Use Of Evidence-based Therapies Research Articles

Primary results of the brazilian registry of atherothrombotic disease (NEAT)

There is limited contemporary prospective real-world evidence of patients with chronic arterial disease in Latin America. The Network to control atherothrombosis (NEAT) registry is a national prospective observational study of patients with known coronary (CAD) and/or peripheral arterial disease (PAD) in Brazil. A total of 2,005 patients were enrolled among 25 sites from September 2020 to March 2022. Patient characteristics, medications and laboratorial data were collected. Primary objective was to assess the proportion of patients who, at the initial visit, were in accordance with good medical practices (domains) for reducing cardiovascular risk in atherothrombotic disease. From the total of patients enrolled, 2 were excluded since they did not meet eligibility criteria. Among the 2,003 subjects included in the analysis, 55.6% had isolated CAD, 28.7% exclusive PAD and 15.7% had both diagnoses. Overall mean age was 66.3 (± 10.5) years and 65.7% were male patients. Regarding evidence-based therapies (EBTs), 4% were not using any antithrombotic drug and only 1.5% were using vascular dose of rivaroxaban (2.5 mg bid). Only 0.3% of the patients satisfied all the domains of secondary prevention, including prescription of EBTs and targets of body-mass index, blood pressure, LDL-cholesterol, and adherence of lifestyle recommendations. The main barrier for prescription of EBTs was medical judgement. Our findings highlight that the contemporary practice does not reflect a comprehensive approach for secondary prevention and had very low incorporation of new therapies in Brazil. Large-scale populational interventions addressing these gaps are warranted to improve the use of evidence-based therapies and reduce the burden of atherothrombotic disease.ClinicalTrials.gov NCT04677725

Second-year results from CINEMA: A novel, patient-centered, team-based intervention for patients with Type 2 diabetes or prediabetes at high cardiovascular risk

BackgroundThe care for patients with type 2 diabetes mellitus (T2DM) necessitates a multidisciplinary team approach to reduce cardiovascular (CV) risk but implementation of effective integrated strategies has been limited. Methods and ResultsWe report 2-year results from a patient-centered, team-based intervention called CINEMA at University Hospitals Cleveland Medical Center. Patients with T2DM or prediabetes at high-risk for CV events, including those with established atherosclerotic CVD, elevated coronary artery calcium score ≥100, chronic heart failure with reduced ejection fraction, chronic kidney disease (CKD) stages 2–4, and/or prevalent metabolic syndrome were included. From May 2020 through September 2022, 426 patients were enrolled in the CINEMA program. A total of 227 (54%) completed ≥1 follow-up visit after an initial baseline visit with median (IQR) follow-up time 4 [3–7] months with maximum follow-up time 19 months. Mean age was 60 years, 47 % were women, and 37 % were Black and 85% had prevalent T2DM, 48 % had established ASCVD, 29% had chronic HF, 27% had CKD and mean baseline 10-year ASCVD risk estimate was 25.1 %; baseline use of a SGLT2i or GLP-1RA was 21 % and 18 %, respectively. Patients had significant reductions from baseline in body weight (-5.5 lbs), body mass index (-0.9 kg/m2), systolic (-3.6 mmHg) and diastolic (-1.2 mmHg) blood pressure, Hb A1c (-0.5 %), total (-10.7 mg/dL) and low-density lipoprotein (-9.0 mg/dL) cholesterol, and triglycerides (-13.5 mg/dL) (p<0.05 for all). Absolute 10-year predicted ASCVD risk decreased by ∼2.4 % (p<0.001) with the intervention. In addition, rates of guideline-directed cardiometabolic medication prescriptions significantly increased during follow-up with the most substantive changes seen in rates of SGLT2i and GLP-1RA use which approximately tripled from baseline (21 % to 57 % for SGLT2i and 18 % to 65 % for GLP-1RA, p<0.001 for both). ConclusionsThe CINEMA program, an integrated, patient-centered, team-based intervention for patients with T2DM or prediabetes at high risk for cardiovascular disease has continued to demonstrate effectiveness with significant improvements in ASCVD risk factors and improved use of evidence-based therapies. Successful implementation and dissemination of this care delivery paradigm remains a key priority.

