Gregg Fonarow | University of California, Los Angeles (original) (raw)

Papers by Gregg Fonarow

Circulation: Heart …, Jan 1, 2008

Background-Differences in hospital staffing may influence outcomes for patients with acute condit... more Background-Differences in hospital staffing may influence outcomes for patients with acute conditions, including heart failure (HF), depending on which day of the week the patients are admitted. This study examined the relationship between the day of the week patients are hospitalized for HF and death rate, length of stay (LOS), and rehospitalization rate. Methods and Results-A total of 259 US hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) submitted data on 48 612 patients with HF. Sixty-to 90-day postdischarge follow-up data were collected prospectively in a prespecified 10% sample. We analyzed day of admission and discharge, demographic, medical history, medication use, laboratory, and in-hospital procedure data for their association with hospital LOS and death rate. Patient characteristics were similar for weekday and weekend presentation. LOS was a median of 4.0 days and a mean of 5.7Ϯ5.7 days; in-hospital death rate was 3.8%. In-hospital and postdischarge risk of death were similar for each day of the week in the hospital and follow-up cohorts, respectively. LOS, however, was significantly influenced by day of admission, even after adjustment for other LOS risk factors. The shortest LOS by admission day of the week was Tuesday (5.39 days), and the longest was Friday (5.88 days; PϽ0.001). Conclusions-No differences in death rate by day of admission or discharge for HF hospitalizations were evident.

Circulation: Cardiovascular Quality and Outcomes, 2013

A cute heart failure (AHF) is responsible for many millions of hospitalizations globally each yea... more A cute heart failure (AHF) is responsible for many millions of hospitalizations globally each year. Late mortality has been reported at 30% to 50%, and early rehospitalization is common at nearly 25% at 30 days and 50% at 180 days. 1,2 For 2010, costs associated with HF hospitalizations in the United States alone are estimated at $20.9 billion. 1 In addition to the high rate of healthcare use, significant discrepancies in care and outcomes between local regions occur, as well as between Background-Translation of evidence-based heart failure (HF) therapies to clinical practice is incomplete and may vary internationally. We examined common measures of quality of care in patients enrolled in the international Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure trial. Methods and Results-Patients were admitted to 398 hospitals for acute HF in 5 regions (North America, n=3149; Latin America, n=658; Asia Pacific, n=1744; Central Europe, n=966; and Western Europe, n=490). Predefined quality indicators assessed at hospital discharge included the following: medications (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β-blockers, aldosterone antagonists, hydralazine/nitrates, statin therapy, and warfarin), use (or planned use) of implantable intracardiac devices, and blood pressure control (<140/90 mm Hg). We determined regional variations in quality indicators as well as the temporal variation of these indicators during the course of the trial. There was significant variation in conformity among different quality indicators, ranging from 0% to 89%. Of all potential performance opportunities, 19 076 of 32 268 (59%) were met, with Central Europe highest at 64%, followed by North America (63%), Western Europe (61%), Latin America (56%), and Asia Pacific (51%; P<0.0001). North America, Central Europe, and Asia Pacific regions demonstrated a modest increase in quality indicator conformity over time, although there was no significant change in other regions. Conclusions-Quality of care for patients hospitalized with acute HF varies and remains suboptimal even within a randomized clinical trial, which included quality improvement interventions. Specific measures designed to improve performance measures should be implemented even within multicenter clinical trials. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00475852.

European journal of heart failure, Jan 30, 2015

This study sought to investigate regional variation in clinical characteristics, therapy utilizat... more This study sought to investigate regional variation in clinical characteristics, therapy utilization, and post-discharge outcomes among patients hospitalized for heart failure (HHF) enrolled in the multinational ASTRONAUT (Aliskiren Trial on Acute Heart Failure Outcomes) trial. The ASTRONAUT trial randomized 1615 HHF patients with ejection fraction ≤40% to aliskiren or placebo. Enrolled patients were from Eastern Europe (n = 495, 30.7%), Asia/Pacific (n = 439, 27.2%), Western Europe (n = 395, 24.5%), Latin America (n = 163, 10.1%), and North America (n = 123, 7.6%). Marked differences were seen across geographic regions in terms of baseline demographics, vital signs, laboratory tests, co-morbidity burden, and use of guideline-recommended therapies. All-cause death at 12 months ranged from 7.3% in North America to 26.7% in Asia/Pacific, with differences largely driven by sudden cardiac death. Rates of repeat HHF at 12 months ranged from 22.7% in Latin America to 43.9% in North Americ...

