BackgroundAtrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all‐cause mortality may guide interventions.Methods and ResultsIn the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose‐adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all‐cause mortality in the 14 171 participants in the intention‐to‐treat population. The median age was 73 years, and the mean CHADS 2 score was 3.5. Over 1.9 years of median follow‐up, 1214 (8.6%) patients died. Kaplan–Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all‐cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33–1.70, P<0.0001) and age ≥75 years (hazard ratio 1.69, 95% CI 1.51–1.90, P<0.0001) were associated with higher all‐cause mortality. Multiple additional characteristics were independently associated with higher mortality, with decreasing creatinine clearance, chronic obstructive pulmonary disease, male sex, peripheral vascular disease, and diabetes being among the most strongly associated (model C‐index 0.677).ConclusionsIn a large population of patients anticoagulated for nonvalvular atrial fibrillation, ≈7 in 10 deaths were cardiovascular, whereas <1 in 10 deaths were caused by nonhemorrhagic stroke or systemic embolism. Optimal prevention and treatment of heart failure, renal impairment, chronic obstructive pulmonary disease, and diabetes may improve survival.Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00403767.
Introduction Congestive heart failure is a leading cause of cardiovascular morbidity and mortality that results in a significant financial burden on healthcare expenditure. Though various strategies have been employed to reduce hospital readmissions, one valuable tool that remains greatly underutilized is the CardioMEMS (Abbott), a remote pulmonary artery pressure-monitoring system, which has been shown to help reduce heart failure rehospitalizations in the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) trial. Methods ICD-9/ICD-10 codes for chronic heart failure were used to identify patients who presented with congestive heart failure. Of this group, those eligible for CardioMEMS device placement, as based on the CHAMPION trial definition, were selected. Subsequently, a retrospective review of the electronic medical records was completed. All patients were on ACC/AHA guideline-directed medical therapy and had at least one hospital admission for NYHA class III symptoms. Results 473 patients met the inclusion criteria, of which, 85 patients were found to be eligible for implantation of CardioMEMS device based on the CHAMPION trial definition. Only 18/85 patients received the device, roughly 21%, and the overall CardioMEMS implantation rate was only 4% (18/473) of the total cohort. Conclusion Despite the benefits to patients and reducing healthcare expenditure, there has been a poor adaptation of this groundbreaking technology. Our study revealed that 79% of eligible heart failure patients did not receive the device. Therefore, efforts need to be undertaken to improve physician and patient education of the device to complement the current standard of care for congestive heart failure.
Objective Hyperlipidemia is an important risk factor for atherosclerotic cardiovascular disease. Many patients are intolerant to or have limited benefit from statins. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been approved for treating hyperlipidemia in these patients. We sought to investigate the impact of these medications in a real-world cardiology practice. Methods This was a retrospective study of 17 patients with either heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease with low-density lipoprotein cholesterol (LDL-C) levels above the treatment target despite maximally tolerated statins. Baseline lipid profile was compared with a repeat lipid profile obtained 4 to 6 weeks after initiating treatment with a PCSK9 inhibitor. Results The average duration of PCSK9 inhibitor treatment was 10.7 months. Lipid profile comparison showed that total cholesterol decreased from 243 ± 72 to 148 ± 39 (mg/dL) (39% reduction), triglycerides decreased from 185 ± 86 to 149 ± 62 (mg/dL) (19.5% reduction), high-density lipoprotein cholesterol increased from 56 ± 20 to 62 ± 26 (mg/dL) (10.7% increase), and LDL-C decreased from 154 ± 30 to 57 ± 32 (mg/dL) (63% reduction) from baseline. Conclusions PCSK9 inhibitors as add-on therapy to maximally tolerated statins resulted in an approximately 63% reduction in LDL-C.
Background Transesophageal echocardiogram (TEE) is a valuable tool in healthcare today with its ease of use, ability to visualize important structures not seen on transthoracic echocardiogram (TTE), and the relatively lower cost of TEE, high yield, and no significant radiation exposure. The American Society of Echocardiography (ASE) has developed an appropriate use criteria for use of TTE and TEE, which outline various scenarios where a TEE is indicated as an initial diagnostic testing modality and when it is useful as an adjunctive test in hopes of decreasing inappropriate use. Using these criteria as a guide, we devised a quality assessment study to investigate how well TEEs performed at our institution fit the appropriate use criteria specifically for the diagnostic workup of infective endocarditis. Methods A retrospective chart review was performed for all TEEs performed in 2017 with the indication of endocarditis. Baseline patient characteristics, presence of bacteremia, and the quality of the TTE preceding the TEE were noted, as well as whether a vegetation, abscess, or perforation was visualized. We also determined if there was a cardiology consultation placed prior to TEE and if the patient had met the definition for endocarditis as defined by the Duke criteria. Finally, we made note of the TEE findings and assessed whether the TEE met appropriate use criteria developed by the American Society of Echocardiography. Results A total of 50 patients who underwent TEE with the indication of “endocarditis” were identified. 36% of the TTEs prior to the TEE were rated as good quality, 40% as adequate, 4% as fair, 4% as suboptimal, 12% as technically difficult, and 4% were not rated. Vegetations were visualized on 12% of TTEs, 6% of patients had a prosthetic valve, and 6% had a cardiac device. In 20% of the cases, there was no cardiology consultation prior to the TEE and in 20% of the cases, there was no documented bacteremia. 26% of patients met the Duke criteria for endocarditis prior to TEE. Only 36% of TEEs revealed evidence of infection and of the patients with no evidence of infection, only 38% met appropriate use criteria. Overall, only 56% of patients met appropriate use criteria for TEE. Conclusion Transesophageal echocardiography is a valuable tool in a modern physician's arsenal for managing a variety of diseases and conditions. However, the procedure is not without associated risks and its ease of use and widespread adoption has led to frequent questionable appropriateness of use of the test. Only 56% of the TEEs performed in our analysis met appropriate use. More awareness and education is needed for the appropriate use criteria for transesophageal echocardiography as outlined by the ASE to help reduce patient exposure to procedure related complications and to decrease medical costs on unnecessary procedures.
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