Use Of Guideline-recommended Therapies Research Articles

Prevalence and outcome of clinical misdiagnosis of non-ST-elevation myocardial infarction

Abstract Background The prevalence of clinical misdiagnosis of non-ST-elevation myocardial infarction (NSTEMI) and its impact on patient outcomes is largely unknown. Methods We prospectively enrolled adult patients presenting with suspected acute coronary syndromes at 12 sites in five European countries. All patients provided written informed consent and were managed as per local clinical care using conventional, sensitive or high-sensitivity cardiac troponin (hs-cTn) assays. Study blood samples were taken at presentation and serially thereafter for measurements of hs-cTn concentrations. Final diagnoses were adjudicated by two independent cardiologists according to current guidelines and the 4th universal definition of myocardial infarction using all information including serial hs-cTnT measurements and imaging. The primary diagnostic endpoint was the prevalence of clinical NSTEMI misdiagnosis. Co-primary prognostic endpoints were 30 day and two year all-cause and cardiovascular (CV) death. Results In 7,678 patients (median age 61 [IQR 48-73], 34% women), the prevalence of adjudicated and clinical NSTEMI was 17.8% and 12.3%, respectively (P<0.001). Among 1,363 patients with an adjudicated NSTEMI (77% type 1 MI, 23% type 2 MI), 470/1,363 (34%) had a clinical NSTEMI misdiagnosis. These patients were older, more often female, had lower median cTn concentrations, and were more likely managed at centers using non-hs-cTn assays at time of enrolment. Compared to patients with an adjudicated and clinical NSTEMI diagnosis, missed patients were less likely to undergo coronary angiography or revascularization and less often discharged on evidence-based treatment (dual antiplatelet therapy 24% vs 79%, statin 64% vs 92%, betablocker 68% vs 81%, all P<0.001). Finally, patients with a clinical NSTEMI misdiagnosis were at much higher risk of premature all-cause (HR 1.51, 95% CI 1.18-1.94, P<0.001) and CV (HR 1.93, 95%CI 1.42-2.63, P<0.001) death. Conclusion One out of three adjudicated NSTEMI patients was misdiagnosed in routine clinical care. Clinical NSTEMI misdiagnosis was associated with lower use of guideline-recommended therapies and a substantial increase in premature death.Alluvial plotAll-cause death at 2-years

Anticoagulation for Atrial Fibrillation in Acute Coronary Syndrome Survivors Reduces Major Cardiovascular Events and Mortality.

The prevalence of atrial fibrillation (AF) in acute coronary syndrome (ACS) patients is increasing. Data on outcomes of anticoagulation in ACS patients with AF are lacking. The aim of our study was to investigate the prevalence of stroke, myocardial infarction, bleeding complications, and all-cause mortality in this population. PL-ACS and AMI-PL registries gather an all-comer population of ACS patients in Poland, exceeding half a million records. We have selected ACS survivors with concomitant AF on admission, divided them into subgroups with regard to the administered anticoagulation, and followed up with them for a 12-month period ( n = 13,973). Subsequently, groups were propensity score matched for age, sex, ejection fraction, diabetes, heart failure, renal impairment, and type of ACS. The study population was divided with regard to the administration of anticoagulation. Anticoagulation was prescribed in 2,466 patients (17.6%). The (D)OAC+ patients were younger; however, comorbidities were more prevalent in this group. The 12-month follow-up showed that the (D)OAC+ patients had significantly lower rates of all-cause mortality, myocardial infarction, and ischemic stroke, with no significant increase in bleeding events. After matching, the study groups consisted of 2,194 patients each and showed no differences in baseline characteristics. The outcomes of the 12-month observation were similar to the findings before matching. This all-comer national registry analysis shows that the use of guideline-recommended therapy and anticoagulation in ACS survivors with AF is associated with a lower rate of all-cause mortality, recurrent myocardial infarction, and ischemic stroke.

Association of secondary prevention medication use after myocardial infarction with mortality in hemodialysis patients.

