Association between vehicle ownership and disparities in mortality after myocardial infarction.

Background: Access to reliable transportation is fundamental in the management of chronic disease. The purpose of this study was to investigate the association between vehicle ownership at the neighborhood-level and long-term mortality after myocardial infarction (MI). Methods: This is a retrospective observational study evaluating adult patients admitted for MI between January 1st, 2006, and December 31st, 2016. Neighborhoods were defined by census tract and household vehicle ownership data was obtained from the American Community Survey courtesy of the University of California, Los Angeles Center for Neighborhood Knowledge. Patients were divided into 2 groups: those living in neighborhoods with higher vehicle ownership, and those living in neighborhoods with lower vehicle ownership. The cutoff of 4.34% of households reporting not owning a vehicle was used to define a neighborhood as one with "higher" vs "lower" vehicle ownership as this was the median value for the cohort. The association between vehicle ownership and all-cause mortality after MI was assessed using Cox proportional hazards regression models. Results: A total of 30,126 patients were included (age 68.1 +/- 13.5 years, 63.2% male). After adjusting for age, sex, race/ethnicity, and medical comorbidities, lower vehicle ownership was associated with increased all-cause mortality after MI (hazard ratio [HR] 1.10; 95% confidence interval [CI] 1.06-1.14; p<0.001). This finding remained significant after adjusting for median household income (HR 1.06; 95% CI 1.02-1.10; p = 0.007). Upon comparison of White and Black patients living in neighborhoods with lower vehicle ownership; Black patients were found to have an increased all-cause mortality after MI (HR 1.21, 95% CI 1.13-1.30, p<0.001), a difference which remained significant after adjusting for income (HR 1.20; 95% CI 1.12-1.29; p<0.001). There was no significant difference in mortality between White and Black patients living in neighborhoods with higher vehicle ownership. Conclusion: Lower vehicle ownership was associated with increased mortality after MI. Black patients living in neighborhoods with lower vehicle ownership had a higher mortality after MI than White patients living in similar neighborhoods but Black patients living in neighborhoods with higher vehicle ownership had no worse mortality than their White counterparts. This study highlights the importance of transportation in determining health status after MI.

Racial and Ethnic Differences in Risk Factors and Outcomes in Adults With Acute Myocardial Infarction.

Introduction Understanding racial/ethnic differences in patients with acute myocardial infarction (AMI) lays the foundation for more equitable health care. This study evaluated racial/ethnic differences in risk factors, treatment, and outcomes in patients with AMI. Methods This retrospective study included patients aged 18-50 years hospitalized for AMI between 2006 and 2016. Cox regression models were used to evaluate the association of race/ethnicity with all-cause mortality. Results Among 1753 patients hospitalized for type 1 AMI (median age 44 years, 85% male), 35.8% self-identified as White, 9.4% non-Hispanic Black, 37.6% Hispanic, 14.5% Asian, and 2.6% as other. Compared to White patients, Black patients were more likely to have hypertension (53.1% vs 32.2%, p < 0.001) and Hispanic patients were more likely to have diabetes (28.2% vs 15.5%, p < 0.001) and obesity (23.9% vs 17.7%, p = 0.008). There were no substantial differences in revascularization rates or initial medical treatment. However, adherence to statin therapy was lower among Black and Hispanic patients (50.3% and 58.6% for Black and Hispanic vs 67.4% and 72.3% for White and Asian patients, respectively). Over a median follow-up of 7.5 years, Black patients had higher all-cause mortality (unadjusted hazard ratio = 1.88, 95% confidence interval = 1.09-3.24) compared to White patients, but this difference was no longer significant after adjustments (adjusted hazard ratio = 1.32, 95% confidence interval = 0.74-2.36). Discussion and Conclusion There are racial/ethnic differences in risk factors and medication adherence patterns in adults with AMI. To achieve equitable care, programs with tailored intervention addressing needs of different groups should be developed.

Factors associated with weight gain during the COVID-19 pandemic.

