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Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Severe Ischemic Left Ventricular Systolic Dysfunction
No full textCoronary artery disease is the most common cause of heart failure, which is the leading cause of cardiovascular-related death worldwide. There are insufficient data to make strong recommendations for percutaneous coronary intervention (PCI) in patients with severe ischemic left ventricular systolic dysfunction (LVSD). In that context, we performed a meta-analysis to compare the outcomes of PCI with those of optimal medical therapy alone in patients with severe ischemic LVSD. A systematic search was conducted in PubMed, EMBASE, and ClinicalTrials.gov from inception to December 2023. Our outcome of interest was all-cause mortality in patients undergoing PCI vs medical therapy. We used random effects models to aggregate data and to calculate pooled incidence and relative risk with 95% CIs. Four studies including 2 randomized controlled trials with 2080 patients (PCI, 1082; optimal medical therapy, 998) were included. All-cause mortality did not differ significantly between the groups: 168 patients (15.5%) in the PCI group vs 200 patients (20.0%) in the optimal medical therapy group (relative risk, 0.88; 95% CI, 0.75-1.09; P=.25). In conclusion, the available evidence indicates that PCI does not improve all-cause mortality in patients with severe LVSD without lifestyle-limiting anginal symptoms. Further data are needed to identify subgroups of patients better served by each modality
Complete versus culprit-only percutaneous coronary intervention in elderly patients with acute coronary syndrome and multivessel coronary artery disease: A systematic review and meta-analysis
No full textBackground: Culprit-only percutaneous coronary intervention (PCI) is commonly performed for acute coronary syndrome (ACS) with multivessel coronary artery disease (MVD) in the elderly. Complete revascularization has been shown to benefit the general population, yet its safety and efficacy in older patients are uncertain.
Methods: Following PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing complete versus culprit-only PCI in patients ≥65 years old with ACS and MVD. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included myocardial infarction (MI), ischemia-driven revascularization (IDR), all-cause mortality, and cardiovascular mortality. Data were pooled using a random effects model with a restricted maximum likelihood estimator to generate risk ratios (RRs).
Results: Five RCTs with 4105 patients aged ≥65 years were included. Compared with culprit-only PCI, complete revascularization reduced MI (RR 0.65; 95 % CI 0.49-0.85; p \u3c 0.01). MACE (RR 0.75; 95 % CI 0.54-1.05; p = 0.09) and IDR (RR 0.41; 95 % CI 0.16-1.04; p = 0.06) were not significantly different between both strategies among those aged ≥65. However, there was a significant reduction in MI (RR 0.69; 95 % CI 0.49-0.96; p-value = 0.03), MACE (RR 0.78; 95 % CI 0.65-0.94; p \u3c 0.01), and IDR (RR 0.60; 95 % CI 0.41-0.89; p \u3c 0.01) in those aged ≥75.
Conclusions: In elderly patients aged ≥65 years with ACS and MVD, a strategy of complete revascularization by PCI reduces MI compared to culprit-only PCI with no significant difference in MACE and IDR. However, complete revascularization reduced MI, MACE, and IDR in those aged ≥75 years suggesting a possible benefit in this age group.
Keywords: Acute coronary syndrome; Complete revascularization; Culprit-only PCI; Elderly; Myocardial infarction; Percutaneous coronary intervention
The role of machine learning models for predicting in-hospital mortality after transcatheter aortic valve replacement
No full textThe joy of surgery: how gender influences surgeons\u27 experiences
No full textIntroduction: Burnout in medicine is an epidemic, and surgeons are not immune. Studies often focus on negative factors leading to burnout, with less emphasis on optimizing joy. The purpose of this study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, was to explore how gender may influence surgeon well-being to better inform organizational change.
Methods: The study team developed a survey with the domains: facilitators of joy, support for best work, time for work tasks, barriers to joy, and what they would do with more time. The survey was emailed to 5777 addresses on the SAGES distribution list. Results were analyzed by calculating summary statistics.
Results: 223 surgeons completed the survey; 62.3% identified as men, 32.3% as women, and 5.4% did not indicate gender. Female compared to male respondents were younger (41.6 vs 52.5 years) and had practiced for fewer years (8.4 vs 19.4 years). The three greatest differences in facilitators of joy were being a leader in the field, leading clinical teams, and teaching, with a \u3e 10 percentage point difference between men/women rating these highly (score of ≥ 8). Women generally perceived less support from their institutions than men. The greatest gender difference was in support for teaching, with 52.8% of men rating this highly compared to 30.2% of women. Only 52% of women felt respected by coworkers most of the time compared to 68.3% of men. Most (96.0%) respondents (men 95.7% and women 98.6%) reported wanting more time with family and friends.
