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Papers by Bimal Shah

Research paper thumbnail of Outcomes After Nonemergent Electrical Cardioversion for Atrial Arrhythmias

American Journal of Cardiology, May 1, 2015

and Vivus Pharmaceuticals (all significant); consulting, honoraria, or other services (including ... more and Vivus Pharmaceuticals (all significant); consulting, honoraria, or other services (including CME) from Portola and Regado Biosciences (modest), Duke Private Diagnostic Clinic (significant); and reimbursement for personal expenses from Bristol Myers Squibb ($5-25K). L Broderick-Forsgren: Dr. Broderick-Forsgren has no relevant disclosures to report.

Research paper thumbnail of Patterns of Stress Testing and Diagnostic Catheterization After Coronary Stenting in 250 350 Medicare Beneficiaries

Circulation-cardiovascular Imaging, 2013

A better understanding of the predictors and downstream impact of imaging after PCI requires both... more A better understanding of the predictors and downstream impact of imaging after PCI requires both rich clinical characteristics and longitudinal outcomes data. Therefore, we examined patterns of stress testing (ST) and invasive coronary angiography (CA) after PCI in a large, contemporary cohort using a unique data set, which combined the Centers for Medicare & Medicaid Services and the National Cardiovascular Data Registry CathPCI Registry. Methods Study Population All patients >65 years receiving PCI with stenting, admitted and discharged between January 1, 2004, and December 31, 2008, and enrolled in the CathPCI Registry (with subsequent date restrictions, described below, for the final study population) were included. The CathPCI Registry is a large, national, clinical registry of patients undergoing cardiac catheterization or PCI. 12,13 The first PCI with a stent procedure for each admission was considered the index event and was the initial unit of analysis; there were 672 617 eligible index events. CathPCI Registry index events were matched to Medicare inpatient claims data using indirect identifiers to link unique admissions. 14 Index CathPCI Registry events lacking Medicare inpatient claims (including procedures performed in the outpatient setting or at Veterans Affairs Administration hospitals and procedures paid through Medicare-managed care plans, employer-sponsored plans, or private insurance plans) could not be matched. Even so, using this Background-Patterns of noninvasive stress test (ST) and invasive coronary angiography (CA) utilization after percutaneous coronary intervention (PCI) are not well described in older populations. Methods and Results-We linked National Cardiovascular Data Registry CathPCI Registry data with longitudinal Medicare claims data for 250 350 patients undergoing PCI from 2005 to 2007 and described subsequent testing and outcomes. Between 60 days post-PCI and end of follow-up (median 24 months), 49% (n=122 894) received ST first, 10% (n=25 512) underwent invasive CA first, and 41% (n=101 944) had no testing. Several clinical risk factors at time of index PCI were associated with decreased likelihood of downstream testing (ST or CA, P<0.05 for all), including older age (hazard ratio [HR] 0.784 per 10-year increase), male sex (HR 0.946), heart failure (HR 0.925), diabetes mellitus (HR 0.954), smoking (HR 0.804), and renal failure (HR 0.880). Fifteen percent of patients with ST first proceeded to subsequent CA within 90 days of testing (n=18 472/101 884); of these, 48% (n=8831) underwent revascularization within 90 days, compared with 53% (n=13 316) of CA first patients (P<0.0001). Conclusions-In this descriptive analysis, ST and invasive CA were common in older patients after PCI. Paradoxically, patients with higher risk features at baseline were less likely to undergo post-PCI testing. The revascularization yield was low on patients referred for ST after PCI, with only 9% undergoing revascularization within 90 days.

Research paper thumbnail of Effects of alirocumab on types of myocardial infarction: insights from the ODYSSEY OUTCOMES trial

European Heart Journal, 2019

Aims The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into... more Aims The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into five types: Type 1, spontaneous; Type 2, related to oxygen supply/demand imbalance; Type 3, fatal without ascertainment of cardiac biomarkers; Type 4, related to percutaneous coronary intervention; and Type 5, related to coronary artery bypass surgery. Low-density lipoprotein cholesterol (LDL-C) reduction with statins and proprotein convertase subtilisin–kexin Type 9 (PCSK9) inhibitors reduces risk of MI, but less is known about effects on types of MI. ODYSSEY OUTCOMES compared the PCSK9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome (ACS) and elevated LDL-C (≥1.8 mmol/L) despite intensive statin therapy. In a pre-specified analysis, we assessed the effects of alirocumab on types of MI. Methods and results Median follow-up was 2.8 years. Myocardial infarction types were prospectively adjudicated and classified. Of 1860 total MIs, 1223 (65.8%) w...

Research paper thumbnail of Predicting Thromboembolic and Bleeding Event Risk in Patients with Non-Valvular Atrial Fibrillation: A Systematic Review

Thrombosis and Haemostasis, 2018

Background Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of str... more Background Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke. Medical therapy for decreasing stroke risk involves anticoagulation, which may increase bleeding risk for certain patients. In determining the optimal therapy for stroke prevention for patients with AF, clinicians use tools with various clinical, imaging and patient characteristics to weigh stroke risk against therapy-associated bleeding risk. Aim This article reviews published literature and summarizes available risk stratification tools for stroke and bleeding prediction in patients with AF. Methods We searched for English-language studies in PubMed, Embase and the Cochrane Database of Systematic Reviews published between 1 January 2000 and 14 February 2018. Two reviewers screened citations for studies that examined tools for predicting thromboembolic and bleeding risks in patients with AF. Data regarding study design, patient characteristics, interventions, outcomes, quality, and...

