Risk factors for rehospitalization for acute coronary syndromes and unplanned revascularization following acute myocardial infarction

Background Rehospitalizations for acute coronary syndromes (ACS) and coronary revascularization after an acute myocardial infarction (AMI) are not only common and costly but can also impact patients’ quality of life. In contrast to mortality and all‐cause readmissions, little insight is available into risk factors associated with ACS and revascularization after AMI. Methods and Results In a multicenter AMI registry, we examined the rates and predictors of rehospitalizations for ACS and revascularization within the year after AMI among 3283 patients. Staged revascularization procedures were excluded. Kaplan–Meier estimated rates of rehospitalization due to ACS and revascularization were 6.8% and 4.1%, respectively. In hierarchical, multivariable models, the strongest predictors of rehospitalization for ACS were coronary artery bypass graft prior to AMI hospitalization (hazard ratio [HR] 2.12, 95% CI 1.45 to 3.10), female sex (HR 1.67, 95% CI 1.23 to 2.25), and in‐hospital PCI (HR 1.85, 95% CI 1.28 to 2.69). The strongest predictors of subsequent revascularization were multivessel disease (HR 2.89, 95% CI 1.90 to 4.39) and in‐hospital percutaneous coronary intervention with a bare metal stent (HR 2.08, 95% CI 1.19 to 3.63). The Global Registry of Acute Coronary Events mortality risk score was not associated with the risk of rehospitalization for ACS or revascularization. Conclusions Unique characteristics are associated with admissions for ACS and revascularization, as compared with survival. These multivariable risk predictors may help identify patients at high risk for ACS and revascularization, in whom intensification of secondary prevention therapies or closer post‐AMI follow‐up may be warranted

Patient Profiles and Health Status Outcomes for Peripheral Artery Disease in High-Income Countries:A Comparison Between the United States and the Netherlands

OBJECTIVES: Peripheral artery disease (PAD) is a global disease. Understanding variability in patient profiles and PAD-specific health status outcomes across health system countries can provide insights into improving PAD care. We compared these features between 2 high-income countries, the United States (US) and the Netherlands. MATERIALS AND METHODS: Patients were identified from the Patient-centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) study - a prospective, international registry of patients presenting to vascular specialty clinics for new onset, or exacerbation of PAD symptoms. PAD-specific health status was measured with the Peripheral Artery Questionnaire (PAQ). General linear mixed models for repeated measures were used to study baseline, 3-, 6-, and 12-month PAD-specific health status outcomes (PAQ summary score) between US and the Netherlands. RESULTS: Out of a total of 1,114 patients, 748 patients (67.1%) were from the US and 366 (32.9%) from the Netherlands. US patients with PAD were older, with more financial barriers, higher cardiovascular risk factor burden, and lower referral rates for exercise treatment (p < 0.001). They had significantly worse PAD-specific adjusted health status scores at presentation, 3-, 6- and 12 months of follow-up (all p < 0.0001). Magnitude of change in 1-year health status scores was smaller in the US cohort as compared with the Netherlands. CONCLUSION: Compared with the Dutch cohort, US patients had worse adjusted PAD-specific health status scores at all time point, improving less over time, despite treatment. Leveraging inter-country differences in care and outcomes could provide important insights into optimizing PAD outcomes

Efficacy of a web-based healthcare innovation to advance the quality of life and care of patients with an implantable cardioverter defibrillator (ACQUIRE-ICD): a randomized controlled trial

AIMS: Modern clinical management of patients with an implantable cardioverter defibrillator (ICD) largely consists of remote device monitoring, although a subset is at risk of mental health issues post-implantation. We compared a 12-month web-based intervention consisting of goal setting, monitoring of patients' mental health-with a psychological intervention if needed-psychoeducational support from a nurse, and an online patient forum, with usual care on participants' device acceptance 12 months after implantation.METHODS AND RESULTS: This national, multi-site, two-arm, non-blinded, randomized, controlled, superiority trial enrolled 478 first-time ICD recipients from all 6 implantation centres in Denmark. The primary endpoint was patient device acceptance measured by the Florida Patient Acceptance Survey (FPAS; general score range = 0-100, with higher scores indicating higher device acceptance) 12 months after implantation. Secondary endpoints included symptoms of depression and anxiety. The primary endpoint of device acceptance was not different between groups at 12 months [B = -2.67, 95% confidence interval (CI) (-5.62, 0.29), P = 0.08]. Furthermore, the secondary endpoint analyses showed no significant treatment effect on either depressive [B = -0.49, 95% CI (-1.19; 0.21), P = 0.17] or anxiety symptoms [B = -0.39, 95% CI (-0.96; 0.18), P = 0.18].CONCLUSION: The web-based intervention as supplement to usual care did not improve patient device acceptance nor symptoms of anxiety and depression compared with usual care. This specific web-based intervention thus cannot be recommended as a standardized intervention in ICD patients.</p

Younger women with symptomatic peripheral arterial disease are at increased risk of depressive symptoms