BACKGROUND: To limit transmission of COVID-19, state governments issued shelter-in-place orders. These orders coincided with a decrease in daily step count and an increase in overeating. We evaluated factors associated with weight gain of ≥ 15 pounds during the pandemic within an integrated health care system. METHODS: We included adults ages 18 and above with at least one weight measurement before the pandemic (March 19, 2019-March 19, 2020) and another measurement after COVID-19 vaccines became available, more than 9 months into the pandemic (December 14, 2020-December 14, 2021). Logistic regression was used to identify factors associated with weight gain of 15 pounds or more. RESULTS: Of 524,451 adults included in the study, median age was 61 years, 43.2% were men, 36.2% self identified as White, 8.6% Black, 35.7% Hispanic, and 16.2% Asian. During the pandemic, 38,213 (7.3%) adults gained ≥ 15 pounds. A higher proportion of young adults gained weight (16.2% age 18-39, 7.6% age 40-64, 4.7% age 65-79%, and 3.1% age ≥ 80). No significant difference was observed between men and women (7.2% men and 7.4% women). Weight gain was more prevalent among adults from low-income neighborhoods (8.9% low-income neighborhoods, 8.0% intermediate-income neighborhoods, and 6.5% high-income neighborhoods). Multivariable logistic regression demonstrated that compared to adults ages 65-79 years, young adults ages 18-39 years had the highest risk of gaining ≥ 15 pounds (adjusted OR 5.19, 95% CI 5.01-5.38). Black race was associated with weight gain in an unadjusted analysis (OR 1.25, 95% CI 1.21-1.30). However, this association was significantly attenuated after adjusting for other risk factors including neighborhood income levels (adjusted OR 1.06, 95% CI 1.02-1.10). Having a diagnosis of depression pre-pandemic was also associated with weight gain during the pandemic (adjusted OR 1.54, 95% CI 1.50-1.58). CONCLUSION: In this racially and ethnically diverse population in southern California, significant weight gain of 15 pounds or more was observed in 7.3% of the adult population during the COVID-19 pandemic. Young adults, individuals who resided in low-income neighborhoods, and patients with depression were disproportionally affected.

Safety and Effectiveness of Direct Oral Anticoagulants Versus Warfarin for Treating Left Ventricular Thrombus.

BACKGROUND: Patients with left ventricular thrombus are at high risk for ischemic stroke and systemic embolization. The mainstay of treatment is anticoagulation, but it remains unclear if direct-acting oral anticoagulants (DOACs) are a safe and effective treatment strategy compared to warfarin. We conducted a population-based retrospective cohort study to evaluate the effectiveness and safety of DOACs compared to warfarin in an integrated health system in the United States. METHODS: Consecutive patients with left ventricular thrombus on transthoracic echocardiogram from May 2010 to April 2020 were identified. Comparative effectiveness and safety of DOACs and warfarin were evaluated using multivariable Cox proportional hazard models and inverse probability of treatment weighting. RESULTS: Among 433 patients with left ventricular thrombus, 134 (30.9%) were treated with DOACs and 299 (69.1%) were treated with warfarin. Patients were followed for a median of 3.4 years. For the primary effectiveness outcome of ischemic stroke, systemic embolism, and transient ischemic attack, no significant difference was observed between use of DOACs compared to warfarin (adjusted hazard ratio [HR] of 0.75, 95% confidence interval [CI] 0.48-1.18, p = 0.21). For the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed requiring hospitalization, DOAC usage was associated with a lower risk of bleeding (HR 0.58, 95% CI 0.39-0.87, p = 0.0008). CONCLUSIONS: In this diverse population-based cohort of patients, DOAC treatment for left ventricular thrombus appears to be as safe and effective as warfarin treatment. These findings support the use of DOACs for patients with left ventricular thrombus.

The Prognostic Utility of Invasive Right Heart Catheterization in Patients Prior to Transcatheter Aortic Valve Replacement.

INTRODUCTION: Invasive right heart catheterization (RHC) provides valuable prognostic information in cases of severe aortic stenosis, but is not done routinely prior to transcatheter aortic valve replacement (TAVR). Therefore, we sought to investigate the prognostic utility of pre-TAVR RHC for assessing outcomes post TAVR. METHODS: This is a single-center, retrospective study of patients who underwent RHC prior to TAVR between June 2011 and March 2019. We evaluated abnormalities in the following variables as predictors of poor outcomes post TAVR: pulmonary capillary wedge pressure (PCWP), systolic pulmonary artery pressure (PASP), mixed venous oxygen saturation (MVO2), right ventricular stroke work index (RVSWI), and right atrial pressure (RAP). Cox proportional hazard regression models were used to assess the primary composite outcome of all-cause mortality and hospitalization for heart failure. RESULTS: A total of 522 patients (mean age, 83.5 ± 4.5 years; 49.4% women) with complete invasive hemodynamic data were included. At a median follow-up of 529.5 days, there were 127 deaths and 59 heart failure hospitalizations. On multivariate analysis, PCWP ≥15 mm Hg (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.02-2.07), PASP ≥50 mm Hg (HR, 1.66; 95% CI, 1.17-2.36), MVO2 ≤60% (HR, 1.42; 95% CI, 1.01-1.98), RVSWI ≥12 g•m/m²/beat (HR, 1.40; 95% CI, 1.004-1.94), and RAP ≥10 mm Hg (HR, 1.66; 95% CI, 1.09-2.51) were independent predictors of death or heart failure hospitalization. CONCLUSIONS: Preprocedural invasive RHC provides useful prognostic information. A comprehensive invasive hemodynamic assessment should be considered for risk stratification in patients undergoing TAVR.