Mortality after myocardial infarction (MI) among patients undergoing dialysis is high. However, studies investigating the use of secondary prevention medications after MI and clinical outcomes in dialysis patients are lacking. This study aimed to examine the association of the number of guideline-recommended medications (antiplatelets, β-blockers, statins and renin-angiotensin-aldosterone system inhibitors) with all-cause mortality after MI in hemodialysis (HD) patients. We conducted a nationwide cohort study of incident HD patients who were admitted for MI between 1 January 2010 and 31 December 2014 and were followed up until 31 December 2015, using Taiwan's national health insurance research database. Of 1471 patients (mean age 68years, 41.9% women) included in the analysis, 281 (19.1%) were treated with one cardioprotective medication, 406 (27.6%) with two, 490 (33.3%) with three and 294 (20%) with four. During a median follow-up of 1.0years, 458 (31.1%) patients died. In a multivariable Cox model, each additional use of guideline-recommended therapies was associated with a significant 12% reduction in the risk of mortality {hazard ratio [HR] 0.88 [95% confidence interval (CI) 0.80-0.97]}. Similar results were obtained in the analysis with the inverse probability of treatment weighting [HR 0.84 (95% CI 0.77-0.92)] and in the propensity score-matched subcohort [HR 0.87 (95% CI 0.77-0.98)]. The decreased mortality risk was consistently observed across all subgroups. The use of more evidence-based medications for secondary prevention after MI was associated with a lower risk of all-cause mortality in HD patients.

Adequacy of blood pressure control in high-risk hypertensive patients: The DEGREE study

IntroductionHypertension is a modifiable risk factor in patients at the highest risk for cardiovascular events. New invasive treatment options are becoming available that might be particularly appealing for high-risk patients. Therefore, the aim of this study was to determine the prevalence of high-risk patients on routine therapy that do not meet guideline recommended ambulatory blood pressure (ABP) targets. MethodsThis single-center, cross-sectional study was conducted at the Erasmus University Medical Center (Rotterdam, The Netherlands). Inclusion criteria were: (1) age 18–80 years, (2) drugs prescribed for hypertension or history of hypertension and (3) high cardiovascular risk as defined according to the European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines. Patients underwent standardized office blood pressure (OBP) and same-day 24-h ABP measurements. Blood pressure (BP) control was defined according to the 2018 ESC/ESH and 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. ResultsA total of 100 patients were enrolled (median age 71 years, 35% female). Mean OBP was 142.2/81.9 ± 18.6/12.6 mmHg and mean 24-h ABP was 126.1/70.1 ± 14.3/9.2 mmHg. Patients were on 2.0 [25th–75th percentile: 1.0–3.3] Defined Daily Doses of antihypertensive drugs. ESC/ESH guideline 24-h ABP and OBP targets were not met in 41.8% (95%CI: 31.5–52.6%) and 52.7% (95%CI: 42.0–63.3%), respectively. ACC/AHA guideline 24-h ABP and OBP targets were not met in 59.3% (95%CI: 48.5–69.5%) and 79.1% (95%CI: 69.3–86.9%), respectively. ConclusionsBP remains uncontrolled in 40–60% of high-risk hypertensive patients despite routine use of guideline-recommended therapy. Our findings support the search towards novel invasive BP lowering treatment options.

684-P: Trends in Type 2 Diabetes Pharmacotherapy and Evolving Use of the Newer Agents