Conclusion: This study demonstrates the complexity of the personal and professional factors that influence joy in surgery, highlight gender differences that impact joy and suggests opportunities for improved gender-based support. These results can inform potential organization-level changes and further research to better understand emerging differences in joy across gender identities.
Keywords: Burnout; Job satisfaction; Joy; Occupational stress; Physician engagement; Psychological well-being; Surgeons; Workplace
Consensus Guidance for Monitoring Individuals With Islet Autoantibody-Positive Pre-Stage 3 Type 1 Diabetes
No full textGiven the proven benefits of screening to reduce diabetic ketoacidosis (DKA) likelihood at the time of stage 3 type 1 diabetes diagnosis, and emerging availability of therapy to delay disease progression, type 1 diabetes screening programs are being increasingly emphasized. Once broadly implemented, screening initiatives will identify significant numbers of islet autoantibody-positive (IAb+) children and adults who are at risk for (confirmed single IAb+) or living with (multiple IAb+) early-stage (stage 1 and stage 2) type 1 diabetes. These individuals will need monitoring for disease progression; much of this care will happen in nonspecialized settings. To inform this monitoring, JDRF, in conjunction with international experts and societies, developed consensus guidance. Broad advice from this guidance includes the following: 1) partnerships should be fostered between endocrinologists and primary care providers to care for people who are IAb+; 2) when people who are IAb+ are initially identified, there is a need for confirmation using a second sample; 3) single IAb+ individuals are at lower risk of progression than multiple IAb+ individuals; 4) individuals with early-stage type 1 diabetes should have periodic medical monitoring, including regular assessments of glucose levels, regular education about symptoms of diabetes and DKA, and psychosocial support; 5) interested people with stage 2 type 1 diabetes should be offered trial participation or approved therapies; and 6) all health professionals involved in monitoring and care of individuals with type 1 diabetes have a responsibility to provide education. The guidance also emphasizes significant unmet needs for further research on early-stage type 1 diabetes to increase the rigor of future recommendations and inform clinical care
Outcomes of Device-detected Atrial High-rate Episodes in Patients with No Prior History of Atrial Fibrillation: A Systematic Review and Meta-analysis
No full textBackground: Outcomes of device-detected AF remain unclear in individuals without a prior history of AF.
Methods: A meta-analysis was conducted to evaluate outcomes in individuals with no prior history of AF who experienced device-detected AF. Outcomes assessed were clinical AF, thromboembolism and all-cause mortality. A fixed-effects model was used to calculate RRs with 95% CI.
Results: Compared to individuals who did not experience device-detected AF, those who did had increased risks of clinical AF (RR 3.33, 95% CI [1.99.5.57]; p\u3c0.0001) and thromboembolic events (RR 2.21; 95% CI [1.72.2.85]; p\u3c0.0001). The risk of all-cause mortality was similar between both groups (RR 1.19; 95% CI [0.95.1.49]; p=0.13). Subgroup analysis revealed an increased risk of thromboembolic events among device-detected AF .24 hours (RR 12.34; 95% CI [2.70.56.36]).
Conclusion: While there is an increased risk of clinical AF and thromboembolism in individuals with device-detected AF, mortality was insignificant.
Keywords: Atrial high-rate episodes; mortality; stroke; subclinical atrial fibrillation; thromboembolism
Your BMC Voice - July 2024
No full textIn this video, Dr. Andy Artenstein sits down with Dr. Raquel Belforti, Associate Dean of Education at UMass Chan Medical School-Baystate for an exclusive interview about the Population-Based Urban & Rural Community Health (PURCH) program. Dr. Kassandra Jean-Marie, 2024 PURCH graduate, joins the conversation and discusses the influence the PURCH program made on her approach to patient care and Lisa Clinton, PURCH Community Engagement & Integration Coordinator, discusses how the PURCH program aligns with the needs of our community.https://scholarlycommons.libraryinfo.bhs.org/bmp_voice/1006/thumbnail.jp
Evaluating Quality of Care for Patients with Asthma in the Readmission Penalty Era
No full textRationale: Asthma poses a significant burden for US patients and health systems, yet inpatient care quality is understudied. National chronic obstructive lung disease (COPD) readmission policies may affect inpatient asthma care through hospital responses to these polices due to imprecise diagnosis and identification of patients with COPD and asthma.
Objectives: Evaluate inpatient care quality care for patients hospitalized with asthma and potential collateral effects of the Medicare COPD Hospital Readmissions Reduction Program (HRRP).
Methods: Retrospective cohort study of patients aged 18-54 years hospitalized for asthma across 924 US hospitals (Premier Healthcare Database).