Research paper thumbnail of Efficacy and Safety of Alirocumab 150 mg Every 4 Weeks in Patients With Hypercholesterolemia Not on Statin Therapy: The ODYSSEY CHOICE II Study

Journal of the American Heart Association, 2016

Background The PCSK 9 antibody alirocumab (75 mg every 2 weeks; Q2W) as monotherapy reduced low‐d... more Background The PCSK 9 antibody alirocumab (75 mg every 2 weeks; Q2W) as monotherapy reduced low‐density lipoprotein‐cholesterol ( LDL ‐C) levels by 47%. Because the option of a monthly dosing regimen is convenient, ODYSSEY CHOICE II evaluated alirocumab 150 mg Q4W in patients with inadequately controlled hypercholesterolemia and not on statin (majority with statin‐associated muscle symptoms), receiving treatment with fenofibrate, ezetimibe, or diet alone. Methods and Results Patients were randomly assigned to placebo, alirocumab 150 mg Q4W or 75 mg Q2W (calibrator arm), with dose adjustment to 150 mg Q2W at week (W) 12 if W8 predefined LDL ‐C target levels were not met. The primary efficacy endpoint was LDL ‐C percentage change from baseline to W24. Mean baseline LDL ‐C levels were 163.9 mg/dL (alirocumab 150 mg Q4W, n=59), 154.5 mg/dL (alirocumab 75 mg Q2W, n=116), and 158.5 mg/dL (placebo, n=58). In the alirocumab 150 mg Q4W and 75 mg Q2W groups (49.1% and 36.0% of patients receiv...

Research paper thumbnail of Outcomes After Nonemergent Electrical Cardioversion for Atrial Arrhythmias

The American Journal of Cardiology, 2015

and Vivus Pharmaceuticals (all significant); consulting, honoraria, or other services (including ... more and Vivus Pharmaceuticals (all significant); consulting, honoraria, or other services (including CME) from Portola and Regado Biosciences (modest), Duke Private Diagnostic Clinic (significant); and reimbursement for personal expenses from Bristol Myers Squibb ($5-25K). L Broderick-Forsgren: Dr. Broderick-Forsgren has no relevant disclosures to report.

Research paper thumbnail of Medication Non-Adherence After Myocardial Infarction: An Exploration of Modifying Factors

Journal of General Internal Medicine, 2014

Research paper thumbnail of Patterns, predictors, variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke

Journal of the American Heart Association, 2012

BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an in... more BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an incoming stroke patient is guideline recommended as a means of increasing the timeliness with which stroke patients are evaluated and treated. Still, data are limited with regard to national use of, variations in, and temporal trends in EMS prenotification and associated predictors of its use. METHODS AND RESULTS#ENTITYSTARTX02014;: We examined 371 988 patients with acute ischemic stroke who were transported by EMS and enrolled in 1585 hospitals participating in Get With The Guidelines-Stroke from April 1, 2003, through March 31, 2011. Prenotification occurred in 249 197 EMS-transported patients (67.0%) and varied widely by hospital (range, 0% to 100%). Substantial variations by geographic regions and by state, ranging from 19.7% in Washington, DC, to 93.4% in Montana, also were noted. Patient factors associated with lower use of prenotification included older age, diabetes mellitus, and p...

Research paper thumbnail of Antithrombotic Therapy Use at Discharge and 1 Year in Patients With Atrial Fibrillation and Acute Stroke

Stroke, 2011

Background and Purpose— Current American Heart Association/American Stroke Association guidelines... more Background and Purpose— Current American Heart Association/American Stroke Association guidelines identify warfarin use as a class IA indication in patients with atrial fibrillation (AF) and ischemic stroke (IS) or transient ischemic attack (TIA). However, few studies have examined factors associated with long-term antithrombotic therapy use in IS/TIA patients with AF. Methods— We utilized the Get With The Guidelines–Stroke national quality improvement registry and the Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) Registry to examine patterns of antithrombotic use at discharge and at 12 months in IS/TIA patients with AF. A multivariate logistic regression model was developed to identify predictors of warfarin use in this patient population at 12 months. Results— Of the 2460 IS/TIA patients, 291 (11.8%) had AF, of which 5.5% of patients were discharged on aspirin alone, 49.1% on warfarin alone, 1.4% on clopidogrel alone, 34.7% on warfarin plus aspirin, 2.1% on aspir...

Research paper thumbnail of Hospital Variation and Characteristics of Implantable Cardioverter-Defibrillator Use in Patients With Heart Failure

Journal of the American College of Cardiology, 2009

Research paper thumbnail of Use of Stress Testing and Diagnostic Catheterization After Coronary Stenting

Journal of the American College of Cardiology, 2013

Research paper thumbnail of Frequency and Impact of Prior Myocardial Infarction Among Patients with Acute Myocardial Infarction Treated in Contemporary Practice: Results from the Ncdr®