Background: Newer treatment options for type 2 diabetes (T2D) and emerging evidence of treatment-specific benefits for ASCVD, CKD, heart failure (HF), hypoglycemia, and obesity provide opportunities for individualizing treatment choices. We used claims data to examine how T2D treatment patterns have changed in recent years as clinical trial data and updated guidelines have emerged. Method: A retrospective observational study of T2D patients in a health insurance claims database (IBM® MarketScan® 2007 to 2019 Commercial and Medicare Databases). Medication use by class was examined from Jan 2015 through Dec 2019. Data since 2007 were used to establish disease history and categorize individuals according to the ADA/EASD Consensus Statement (2019): ASCVD, CKD, HF, hypoglycemia, and obesity defined risk groups. Alignment of risk group with treatment recommendation was evaluated by comparing use rates in the groups with and without risk. A GEE model was fit with guideline alignment as the dependent variable. The slope parameter and the area under the curve were calculated on the probability scale. Results: Use of guideline-recommended therapies in the risk groups increased in both cohorts from 2015 to 2019. The Commercial cohort showed better alignment vs. the Medicare cohort over all years. Guideline-recommended therapy use in 2019 was highest in the Commercial CKD and obesity groups (39.2%; 37.6 %) with 5 year growth rates of 74.5% and 54.9%; and lowest in Medicare HF and CKD groups (16.6%; 18.5% ), but showing rapid 5 year growth (145.5% and 132.2% respectively). Use of SU in the hypoglycemia risk group decreased over time, but at comparable rates to those without the risk. The HF risk group was less likely to receive guideline recommended therapies vs. no HF risk. Conclusion: The data suggest there is considerable room for improvement in individualizing therapies according to ADA risk grouping. Improving alignment through more targeted prescribing could further enhance outcomes without increasing overall use. Disclosure J. P. Bae: Employee; Self; Eli Lilly and Company. D. Liu: Employee; Self; Eli Lilly and Company. C. Chinthammit: Employee; Self; Eli Lilly and Company. Z. A. Kadziola: Employee; Self; Eli Lilly and Company, Stock/Shareholder; Self; Eli Lilly and Company. K. Boye: Employee; Self; Eli Lilly and Company, Employee; Spouse/Partner; Eli Lilly and Company. K. J. Mather: Employee; Self; Eli Lilly and Company.

Peripheral artery disease in Germany (2009-2018): Prevalence, frequency of specialized ambulatory care and use of guideline-recommended therapy - A population-based study.

BackgroundPeripheral artery disease (PAD) patients have high morbidity and mortality rates, demonstrating a need for improved treatment strategies. While underuse and undertreatment have been reported, there is no clear picture of patterns in population-level disease prevalence, prescription of guideline-recommended pharmacotherapy, or frequency of contact with dedicated specialists. We present population-level data on changes in prevalence, care and treatment of PAD from 2009 to 2018 in Germany.MethodsWe analyzed the ambulatory claims data for all statutorily insured patients comprising 70.1 million patients each year and 87% of the German population. Prevalence was assessed by documentation of PAD and stratified by age and sex within the 10-year study timeframe. In addition, current ambulatory care, stratified by vascular specialists (vascular surgeons or angiologists), internists, cardiologists and primary care physicians, were examined.FindingsPrevalence increased from 1·85% in 2009 to 3·14% in 2018, affecting 2·3 million patients in 2018 and more males (55%) than females (45%). A low level of visits to vascular specialists, with 11·1% receiving care from vascular surgeons and 8·1% from angiologists, was shown. Moreover, analysis of guideline-recommended prescriptions revealed increasing, but still insufficient, prescription frequencies among PAD patients between 2009 and 2016, from 42·6% to 56% for statins and from 40·2% to 48·0% for antiplatelets.InterpretationOur results show that the prevalence of PAD in Germany, as assessed by outpatient PAD documentation, is increasing and PAD patients are underutilizing specialized vascular care; moreover, the prescription frequency of guideline-recommended therapies remains low. There is a clear need to improve the referral and treatment algorithms in the high-risk PAD population.FundingNone.

Temporal trends in treatment and outcomes of patients with acute coronary syndrome and concomitant moderate to severe renal failure