The American journal of cardiology, Jan 18, 2015

Device uptake and development have progressed over the last decade, but few quantitative data exi... more Device uptake and development have progressed over the last decade, but few quantitative data exist examining the overall operating characteristics and temporal trends of these clinical trials. We performed a systematic analysis of all cardiovascular device clinical trials from 2001 to 2012 published in medical and cardiovascular journals with the 8 highest impact factors. Of the 1,224 identified cardiovascular clinical trials, 299 (24.4%) focused specifically on devices. Each trial included a median of 335 patients (162 to 745) recruited from a median of 14 sites (3 to 38) over a median enrollment duration of 1.9 years (1.2 to 3.3). Median enrollment rate was 1.1 patients/site/month (0.5 to 4.2). Most device trials targeted coronary artery disease (55.2%), followed by arrhythmias (17.4%). Most were industry sponsored (53.6%) and included mortality as a primary end point (69.6%). The median number of patients (225 to 499, p <0.001 for trend) and enrolling sites (11 to 19, p = 0.0...

Circulation, Jan 20, 2015

-Aspirin is the most widely used antiplatelet drug post-myocardial infarction (MI), yet its optim... more -Aspirin is the most widely used antiplatelet drug post-myocardial infarction (MI), yet its optimal maintenance dose after percutaneous coronary intervention (PCI) with stenting remains uncertain. -We compared outcomes of 10,213 MI patients who underwent PCI and were discharged on dual antiplatelet therapy at 228 United States hospitals in the TRANSLATE-ACS study from 2010-2012. Major adverse cardiovascular events (MACE) and bleeding within 6 months post-discharge were compared between high- (325 mg) and low-dose aspirin (81 mg) using regression models with inverse probability-weighted propensity adjustment. Overall, 6,387 patients (63%) received high-dose aspirin at discharge. MACE risk was not significantly different between groups (high vs. low: unadjusted 8.2% vs. 9.2%; adjusted hazard ratio 0.99, 95% confidence interval [CI] 0.85-1.17). High-dose aspirin use was associated with greater risk of any Bleeding Academic Research Consortium (BARC)-defined bleeding events (unadjusted 24.2% vs. 22.7%; adjusted odds ratio [OR] 1.19, 95% CI 1.06-1.33), driven mostly by minor BARC type 1 or 2 bleeding events not requiring hospitalization (unadjusted 21.4% vs. 19.5%; adjusted OR 1.19, 95% CI 1.05-1.34). Bleeding events requiring hospitalization were similar by aspirin dosing groups (unadjusted 2.8% vs. 3.2%, adjusted OR 1.22, 95% CI 0.87-1.70). Similar associations were observed in landmark analyses accounting for aspirin dosing change over time, and across subgroup analyses by age, sex, baseline aspirin use, and type of ADP receptor inhibitor (clopidogrel vs. prasugrel/ticagrelor). -Among PCI-treated MI patients, high maintenance dose aspirin was associated with similar rates of MACE, but greater risk of minor bleeding compared with those discharged on low-dose aspirin.

European Journal of Heart Failure, 2015

Previous reports have provided conflicting data regarding the relationship between length of stay... more Previous reports have provided conflicting data regarding the relationship between length of stay (LOS) and subsequent readmission risk among patients hospitalized for heart failure (HF). We performed a post-hoc analysis of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial to evaluate the differences in LOS overall and between geographic regions (North America, South America, Western Europe, and Eastern Europe) in association with all-cause and cause-specific [HF, cardiovascular (CV) non-HF, and non-CV] readmissions within 30 days of discharge after HF hospitalization. The present analysis included 4020 patients enrolled from 20 countries who were alive at discharge. Median [interquartile range (IQR)] LOS was 8 (4-11) days. The 30-day readmission rates were 15.7% [95% confidence interval (CI) 14.6-16.8] for all-cause; 5.6% (95% CI 4.9-6.3) for HF; 4.4% (95% CI 3.8-5.1) for CV non-HF; and 5.8% (95% CI 5.1-6.6) for non-CV readmissions. There was a positive correlation between LOS and all-cause readmissions (r = 0.09, 95% CI 0.06-0.12). The adjusted odds ratio for the top (≥14 days) vs. the bottom (≤3 days) quintile for LOS was 1.39 (95% CI 0. 92-2.11) for all-cause readmissions, 0.43 (95% CI 0.24-0.79) for HF, 2.99 (95% CI 1.49-6.02) for CV non-HF, and 1.72 (95% CI 1.05-2.81) for non-CV readmissions. With the exception of Western Europe, these findings remained largely consistent across geographic regions. In this large multinational cohort of hospitalized HF patients, longer LOS was associated with a higher risk for all-cause, CV non-HF, and non-CV readmissions, but a lower risk of HF readmissions within 30 days of discharge. These results may inform strategies to reduce readmissions.

