Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes

Background: The persistence of depressive symptoms after hospitalization is a strong risk factor for mortality after acute coronary syndromes (ACS). Poor adherence to secondary prevention behaviors may be a mediator of the relationship between depression and increased mortality. Objective: To determine whether rates of adherence to risk reducing behaviors were affected by depressive status during hospitalization and 3 months later. Design: Prospective observational cohort study. Setting: Three university hospitals. Participants: Five hundred and sixty patients were enrolled within 7 days after ACS. Of these, 492 (88%) patients completed 3-month follow-up. Measurements: We used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and 3 months after discharge. We assessed adherence to 5 risk-reducing behaviors by patient self-report at 3 months. We used χ2 analysis to compare differences in adherence among 3 groups: persistently nondepressed (BDI<10 at hospitalization and 3 months); remittent depressed (BDI ≥10 at hospitalization; <10 at 3 months); and persistently depressed patients (BDI ≥10 at hospitalization and 3 months). Results: Compared with persistently nondepressed, persistently depressed patients reported lower rates of adherence to quitting smoking (adjusted odds ratio [OR] 0.23, 95% confidence interval [95% CI] 0.05 to 0.97), taking medications (adjusted OR 0.50, 95% CI 0.27 to 0.95), exercising (adjusted OR 0.57, 95% CI 0.34 to 0.95), and attending cardiac rehabilitation (adjusted OR 0.5, 95% CI 0.27 to 0.91). There were no significant differences between remittent depressed and persistently nondepressed patients. Conclusions: Persistently depressed patients were less likely to adhere to behaviors that reduce the risk of recurrent ACS. Differences in adherence to these behaviors may explain in part why depression predicts mortality after ACS. Key Words: cardiovascular diseases, depression, medication adherence, prevention, self car

Predicting out of intensive care unit cardiopulmonary arrest or death using electronic medical record data

BACKGROUND: Accurate, timely and automated identification of patients at high risk for severe clinical deterioration using readily available clinical information in the electronic medical record (EMR) could inform health systems to target scarce resources and save lives. METHODS: We identified 7,466 patients admitted to a large, public, urban academic hospital between May 2009 and March 2010. An automated clinical prediction model for out of intensive care unit (ICU) cardiopulmonary arrest and unexpected death was created in the derivation sample (50% randomly selected from total cohort) using multivariable logistic regression. The automated model was then validated in the remaining 50% from the total cohort (validation sample). The primary outcome was a composite of resuscitation events, and death (RED). RED included cardiopulmonary arrest, acute respiratory compromise and unexpected death. Predictors were measured using data from the previous 24 hours. Candidate variables included vital signs, laboratory data, physician orders, medications, floor assignment, and the Modified Early Warning Score (MEWS), among other treatment variables. RESULTS: RED rates were 1.2% of patient-days for the total cohort. Fourteen variables were independent predictors of RED and included age, oxygenation, diastolic blood pressure, arterial blood gas and laboratory values, emergent orders, and assignment to a high risk floor. The automated model had excellent discrimination (c-statistic=0.85) and calibration and was more sensitive (51.6% and 42.2%) and specific (94.3% and 91.3%) than the MEWS alone. The automated model predicted RED 15.9 hours before they occurred and earlier than Rapid Response Team (RRT) activation (5.7 hours prior to an event, p=0.003) CONCLUSION: An automated model harnessing EMR data offers great potential for identifying RED and was superior to both a prior risk model and the human judgment-driven RRT

Clinical and operative predictors of outcomes of carotid endarterectomy

ObjectiveThe net benefit for patients undergoing carotid endarterectomy is critically dependent on the risk of perioperative stroke and death. Information about risk factors can aid appropriate selection of patients and inform efforts to reduce complication rates. This study identifies the clinical, radiographic, surgical, and anesthesia variables that are independent predictors of deaths and stroke following carotid endarterectomy.MethodsA retrospective cohort study of patients undergoing carotid endarterectomy in 1997 and 1998 by 64 surgeons in 6 hospitals was performed (N = 1972). Detailed information on clinical, radiographic, surgical, anesthesia, and medical management variables and deaths or strokes within 30 days of surgery were abstracted from inpatient and outpatient records. Multivariate logistic regression models identified independent clinical characteristics and operative techniques associated with risk-adjusted rates of combined death and nonfatal stroke as well as all strokes.ResultsDeath or stroke occurred in 2.28% of patients without carotid symptoms, 2.93% of those with carotid transient ischemic attacks, and 7.11% of those with strokes (P < .0001). Three clinical factors increased the risk-adjusted odds of complications: stroke as the indication for surgery (odds ratio [OR], 2.84; 95% confidence interval [CI] = 1.55-5.20), presence of active coronary artery disease (OR, 3.58; 95% CI = 1.53-8.36), and contralateral carotid stenosis ≥50% (OR, 2.32; 95% CI = 1.33-4.02). Two surgical techniques reduced the risk-adjusted odds of death or stroke: use of local anesthesia (OR, 0.30; 95% CI = 0.16-0.58) and patch closure (OR, 0.43; 95% CI = 0.24-0.76).ConclusionsInformation about these risk factors may help physicians weigh the risks and benefits of carotid endarterectomy in individual patients. Two operative techniques (use of local anesthesia and patch closure) may lower the risk of death or stroke