Abstract Introduction Limited information about the management and outcomes of patients with acute coronary syndromes (ACS) and moderate to severe renal failure (RF) is available owing to underrepresentation of this population in most studies. Methods We evaluated the use of guideline-recommended therapies and in-hospital outcomes of totally 49'191 ACS patients with normal-mild renal failure (RF) (defined as eGFR >45ml/min/m2) versus moderate-severe RF (eGFR <45ml/min/m2) enrolled in the prospective Acute Myocardial Infarction in Switzerland (AMIS) cohort between 2002 and 2019 according to 2-year periods. Results Overall, 3'478 (7.1%) patients had moderate-severe RF. They were older (65.2+12.9 versus 77.2+10.6 years) and had significantly more comorbidities (including heart failure, cerebrovascular and peripheral vascular disease). Moderate-severe RF patients received less frequently guideline-recommended drugs, including P2Y12 inhibitors, ACEI/ARBs and statins (p<0.0001). Between the first and last 2-year periods, the number of patients with moderate-severe RF and number of performed percutaneous coronary interventions (PCI) increased in this cohort (p-for-trend=0.001). At the same time, in-hospital mortality significantly decreased among ACS patients with and without RF (17.5% to 10.5% and 6.0% to 3.9%, respectively, p-for-trend=0.001 for both, see Figure). Similar trends were observed for other complications, namely cardiogenic shock and reinfarction. However, major bleedings increased significantly over time in patients with and without RF (p-for-trend=0.038 and <0.001, respectively). Conclusions Outcomes of ACS patients with moderate to severe RF improved over the last two decades. Even though the rate of PCI increased in ACS patients with moderate-severe RF, they were less likely to receive guideline-recommended therapies and still suffer a high in-hospitality mortality (>10%). With respect to the increasing burden of ACS patients with RF, our study implicates that more efforts should be undertaken to further improve outcomes of those patients. Funding Acknowledgement Type of funding source: None

Underuse of Prevention and Lifestyle Counseling in Patients With Peripheral Artery Disease

BackgroundLittle is known about patterns of medication use and lifestyle counseling in patients with peripheral artery disease (PAD) in the United States. ObjectivesThe authors sought to evaluate trends in both medical therapy and lifestyle counseling for PAD patients in the United States from 2005 through 2012. MethodsData from 1,982 outpatient visits among patients with PAD were obtained from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, a nationally representative assessment of office-based and hospital outpatient department practice. Trends in the proportion of visits with medication use (antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs], and cilostazol) and lifestyle counseling (exercise or diet counseling and smoking cessation) were evaluated. ResultsOver the 8-year period, the average annual number of ambulatory visits in the United States for PAD was 3,883,665. Across all visits, mean age was 69.2 years, 51.8% were female, and 56.6% were non-Hispanic white. Comorbid coronary artery disease (CAD) was present in 24.3% of visits. Medication use for cardiovascular prevention and symptoms of claudication was low: any antiplatelet therapy in 35.7% (standard error [SE]: 2.7%), statin in 33.1% (SE: 2.4%), ACEI/ARB in 28.4% (SE: 2.0%), and cilostazol in 4.7% (SE: 1.0%) of visits. Exercise or diet counseling was used in 22% (SE: 2.3%) of visits. Among current smokers with PAD, smoking cessation counseling or medication was used in 35.8% (SE: 4.6%) of visits. There was no significant change in medication use or lifestyle counseling over time. Compared with visits for patients with PAD alone, comorbid PAD and CAD were more likely to be prescribed antiplatelet therapy (odds ratio [OR]: 2.6; 95% confidence interval [CI]: 1.8 to 3.9), statins (OR: 2.6; 95% CI: 1.8 to 3.9), ACEI/ARB (OR: 2.6; 95% CI: 1.8 to 3.9), and smoking cessation counseling (OR: 4.4; 95% CI: 2.0 to 9.6). ConclusionsThe use of guideline-recommended therapies in patients with PAD was much lower than expected, which highlights an opportunity to improve the quality of care in these high-risk patients.