Journal of the American College of Cardiology, 2013

Background: Despite improved secondary prevention strategies, patients with a previous MI frequen... more Background: Despite improved secondary prevention strategies, patients with a previous MI frequently have another event; however, few studies have described contemporary features, management, and in-hospital outcomes of those with and without a prior MI. methods: A total of 307,646 consecutive MI patients in the NCDR® from 01/2007[[Unable to Display Character: –]]03/2012 were studied. Baseline characteristics, home medications, and in-hospital mortality rates were compared. The NCDR® mortality model was used for adjustment (c=0.84). results: Prior MI was documented in 19% of STEMI (n=116,331) and 29% of NSTEMI patients (n=191,315). Patients with prior MI were older, more likely to be male, have hypertension, dyslipidemia, and diabetes mellitus, and more likely to be treated with evidence-based medications at home compared with those without prior MI. The unadjusted in-hospital mortality rates were higher with prior MI for STEMI (3.9% vs. 3.3%) and NSTEMI patients (3.7% vs. 2.9%). Nevertheless, the risk of adjusted mortality was similar with prior MI in STEMI patients (adjusted OR 1.00, 95% CI 0.90[[Unable to Display Character: –]]1.10), but significantly higher in NSTEMI patients (adjusted OR 1.08, 95% CI 1.03[[Unable to Display Character: –]]1.15, p=0.004). conclusions: More than 20% of acute MI patients have had a prior MI event and these patients have a higher burden of modifiable risk factors and are more likely to be treated with evidence-based medications before hospitalization. However, prior MI is independently associated with inhospital mortality only in NSTEMI patients.

Research paper thumbnail of Patterns of Cardiac Stress Testing After Revascularization in Community Practice

Journal of the American College of Cardiology, 2010

The purpose of this study was to determine the pattern of cardiac stress testing after coronary r... more The purpose of this study was to determine the pattern of cardiac stress testing after coronary revascularization in community practice. Background The American College of Cardiology Foundation appropriate use criteria provide guidance for the use of cardiac stress imaging after coronary revascularization. However, little is known regarding the use of routine cardiac stress testing in coronary artery bypass grafting or percutaneous coronary intervention patients as well as their downstream use of invasive procedures after noninvasive testing in community practice. Methods Use and timing of stress testing more than 90 days after revascularization in patients 18 to 64 years of age were determined from a national health insurance claims database from July 1, 2004, through June 30, 2007. Subsequent rates of angiography and repeat revascularization after stress testing also were examined. Results Of 28,177 patients undergoing revascularization (21,046 percutaneous coronary intervention procedures and 7,131 coronary artery bypass grafting procedures), 59% had at least 1 cardiac stress test within 24 months. Sixty-one percent of patients with percutaneous coronary intervention and 51% of patients with coronary artery bypass grafting had undergone testing by 24 months. Nuclear imaging was the predominant testing method. The incidence of testing was found to increase at both 6 months and 12 months after revascularization, suggesting an association with elective follow-up office visits. Furthermore, testing varied according to geographic location. Of those tested, only 11% underwent subsequent cardiac catheterization and only 5% underwent repeat revascularization. Conclusions Although there is limited consensus as to the appropriate role of elective stress testing after coronary revascularization, more than one half of all patients in community practice had at least 1 stress test within 24 months of revascularization. Yield on such testing was low: only 5% of patients tested ultimately required repeat revascularization. These findings support the need to define better the role of stress testing after recent revascularization.

Research paper thumbnail of The Impact of For-Profit Hospital Status on the Care and Outcomes of Patients With Non–ST-Segment Elevation Myocardial Infarction

Journal of the American College of Cardiology, 2007

We sought to determine whether for-profit status influenced hospitals' care or outcomes among non... more We sought to determine whether for-profit status influenced hospitals' care or outcomes among non-STsegment elevation myocardial infarction (NSTEMI) patients. Background While for-profit hospitals potentially have financial incentives to selectively care for younger, healthier patients, perform highly reimbursed procedures, reduce costs by limiting access to expensive medications, and encourage shorter in-patient length of stay, there are limited data available to investigate these issues objectively. Methods Using data from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines) Initiative, we investigated whether for-profit status influenced hospitals' patient case mix, care, or outcomes among 145,357 patients with NSTEMI treated between January 1, 2001, and December 31, 2005, at 532 U.S. hospitals. Impact of for-profit status on care and outcomes was analyzed overall and after adjustment for clinical and facility factors using regression modeling. Results Patients (n ϭ 11,658) treated at 58 for-profit hospitals were of similar age and gender, but were more likely to be nonwhite (black, Asian, Hispanic, and other) and have health maintenance organization/private insurance, diabetes mellitus, congestive heart failure, hypertension, and renal insufficiency compared with 133,699 patients treated at 474 nonprofit hospitals. For-profit hospitals were less likely to use discharge beta-blockers, but all other treatments were similar including the use of interventional procedures (cardiac catheterization and revascularization procedures) compared with nonprofit centers. In-hospital length of stay and mortality were also similar by hospital type. Conclusions We found no evidence that for-profit hospitals selectively treat less sick patients, provide less evidence-based care, limit in-hospital stays, or have patients with worse acute outcomes than nonprofit centers.

Research paper thumbnail of Association Between Physician Billing and Cardiac Stress Testing Patterns Following Coronary Revascularization

JAMA, 2011

ARDIAC STRESS TESTING PROcedures performed in the office setting can enable more rapid, efficient... more ARDIAC STRESS TESTING PROcedures performed in the office setting can enable more rapid, efficient diagnostic testing and use of these procedures has increased significantly during the past decade. 1 However, physician ownership of imaging equipment also could potentially induce testing in more discretionary situations, because the capital outlay for equipment is high and these investments must be recouped via procedure-related "technical fees," which cover associated equipment and practice costs. Similar concerns have been raised regarding whether physicians who bill for the professional fees covering test interpretation might more often refer their own patients for these tests than those who do not bill for these services. 2-4 However, little is known about how these reimbursement incentives might affect the routine use of cardiac stress testing. For editorial comment see p 2028.