#2569 HEART FAILURE AND DIABETES IN CHRONIC KIDNEY DISEASE

Abstract Background and Aims Few studies have investigated the prognosis in chronic kidney disease (CKD) patients with heart failure (HF) and diabetes (DM). In the clinical setting, treating a combination of these conditions is challenging but novel treatments such as SGLT2-inhibitors are now emerging. The aim of this study is to investigate the prevalence and outcomes of survival and major cardiovascular events (MACE) in CKD patients with HF and/or DM before these new treatments were commonly used. Method In this retrospective observational study, we extracted data from 26647 nephrology-referred patients ≥18 years old with eGFR 60 ≤ ml/min/1,73 m2 from the Swedish Renal Registry – Chronic Kidney Disease (SRR-CKD) and health registers at the National Board of Health and Welfare in Sweden during an observational period of January 2005 – June 2017. HF and DM was categorized based on International Classification of Disease 10 (ICD-10) diagnostic codes prior to inclusion in the SRR-CKD. Outcomes were death by any cause and MACE, defined as a composite of hospitalization for nonfatal myocardial infarction, coronary heart disease, congestive heart failure, nonfatal stroke or cardiovascular death. Secondary outcome was start of kidney replacement therapy (KRT) defined as start of dialysis or kidney transplantation. Results There were 12910 (47.7%) patients with CKD, 3458 (12.5%) with CKD+HF, 7595 (27.3%) with CKD+DM and 3684 (13.3%) with CKD+HF+DM. Median age was higher in the cohorts with heart failure (CKD+HF and CKD+HF+DM), 77 and 74 years vs 67 and 69 years (CKD and CKD+DM). Most patients were men in all four groups (62-66%). The use of evidence based therapies such as ACE-inhibitors/ARBs, varied across the groups between 62.9, 66.6, 78.5 and 78.7% (CKD, CKD+HF, CKD+DM, CKD+HF+DM). Statins were used in 42.0, 50.7, 71.1 and 73.7% and betablockers in 53.9, 83.7, 65.9, and 86.1%. Survival data is presented in a Kaplan-Meier curve (Figure 1). Adjusted hazard ratio (HR) for all cause-death was highest in the cohorts with heart failure CKD+HF (2.54 [95% CI 2.40–2.68]) and CKD+DM+HF (3.22 [3.05–3.39]) followed by CKD+DM (HR 1.53 [1.45–1.60]) compared to patients with only CKD. The cumulative incidence of MACE is illustrated below (Figure 2). Adjusted HR for MACE was substantially higher in patients with heart failure, 3.82 (3.62–4.03) and 4.82 (4.59–5.08) for CKD+HF and CKD+HF+DM respectively while it was 1.63 (1.56–1.72) for CKD+DM. The risk of initiation of KRT was similar in all four groups, but risk of death before start of KRT was higher in patients with HF. Conclusion In CKD-patients, a heart failure diagnosis comprises approximately three to four times greater risk of death and MACE compared to patients with only CKD. The combination of CKD+HF+DM is the most severe. In all patient groups the use of evidence-based therapies was surprisingly low. This may reflect both deviation from guidelines for CKD-patients and the clinical challenge in treating comorbidities in CKD-patients. The results underlie the importance of identifying CKD-patients with HF and DM early to optimize treatment.

Contemporary use of cardiovascular risk reduction strategies in type 2 diabetes. Insights from the diabetes collaborative registry

Cardiovascular disease remains the primary source of morbidity and mortality in type 2 diabetes (T2D). We characterized the change over time in the use of evidence-based therapies to reduce cardiovascular risk in US patients with T2D. Data from a longitudinal outpatient diabetes registry were used to calculate the prescription of SGLT2i or GLP-1RA over time and among those with high-risk comorbidities (atherosclerotic cardiovascular disease [ASCVD], heart failure [HF], chronic kidney disease [CKD]) and a diabetes cardiovascular composite score (DCCS; calculated as: #eligible medications prescribed/#eligible medications x 100 for SGLT2i, GLP-1RA, statin, antiplatelet/anticoagulant therapy, ACEi/ARB/ARNI). Scores ranged from 0% to 100% (higher=more optimal care). Among 1,001,542 outpatients from 391 US sites, 51.7% patients had ASVCD, 17.7% HF, and 23.0% CKD. The percentage of patients prescribed an SGLT2i or GLP-1RA increased over time (7.3% in 2013 to 28.8% in 2019), and 18.3% of patients with ASCVD, HF, or CKD were on at least one of these medications at last follow-up vs 25.5% of patients without any of these comorbidities. Mean DCCS was 54±36%; 54±25% in patients with ASCVD, HF, or CKD vs 52±50% in patients without any of these comorbidities (P<0.001 for both). In a hierarchical linear model, male sex, and a diagnosis of CKD were independently associated with higher DCCS whereas a diagnosis of HF or ASCVD was associated with a lower DCCS. In a large, contemporary cohort of patients with T2D, we found improvement in the use of SGLT2i and GLP-1RA but unexpectedly lower use in patients with ASCVD, heart failure, and CKD, highlighting a treatment-risk paradox. Further education is needed to shift the understanding of these medications as tools for glucose-lowering to cardiovascular risk reduction and to improve their implementation in clinical practice.