PLOS ONE, 2015

Autonomic, cognitive, and neuropsychologic deficits appear in heart failure (HF) subjects, and th... more Autonomic, cognitive, and neuropsychologic deficits appear in heart failure (HF) subjects, and these compromised functions depend on cerebral cortex integrity in addition to that of subcortical and brainstem sites. Impaired autoregulation, low cardiac output, sleep-disordered-breathing, hypertension, and diabetic conditions in HF offer considerable potential to affect cortical areas by loss of neurons and glia, which would be expressed as reduced cortical thicknesses. However, except for gross descriptions of cortical volume loss/injury, regional cortical thickness integrity in HF is unknown. Our goal was to assess regional cortical thicknesses across the brain in HF, compared to control subjects.

Journal of the American College of Cardiology, 2015

Electronic health records (EHRs) may be key tools for improving the quality of health care, parti... more Electronic health records (EHRs) may be key tools for improving the quality of health care, particularly for conditions for which guidelines are rapidly evolving and timely care is critical, such as ischemic stroke. The goal of this study was to determine whether hospitals with EHRs differed on quality or outcome measures for ischemic stroke from those without EHRs. We studied 626,473 patients from 1,236 U.S. hospitals in Get With the Guidelines-Stroke (GWTG-Stroke) from 2007 through 2010, linked with the American Hospital Association annual survey to determine the presence of EHRs. We conducted patient-level logistic regression analyses for each of the outcomes of interest. A total of 511 hospitals had EHRs by the end of the study period. Hospitals with EHRs were larger and were more often teaching hospitals and stroke centers. After controlling for patient and hospital characteristics, patients admitted to hospitals with EHRs had similar odds of receiving &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;all-or-none&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; care (odds ratio [OR]: 1.03; 95% CI: 0.99 to 1.06; p = 0.12), of discharge home (OR: 1.02; 95% CI: 0.99 to 1.04; p = 0.15), and of in-hospital mortality (OR: 1.01; 95% CI: 0.96 to 1.05; p = 0.82). The odds of having a length of stay &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;4 days was slightly lower at hospitals with EHRs (OR: 0.97; 95% CI: 0.95 to 0.99; p = 0.01). In our sample of GWTG-Stroke hospitals, EHRs were not associated with higher-quality care or better clinical outcomes for stroke care. Although EHRs may be necessary for an increasingly high-tech, transparent healthcare system, as currently implemented, they do not appear to be sufficient to improve outcomes for this important disease.

The American Journal of Medicine, 2015

Journal of the American Heart Association, 2015

Whether heart rate upon discharge following hospitalization for heart failure is associated with ... more Whether heart rate upon discharge following hospitalization for heart failure is associated with long-term adverse outcomes and whether this association differs between patients with sinus rhythm (SR) and atrial fibrillation (AF) have not been well studied. We conducted a retrospective cohort study from clinical registry data linked to Medicare claims for 46 217 patients participating in Get With The Guidelines(®)-Heart Failure. Cox proportional-hazards models were used to estimate the association between discharge heart rate and all-cause mortality, all-cause readmission, and the composite outcome of mortality/readmission through 1 year. For SR and AF patients with heart rate ≥75, the association between heart rate and mortality (expressed as hazard ratio [HR] per 10 beats-per-minute increment) was significant at 0 to 30 days (SR: HR 1.30, 95% CI 1.22 to 1.39; AF: HR 1.23, 95% CI 1.16 to 1.29) and 31 to 365 days (SR: HR 1.15, 95% CI 1.12 to 1.20; AF: HR 1.05, 95% CI 1.01 to 1.08). ...

The American Journal of Cardiology, 2015

European Journal of Cardio-thoracic Surgery, 2011

... J Am Coll Cardiol 2008;52:587-598. Abstract/FREE Full Text. [9]↵: Rose EA,; Gelijns AC,; Mosk... more ... J Am Coll Cardiol 2008;52:587-598. Abstract/FREE Full Text. [9]↵: Rose EA,; Gelijns AC,; Moskowitz AJ,; Heitjan DF,; Stevenson LW,; Dembitsky W.,; Long JW,; Ascheim DD,; Tierney AR,; ... LW,; Pagani FD,; Russell SD,; John R.,; Boyle AJ,; Aaronson KD,; Conte JV,; Naka Y.,; Mancini ...