Research paper thumbnail of Patterns and Predictors of Stress Testing Modality After Percutaneous Coronary Stenting

JACC: Cardiovascular Imaging, 2012

We evaluated temporal trends and geographic variation in choice of stress testing modality after ... more We evaluated temporal trends and geographic variation in choice of stress testing modality after percutaneous coronary intervention (PCI), as well as associations between modality and procedure use after testing. B A C K G R O U N D Stress testing is frequently performed post-PCI, but the choices among available modalities (electrocardiography only, nuclear, or echocardiography; pharmacological or exercise stress) and consequences of such choices are not well characterized. M E T H O D S CathPCI Registry® data were linked with identifiable Medicare claims to capture stress testing use between 60 and 365 days post-PCI and procedures within 90 days after testing. Testing rates and modality used were modeled on the basis of patient, procedure, and PCI facility factors, calendar quarter, and Census Divisions using Poisson and logistic regression. Post-test procedure use was assessed using Gray's test. R E S U L T S Among 284,971 patients, the overall stress testing rate after PCI was 53.1 per 100 person-years. Testing rates declined from 59.3 in quarter 1 (2006) to 47.1 in quarter 4 (2008), but the relative use of modalities changed little. Among exercise testing recipients, adjusted proportions receiving electrocardiography-only testing varied from 6.8% to 22.8% across Census Divisions; and among exercise testing recipients having an imaging test, the proportion receiving echocardiography (versus nuclear) varied from 9.4% to 34.1%. Post-test procedure use varied among modalities; exercise electrocardiography-only testing was associated with more subsequent stress testing (13.7% vs. 2.9%; p Ͻ 0.001), but less catheterization (7.4% vs. 14.1%; p Ͻ 0.001) than imaging-based tests.

Research paper thumbnail of Influence of Clinical Trial Participation on Subsequent Antithrombin Use

Clinical Cardiology, 2010

BackgroundResults from the Superior Yield of the New Strategy of Enoxaparin, Revascularization, a... more BackgroundResults from the Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial showed that the low‐molecular‐weight heparin (LMWH) enoxaparin was non‐inferior compared with unfractionated heparin (UFH) in patients with non‐ST‐elevation acute coronary syndromes (NSTE‐ACS) managed invasively.HypothesisWe explored the influence of SYNERGY trial site participation on subsequent patterns of heparin use for NSTE‐ACS patients treated in routine practice.MethodsWe examined temporal patterns of LMWH use compared with UFH use among 122 764 patients with NSTE‐ACS enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative between January 1, 2002 and June 30, 2006, to determine whether site participation in SYNERGY influenced the type of heparin used before and after publication of the SYNERGY r...

Research paper thumbnail of Secondary Prevention Risk Interventions Via Telemedicine and Tailored Patient Education (SPRITE)

Circulation: Cardiovascular Quality and Outcomes, 2011

Background— Secondary prevention by risk factor modification improves patient outcomes, yet it is... more Background— Secondary prevention by risk factor modification improves patient outcomes, yet it is often not achieved in clinical practice. Reasons for failure stem from challenges of prioritizing risk factor reduction and engaging patients in changing their behaviors. We hypothesize that a novel telemedicine intervention with tailored patient education could improve cardiovascular risk factors. Methods— To evaluate this intervention, we propose enrolling 450 patients with a recent myocardial infarction and hypertension into a 3-arm randomized, controlled trial. The first arm (n=150) will receive home blood pressure (BP) monitors plus a nurse-delivered, telephone-based tailored patient education intervention and will be enrolled into HealthVault, a Microsoft electronic health record platform. The second arm (n=150) will also receive BP monitors plus a tailored patient education intervention and be enrolled in HeartVault. However, the patient education intervention will be delivered b...

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

Circulation: Cardiovascular Quality and Outcomes, 2011

Background— Several studies that used claims and registry data have reported that 40% to 80% of p... more 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 w...

Research paper thumbnail of Emergency Medical Service Hospital Prenotification Is Associated With Improved Evaluation and Treatment of Acute Ischemic Stroke

Circulation: Cardiovascular Quality and Outcomes, 2012

Background— The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stro... more Background— The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stroke are time-dependent. Emergency medical services (EMS) hospital prenotification of an incoming patient with potential stroke may provide a means of reducing evaluation and treatment times and improving treatment rates; yet, available data are limited. Methods and Results— We examined 371 988 patients with acute ischemic stroke transported by EMS and enrolled in Get With The Guidelines–Stroke from April 1, 2003, to March 31, 2011. Prenotification occurred in 249 197 (67.0%) of EMS-transported patients. Among eligible patients arriving by 2 hours, patients with EMS prenotification were more likely to be treated with tPA within 3 hours (82.8% versus 79.2%, absolute difference +3.5%, P <0.0001, the National Institutes of Health Stroke Scale-documented cohort; 73.0% versus 64.0%, absolute difference +9.0%, P <0.0001, overall cohort). Patients with EMS prenotification had shorter door-t...