Guideline-adherent therapy for stroke prevention in atrial fibrillation in different health care settings: Results from RAMSES study

ObjectiveNo studies have been conducted in Turkey to compare the quality of stroke prevention therapies provided in different healthcare settings in patients with atrial fibrillation (AF). Therefore, we aimed to evaluate possible differences between secondary (SH) and tertiary hospital (TH) settings in the effectiveness of implementing AF treatment strategies. MethodsBaseline characteristics of 6273 patients with non-valvular AF enrolled in the RAMSES (ReAl-life Multicentre Survey Evaluating Stroke Prevention Strategies in Turkey) study were compared. ResultsOf the study population, 3312 (52.8%) patients were treated in THs and 2961 (47.2%) patients were treated in SHs. Patients treated in the SH setting were older (70.8±9.8 vs. 68.7±11.4years, p<0.001), had a lower socioeconomic status, had a higher CHA2DS2VASc and HASBLED scores (3.4±1.4 vs. 3.1±1.7, p<0.001 and 1.7±1.0 vs. 1.6±1.1, p<0.001 respectively), and had more comorbidities than patients treated in THs. Inappropriate oral anticoagulant use was more prevalent in SHs than THs (31.4% vs. 25.6%, p<0.001). When over- and undertreatment rates were compared among hospital types, overtreatment was more prevalent in THs (7.6% vs. 0.9%, p<0.001) while undertreatment was more common in SHs (30.5% vs. 17.9%, p<0.001). ConclusionThis study demonstrates the marked disparity between patient groups with AF presenting at SHs and THs. The use of guideline-recommended therapy is not adequate in either type of centre, overtreatment was more prevalent in THs and undertreatment was more prevalent in SHs.

Improving the Cardiovascular Health of Women in the Nation: Moving Beyond the Bikini Boundaries.

Despite recent declines in cardiovascular mortality in women over the past decade, cardiovascular disease (CVD) remains the number 1 killer of women.1 Deaths attributable to CVD outnumber the deaths attributable to breast, ovarian, uterine, cervical, or vaginal cancers, or childbirth combined, and yet, when the medical community refers to women’s health, they continue to focus on the bikini boundaries. Women continue to be labeled as a special population in many guidelines relating to CVD, despite being the majority of the population. Nonetheless, when presenting with an acute coronary syndrome, it is women, in particular, younger women, who are less likely to receive guideline-recommended therapies, timeliness of care, or diagnostic and invasive therapies resulting in worse outcomes in comparison with men.2 Women who experience cardiac arrest are less likely to receive bystander CPR than men, and less likely to receive guideline-recommended therapies. The prevalence of heart failure is greater in women than in men, and, despite the sex differences in the causes and types of heart failure, women with heart failure with reduced ejection fraction are less likely to receive evidence-based therapies, including medications, implantable cardioverter defibrillators, ventricular assist devices, and heart transplant, despite improved survival and quality of life when receiving these therapies. Asymptomatic peripheral artery disease is twice as common in women as in men, and once a diagnosis of peripheral artery disease is made, women have greater functional impairment, lower rates of revascularization, and an increased likelihood of emergent procedures. This persistent pattern of poorer cardiovascular outcomes appears predominantly attributable to suboptimal use of guideline-recommended therapy in women, despite the strong evidence that management of CVD with evidence-based therapies benefits both sexes equally. …

Temporal trends in the treatment and outcomes of elderly patients with acute coronary syndrome.

To determine whether treatment and outcomes of older acute coronary syndrome (ACS) patients changed over time. We analysed the use of guideline-recommended therapies and in-hospital outcomes of 13 662 ACS patients ≥70 years enrolled in the prospective Acute Myocardial Infarction in Switzerland (AMIS) cohort between 2001 and 2012 according to 4-year periods (2001-2004, 2005-2008, and 2009-2012). Between first and last 4-year period, percutaneous coronary intervention (PCI) use increased from 43.8 to 69.6% of older ACS patients ( ITALIC! P < 0.001). Use of guideline-recommended drugs as well increased. At the same time, in-hospital mortality of the overall population decreased from 11.6% in the first to 10.0% in the last 4-year period ( ITALIC! P = 0.020), and in-hospital major adverse cardiac and cerebrovascular events from 14.4 to 11.3% ( ITALIC! P < 0.001). Percutaneous coronary intervention was used in increasingly older and co-morbid patients over time (mean age of patients treated with PCI 76.2 years in 2001-2004 and 78.1 years in 2009-2012, ITALIC! P < 0.001; Charlson score ≥2 was found for 27.6% of patients treated with PCI in 2001-2004 and for 32.1% in 2009-2012, ITALIC! P = 0.003). Percutaneous coronary intervention use was associated with similar odds ratios (ORs) of in-hospital mortality over time (adjusted OR 0.29, 95% confidence interval, CI, 0.22-0.40, in 2001-2004; and, adjusted OR 0.26, 95% CI 0.20-0.35, in 2009-2012). Use of guideline-recommended therapies for ACS increased and in-hospital outcomes improved over the observed 12-year period. Though PCI was used in increasingly older and co-morbid patients, PCI use was associated with similar ORs of in-hospital mortality over time. This study suggests that increasing use of guideline-recommended therapies was appropriate. ClinicalTrials.gov Identifier: NCT01305785.