Journal of the American Society of Hypertension : JASH

Some beta-blockers, although they are effective antihypertensive agents, may adversely effect dys... more Some beta-blockers, although they are effective antihypertensive agents, may adversely effect dyslipidemia and decrease insulin sensitivity. beta-blockers without adverse metabolic effects may provide an improvement in long-term hypertension therapy. Hypertensive patients (n = 568) without diabetes, not requiring lipid-lowering therapy, were randomized to once-daily extended-release carvedilol or extended-release metoprolol and titrated to target blood pressure (BP). Co-primary endpoints were comparison between groups in high-density lipoprotein (HDL) or triglycerides at 24 weeks. Extended-release carvedilol was superior to extended-release metoprolol in meeting the primary endpoint of a difference in triglycerides; the median % change in triglycerides being -8.026% (P = .0141; 97.5% confidence interval [CI], -15.35, -0.67)] from baseline to 24 weeks. Triglycerides were unchanged with carvedilol and increased with metoprolol. There was no significant difference in effect on HDL. BP ...

The American journal of medicine, 2014

JACC. Heart failure, 2013

Readmission for heart failure remains a major focus of policymakers, clinicians, and patients. De... more Readmission for heart failure remains a major focus of policymakers, clinicians, and patients. Despite meeting key national performance measures and frequent use of evidence-based therapies, rates of 30-day post-discharge rehospitalization may be as high as 25%. Digoxin and mineralocorticoid antagonists are known to reduce admissions for heart failure, but are significantly underused in current clinical practice despite their proven benefits.

Journal of the American College of Cardiology, Jan 3, 2014

New therapeutic targets, agents, and strategies are needed to prevent and treat heart failure (HF... more New therapeutic targets, agents, and strategies are needed to prevent and treat heart failure (HF) after a decade of failed research efforts to improve long-term patient outcomes, especially in patients after hospitalization for HF. Conceptually, an accurate assessment of left ventricular structure is an essential step in the development of novel therapies because heterogeneous pathophysiologies underlie chronic HF and hospitalization for HF. Improved left ventricular characterization permits the identification and targeting of the intrinsic fundamental disease-modifying pathways that culminate in HF. Interstitial heart disease is one such pathway, characterized by extracellular matrix (ECM) expansion that is associated with mechanical, electrical, and vasomotor dysfunction and adverse outcomes. Previous landmark trials that appear to treat interstitial heart disease were effective in improving outcomes. Advances in cardiovascular magnetic resonance now enable clinicians and researc...

The American journal of medicine, 2014

One quarter of patients hospitalized for heart failure are readmitted within 30 days, perhaps rel... more One quarter of patients hospitalized for heart failure are readmitted within 30 days, perhaps related to ineffective decongestion. Limited data exist guiding the extent and duration of diuresis in patients hospitalized for heart failure. The objective of this review was to determine the prognostic value of hemoconcentration, or the relative increase in the cellular elements in blood, in patients hospitalized for heart failure and to clarify its role in guiding inpatient diuretic practices. Six post hoc retrospective studies from 2010 to 2013 were available for review. Hemoconcentration was consistently associated with markers of aggressive fluid removal, including higher diuretic dosing and reduced body weight, but increased risk of in-hospital worsening renal function. Despite this, hemoconcentration was associated with improved short-term mortality and rehospitalization. Hemoconcentration is a practical, readily available, noninvasive, economically feasible strategy to help guide ...

The American journal of cardiology, Jan 8, 2008

In 2002, the number of patients discharged from US hospitals after an acute coronary syndrome (AC... more In 2002, the number of patients discharged from US hospitals after an acute coronary syndrome (ACS) was estimated conservatively at 942,000. About 85% of these patients had a myocardial infarction (MI) and the remaining 15% experienced unstable angina without MI. 1 When secondary discharge diagnoses are included, the corresponding number of hospital discharges that year for ACS was approximately 1.7 million: 973,000 for MI and 728,000 for unstable angina. 1 The percentage of patients with ACS who have ST-segment elevation MI is estimated at 30%-45%. 1 First-time MIs account for approximately 65% of all events and the average age at the time of MI is 65.8 years for men and 70.4 years for women. 1 The above numbers call attention to the prevalence of MI in the United States and the need for action to be taken to provide these patients with optimal medical care.

background: Outcomes among hospitalized heart failure (HF) patients with preserved (pEF), borderl... more background: Outcomes among hospitalized heart failure (HF) patients with preserved (pEF), borderline (bEF), and reduced (rEF) ejection fraction have not been well studied. We sought to characterize post-discharge mortality and readmission in HF patients by EF group in the modern era.