Research paper thumbnail of Outcomes After Nonemergent Electrical Cardioversion for Atrial Arrhythmias

American Journal of Cardiology, May 1, 2015

and Vivus Pharmaceuticals (all significant); consulting, honoraria, or other services (including ... more and Vivus Pharmaceuticals (all significant); consulting, honoraria, or other services (including CME) from Portola and Regado Biosciences (modest), Duke Private Diagnostic Clinic (significant); and reimbursement for personal expenses from Bristol Myers Squibb ($5-25K). L Broderick-Forsgren: Dr. Broderick-Forsgren has no relevant disclosures to report.

Research paper thumbnail of Patterns of Stress Testing and Diagnostic Catheterization After Coronary Stenting in 250 350 Medicare Beneficiaries

Circulation-cardiovascular Imaging, 2013

A better understanding of the predictors and downstream impact of imaging after PCI requires both... more A better understanding of the predictors and downstream impact of imaging after PCI requires both rich clinical characteristics and longitudinal outcomes data. Therefore, we examined patterns of stress testing (ST) and invasive coronary angiography (CA) after PCI in a large, contemporary cohort using a unique data set, which combined the Centers for Medicare & Medicaid Services and the National Cardiovascular Data Registry CathPCI Registry. Methods Study Population All patients >65 years receiving PCI with stenting, admitted and discharged between January 1, 2004, and December 31, 2008, and enrolled in the CathPCI Registry (with subsequent date restrictions, described below, for the final study population) were included. The CathPCI Registry is a large, national, clinical registry of patients undergoing cardiac catheterization or PCI. 12,13 The first PCI with a stent procedure for each admission was considered the index event and was the initial unit of analysis; there were 672 617 eligible index events. CathPCI Registry index events were matched to Medicare inpatient claims data using indirect identifiers to link unique admissions. 14 Index CathPCI Registry events lacking Medicare inpatient claims (including procedures performed in the outpatient setting or at Veterans Affairs Administration hospitals and procedures paid through Medicare-managed care plans, employer-sponsored plans, or private insurance plans) could not be matched. Even so, using this Background-Patterns of noninvasive stress test (ST) and invasive coronary angiography (CA) utilization after percutaneous coronary intervention (PCI) are not well described in older populations. Methods and Results-We linked National Cardiovascular Data Registry CathPCI Registry data with longitudinal Medicare claims data for 250 350 patients undergoing PCI from 2005 to 2007 and described subsequent testing and outcomes. Between 60 days post-PCI and end of follow-up (median 24 months), 49% (n=122 894) received ST first, 10% (n=25 512) underwent invasive CA first, and 41% (n=101 944) had no testing. Several clinical risk factors at time of index PCI were associated with decreased likelihood of downstream testing (ST or CA, P<0.05 for all), including older age (hazard ratio [HR] 0.784 per 10-year increase), male sex (HR 0.946), heart failure (HR 0.925), diabetes mellitus (HR 0.954), smoking (HR 0.804), and renal failure (HR 0.880). Fifteen percent of patients with ST first proceeded to subsequent CA within 90 days of testing (n=18 472/101 884); of these, 48% (n=8831) underwent revascularization within 90 days, compared with 53% (n=13 316) of CA first patients (P<0.0001). Conclusions-In this descriptive analysis, ST and invasive CA were common in older patients after PCI. Paradoxically, patients with higher risk features at baseline were less likely to undergo post-PCI testing. The revascularization yield was low on patients referred for ST after PCI, with only 9% undergoing revascularization within 90 days.

Research paper thumbnail of Effects of alirocumab on types of myocardial infarction: insights from the ODYSSEY OUTCOMES trial

European Heart Journal, 2019

Aims The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into... more Aims The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into five types: Type 1, spontaneous; Type 2, related to oxygen supply/demand imbalance; Type 3, fatal without ascertainment of cardiac biomarkers; Type 4, related to percutaneous coronary intervention; and Type 5, related to coronary artery bypass surgery. Low-density lipoprotein cholesterol (LDL-C) reduction with statins and proprotein convertase subtilisin–kexin Type 9 (PCSK9) inhibitors reduces risk of MI, but less is known about effects on types of MI. ODYSSEY OUTCOMES compared the PCSK9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome (ACS) and elevated LDL-C (≥1.8 mmol/L) despite intensive statin therapy. In a pre-specified analysis, we assessed the effects of alirocumab on types of MI. Methods and results Median follow-up was 2.8 years. Myocardial infarction types were prospectively adjudicated and classified. Of 1860 total MIs, 1223 (65.8%) w...

Research paper thumbnail of Predicting Thromboembolic and Bleeding Event Risk in Patients with Non-Valvular Atrial Fibrillation: A Systematic Review

Thrombosis and Haemostasis, 2018

Background Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of str... more Background Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke. Medical therapy for decreasing stroke risk involves anticoagulation, which may increase bleeding risk for certain patients. In determining the optimal therapy for stroke prevention for patients with AF, clinicians use tools with various clinical, imaging and patient characteristics to weigh stroke risk against therapy-associated bleeding risk. Aim This article reviews published literature and summarizes available risk stratification tools for stroke and bleeding prediction in patients with AF. Methods We searched for English-language studies in PubMed, Embase and the Cochrane Database of Systematic Reviews published between 1 January 2000 and 14 February 2018. Two reviewers screened citations for studies that examined tools for predicting thromboembolic and bleeding risks in patients with AF. Data regarding study design, patient characteristics, interventions, outcomes, quality, and...

