (CV), and non-CV mortalities. Participants had a mean age of 73 years (± 6 years), 58% were women, and 15% African-American. During 13 years of follow-up, all-cause mortality occurred in 43%, 66%, 74%, and 85% of those with neither, AF only, HF only, and both, respectively. Compared with neither, aHR (95% CIs) for all-cause mortality associated with AF only, HF only, and both was 1.36 (1.08 to 1.72), 2.31 (1.97 to 2.71), and 3.04 (2.15 to 4.29), respectively. Similar associations were observed with CV mortality, but HF only also had greater non-CV mortality (aHR 1.72, 95% CI 1.35 to 2.18). Compared with AF alone, aHR (95% CIs) associated with HF alone for all-cause, CV, and non-CV mortalities was 1.69 (1.29 to 2.23), 1.73 (1.20 to 2.51), and 1.64 (1.09 to 2.46), respectively. Compared with HF alone, those with both conditions had greater CV but not all-cause mortality. In conclusion, community-dwelling older adults with AF have greater mortality than those without but lesser than those with HF, and both conditions were associated with greater CV and all-cause mortalities, whereas only those with HF had greater non-CV mortality.

Outcomes of patients with chronic kidney disease and implantable cardiac defibrillator: Primary versus secondary prevention

BACKGROUND Chronic kidney disease (CKD) is associated with worse survival in patients with implantable cardiac defibrillators (ICDs). This study examined the association of outcomes with CKD in patients receiving an ICD for primary versus secondary prevention. METHODS The study included 696 patients who underwent ICD placement for clinical reasons (59% primary, 41% secondary prevention) at the University of Alabama at Birmingham between January 2002 and September 2007. CKD was defined as an estimated glomerular filtration rate<60 ml/min/1.73 m(2) but not on dialysis. Outcomes of interest included overall mortality and first appropriate ICD therapy (shocks or anti-tachycardia pacing). RESULTS After a follow-up of 50 ± 24 months, 213 patients died (31%) and 111 (16%) received appropriate ICD therapy. Patients with CKD had higher mortality than patients with no CKD in the primary (43% vs. 15%, p<0.001) and secondary prevention (37% vs. 23%, p = 0.003) groups. Patients with CKD were at higher risk of receiving an appropriate ICD therapy than patients without CKD in the primary (p<0.001) but not secondary prevention (p = 0.9) cohort. After adjusting for age, gender and multiple risk factors, CKD was independently associated with all-cause mortality and ICD therapy in the primary prevention group (HR 2.08 [1.34-3.23] and 3.53 [1.75-7.10], p = 0.001 and <0.0001, respectively) but not in the secondary prevention group (HR 1.27 [0.81-2.00], and 0.63 [0.35-1.13], p=0.3 and 0.2, respectively). CONCLUSIONS CKD is independently associated with increased mortality and appropriate ICD therapy in patients undergoing ICD implantation for primary but not secondary prevention.

Comparison of failure rates of crossing side branch with pressure vs. coronary guidewire: a meta-analysis

The aim of this study was to compare the failure rates of crossing side branch (SB) with pressure guidewire vs. coronary guidewire after main vessel (MV) stenting in coronary bifurcation lesions (CBL).

DISCHARGE INITIATION OF ACE INHIBITORS OR ARBS IS ASSOCIATED WITH SIGNIFICANTLY LOWER 30-DAY ALL-CAUSE READMISSION IN HOSPITALIZED OLDER PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION

Heart failure (HF) is the leading cause of 30-day all-cause readmission, the reduction of which is a goal of the Affordable Care Act. Prior studies (AHA 2013) suggest that beta-blockers and aldosterone antagonists may not lower 30-day all-cause readmission in HF and reduced EF (HFrEF). In the

GPIIB/IIIA INHIBITORS USE IMPROVES OUTCOMES AFTER ASPIRATION THROMBECTOMY IN PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION: A METAREGRESSION ANALYSIS

results: Metaregression of 13 RCTs showed that studies with higher GpIIb/IIIa inhibitor use had higher mortality benefit with TA, compared with studies with lower GpIIb/IIIa inhibitor use (0.07 reduction in log-relative risk per 10% increase in GpIIb/IIIa inhibitor use, p=0.047, Figure). A second metaregression to evaluate the association between the prevalence of GpIIb/IIIa inhibitors use in the TA arm minus the prevalence of GpIIb/IIIa inhibitors use in control arm and all-cause mortality with use of TA showed that studies with higher proportion of GpIIb/IIIa inhibitors use in TA arm (than control arm in the same study) showed a higher mortality benefit with TA (0.09 reduction in log-relative risk for every percent higher GpIIb/IIIa inhibitors use in the TA arm, compared with the control arm, p=0.02).

A COMPARATIVE META-ANALYSIS FOR LONG-TERM STROKE IN PATIENTS RECEIVING EDWARDS-SAPIEN VERSUS COREVALVE

Stroke has emerged as an ominous complication after transcatheter aortic valve replacement. While short-term stroke risk of this procedure has been studied, long-term stroke risk with different valve types is not defined. We performed a comprehensive meta-analysis to compare long-term risk of two

COMPLETE VERSUS CULPRIT LESION REVASCULARIZATION DURING PRIMARY PERCUTANEOUS INTERVENTION (PCI) WITH ST-ELEVATION MYOCARDIAL INFARCTION (STEMI): A COMPREHENSIVE META-ANALYSIS OF RANDOMIZED CONTROL TRIALS

Patients with multi-vessel coronary artery disease (CAD) presenting with STEMI, generally undergo primary PCI, which is limited to treating the culprit lesion (CL) rather than complete revascularization (CR). The results from available randomized control trials (RCTs) are conflicting. We performed a