Safety and efficacy of new potassium binders on hyperkalemia management in patients with heart failure: a systematic review and meta-analysis of randomized controlled trials.

Hyperkalemia leads to suboptimal use of evidence-based therapies in patients with heart failure (HF). Therefore, we aimed to assess whether new potassium binders are effective and safe to promote medical optimization in patients with HF. MEDLINE, Cochrane, and Embase were searched for randomized controlled trials (RCTs) that reported outcomes after initiation of Patiromer or Sodium Zirconium Cyclosilicate (SZC) versus placebo in patients with HF at high risk of hyperkalemia development. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random effects model. Quality assessment and risk of bias were performed according to Cochrane recommendations. A total of 1432 patients from 6 RCTs were included, of whom 737 (51.5%) patients received potassium binders. In patients with HF, potassium binders increased the use of renin-angiotensin-aldosterone inhibitors (RR 1.14; 95% CI 1.02-1.28; p = 0.021; I2 = 44%) and reduced the risk of hyperkalemia (RR 0.66; 95% CI 0.52-0.84; p < 0.001; I2 = 46%). The risk of hypokalemia was significantly increased in patients treated with potassium binders (RR 5.61; 95% CI 1.49-21.08; p = 0.011; I2 = 0%). There was no difference between groups in all-cause mortality rates (RR 1.13; 95% CI 0.59-2.16; p = 0.721; I2 = 0%) or in adverse events leading to drug discontinuation (RR 1.08; 95% CI 0.60-1.93; p = 0.801; I2 = 0%). The use of new potassium binders Patiromer or SZC in patients with HF at risk for hyperkalemia increased the rates of medical therapy optimization with renin-angiotensin-aldosterone inhibitors and reduced the incidence of hyperkalemia, at the cost of an increased prevalence of hypokalemia.

A systematic review on de-escalation of antibiotics uses in surgical patients in clinical sepsis

Antimicrobial resistance is a feature of the current topography of clinical sepsis, and in the future, fewer and fewer new antibiotics, especially those from novel classes1, will be developed to address these problems. Effective antimicrobial treatment is necessary to ensuring good patient outcomes. Increased duration of stay, multidrug-resistant infections, and death can result from improper or inefficient use of antibiotics. Patients in intensive care who are critically sick are at risk for antibiotic failure and secondary infections brought on by improper antibiotic usage, especially those with severe sepsis and septic shock. Providers can speed up the treatment of common intensive care unit (ICU) infections by starting active empiric antibiotic therapy based on local susceptibilities, daily review of infection signs and symptoms, and, where practical, restricting antibiotic therapy. Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat. Early detection of septic patients enables the use of evidence-based therapies, including goal-directed resuscitation, rapid antibiotic administration, and activated protein C. It may be simpler to provide appropriate care for sepsis if this clinical entity is divided into several phases and new delivery structures that span traditional boundaries are implemented. More specialized treatments will be possible with a better understanding of the molecular underpinnings of the illness process.

TREATING CHILDREN IN FOSTER CARE: TRENDS, OVERSIGHT, QUALITY IMPROVEMENT, AND FUTURE DIRECTIONS

Data on very young publicly insured children can inform prescription drug use patterns and the impact of oversight programs. Children in foster care are a particularly vulnerable population as a result of trauma exposure and challenges to access to care. Medicaid claims data show that children in foster care experience higher rates of psychotropic medication use compared to their Medicaid-enrolled peers, and case review data show gaps in use of evidence-based therapies and monitoring response to psychotropic medications.