Global variation in clinical profile, management, and post-discharge outcomes among patients hospitalized for worsening chronic heart failure: findings from the ASTRONAUT trial.

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 America. After adjustment for patient characteristics, region was an independent predictor of death at 12 months, with highest risk in Asia/Pacific (hazard ratio 3.04, 95% confidence interval 1.47-6.29, compared with North America) and lowest risk in North America and Western Europe. There was no association between region and the composite of cardiovascular mortality or HHF. For patients enrolled in this HHF trial, baseline characteristics and risk of death differed markedly by geographic region. Rates of death and repeat HHF demonstrated a general inverse relationship. Global differences in patient characteristics and outcomes should be accounted for when designing future HHF clinical trials.

Response to: Modifiable lifestyle risks, cardiovascular disease, and all-cause mortality

[1] Fonarow GCA NM, Curtis AB, Gheorghiade M, et al. Incremental reduction in risk of death associated with use of guideline-recommended therapies in patients with heart failure: a nested case–control analysis of IMPROVE HF. J Am Heart Assoc 2012;1:16–26. [2] Ghali JK, Massie BM, Mann DL, Rich MW. Heart failure guidelines, performance measures, and the practice of medicine: mind the gap. J Am Coll Cardiol 2010;56(25):2077–80. [3] Lee DS, Tu JV, Juurlink DN, et al. Risk-treatment mismatch in the pharmacotherapy of heart failure. JAMA 2005;294(10):1240–7. [4] Gheorghiade M, Pang PS. Acute heart failure syndromes. J Am Coll Cardiol 2009;53(7):557–73. [5] Gibbons RJ, Gardner TJ, Anderson JL, et al. The American Heart Association's principles for comparative effectiveness research: a policy statement from the American Heart Association. Circulation 2009;119(22):2955–62. [6] Jackevicius CA, Paterson JM, Naglie G. Concordance between discharge prescriptions and insurance claims inpost-myocardial infarction patients. Pharmacoepidemiol Drug Saf 2007;16(2):207–15. [7] Saczynski JS, Andrade SE, Harrold LR, et al. A systematic review of validated methods for identifying heart failure using administrative data. Pharmacoepidemiol Drug Saf 2012;21(Suppl 1):129–40. [8] Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA 2013;309(6):587–93.

Do patients treated at academic hospitals have better longitudinal outcomes after admission for non–ST-elevation myocardial infarction?

Prior studies have found that academic hospitals provide more consistent use of guideline-recommended therapies in patients with non-ST-segment myocardial infarction (NSTEMI) compared with nonacademic centers, yet it is unclear whether these care differences translate into longer-term outcome differences. Using data from the CRUSADE Registry linked to Center for Medicare & Medicaid Services claims, we compared 30-day and 1-year all-cause mortality among 12,194 older patients with NSTEMI (age ≥65 years) treated at 103 academic centers and 28,335 patients treated at 302 nonacademic centers from February 2003 to December 2006. Outcomes were first adjusted for clinical characteristics, followed by adjustment for hospital performance, on 13 acute and discharge guideline-recommended therapies using a shared frailty model (an extension of the Cox proportional hazard model). Compared with older patients with NSTEMI treated at nonacademic hospitals, those treated at academic hospitals had greater and more consistent use of evidence-based acute and discharge therapies, were more likely to receive in-hospital revascularization (61.1% vs 54.2%; P < .0001), and had modestly lower risk-adjusted 30-day mortality after adjustment for patient-level clinical characteristics (8.9% vs 10.2%, adjusted hazard ratio [HR] 0.89, 95% CI 0.80-0.99). These differences were attenuated (HR 0.94, 95% CI 0.83-1.02) after further adjustment for hospital delivery of evidence-based treatments, yet did not persist out to 1 year (unadjusted HR 0.92, 95% CI 0.84-1.01, P = .089). Patients with NSTEMI treated at academic centers are more likely to receive guideline-recommended therapies and had modestly better 30-day outcomes. Nevertheless, these differences do not persist out to 1 year.