Research paper thumbnail of Efficacy and Safety of Alirocumab 150 mg Every 4 Weeks in Patients With Hypercholesterolemia Not on Statin Therapy: The ODYSSEY CHOICE II Study

Journal of the American Heart Association, 2016

Background The PCSK 9 antibody alirocumab (75 mg every 2 weeks; Q2W) as monotherapy reduced low‐d... more Background The PCSK 9 antibody alirocumab (75 mg every 2 weeks; Q2W) as monotherapy reduced low‐density lipoprotein‐cholesterol ( LDL ‐C) levels by 47%. Because the option of a monthly dosing regimen is convenient, ODYSSEY CHOICE II evaluated alirocumab 150 mg Q4W in patients with inadequately controlled hypercholesterolemia and not on statin (majority with statin‐associated muscle symptoms), receiving treatment with fenofibrate, ezetimibe, or diet alone. Methods and Results Patients were randomly assigned to placebo, alirocumab 150 mg Q4W or 75 mg Q2W (calibrator arm), with dose adjustment to 150 mg Q2W at week (W) 12 if W8 predefined LDL ‐C target levels were not met. The primary efficacy endpoint was LDL ‐C percentage change from baseline to W24. Mean baseline LDL ‐C levels were 163.9 mg/dL (alirocumab 150 mg Q4W, n=59), 154.5 mg/dL (alirocumab 75 mg Q2W, n=116), and 158.5 mg/dL (placebo, n=58). In the alirocumab 150 mg Q4W and 75 mg Q2W groups (49.1% and 36.0% of patients receiv...

Research paper thumbnail of Outcomes After Nonemergent Electrical Cardioversion for Atrial Arrhythmias

The American Journal of Cardiology, 2015

and Vivus Pharmaceuticals (all significant); consulting, honoraria, or other services (including ... more and Vivus Pharmaceuticals (all significant); consulting, honoraria, or other services (including CME) from Portola and Regado Biosciences (modest), Duke Private Diagnostic Clinic (significant); and reimbursement for personal expenses from Bristol Myers Squibb ($5-25K). L Broderick-Forsgren: Dr. Broderick-Forsgren has no relevant disclosures to report.

Research paper thumbnail of Medication Non-Adherence After Myocardial Infarction: An Exploration of Modifying Factors

Journal of General Internal Medicine, 2014

Research paper thumbnail of Patterns, predictors, variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke

Journal of the American Heart Association, 2012

BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an in... more BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an incoming stroke patient is guideline recommended as a means of increasing the timeliness with which stroke patients are evaluated and treated. Still, data are limited with regard to national use of, variations in, and temporal trends in EMS prenotification and associated predictors of its use. METHODS AND RESULTS#ENTITYSTARTX02014;: We examined 371 988 patients with acute ischemic stroke who were transported by EMS and enrolled in 1585 hospitals participating in Get With The Guidelines-Stroke from April 1, 2003, through March 31, 2011. Prenotification occurred in 249 197 EMS-transported patients (67.0%) and varied widely by hospital (range, 0% to 100%). Substantial variations by geographic regions and by state, ranging from 19.7% in Washington, DC, to 93.4% in Montana, also were noted. Patient factors associated with lower use of prenotification included older age, diabetes mellitus, and p...

Research paper thumbnail of Antithrombotic Therapy Use at Discharge and 1 Year in Patients With Atrial Fibrillation and Acute Stroke

Stroke, 2011

Background and Purpose— Current American Heart Association/American Stroke Association guidelines... more Background and Purpose— Current American Heart Association/American Stroke Association guidelines identify warfarin use as a class IA indication in patients with atrial fibrillation (AF) and ischemic stroke (IS) or transient ischemic attack (TIA). However, few studies have examined factors associated with long-term antithrombotic therapy use in IS/TIA patients with AF. Methods— We utilized the Get With The Guidelines–Stroke national quality improvement registry and the Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) Registry to examine patterns of antithrombotic use at discharge and at 12 months in IS/TIA patients with AF. A multivariate logistic regression model was developed to identify predictors of warfarin use in this patient population at 12 months. Results— Of the 2460 IS/TIA patients, 291 (11.8%) had AF, of which 5.5% of patients were discharged on aspirin alone, 49.1% on warfarin alone, 1.4% on clopidogrel alone, 34.7% on warfarin plus aspirin, 2.1% on aspir...

Research paper thumbnail of Hospital Variation and Characteristics of Implantable Cardioverter-Defibrillator Use in Patients With Heart Failure

Journal of the American College of Cardiology, 2009

Research paper thumbnail of Use of Stress Testing and Diagnostic Catheterization After Coronary Stenting

Journal of the American College of Cardiology, 2013

Research paper thumbnail of Frequency and Impact of Prior Myocardial Infarction Among Patients with Acute Myocardial Infarction Treated in Contemporary Practice: Results from the Ncdr®