The role of neighborhood disadvantage in predicting mortality in patients after transcatheter aortic valve replacement.

BACKGROUND: Neighborhoods have a powerful impact on health. Prior investigations into disparities associated with transcatheter aortic valve replacement (TAVR) have focused on race and access to the procedure. We sought to investigate the role of neighborhood disadvantage on mortality post-TAVR. METHODS: Patients who underwent TAVR at Kaiser Permanente Los Angeles Medical Center between June, 2011 and March, 2019 were evaluated. Neighborhood disadvantage was defined using the area deprivation index, an established and validated index that considers multiple socioeconomic metrics. Cutoffs used for disadvantage were national percentile ≥25% and state decile ≥6. Cox proportional hazards regression analysis was used to assess outcomes. RESULTS: A total of 668 patients (age 82.1 ± 7.5 years, 49% female) were included, of which 215 (32.2%) were from disadvantaged neighborhoods by state decile, and 167 (25%) by national percentile. At a median follow-up of 18.8 months (interquartile range 8.7-36.5 months), neighborhood disadvantage was independently associated with increased all-cause mortality (National percentile: hazard ratio [HR] 1.91, 95% confidence interval [CI] 1.35-2.69; state decile: HR 1.68, 95% CI 1.21-2.34). On propensity scored analysis, neighborhood disadvantaged remained independently associated with increased all-cause mortality (National percentile: IPTW HR 1.86, 95% CI 1.52-2.28, PSM HR 1.67, 95% CI 1.11-2.51; state decile: IPTW HR 1.55, 95% CI 1.26-1.91, PSM HR 2.0, 95% CI 1.33-2.99). CONCLUSION: Living in a disadvantaged neighborhood was independently associated with increased mortality post-TAVR on multivariate and propensity score matched analysis. Further investigations into the role of neighborhood disadvantage are needed to address disparities and improve outcomes post-TAVR.

Predictors of conduction recovery after permanent pacemaker implantation following transcatheter aortic valve replacement.

PURPOSE: Conduction disturbances after transcatheter aortic valve replacement (TAVR) requiring pacemaker (PPM) implantation are a known complication and may be reversible. Therefore, we sought to evaluate the incidence and predictors for atrioventricular (AV) conduction recovery after TAVR. METHODS: A single-center, retrospective study of patients undergoing PPM implantation for conduction disorders after TAVR between June 2011 and March 2019. Conduction recovery was defined as ≤ 1% ventricular pacing (VP) on follow-up PPM interrogation. RESULTS: A total of 110 patients (mean age 83.6 ± 6.6 years, 46.8% female) were included. At a median follow-up of 438 days (interquartile range [IQR] 111-760 days), 35 patients (32%) had conduction recovery, with 50% of these occurring within the first 6 months. On multivariate analysis, predictors of conduction recovery include female sex (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.01-6.4, p = 0.048), non-VP/non-complete heart block rhythm immediately post-TAVR (HR 5.2, 95% CI 1.5-18.1, p = 0.011), normal sinus rhythm 7 days post-TAVR (HR 3.9, 95% CI 1.7-9.2, p = 0.002), and smaller valve size (mm) (HR 0.81, 95% CI 0.7-0.996, p = 0.045). Significant narrowing of the QRS and resolution of new-onset left bundle branch block within 1 month post-TAVR occurred in those with conduction recovery on PPM interrogation. CONCLUSIONS: One-third of patients receiving new PPM implantation have conduction recovery after TAVR, with 50% occurring within the first 6 months. Patient gender, valve size, and rhythm on serial ECGs after TAVR can help identify patients that may recover AV conduction. A conservative approach rather than immediate PPM implantation may be considered in these patients.