ObjectivesGender disparities, particularly among young women with cardiovascular disease, are a growing cause for concern. Depression is a prevalent and prognostically important comorbidity in peripheral arterial disease (PAD), but its prevalence has not been described as a function of gender and age. Therefore, we compared depressive symptoms at the time of PAD diagnosis and 6 months later by gender and age in PAD patients.MethodsThe study enrolled 444 newly diagnosed patients with PAD (32% women) from two Dutch vascular outpatient clinics. Patients' depressive symptoms were assessed with the 10-item Center for Epidemiological Studies Depression Scale (CES-D) at baseline and 6 months later (CES-D scores ≥4 indicate significant depressive symptoms). Logistic regression models were constructed to evaluate the relationship among four gender-age groups (women <65 and ≥65 years; men <65 and ≥65 years [reference category]) and baseline and 6-month follow-up depressive symptoms.ResultsInitially, 33% of women <65 years had significant depressive symptoms, and 6 months later, significant depressive symptoms had developed in 19% of the other younger women. These rates were much higher than other gender-age groups (range at baseline, 11%-16%; 6-month incidence, 6%-10%; P ≤ .03). Adjusting for demographics and clinical factors, women <65 years experienced a fourfold greater odds of baseline (odds ratio [OR], 4.3; 95% confidence interval [CI], 2.2-8.7) and follow-up depressive symptoms (OR, 4.1; 95% CI, 2.0-8.4) compared with men ≥65 years, whereas other gender-age groups were not at risk. Additional adjustment for change in the ankle-brachial index did not explain the increased depression risk in younger women (OR, 3.5; 95% CI, 1.2-10.2).ConclusionsSignificant depressive symptoms are more common in younger women with PAD than in other gender-age groups, both at the time of diagnosis and 6 months later. To eradicate gender-based disparities in PAD, depression screening and monitoring in younger women may be an important direction for future research and intervention

Drug‐Coated Balloon and Drug‐Eluting Stent Safety in Patients With Femoropopliteal and Severe Chronic Kidney Disease

Background Patients with severe‐stage chronic kidney disease (CKD) were excluded from femoropopliteal disease trials evaluating drug‐coated balloons (DCBs) and drug‐eluting stents (DESs) versus plain balloon angioplasty (POBA) and bare metal stents (BMSs). We examined the interaction between CKD status and device type for the association with 24‐month all‐cause mortality and major amputation risk. Methods and Results We studied patients undergoing femoropopliteal interventions (September 2016–December 2018) from Medicare‐linked VQI (Vascular Quality Initiative) registry data. We compared outcomes for: (1) early‐stage CKD (stages 1–3) receiving DCB/DES, (2) early‐stage CKD receiving POBA/BMS, (3) severe‐stage (4 and 5) CKD receiving DCB/DES, and (4) severe‐stage CKD receiving POBA/BMS. We studied 8799 patients (early‐stage CKD: 94%; severe‐stage: 6%). DCB/DES use was 57% versus 51% in patients with early‐stage versus severe‐stage CKD. Twenty‐four‐month mortality risk for patients with early‐stage CKD receiving DCB/DES (reference) was 21% versus 28% (hazard ratio [HR], 1.47 [95% CI, 1.31–1.65]) for those receiving POBA/BMS; patients with severe‐stage CKD: those receiving DCB/DES had a 49% (HR, 2.61 [95% CI, 2.06–3.31]) mortality risk versus 52% (HR, 3.64 [95% CI, 2.91–4.55]) for those receiving POBA/BMS (interaction P<0.001). Adjusted analyses attenuated these results. For severe‐stage CKD, DCB/DES versus POBA/BMS mortality risk was not significant at 24 months (post hoc comparison P=0.06) but was higher for the POBA/BMS group at 18 months (post hoc P<0.05). Patients with early‐stage CKD receiving DCB/DES had the lowest 24‐month amputation risk (6%), followed by 11% for early‐stage CKD‐POBA/BMS, 15% for severe‐stage CKD‐DCB/DES, and 16% for severe‐stage CKD‐POBA/BMS (interaction P<0.001). DCB/DES versus POBA/BMS amputation rates in patients with severe‐stage CKD did not differ (post hoc P=0.820). Conclusions DCB/DES versus POBA/BMS use in patients with severe‐stage CKD was associated with lower mortality and no difference in amputation outcomes

Determinants of invasive treatment in lower extremity peripheral arterial disease

Objective Since it is unknown what factors are weighed in a clinician's decision to refer patients with symptomatic lower extremity peripheral arterial disease (PAD) for invasive treatment, we examined the relationship between health status, lesion location, and site variations and invasive treatment referral ≤1 year following diagnosis in patients with PAD. Methods This was a prospective observational cohort study on ambulatory patients that presented themselves at two vascular surgery outpatient clinics. A total of 970 patients with new symptoms of PAD or with an exacerbation of existing PAD symptoms that required clinical evaluation and treatment (Rutherford Grade I) were eligible, 884 consented and were included between March 2006 and November 2010. We report on 505 patients in the current study. Prior to patients' initial PAD evaluation, the Short Form-12, Physical Component Scale (PCS) was administered to measure health status. Anatomical lesion location (proximal vs distal) was derived from duplex ultrasounds. PCS scores, lesion location, and site were evaluated as determinants of receiving invasive (endovascular, surgery) vs noninvasive treatment ≤1 year following diagnosis in Poisson regression analyses, adjusting for demographics, ankle-brachial index, and risk factors. Results Invasive treatment as a first-choice was offered to 167 (33%) patients. While an association between poorer health status and invasive therapy was found in unadjusted analyses (relative risk [RR], 0.98; 95% confidence interval [CI], 0.97-1.00; P = .011), proximal lesion location (RR, 3.66; 95% CI, 2.70-4.96; P < .0001) and site (RR, 1.69; 95% CI, 1.11-2.58; P = .014) were independent predictors of invasive treatment referral in the final model. Conclusions One-third of patients were treated invasively following PAD diagnosis. Patients' health status was considered in providers' decision to refer patients for invasive treatment, but having a proximal lesion was the strongest predictor. This study also found some important first indications of site variations in offering invasive treatment among patients with PAD. Future work is needed to further document these variations in care