Characteristics, in-hospital management, and complications of acute myocardial infarction in northern and Central Vietnam

IntroductionContemporary data on the epidemiology of acute myocardial infarction (AMI) in Vietnam are extremely limited. MethodsWe established population-based registries of residents from 2 provinces in a northern urban (Hai Phong), and a central rural (Thanh Hoa), province of Vietnam hospitalized with a validated first AMI in 2018. We described patient characteristics, in-hospital management and clinical complications, and estimated incidence rates of AMI in these two registries. ResultsA total of 785 patients (mean age = 71.2 years, 64.7% men) were admitted to the two hospitals with a validated first AMI. Approximately 64% of the AMI cases were ST-segment-elevation AMI. Patients from Thanh Hoa compared with Hai Phong were more likely to delay seeking acute hospital care. The incidence rates (per 100,000 population) of initial AMI in Thanh Hoa and Hai Phong were 16 and 30, respectively. Most patients were treated with aspirin (Thanh Hoa: 96%; Hai Phong: 90%) and statins (both provinces: 91%) during their hospitalization. A greater proportion of patients in Hai Phong (69%) underwent percutaneous revascularization than those in Thanh Hoa (58%). The most common in-hospital complications were heart failure (both provinces:12%), cardiogenic shock (Thanh Hoa: 10%; Hai phong: 7%); and cardiac arrest (both provinces: 9%). The in-hospital case-fatality rates for patients from Thanh Hoa and Hai Phong were 6.8% and 3.8%, respectively. ConclusionsThe incidence and hospital case-fatality rates of AMI were low in two Vietnamese provinces. Extent of pre-hospital delay and in-hospital use of evidence-based therapies were suboptimal, being more prominent in the rural province.

425-P: Lessons Learned from a Patient-Centered, Team-Based Intervention for Patients with Type 2 Diabetes at High Cardiovascular Risk: Year 1 Results from the CINEMA Program

Background: Persons with type 2 diabetes mellitus (T2DM) often experience fragmented and complex care and across multiple specialties. We implemented a patient-centered, multidisciplinary team-based intervention called CINEMA to improve care delivery and outcomes. Methods: Patients with T2DM at high-risk for cardiovascular disease events, including those with established atherosclerotic cardiovascular disease, elevated coronary artery calcium score &amp;gt;100, chronic heart failure with reduced ejection fraction, and/or chronic kidney disease stages 2-4 were included in the program in Cleveland, OH. The program included 5 cardiologists with a special focus on T2DM, a pharmacist, a certified diabetes care and education specialist/dietician, a nurse navigator, and collaboration with endocrinologists and nephrologists. Data was collected from baseline within 3 months prior to patients’ first visit to up to 1 month after the follow-up visit. From May 2020 through May 2021, there were 316 referrals to the program. Of those referred, 47% met inclusion criteria. Among eligible patients, 96 (64%) completed a baseline and follow-up visit, with mean (std dev) follow-up time of 1 (34) days. Among patients completing the initial 3-month visit, 50% were ≥age 60 years with 48% female and 34% Black patients. Patients had significant reductions from baseline in Hb A1c (-8.7%) , total (-10.4%) , LDL (-15.7%) , and non-HDL (-14.9%) cholesterol, body weight (-3.7%) , and body mass index (-3.8%) (p&amp;lt;0.0for all) . In addition, among eligible patients, 87.5% were started on evidenced-based therapy with SGLT2i (n=24) , GLP-1 RA (n=40) , or both (n=20) to reduce the risk of CVD. Conclusions: A team-based, patient-centered approach to high-risk disease management appears to be a promising paradigm for care delivery associated with greater use of evidence-based therapies and improved control of multiple CV risk factors. Disclosure I. Neeland: Advisory Panel; Boehringer Ingelheim International GmbH, Merck &amp; Co., Inc. Consultant; Nestlé Health Science. S.G. Al-Kindi: None. N. Tashtish: None. S. Rahmani: None. D. Berg: None. M.N. Rana: None. C. Sullivan: None. B. Hatipoglu: None.

Clinical Frailty Scale classes are independently associated with 6-month mortality for patients after acute myocardial infarction.