Journal of the American College of Cardiology, 2013

Background: Despite improved secondary prevention strategies, patients with a previous MI frequen... more Background: Despite improved secondary prevention strategies, patients with a previous MI frequently have another event; however, few studies have described contemporary features, management, and in-hospital outcomes of those with and without a prior MI. methods: A total of 307,646 consecutive MI patients in the NCDR® from 01/2007[[Unable to Display Character: –]]03/2012 were studied. Baseline characteristics, home medications, and in-hospital mortality rates were compared. The NCDR® mortality model was used for adjustment (c=0.84). results: Prior MI was documented in 19% of STEMI (n=116,331) and 29% of NSTEMI patients (n=191,315). Patients with prior MI were older, more likely to be male, have hypertension, dyslipidemia, and diabetes mellitus, and more likely to be treated with evidence-based medications at home compared with those without prior MI. The unadjusted in-hospital mortality rates were higher with prior MI for STEMI (3.9% vs. 3.3%) and NSTEMI patients (3.7% vs. 2.9%). Nevertheless, the risk of adjusted mortality was similar with prior MI in STEMI patients (adjusted OR 1.00, 95% CI 0.90[[Unable to Display Character: –]]1.10), but significantly higher in NSTEMI patients (adjusted OR 1.08, 95% CI 1.03[[Unable to Display Character: –]]1.15, p=0.004). conclusions: More than 20% of acute MI patients have had a prior MI event and these patients have a higher burden of modifiable risk factors and are more likely to be treated with evidence-based medications before hospitalization. However, prior MI is independently associated with inhospital mortality only in NSTEMI patients.

Research paper thumbnail of Patterns of Cardiac Stress Testing After Revascularization in Community Practice

Journal of the American College of Cardiology, 2010

The purpose of this study was to determine the pattern of cardiac stress testing after coronary r... more The purpose of this study was to determine the pattern of cardiac stress testing after coronary revascularization in community practice. Background The American College of Cardiology Foundation appropriate use criteria provide guidance for the use of cardiac stress imaging after coronary revascularization. However, little is known regarding the use of routine cardiac stress testing in coronary artery bypass grafting or percutaneous coronary intervention patients as well as their downstream use of invasive procedures after noninvasive testing in community practice. Methods Use and timing of stress testing more than 90 days after revascularization in patients 18 to 64 years of age were determined from a national health insurance claims database from July 1, 2004, through June 30, 2007. Subsequent rates of angiography and repeat revascularization after stress testing also were examined. Results Of 28,177 patients undergoing revascularization (21,046 percutaneous coronary intervention procedures and 7,131 coronary artery bypass grafting procedures), 59% had at least 1 cardiac stress test within 24 months. Sixty-one percent of patients with percutaneous coronary intervention and 51% of patients with coronary artery bypass grafting had undergone testing by 24 months. Nuclear imaging was the predominant testing method. The incidence of testing was found to increase at both 6 months and 12 months after revascularization, suggesting an association with elective follow-up office visits. Furthermore, testing varied according to geographic location. Of those tested, only 11% underwent subsequent cardiac catheterization and only 5% underwent repeat revascularization. Conclusions Although there is limited consensus as to the appropriate role of elective stress testing after coronary revascularization, more than one half of all patients in community practice had at least 1 stress test within 24 months of revascularization. Yield on such testing was low: only 5% of patients tested ultimately required repeat revascularization. These findings support the need to define better the role of stress testing after recent revascularization.

Research paper thumbnail of The Impact of For-Profit Hospital Status on the Care and Outcomes of Patients With Non–ST-Segment Elevation Myocardial Infarction

Journal of the American College of Cardiology, 2007

We sought to determine whether for-profit status influenced hospitals' care or outcomes among non... more We sought to determine whether for-profit status influenced hospitals' care or outcomes among non-STsegment elevation myocardial infarction (NSTEMI) patients. Background While for-profit hospitals potentially have financial incentives to selectively care for younger, healthier patients, perform highly reimbursed procedures, reduce costs by limiting access to expensive medications, and encourage shorter in-patient length of stay, there are limited data available to investigate these issues objectively. Methods Using data from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines) Initiative, we investigated whether for-profit status influenced hospitals' patient case mix, care, or outcomes among 145,357 patients with NSTEMI treated between January 1, 2001, and December 31, 2005, at 532 U.S. hospitals. Impact of for-profit status on care and outcomes was analyzed overall and after adjustment for clinical and facility factors using regression modeling. Results Patients (n ϭ 11,658) treated at 58 for-profit hospitals were of similar age and gender, but were more likely to be nonwhite (black, Asian, Hispanic, and other) and have health maintenance organization/private insurance, diabetes mellitus, congestive heart failure, hypertension, and renal insufficiency compared with 133,699 patients treated at 474 nonprofit hospitals. For-profit hospitals were less likely to use discharge beta-blockers, but all other treatments were similar including the use of interventional procedures (cardiac catheterization and revascularization procedures) compared with nonprofit centers. In-hospital length of stay and mortality were also similar by hospital type. Conclusions We found no evidence that for-profit hospitals selectively treat less sick patients, provide less evidence-based care, limit in-hospital stays, or have patients with worse acute outcomes than nonprofit centers.

Research paper thumbnail of Association Between Physician Billing and Cardiac Stress Testing Patterns Following Coronary Revascularization

JAMA, 2011

ARDIAC STRESS TESTING PROcedures performed in the office setting can enable more rapid, efficient... more ARDIAC STRESS TESTING PROcedures performed in the office setting can enable more rapid, efficient diagnostic testing and use of these procedures has increased significantly during the past decade. 1 However, physician ownership of imaging equipment also could potentially induce testing in more discretionary situations, because the capital outlay for equipment is high and these investments must be recouped via procedure-related "technical fees," which cover associated equipment and practice costs. Similar concerns have been raised regarding whether physicians who bill for the professional fees covering test interpretation might more often refer their own patients for these tests than those who do not bill for these services. 2-4 However, little is known about how these reimbursement incentives might affect the routine use of cardiac stress testing. For editorial comment see p 2028.