Circulation: Heart …, Jan 1, 2008

Background-Differences in hospital staffing may influence outcomes for patients with acute condit... more Background-Differences in hospital staffing may influence outcomes for patients with acute conditions, including heart failure (HF), depending on which day of the week the patients are admitted. This study examined the relationship between the day of the week patients are hospitalized for HF and death rate, length of stay (LOS), and rehospitalization rate. Methods and Results-A total of 259 US hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) submitted data on 48 612 patients with HF. Sixty-to 90-day postdischarge follow-up data were collected prospectively in a prespecified 10% sample. We analyzed day of admission and discharge, demographic, medical history, medication use, laboratory, and in-hospital procedure data for their association with hospital LOS and death rate. Patient characteristics were similar for weekday and weekend presentation. LOS was a median of 4.0 days and a mean of 5.7Ϯ5.7 days; in-hospital death rate was 3.8%. In-hospital and postdischarge risk of death were similar for each day of the week in the hospital and follow-up cohorts, respectively. LOS, however, was significantly influenced by day of admission, even after adjustment for other LOS risk factors. The shortest LOS by admission day of the week was Tuesday (5.39 days), and the longest was Friday (5.88 days; PϽ0.001). Conclusions-No differences in death rate by day of admission or discharge for HF hospitalizations were evident.

Circulation: Cardiovascular Quality and Outcomes, 2013

A cute heart failure (AHF) is responsible for many millions of hospitalizations globally each yea... more A cute heart failure (AHF) is responsible for many millions of hospitalizations globally each year. Late mortality has been reported at 30% to 50%, and early rehospitalization is common at nearly 25% at 30 days and 50% at 180 days. 1,2 For 2010, costs associated with HF hospitalizations in the United States alone are estimated at $20.9 billion. 1 In addition to the high rate of healthcare use, significant discrepancies in care and outcomes between local regions occur, as well as between Background-Translation of evidence-based heart failure (HF) therapies to clinical practice is incomplete and may vary internationally. We examined common measures of quality of care in patients enrolled in the international Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure trial. Methods and Results-Patients were admitted to 398 hospitals for acute HF in 5 regions (North America, n=3149; Latin America, n=658; Asia Pacific, n=1744; Central Europe, n=966; and Western Europe, n=490). Predefined quality indicators assessed at hospital discharge included the following: medications (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β-blockers, aldosterone antagonists, hydralazine/nitrates, statin therapy, and warfarin), use (or planned use) of implantable intracardiac devices, and blood pressure control (<140/90 mm Hg). We determined regional variations in quality indicators as well as the temporal variation of these indicators during the course of the trial. There was significant variation in conformity among different quality indicators, ranging from 0% to 89%. Of all potential performance opportunities, 19 076 of 32 268 (59%) were met, with Central Europe highest at 64%, followed by North America (63%), Western Europe (61%), Latin America (56%), and Asia Pacific (51%; P<0.0001). North America, Central Europe, and Asia Pacific regions demonstrated a modest increase in quality indicator conformity over time, although there was no significant change in other regions. Conclusions-Quality of care for patients hospitalized with acute HF varies and remains suboptimal even within a randomized clinical trial, which included quality improvement interventions. Specific measures designed to improve performance measures should be implemented even within multicenter clinical trials. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00475852.

European journal of heart failure, Jan 30, 2015

This study sought to investigate regional variation in clinical characteristics, therapy utilizat... more This study sought to investigate regional variation in clinical characteristics, therapy utilization, and post-discharge outcomes among patients hospitalized for heart failure (HHF) enrolled in the multinational ASTRONAUT (Aliskiren Trial on Acute Heart Failure Outcomes) trial. The ASTRONAUT trial randomized 1615 HHF patients with ejection fraction ≤40% to aliskiren or placebo. Enrolled patients were from Eastern Europe (n = 495, 30.7%), Asia/Pacific (n = 439, 27.2%), Western Europe (n = 395, 24.5%), Latin America (n = 163, 10.1%), and North America (n = 123, 7.6%). Marked differences were seen across geographic regions in terms of baseline demographics, vital signs, laboratory tests, co-morbidity burden, and use of guideline-recommended therapies. All-cause death at 12 months ranged from 7.3% in North America to 26.7% in Asia/Pacific, with differences largely driven by sudden cardiac death. Rates of repeat HHF at 12 months ranged from 22.7% in Latin America to 43.9% in North Americ...