Abstract 9416: Undiagnosed Peripheral Arterial Disease (PAD) is Common in Patients Referred for Stress Tests Without a History of Atherosclerotic Heart Disease

Background: The ankle brachial index (ABI) is a highly sensitive and specific method to diagnose peripheral arterial disease (PAD). Abnormal ABI (≤0.9 or ≥1.4) predicts cardiovascular events and mortality, independent of traditional risk factors. Post-exercise ABIs can identify additional individuals with hemodynamically significant PAD. METHODS: ABI was measured at rest and immediately post-exercise in patients referred for stress testing without known carotid, coronary, or peripheral atherosclerotic disease. ABI was classified as normal (1-1.39), borderline (0.91-0.99), low (≤0.9), or consistent with poorly compressible arteries (≥1.4). Abnormal post-exercise ABI was defined according to guidelines as a ≥20% decrease in ABI or a decline in ankle systolic blood pressure of ≥30 mmHg. ABIs were measured using automated oscillometric cuffs, which correlate well with Doppler and have excellent specificity. RESULTS: 223 patients were enrolled in this ongoing study at the time of analysis, 108 of whom had post-exercise measurements. At rest, 20/223 (9%) had poorly compressible arteries, 7/223 (3.1%) had borderline ABI, and 1/223 (0.5%) had low ABI. Of those with normal ABI for whom post-exercise ABI was obtained, 34/108 (31.5%) had abnormal post-exercise ABI. Among patients with PAD by ABI, rates of use of aspirin (12/35), statins (9/35), and ACE-inhibitor/angiotensin receptor blockers (10/35) were low. Only 2 of 35 patients diagnosed with PAD had abnormal stress tests. 12 of the 223 patients overall had positive stress tests for ischemia. CONCLUSIONS: ABI measurement in patients referred for stress testing led to a diagnosis of peripheral vascular disease (poorly compressible arteries or PAD) in 24.6% of patients, despite low rates of ischemia on clinically indicated stress tests. ABI screening in this patient population may improve our ability to target use of guideline-recommended therapies for the prevention of cardiovascular events.

Recent Trends in the Incidence, Treatment, and Prognosis of Patients With Heart Failure and Atrial Fibrillation (the Worcester Heart Failure Study)

Atrial fibrillation (AF) and heart failure (HF) are common cardiovascular diseases and the co-occurrence of AF and HF has been associated with reduced survival. Data are needed on the potentially changing trends in the characteristics, treatment, and prognosis of patients with acute decompensated HF (ADHF) and AF. The study population consisted of 9,748 patients hospitalized with ADHF at 11 hospitals in the Worcester, Massachusetts, metropolitan area during 4 study years (1995, 2000, 2002, and 2004). Of the 9,748 patients admitted with ADHF, 3,868 (39.7%) had a history of AF and 449 (4.6%) developed new-onset AF during hospitalization. The rates of new-onset AF remained stable (4.9% in 1995; 5.0% in 2004), but the proportion of patients with pre-existing AF (34.5% in 1995; 41.6% in 2004) increased over time. New-onset and pre-existing AF were associated with older age, but pre-existing AF was more closely linked to a greater co-morbid disease burden. The use of HF therapies did not differ greatly by AF status. Despite this, new-onset AF was associated with a longer length of stay (7.5 vs 6.1 days) and greater in-hospital death rates (11.4% vs 6.6%). In contrast, pre-existing AF was associated with lower rates of postdischarge survival compared to patients with no AF (p <0.05 for all). The mortality rates improved significantly over time in patients with AF. In conclusion, AF was common among patients with ADHF, and the proportion of ADHF patients with co-occurring AF increased during the study period. Despite improving trends in survival, patients with ADHF and AF are at increased risk of in-hospital and postdischarge mortality.