AimsData on the prognostic value of frailty to guide clinical decision-making for patients with myocardial infarction (MI) are scarce. To analyse the association between frailty classification, treatment patterns, in-hospital outcomes, and 6-month mortality in a large population of patients with MI.Methods and resultsAn observational, multicentre study with a retrospective analysis of prospectively collected data using the SWEDEHEART registry. In total, 3381 MI patients with a level of frailty assessed using the Clinical Frailty Scale (CFS-9) were included. Of these patients, 2509 (74.2%) were classified as non-vulnerable non-frail (CFS 1–3), 446 (13.2%) were vulnerable non-frail (CFS 4), and 426 (12.6%) were frail (CFS 5–9). Frailty and non-frail vulnerability were associated with worse in-hospital outcomes compared with non-frailty, i.e. higher rates of mortality (13.4% vs. 4.0% vs. 1.8%), cardiogenic shock (4.7% vs. 2.5% vs. 1.9%), and major bleeding (4.5% vs. 2.7% vs. 1.1%) (all P < 0.001), and less frequent use of evidence-based therapies. In Cox regression analyses, frailty was strongly and independently associated with 6-month mortality compared with non-frailty, after adjustment for age, sex, the GRACE risk score components, and other potential risk factors [hazard ratio (HR) 3.32, 95% confidence interval (CI) 2.30–4.79]. A similar pattern was seen for vulnerable non-frail patients (fully adjusted HR 2.07, 95% CI 1.41–3.02).ConclusionFrailty assessed with the CFS was independently and strongly associated with all-cause 6-month mortality, also after comprehensive adjustment for baseline differences in other risk factors. Similarly, non-frail vulnerability was independently associated with higher mortality compared with those with preserved functional ability.

Abstract 14295: Exploratory Findings Of A Quality Improvement Collaborative To Optimize Care Provided To Heart Failure Patient In A Network Of Heart Failure Clinics In Argentina

Introduction: The in-patient management of heart failure (HF) in Argentina has shown profound gaps in performance. Measurement and feedback as well benchmark comparisons showed increase in the use of evidence-based therapies, adherence to performance measures, and shortened lengths of stay in patients hospitalized with HF. Quality improvement collaboratives (QICs) have been used to improve health care for several decades. Our aim was to adopt a HF discharge bundle of care in 50% of enrolled subjects on discharge will reduce readmission by 10%. Methods: we are conducting a learning QIC, evaluated through a before-after design, from august 2020 to may 2021 (interim analysis), in 8 HF clinics of Argentina, where patients with newly diagnosed or known HF (LVEF &lt;40%) were enrolled when their discharge process was started after an hospital admission. We implemented a HF bundle of care based on four categories that comprised 12 specific interventions: medication, continuum of care, lifestyle habits, pre-discharge exams. Local hospital teams were trained in improvement and change facilitation. The implementation of the bundle was laid out along 8 learning sessions and periods of action using Plan-Do-Check-Act-cycles and an online platform to register interventions and performance.This an ongoing collaborative to be ended in July 2021. IRB approval was granted in all sites. Results: we enrolled 84 patients during baseline (BP) and 96 patients so far after the start of the intervention (IP). No differences were observed related to age, sex, morbidities and left ventricular ejection fraction (LVEF) between periods. Few more patients had history of stroke in the IP period (BP 3.6% vs IP 9.3%, p&lt;0.001). There wasn’t a statistical difference in the accomplishment of all the items of the intervention -all or nothing approach- (BP 10.7% vs IP 17.7%, p=0.183). However, there was a difference in the continuum of care category (BP 27.4% vs IP 53.6%, p&lt;0.001). No differences were observed in the rate of readmissions (BP 8.3% vs IP 3.8%, p=0.231). Conclusions: Initial results of a QIC to improve care before discharge of in-patients with HF NYHA class II-III showed an increase in the adoption of an evidence based practices bundle and no changes were observed in the rate of readmissions.

Abstract 14383: Medical Therapy Before, During, and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: The Get With the Guidelines - Heart Failure Registry