The American journal of cardiology, Jan 18, 2015

Device uptake and development have progressed over the last decade, but few quantitative data exi... more Device uptake and development have progressed over the last decade, but few quantitative data exist examining the overall operating characteristics and temporal trends of these clinical trials. We performed a systematic analysis of all cardiovascular device clinical trials from 2001 to 2012 published in medical and cardiovascular journals with the 8 highest impact factors. Of the 1,224 identified cardiovascular clinical trials, 299 (24.4%) focused specifically on devices. Each trial included a median of 335 patients (162 to 745) recruited from a median of 14 sites (3 to 38) over a median enrollment duration of 1.9 years (1.2 to 3.3). Median enrollment rate was 1.1 patients/site/month (0.5 to 4.2). Most device trials targeted coronary artery disease (55.2%), followed by arrhythmias (17.4%). Most were industry sponsored (53.6%) and included mortality as a primary end point (69.6%). The median number of patients (225 to 499, p <0.001 for trend) and enrolling sites (11 to 19, p = 0.0...

Circulation, Jan 20, 2015

-Aspirin is the most widely used antiplatelet drug post-myocardial infarction (MI), yet its optim... more -Aspirin is the most widely used antiplatelet drug post-myocardial infarction (MI), yet its optimal maintenance dose after percutaneous coronary intervention (PCI) with stenting remains uncertain. -We compared outcomes of 10,213 MI patients who underwent PCI and were discharged on dual antiplatelet therapy at 228 United States hospitals in the TRANSLATE-ACS study from 2010-2012. Major adverse cardiovascular events (MACE) and bleeding within 6 months post-discharge were compared between high- (325 mg) and low-dose aspirin (81 mg) using regression models with inverse probability-weighted propensity adjustment. Overall, 6,387 patients (63%) received high-dose aspirin at discharge. MACE risk was not significantly different between groups (high vs. low: unadjusted 8.2% vs. 9.2%; adjusted hazard ratio 0.99, 95% confidence interval [CI] 0.85-1.17). High-dose aspirin use was associated with greater risk of any Bleeding Academic Research Consortium (BARC)-defined bleeding events (unadjusted 24.2% vs. 22.7%; adjusted odds ratio [OR] 1.19, 95% CI 1.06-1.33), driven mostly by minor BARC type 1 or 2 bleeding events not requiring hospitalization (unadjusted 21.4% vs. 19.5%; adjusted OR 1.19, 95% CI 1.05-1.34). Bleeding events requiring hospitalization were similar by aspirin dosing groups (unadjusted 2.8% vs. 3.2%, adjusted OR 1.22, 95% CI 0.87-1.70). Similar associations were observed in landmark analyses accounting for aspirin dosing change over time, and across subgroup analyses by age, sex, baseline aspirin use, and type of ADP receptor inhibitor (clopidogrel vs. prasugrel/ticagrelor). -Among PCI-treated MI patients, high maintenance dose aspirin was associated with similar rates of MACE, but greater risk of minor bleeding compared with those discharged on low-dose aspirin.

European Journal of Heart Failure, 2015

Previous reports have provided conflicting data regarding the relationship between length of stay... more Previous reports have provided conflicting data regarding the relationship between length of stay (LOS) and subsequent readmission risk among patients hospitalized for heart failure (HF). We performed a post-hoc analysis of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial to evaluate the differences in LOS overall and between geographic regions (North America, South America, Western Europe, and Eastern Europe) in association with all-cause and cause-specific [HF, cardiovascular (CV) non-HF, and non-CV] readmissions within 30 days of discharge after HF hospitalization. The present analysis included 4020 patients enrolled from 20 countries who were alive at discharge. Median [interquartile range (IQR)] LOS was 8 (4-11) days. The 30-day readmission rates were 15.7% [95% confidence interval (CI) 14.6-16.8] for all-cause; 5.6% (95% CI 4.9-6.3) for HF; 4.4% (95% CI 3.8-5.1) for CV non-HF; and 5.8% (95% CI 5.1-6.6) for non-CV readmissions. There was a positive correlation between LOS and all-cause readmissions (r = 0.09, 95% CI 0.06-0.12). The adjusted odds ratio for the top (≥14 days) vs. the bottom (≤3 days) quintile for LOS was 1.39 (95% CI 0. 92-2.11) for all-cause readmissions, 0.43 (95% CI 0.24-0.79) for HF, 2.99 (95% CI 1.49-6.02) for CV non-HF, and 1.72 (95% CI 1.05-2.81) for non-CV readmissions. With the exception of Western Europe, these findings remained largely consistent across geographic regions. In this large multinational cohort of hospitalized HF patients, longer LOS was associated with a higher risk for all-cause, CV non-HF, and non-CV readmissions, but a lower risk of HF readmissions within 30 days of discharge. These results may inform strategies to reduce readmissions.