Results: Care quality for patients with asthma was evaluated pre-HRRP implementation (n=20,820; January 2010-September 2014) and post-HRRP implementation (n=26,885; October 2014-December 2018) using adherence to inpatient care guidelines (recommended, non-recommended, and ideal care [all recommended with no non-recommended care]). Between 2010-2018, at least 80% of patients received recommended care annually. Recommended care decreased similarly (rate of 0.02%/month) post vs. pre-HRRP (p=0.8). Non-recommended care decreased more rapidly post-HRRP (rate of 0.29%/month) vs. pre-HRRP (rate of 0.17%/month; p
Conclusions: Post-HRRP trends suggest asthma care improved with increased rates of guideline concordance in non-recommended and ideal care. While federal policies (e.g., HRRP) may have had positive collateral effects such as with asthma care, parallel care efforts including antibiotic stewardship likely contributed to these improvements
Effectiveness of Updated 2023-2024 (Monovalent XBB.1.5) COVID-19 Vaccination Against SARS-CoV-2 Omicron XBB and BA.2.86/JN.1 Lineage Hospitalization and a Comparison of Clinical Severity-IVY Network, 26 Hospitals, October 18, 2023-March 9, 2024
No full textBackground: Assessing variant-specific COVID-19 vaccine effectiveness (VE) and severity can inform public health risk assessments and decisions about vaccine composition. BA.2.86 and its descendants, including JN.1 (referred to collectively as JN lineages ), emerged in late 2023 and exhibited substantial divergence from co-circulating XBB lineages.
Methods: We analyzed patients hospitalized with COVID-19-like illness at 26 hospitals in 20 U.S. states admitted October 18, 2023-March 9, 2024. Using a test-negative, case-control design, we estimated effectiveness of an updated 2023-2024 (Monovalent XBB.1.5) COVID-19 vaccine dose against sequence-confirmed XBB and JN lineage hospitalization using logistic regression. Odds of severe outcomes, including intensive care unit (ICU) admission and invasive mechanical ventilation (IMV) or death, were compared for JN versus XBB lineage hospitalizations using logistic regression.
Results: 585 case-patients with XBB lineages, 397 case-patients with JN lineages, and 4,580 control-patients were included. VE in the first 7-89 days after receipt of an updated dose was 54.2% (95% CI = 36.1%-67.1%) against XBB lineage hospitalization and 32.7% (95% CI = 1.9%-53.8%) against JN lineage hospitalization. Odds of ICU admission (adjusted odds ratio [aOR] 0.80; 95% CI = 0.46-1.38) and IMV or death (aOR 0.69; 95% CI = 0.34-1.40) were not significantly different among JN compared to XBB lineage hospitalizations.
Conclusions: Updated 2023-2024 COVID-19 vaccination provided protection against both XBB and JN lineage hospitalization, but protection against the latter may be attenuated by immune escape. Clinical severity of JN lineage hospitalizations was not higher relative to XBB.
Keywords: COVID-19 severity; COVID-19 vaccine effectiveness; JN.1 and BA.2.86; SARS-COV-2 variants; test-negative design
Economic Disparities in Utilization and Outcomes of Structural Heart Disease Interventions in the United States
No full textBackground: Disparities in access to care cause negative health consequences for underserved populations. Economic disparities in structural heart disease (SHD) interventions are not well characterized.
Objectives: The objective of this study was to evaluate economic disparities in the utilization and outcomes of SHD interventions in the United States.
Methods: We queried the National Inpatient Sample (2016-2020) to examine economic disparities in the utilization, in-hospital outcomes, length of stay, and cost of SHD interventions among patients ≥65 years of age. Outcomes were determined using logistic regression models.
Results: A total of 401,005 weighted hospitalizations for transcatheter aortic valve replacement, left atrial appendage occlusion, transcatheter mitral valve repair, and transcatheter mitral valve replacement were included. Utilization rates (number of procedures performed per 100,000 hospitalizations) were higher in patients with high income compared with medium and low income for transcatheter aortic valve replacement (559 vs 456 vs 338), left atrial appendage occlusion (148 vs 136 vs 99), transcatheter mitral valve repair (65 vs 54 vs 41), and transcatheter mitral valve replacement (7.7 vs 6.7 vs 1.2) (all P \u3c 0.01). Low- and medium-income patients had distinctive demographic and clinical risk profiles compared with high-income patients. There were no significant differences in the adjusted in-hospital mortality, key complications, or length of stay between high-, medium-, and low-income patients following any of the 4 SHD interventions. High-income patients incurred a modestly higher cost with any of the 4 SHD interventions compared with medium- and low-income patients.
Conclusions: Economic disparities exist in the utilization of SHD interventions in the United States. Nonetheless, adjusted in-hospital outcomes were comparable among high-, medium-, and low-income patients. Multifaceted implementation strategies are needed to attenuate these utilization disparities.
Keywords: LAAO; TAVR; TMVR; TMVr; economic disparities; structural heart disease