Introduction: Patients with heart failure with reduced ejection fraction (HFrEF) and diabetes mellitus (DM) are at risk for worsening HF events, yet little is known about therapeutic changes surrounding hospitalization. We aimed to characterize use of medical therapies before, during, and after hospitalization for HF. Methods: We identified Medicare beneficiaries in the GWTG-HF registry with HFrEF and DM who were hospitalized between July 2016 and September 2017 and had Part D prescription coverage for ≥6 months before and ≥3 months after hospital discharge. Medication fills for evidence-based HFrEF and antihyperglycemic therapies were assessed at 6 and 3 months before hospitalization, at hospital discharge, and 3 months post-discharge. Results: Among 3,272 Medicare beneficiaries with HFrEF and DM, mean age was 77±7y, 41% were women, and 15% were Black. Overall, 92%, 56%, 28%, and 6% were prescribed β-blocker, ACEi/ARB, MRA, and ARNI at discharge. Rates of all therapies were higher at discharge than immediately prior to hospitalization, though rates of β-blocker and ACEi/ARB use declined 3-months post-discharge. ‘Triple therapy’ (ACEI/ARB/ARNI+β-blocker+MRA) was prescribed in 9% prior to hospitalization and 20-21% at discharge and early-post-discharge. After hospitalization, insulin was prescribed most frequently (35%), followed by metformin (21%), sulfonylureas (19%), and DPP4i (11%), while GLP-1RA (2%) and SGLT2i (0.5%) use was infrequent. Modest changes in antihyperglycemic therapies were observed pre- vs. post-hospitalization, including an increase in insulin from 32% to 35% and decrease in metformin from 26% to 21% and SGLT2i from 0.8% to 0.5%. Conclusions: Despite modest improvements in use of evidence-based therapies for HFrEF during and shortly after hospitalization for HF, only 1 out of 5 patients are treated with comprehensive medical therapy. Early adoption in 2016-2017 of SGLT2i was low in a high-risk population with comorbid HFrEF and DM.

COVID-19 and Diabetes: Relationship and Factors of Severity

The first case of pneumonia caused by a SARS-CoV-like coronavirus was diagnosed in December 2019 in Wuhan, in Hubei Province of China. World Health Organization (WHO) declared this pneumonia outbreak as a public health emergency of international concern and officially named it "coronavirus disease 2019 (COVID-19)" on 11th February 2020. COVID-19 has spread unexpectedly and very rapidly around the world, leading to the 2019-2020 pandemic. According to recent data from September 24th, 2021, more than 230 million cases of COVID-19 have been confirmed worldwide and more than 4.72 million deaths reported since December 31st, 2019. Diabetes and COVID-19 have in common acute and chronic inflammation, insulin resistance and kidney damage. Both diseases can influence each other in terms of clinical course and outcome, and a fusion between these inflammatory states can increase the damage induced by the inflammations. Diabetes mellitus, epidemiologically, is the second most common comorbidity of COVID-19. Studies have shown that 12 to 16% of patients with a complication were diabetic, with mortality approximately 3-fold higher in diabetics. The roles of angiotensin-converting-enzyme-2 and dipeptidyl peptidase-4 in COVID-19 infection and diabetes, as well as the side effects of some drugs used in the management of diabetic patients infected by COVID-19, are the major factors of severity in COVID-19 infection, thus increasing mortality in these patients. To date, there is no established treatment regimen for diabetic patients infected with COVID-19. The best alternative for diabetic patients remains prevention and then, in the event of infection, the use of evidence-based therapy.

The prevalence, management, and thirty-day outcomes of symptomatic atrial fibrillation in a Tanzanian emergency department.

IntroductionData describing atrial fibrillation (AF) care in emergency centres (ECs) in sub-Saharan Africa is lacking. We sought to describe the prevalence and outcomes of AF in a Tanzanian EC.MethodsIn a prospective, observational study, adults presenting with chest pain or shortness of breath to a Tanzanian EC were enrolled from January through October 2019. Participants underwent electrocardiogram testing which were reviewed by two independent physician judges to determine presence of AF. Participants were asked about their medical history and medication use at enrollment, and a follow-up questionnaire was administered via telephone thirty days later to assess mortality, interim stroke, and medication use.ResultsOf 681 enrolled patients, 53 (7.8%) had AF. The mean age of participants with AF was 68.1, with a standard deviation (sd) of 21.1 years, and 23 of the 53 (43.4%) being male. On presentation, none of the participants found to have AF reported a previous history of AF. The median CHADS-VASC score among participants was 4 with an interquartile range (IQR) of 2-4. No participants were taking an anticoagulant at baseline. On index presentation, 49 (92.5%) participants with AF were hospitalised with 52 (98.1%) participants completing 30-day follow-up. 18 (34%) participants died, and 5 (9.6%) suffered a stroke. Of the surviving 31 participants with AF and a CHADS-VASC score ≥ 2, none were taking other anti-coagulants at 30 days. Compared to participants without AF, participants with AF were more likely to be hospitalised (OR 5.25, 95% CI 2.10-17.95, p < 0.001), more likely to die within thirty days (OR 1.93, 95% CI 1.03-3.50, p = 0.031), and more likely to suffer a stroke within thirty days (OR 5.91, 95% CI 1.76-17.28, p < 0.001).DiscussionAF is common in a Tanzanian EC, with thirty-day mortality being high, but use of evidence-based therapies is rare. There is an opportunity to improve AF care and outcomes in Tanzania.

Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology.

Primary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice. A multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time. We collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months. Standardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.

Prescription Filling Patterns of Evidence-Based Medical Therapies for Heart Failure During the COVID-19 Pandemic in the United States

BackgroundMaintaining a steady medication supply during a public health crisis is a major health priority. We leveraged a large U.S. pharmacy-claims database to understand the use of evidence-based therapies in heart failure (HF) care during the coronavirus disease-2019 (COVID-19) pandemic.MethodsWe analyzed 27,027,650 individual claims from an all-payer pharmacy-claims database across 56,155 chain, independent and mail-order pharmacies in 14,164 zip codes in 50 states. Prescriptions dispensed (in 2-week intervals) of evidence-based HF therapies in 2020 were indexed to comparable timeframes in 2019. We normalized these year-to-year changes in HF medical therapies relative to those observed with a stable basket of drugs.ResultsFills of losartan, lisinopril, carvedilol, and metoprolol all peaked in the weeks of March 2020 and demonstrated trajectories thereafter that were relatively consistent with the reference set of drugs. Fills of spironolactone (+4%) and eplerenone (+18%) showed modest trends toward increased relative use during 2020. Fills of empagliflozin (+75%), dapagliflozin (+65%) and sacubitril/valsartan (+61%) showed striking longitudinal increases throughout 2020 that deviated substantially from year-to-year trends of the overall basket of drugs. For all 3 therapies, fills of all quantity sizes increased relatively throughout 2020. For both generic and brand-name therapies, prescription fill patterns from mail-order pharmacies increased substantially over expected trends beginning in March 2020ConclusionPrescription fills of most established generic therapies used in HF care were maintained, whereas those of sacubitril/valsartan and the sodium-glucose cotransporter-2 inhibitors steeply increased during the COVID-19 pandemic. These nationwide pharmacy claims data provide reassurance about therapeutic access, during a public health crisis, to evidence-based medications used in HF care.

Prescription Practices in Patients With Mild to Moderate CKD in India

IntroductionPatients with chronic kidney disease (CKD) require multiple medications. There is no information on prescription patterns or the use of evidence-based therapies for management of CKD from low-middle-income countries. Using baseline data from the Indian CKD (ICKD) cohort, we describe the drug prescription practices in patients with mild to moderate CKD.MethodsThe ICKD study is a prospective, observational cohort study of mild to moderate kidney disease across 11 centers in India. We analyzed all the prescriptions captured at enrollment in the ICKD study. Drugs were categorized into 11 different groups. We provide descriptive data on prescription details and evaluate the appropriateness of medication use.ResultsComplete prescription data were available in 3966 out of 4056 (97.8%) subjects enrolled in the ICKD database. Most patients had stage 3 CKD, 24.9% had diabetic kidney disease, 87% had hypertension, and 25.5% had moderate to severe proteinuria. Renin-angiotensin-aldosterone system blockers were prescribed in less than half (47.9%) and in 58.8% of patients with proteinuric CKD. Metformin was prescribed in 25.7% of diabetic subjects with CKD. Only 40.4% of patients were taking statins; 31.1% and 2.8% subjects with anemia were receiving iron and erythropoiesis-stimulating agents, respectively.ConclusionThis study highlights the missed opportunities for improving outcomes through appropriate prescriptions of drugs in patients with CKD. There is need for dissemination of evidence-based guidelines and institution of sustainable implementation practices for improving the overall health of patients with CKD.

Socioeconomic Status and Outcomes in Heart Failure With Reduced Ejection Fraction From Asia.