PLOS ONE, 2015

Autonomic, cognitive, and neuropsychologic deficits appear in heart failure (HF) subjects, and th... more Autonomic, cognitive, and neuropsychologic deficits appear in heart failure (HF) subjects, and these compromised functions depend on cerebral cortex integrity in addition to that of subcortical and brainstem sites. Impaired autoregulation, low cardiac output, sleep-disordered-breathing, hypertension, and diabetic conditions in HF offer considerable potential to affect cortical areas by loss of neurons and glia, which would be expressed as reduced cortical thicknesses. However, except for gross descriptions of cortical volume loss/injury, regional cortical thickness integrity in HF is unknown. Our goal was to assess regional cortical thicknesses across the brain in HF, compared to control subjects.

Journal of the American College of Cardiology, 2015

Electronic health records (EHRs) may be key tools for improving the quality of health care, parti... more Electronic health records (EHRs) may be key tools for improving the quality of health care, particularly for conditions for which guidelines are rapidly evolving and timely care is critical, such as ischemic stroke. The goal of this study was to determine whether hospitals with EHRs differed on quality or outcome measures for ischemic stroke from those without EHRs. We studied 626,473 patients from 1,236 U.S. hospitals in Get With the Guidelines-Stroke (GWTG-Stroke) from 2007 through 2010, linked with the American Hospital Association annual survey to determine the presence of EHRs. We conducted patient-level logistic regression analyses for each of the outcomes of interest. A total of 511 hospitals had EHRs by the end of the study period. Hospitals with EHRs were larger and were more often teaching hospitals and stroke centers. After controlling for patient and hospital characteristics, patients admitted to hospitals with EHRs had similar odds of receiving &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;all-or-none&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; care (odds ratio [OR]: 1.03; 95% CI: 0.99 to 1.06; p = 0.12), of discharge home (OR: 1.02; 95% CI: 0.99 to 1.04; p = 0.15), and of in-hospital mortality (OR: 1.01; 95% CI: 0.96 to 1.05; p = 0.82). The odds of having a length of stay &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;4 days was slightly lower at hospitals with EHRs (OR: 0.97; 95% CI: 0.95 to 0.99; p = 0.01). In our sample of GWTG-Stroke hospitals, EHRs were not associated with higher-quality care or better clinical outcomes for stroke care. Although EHRs may be necessary for an increasingly high-tech, transparent healthcare system, as currently implemented, they do not appear to be sufficient to improve outcomes for this important disease.

The American Journal of Medicine, 2015

Journal of the American Heart Association, 2015

Whether heart rate upon discharge following hospitalization for heart failure is associated with ... more Whether heart rate upon discharge following hospitalization for heart failure is associated with long-term adverse outcomes and whether this association differs between patients with sinus rhythm (SR) and atrial fibrillation (AF) have not been well studied. We conducted a retrospective cohort study from clinical registry data linked to Medicare claims for 46 217 patients participating in Get With The Guidelines(®)-Heart Failure. Cox proportional-hazards models were used to estimate the association between discharge heart rate and all-cause mortality, all-cause readmission, and the composite outcome of mortality/readmission through 1 year. For SR and AF patients with heart rate ≥75, the association between heart rate and mortality (expressed as hazard ratio [HR] per 10 beats-per-minute increment) was significant at 0 to 30 days (SR: HR 1.30, 95% CI 1.22 to 1.39; AF: HR 1.23, 95% CI 1.16 to 1.29) and 31 to 365 days (SR: HR 1.15, 95% CI 1.12 to 1.20; AF: HR 1.05, 95% CI 1.01 to 1.08). ...

The American Journal of Cardiology, 2015

European Journal of Cardio-thoracic Surgery, 2011

... J Am Coll Cardiol 2008;52:587-598. Abstract/FREE Full Text. [9]↵: Rose EA,; Gelijns AC,; Mosk... more ... J Am Coll Cardiol 2008;52:587-598. Abstract/FREE Full Text. [9]↵: Rose EA,; Gelijns AC,; Moskowitz AJ,; Heitjan DF,; Stevenson LW,; Dembitsky W.,; Long JW,; Ascheim DD,; Tierney AR,; ... LW,; Pagani FD,; Russell SD,; John R.,; Boyle AJ,; Aaronson KD,; Conte JV,; Naka Y.,; Mancini ...