758 High Use of Guideline-Recommended Therapies in Canadian Outpatients with Stable Coronary Artery Disease: Insights From the Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) Registry

758 High Use of Guideline-Recommended Therapies in Canadian Outpatients with Stable Coronary Artery Disease: Insights From the Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) Registry

Incremental Reduction in Risk of Death Associated With Use of Guideline-Recommended Therapies in Patients With Heart Failure: A Nested Case-Control Analysis of IMPROVE HF

Incremental Reduction in Risk of Death Associated With Use of Guideline-Recommended Therapies in Patients With Heart Failure: A Nested Case-Control Analysis of IMPROVE HF

Race and Improvements in the Use of Guideline-Recommended Therapies for Patients With Heart Failure: Findings From IMPROVE HF

Race is associated with differences in use of guideline-recommended therapies for patients with heart failure (HF). To evaluate whether a practice-based performance improvement intervention is associated with similar improvements in evidence-based care for black, white, and race-undocumented patients. IMPROVE HF is a longitudinal evaluation of a performance improvement intervention on use of evidence-based therapies for outpatients with HF or prior myocardial infarction and left ventricular ejection fraction less than or equal to 35%. Data were available for 7605 patients. Changes in use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, aldosterone antagonist, cardiac resynchronization therapy, implantable cardioverter-defibrillator therapy, anticoagulant for atrial fibrillation, and HF education were analyzed by patient race (black, white, or undocumented/missing). Multivariate analyses identified variables independently associated with changes in each therapy. There were 686 black patients (9.0%) and 3238 white patients (42.6%), and race was undocumented for 3537 (46.5%). Baseline use of B-blockers and aldosterone antagonists was significantly higher in black patients than in the other 2 groups, and use of aldosterone antagonists and HF education was higher among black patients at 24 months. Postintervention use of 4 of 7 therapies increased equitably for the 3 groups, and treatment rates were similar between black and white patients for 5 of 7 individual quality measures. Improvements in care were independent of race. These findings offer some indication that race-based differences in delivery of evidence-based HF care may be decreasing in outpatient cardiology practices. Application of clinical decision support and performance feedback may facilitate equitable improvements in HF care in outpatient settings regardless of patient race. NCT00303979, wwwv.clinicaltrials.gov.

Differences in the use of guideline-recommended therapies among 14 European countries in patients with acute coronary syndromes undergoing PCI

Despite common European Society of Cardiology recommendations, adherence to guideline therapy varies, both temporally and geographically. We sought to examine current differences in the use of guideline-recommended therapies among 14 European countries in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Data were obtained from the Antiplatelet Therapy Observational Registry (APTOR), a non-interventional, prospective observational cohort study enrolling patients with ACS undergoing PCI. Medication data were captured through 1 year. The large majority of patients in the APTOR registry received statins at hospital discharge (89%) and remained on statins at 1 year (87%), a finding that was consistent across countries. Likewise, beta-blocker use was similar at discharge and 1 year (83 and 81%, respectively). There was large disparity in aspirin loading dose between countries, but the discharge maintenance dose was more consistent, with most receiving ≤ 100 mg (87%). While 95% of patients were discharged on dual antiplatelet therapy, 71% remained on both treatments by 1 year, with wide variation by country in 1-year use. These data from the APTOR study provide key information on current European ACS patient care management from hospitalization through 1 year. Even with European Society of Cardiology (ESC) guidelines, variations in practice patterns exist among ACS patients treated with PCI between the 14 European countries studied, including the use of proven therapies, as well as appropriate duration and dosing of antiplatelet regimens. Efforts are needed to further explain why such variation exists and to continue to improve adherence to ESC guidelines to improve patient care.