Little is known regarding the impact of socioeconomic factors on the use of evidence-based therapies and outcomes in patients with heart failure with reduced ejection fraction across Asia. We investigated the association of both patient-level (household income, education levels) and country-level (regional income level by World Bank classification, income disparity by Gini index) socioeconomic indicators on use of guideline-directed therapy and clinical outcomes (composite of 1-year mortality or HF hospitalization, quality of life) in the prospective multinational ASIAN-HF study (Asian Sudden Cardiac Death in Heart Failure). Among 4540 patients (mean age: 60±13 years, 23% women) with heart failure with reduced ejection fraction, 39% lived in low-income regions; 34% in regions with high-income disparity (Gini ≥42.8%); 64.4% had low monthly household income (<US$1000); and 29.5% had no/only primary education. The largest disparity in treatment across regional income levels pertained to β-blocker and device therapies, with patients from low-income regions being less likely to receive these treatments compared with those from high-income regions and even greater disparity among patients with lower education status and lower household income within each regional income strata. Higher country- and patient-level socioeconomic indicators related to higher quality of life scores and lower risk of the primary composite outcome. Notably, we found a significant interaction between regional income level and both household income and education status (Pinteraction <0.001 for both), where the association of low household income and low education status with poor outcomes was more pronounced in high-income compared with lower income regions. These findings highlight the importance of socioeconomic determinants among patients with heart failure in Asia and suggest that attention should be paid to address disparities in access to care among the poor and less educated, including those from wealthy regions. Registration: URL: https://clinicaltrials.gov; Unique Identifier: NCT01633398.

The relevance of specific heart failure outpatient programs in the COVID era: an appropriate model for every disease.

Heart Failure (HF) is characterized by an elevated readmission rate, with almost 50% of events occurring after the first episode over the first 6 months of the post-discharge period. In this context, the vulnerable phase represents the period when patients elapse from a sub-acute to a more stabilized chronic phase. The lack of an accurate approach for each HF subtype is probably the main cause of the inconclusive data in reducing the trend of recurrent hospitalizations. Most care programs are based on the main diagnosis and the HF stages, but a model focused on the specific HF etiology is lacking. The HF clinic route based on the HF etiology and the underlying diseases responsible for HF could become an interesting approach, compared with the traditional programs, mainly based on non-specific HF subtypes and New York Heart Association class, rather than on detailed etiologic and epidemiological data. This type of care may reduce the 30-day readmission rates for HF, increase the use of evidence-based therapies, prevent the exacerbation of each comorbidity, improve patient compliance, and decrease the use of resources. For all these reasons, we propose a dedicated outpatient HF program with a daily practice scenario that could improve the early identification of symptom progression and the quality-of-life evaluation, facilitate the access to diagnostic and laboratory tools and improve the utilization of financial resources, together with optimal medical titration and management.

Evaluation of 1-Year Follow-up of Patients Included in the Registry of Clinical Practice in Patients at High Cardiovascular Risk (REACT).

ResumoFundamento Na prática clínica, há evidências de falhas na prescrição de terapias baseadas em evidências para pacientes de alto risco cardiovascular. Entretanto, no Brasil, ainda são insuficientes os dados sobre a evolução ao longo de 1 ano desses pacientes.Objetivos Descrição no acompanhamento de 12 meses da utilização de terapias baseadas em evidência e da ocorrência de desfechos cardiovasculares maiores e seus principais preditores em um registro brasileiro multicêntrico de pacientes de alto risco cardiovascular.Métodos Estudo observacional prospectivo que documentou a prática clínica ambulatorial de indivíduos acima de 45 anos e de alto risco cardiovascular tanto em prevenção primária como secundária. Os pacientes foram seguidos por 1 ano e avaliou-se a prescrição de terapias baseadas em evidência e a ocorrência de eventos cardiovasculares maiores (infarto agudo do miocárdio [IAM], acidente vascular cerebral [AVC], parada cardíaca e mortalidade por causa cardiovascular). Valores de p < 0,05 foram considerados estatisticamente significantes.Resultados De julho de 2010 até agosto de 2014, 5.076 indivíduos foram incluídos em 48 centros, sendo 91% dos 4.975 pacientes elegíveis acompanhados em centros de cardiologia e 68,6% em prevenção secundária. Em 1 ano, o uso concomitante de antiplaquetários, estatinas e inibidores da enzima conversora de angiotensina (IECA) reduziu de 28,3% para 24,2% (valor de p < 0,001). A taxa de eventos cardiovasculares maiores foi de 5,46%, e os preditores identificados foram: idade, pacientes em prevenção secundária e nefropatia diabética.Conclusões Neste grande registro nacional de pacientes de alto risco cardiovascular, foram identificados preditores de risco semelhantes aos registros internacionais, porém a adesão da prescrição médica a terapias baseadas em evidência esteve abaixo dos dados da literatura internacional e apresentou piora significativa em 1 ano. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)