Journal of the American Society of Hypertension : JASH

Some beta-blockers, although they are effective antihypertensive agents, may adversely effect dys... more Some beta-blockers, although they are effective antihypertensive agents, may adversely effect dyslipidemia and decrease insulin sensitivity. beta-blockers without adverse metabolic effects may provide an improvement in long-term hypertension therapy. Hypertensive patients (n = 568) without diabetes, not requiring lipid-lowering therapy, were randomized to once-daily extended-release carvedilol or extended-release metoprolol and titrated to target blood pressure (BP). Co-primary endpoints were comparison between groups in high-density lipoprotein (HDL) or triglycerides at 24 weeks. Extended-release carvedilol was superior to extended-release metoprolol in meeting the primary endpoint of a difference in triglycerides; the median % change in triglycerides being -8.026% (P = .0141; 97.5% confidence interval [CI], -15.35, -0.67)] from baseline to 24 weeks. Triglycerides were unchanged with carvedilol and increased with metoprolol. There was no significant difference in effect on HDL. BP ...

The American journal of medicine, 2014

JACC. Heart failure, 2013

Readmission for heart failure remains a major focus of policymakers, clinicians, and patients. De... more Readmission for heart failure remains a major focus of policymakers, clinicians, and patients. Despite meeting key national performance measures and frequent use of evidence-based therapies, rates of 30-day post-discharge rehospitalization may be as high as 25%. Digoxin and mineralocorticoid antagonists are known to reduce admissions for heart failure, but are significantly underused in current clinical practice despite their proven benefits.

Journal of the American College of Cardiology, Jan 3, 2014

New therapeutic targets, agents, and strategies are needed to prevent and treat heart failure (HF... more New therapeutic targets, agents, and strategies are needed to prevent and treat heart failure (HF) after a decade of failed research efforts to improve long-term patient outcomes, especially in patients after hospitalization for HF. Conceptually, an accurate assessment of left ventricular structure is an essential step in the development of novel therapies because heterogeneous pathophysiologies underlie chronic HF and hospitalization for HF. Improved left ventricular characterization permits the identification and targeting of the intrinsic fundamental disease-modifying pathways that culminate in HF. Interstitial heart disease is one such pathway, characterized by extracellular matrix (ECM) expansion that is associated with mechanical, electrical, and vasomotor dysfunction and adverse outcomes. Previous landmark trials that appear to treat interstitial heart disease were effective in improving outcomes. Advances in cardiovascular magnetic resonance now enable clinicians and researc...

The American journal of medicine, 2014

One quarter of patients hospitalized for heart failure are readmitted within 30 days, perhaps rel... more One quarter of patients hospitalized for heart failure are readmitted within 30 days, perhaps related to ineffective decongestion. Limited data exist guiding the extent and duration of diuresis in patients hospitalized for heart failure. The objective of this review was to determine the prognostic value of hemoconcentration, or the relative increase in the cellular elements in blood, in patients hospitalized for heart failure and to clarify its role in guiding inpatient diuretic practices. Six post hoc retrospective studies from 2010 to 2013 were available for review. Hemoconcentration was consistently associated with markers of aggressive fluid removal, including higher diuretic dosing and reduced body weight, but increased risk of in-hospital worsening renal function. Despite this, hemoconcentration was associated with improved short-term mortality and rehospitalization. Hemoconcentration is a practical, readily available, noninvasive, economically feasible strategy to help guide ...

The American journal of cardiology, Jan 8, 2008

In 2002, the number of patients discharged from US hospitals after an acute coronary syndrome (AC... more In 2002, the number of patients discharged from US hospitals after an acute coronary syndrome (ACS) was estimated conservatively at 942,000. About 85% of these patients had a myocardial infarction (MI) and the remaining 15% experienced unstable angina without MI. 1 When secondary discharge diagnoses are included, the corresponding number of hospital discharges that year for ACS was approximately 1.7 million: 973,000 for MI and 728,000 for unstable angina. 1 The percentage of patients with ACS who have ST-segment elevation MI is estimated at 30%-45%. 1 First-time MIs account for approximately 65% of all events and the average age at the time of MI is 65.8 years for men and 70.4 years for women. 1 The above numbers call attention to the prevalence of MI in the United States and the need for action to be taken to provide these patients with optimal medical care.

background: Outcomes among hospitalized heart failure (HF) patients with preserved (pEF), borderl... more background: Outcomes among hospitalized heart failure (HF) patients with preserved (pEF), borderline (bEF), and reduced (rEF) ejection fraction have not been well studied. We sought to characterize post-discharge mortality and readmission in HF patients by EF group in the modern era.