Research paper thumbnail of Patterns and Predictors of Stress Testing Modality After Percutaneous Coronary Stenting

JACC: Cardiovascular Imaging, 2012

We evaluated temporal trends and geographic variation in choice of stress testing modality after ... more We evaluated temporal trends and geographic variation in choice of stress testing modality after percutaneous coronary intervention (PCI), as well as associations between modality and procedure use after testing. B A C K G R O U N D Stress testing is frequently performed post-PCI, but the choices among available modalities (electrocardiography only, nuclear, or echocardiography; pharmacological or exercise stress) and consequences of such choices are not well characterized. M E T H O D S CathPCI Registry® data were linked with identifiable Medicare claims to capture stress testing use between 60 and 365 days post-PCI and procedures within 90 days after testing. Testing rates and modality used were modeled on the basis of patient, procedure, and PCI facility factors, calendar quarter, and Census Divisions using Poisson and logistic regression. Post-test procedure use was assessed using Gray's test. R E S U L T S Among 284,971 patients, the overall stress testing rate after PCI was 53.1 per 100 person-years. Testing rates declined from 59.3 in quarter 1 (2006) to 47.1 in quarter 4 (2008), but the relative use of modalities changed little. Among exercise testing recipients, adjusted proportions receiving electrocardiography-only testing varied from 6.8% to 22.8% across Census Divisions; and among exercise testing recipients having an imaging test, the proportion receiving echocardiography (versus nuclear) varied from 9.4% to 34.1%. Post-test procedure use varied among modalities; exercise electrocardiography-only testing was associated with more subsequent stress testing (13.7% vs. 2.9%; p Ͻ 0.001), but less catheterization (7.4% vs. 14.1%; p Ͻ 0.001) than imaging-based tests.

Research paper thumbnail of Influence of Clinical Trial Participation on Subsequent Antithrombin Use

Clinical Cardiology, 2010

BackgroundResults from the Superior Yield of the New Strategy of Enoxaparin, Revascularization, a... more BackgroundResults from the Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial showed that the low‐molecular‐weight heparin (LMWH) enoxaparin was non‐inferior compared with unfractionated heparin (UFH) in patients with non‐ST‐elevation acute coronary syndromes (NSTE‐ACS) managed invasively.HypothesisWe explored the influence of SYNERGY trial site participation on subsequent patterns of heparin use for NSTE‐ACS patients treated in routine practice.MethodsWe examined temporal patterns of LMWH use compared with UFH use among 122 764 patients with NSTE‐ACS enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative between January 1, 2002 and June 30, 2006, to determine whether site participation in SYNERGY influenced the type of heparin used before and after publication of the SYNERGY r...

Research paper thumbnail of Secondary Prevention Risk Interventions Via Telemedicine and Tailored Patient Education (SPRITE)

Circulation: Cardiovascular Quality and Outcomes, 2011

Background— Secondary prevention by risk factor modification improves patient outcomes, yet it is... more Background— Secondary prevention by risk factor modification improves patient outcomes, yet it is often not achieved in clinical practice. Reasons for failure stem from challenges of prioritizing risk factor reduction and engaging patients in changing their behaviors. We hypothesize that a novel telemedicine intervention with tailored patient education could improve cardiovascular risk factors. Methods— To evaluate this intervention, we propose enrolling 450 patients with a recent myocardial infarction and hypertension into a 3-arm randomized, controlled trial. The first arm (n=150) will receive home blood pressure (BP) monitors plus a nurse-delivered, telephone-based tailored patient education intervention and will be enrolled into HealthVault, a Microsoft electronic health record platform. The second arm (n=150) will also receive BP monitors plus a tailored patient education intervention and be enrolled in HeartVault. However, the patient education intervention will be delivered b...

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

Circulation: Cardiovascular Quality and Outcomes, 2011

Background— Several studies that used claims and registry data have reported that 40% to 80% of p... more 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 w...

Research paper thumbnail of Emergency Medical Service Hospital Prenotification Is Associated With Improved Evaluation and Treatment of Acute Ischemic Stroke

Circulation: Cardiovascular Quality and Outcomes, 2012

Background— The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stro... more Background— The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stroke are time-dependent. Emergency medical services (EMS) hospital prenotification of an incoming patient with potential stroke may provide a means of reducing evaluation and treatment times and improving treatment rates; yet, available data are limited. Methods and Results— We examined 371 988 patients with acute ischemic stroke transported by EMS and enrolled in Get With The Guidelines–Stroke from April 1, 2003, to March 31, 2011. Prenotification occurred in 249 197 (67.0%) of EMS-transported patients. Among eligible patients arriving by 2 hours, patients with EMS prenotification were more likely to be treated with tPA within 3 hours (82.8% versus 79.2%, absolute difference +3.5%, P <0.0001, the National Institutes of Health Stroke Scale-documented cohort; 73.0% versus 64.0%, absolute difference +9.0%, P <0.0001, overall cohort). Patients with EMS prenotification had shorter door-t...