Survival and risk of adverse events in older patients receiving postoperative adjuvant chemotherapy for resected stages II-IIIA lung cancer: observational cohort study

Objective To compare the survival and risk of serious adverse events in older patients with stages II-IIIA non-small cell lung cancer treated with or without postoperative platinum based chemotherapy

Physicians, Clinics, and Neighborhoods: Multiple Levels of Influence on Colorectal Cancer Screening

This article describes variability in colorectal cancer (CRC) test use and compares the performance of novel cross-classified and traditional hierarchical models

Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis

Importance Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke. The clinical benefit observed in randomized clinical trials (RCTs) may not extend to real-world practice. Objective To examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis. Design, Setting, and Participants This comparative effectiveness study was conducted from August 28, 2018, to March 2, 2020, using the Corporate Data Warehouse, Suicide Data Repository, and other databases of the US Department of Veterans Affairs. Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Patients without a carotid imaging report, those with carotid stenosis of less than 50% or hemodynamically insignificant stenosis, and those with a history of stroke or transient ischemic attack in the 6 months before index imaging were excluded. A cohort of patients who received initial medical therapy and a cohort of similar patients who received CEA were constructed and followed up for 5 years. The target trial method was used to compute weighted Kaplan-Meier curves and estimate the risk of fatal and nonfatal strokes in each cohort in the pragmatic sample across 5 years of follow-up. This analysis was repeated after restricting the sample to patients who met RCT inclusion criteria. Cumulative incidence functions for fatal and nonfatal strokes were estimated, accounting for nonstroke deaths as competing risks in both the pragmatic and RCT-like samples. Exposures Receipt of CEA vs initial medical therapy. Main Outcomes and Measures Fatal and nonfatal strokes. Results Of the total 5221 patients, 2712 (51.9%; mean [SD] age, 73.6 [6.0] years; 2678 men [98.8%]) received CEA and 2509 (48.1%; mean [SD] age, 73.6 [6.0] years; 2479 men [98.8%]) received initial medical therapy within 1 year after the index carotid imaging. The observed rate of stroke or death (perioperative complications) within 30 days in the CEA cohort was 2.5% (95% CI, 2.0%-3.1%). The 5-year risk of fatal and nonfatal strokes was lower among patients randomized to CEA compared with patients randomized to initial medical therapy (5.6% vs 7.8%; risk difference, −2.3%; 95% CI, −4.0% to −0.3%). In an analysis that incorporated the competing risk of death, the risk difference between the 2 cohorts was lower and not statistically significant (risk difference, −0.8%; 95% CI, −2.1% to 0.5%). Among patients who met RCT inclusion criteria, the 5-year risk of fatal and nonfatal strokes was 5.5% (95% CI, 4.5%-6.5%) among patients randomized to CEA and was 7.6% (95% CI, 5.7%-9.5%) among those randomized to initial medical therapy (risk difference, −2.1%; 95% CI, −4.4% to −0.2%). Accounting for competing risks resulted in a risk difference of −0.9% (95% CI, −2.9% to 0.7%) that was not statistically significant. Conclusions and Relevance This study found that the absolute reduction in the risk of fatal and nonfatal strokes associated with early CEA was less than half the risk difference in trials from 20 years ago and was no longer statistically significant when the competing risk of nonstroke deaths was accounted for in the analysis. Given the nonnegligible perioperative 30-day risks and the improvements in stroke prevention, medical therapy may be an acceptable therapeutic strategy

Common Reasons That Asymptomatic Patients Who Are 65 Years and Older Receive Carotid Imaging

IMPORTANCE: National guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic. OBJECTIVE: To better understand why asymptomatic patients who undergo revascularization receive initial carotid imaging. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 4127 Veterans Health Administration patients 65 years and older undergoing carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009. MAIN OUTCOMES AND MEASURES: Indications for carotid ultrasounds were extracted using trained abstractors. Frequency of indications and appropriateness of initial carotid ultrasound imaging for patients within each rating category after the intervention were reported. RESULTS: The mean (SD) age of this cohort of 4127 patients was 73.6 (5.9) years; 4014 (98.8%) were male. Overall, there were 5226 indications for 4063 carotid ultrasounds. The most common indications listed were carotid bruit (1578 [30.2% of indications]) and follow-up for carotid disease (stenosis/history of carotid disease) in patients who had previously documented carotid stenosis (1087 [20.8% of indications]). Multiple vascular risk factors were the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imaging were 5.4% (227 indications), 83.4% (3387 indications), and 11.3% (458 indications), respectively. Among the most common inappropriate indications were dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0%) received a carotid endarterectomy. Overall, 663 procedures were performed in patients 80 years and older. CONCLUSIONS AND RELEVANCE: Carotid bruit and follow-up for carotid disease accounted for approximately half of all indications provided by physicians for carotid testing. Strong consideration should be given to improving the evidence base around carotid testing, especially around monitoring stenosis over long periods and evaluating carotid bruits. Targeting carotid ultrasound ordering with decision support tools may also be an important step in reducing use of low-value imaging