Contemporary Use of Ticagrelor in Interventional Practice (from Blue Cross Blue Shield of Michigan Cardiovascular Consortium).

Ticagrelor has greater antiplatelet activity than clopidogrel and is approved for use in patients with acute coronary syndrome (ACS). There are limited data on use of ticagrelor in real-world practice. We assessed ticagrelor use in 64,600 patients who underwent percutaneous coronary intervention from January 2012 to March 2014 at 47 Michigan hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Preprocedural risk of major adverse events was estimated with Blue Cross Blue Shield of Michigan Cardiovascular Consortium risk prediction models. The proportion of patients receiving clopidogrel, prasugrel, and ticagrelor was 72% (n = 46,864), 20% (n = 12,596), and 8% (n = 5,140), respectively, using ticagrelor increasing over time. Ticagrelor was used at 45 hospitals, ranging from 0.5% to 64.9% of discharges. Patients receiving ticagrelor were older (63.6 vs 59.4), more often women (32.9% vs 26.7%), and were more likely to present with ST-segment elevation myocardial infarction (24.4% vs 18.8%), cardiogenic shock within 24 hours (1.3% vs 0.9%), and anginal class IV (47.8% vs 43.0%) (p <0.05). Compared with prasugrel, ticagrelor was prescribed in patients with a higher predicted risk of percutaneous coronary intervention complications: contrast nephropathy (2.5% vs 1.6%), transfusion (2.2% vs 1.4%), and death (1.2% vs 0.7%) (p <0.001); >10% of patients were given prasugrel or ticagrelor for a non-ACS indication. Ticagrelor is prescribed to a higher risk population, and 1 in 10 patients prescribed ticagrelor or prasugrel did not have ACS.

Prevalence, diagnosis, and treatment of impaired fasting glucose and impaired glucose tolerance in nondiabetic U.S. adults.

OBJECTIVE: To estimate the rates of prevalence, diagnosis, and treatment of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). RESEARCH DESIGN AND METHODS: A representative sample of the U.S. population (the National Health and Nutrition Examination Survey [NHANES]) from 2005-2006 including 1,547 nondiabetic adults (>18 years of age) without a history of myocardial infarction was assessed to determine the proportion of adults who met the criteria for IFG/IGT, and the proportion of IFG/IGT subjects who: 1) reported receiving a diagnosis from their physicians; 2) were prescribed lifestyle modification or an antihyperglycemic agent; and 3) were currently on therapy. We used multivariable regression analysis to identify predictors of diagnosis and treatment. RESULTS: Of the 1,547 subjects, 34.6% (CI 30.3-38.9%) had pre-diabetes; 19.4% had IFG only; 5.4% had IGT only, and 9.8% had both IFG and IGT. Only 4.8% of those with pre-diabetes reported having received a formal diagnosis from their physicians. No subjects with pre-diabetes received oral antihyperglycemics, and the rates of recommendation for exercise or diet were 31.7% and 33.5%, respectively. Among the 47.7% pre-diabetic subjects who exercised, 49.4% reported exercising for at least 30 min daily. CONCLUSIONS: Three years after a major clinical trial demonstrated that interventions could greatly reduce progression from IFG/IGT to type 2 diabetes, the majority of the U.S. population with IFG/IGT was undiagnosed and untreated with interventions. Whether this is due to physicians being unaware of the evidence, unconvinced by the evidence, or clinical inertia is unclear.

Association of patient case-mix adjustment, hospital process performance rankings, and eligibility for financial incentives.

CONTEXT: While most comparisons of hospital outcomes adjust for patient characteristics, process performance comparisons typically do not. OBJECTIVE: To evaluate the degree to which hospital process performance ratings and eligibility for financial incentives are altered after accounting for hospitals' patient demographics, clinical characteristics, and mix of treatment opportunities. DESIGN, SETTING, AND PATIENTS: Using data from the American Heart Association's Get With the Guidelines program between January 2, 2000, and March 28, 2008, we analyzed hospital process performance based on the Centers for Medicare & Medicaid Services' defined core measures for acute myocardial infarction. Hospitals were initially ranked based on crude composite process performance and then ranked again after accounting for hospitals' patient demographics, clinical characteristics, and eligibility for measures using a hierarchical model. We then compared differences in hospital performance rankings and pay-for-performance financial incentive categories (top 20%, middle 60%, and bottom 20% institutions). MAIN OUTCOME MEASURES: Hospital process performance ranking and pay-for-performance financial incentive categories. RESULTS: A total of 148,472 acute myocardial infarction patients met the study criteria from 449 centers. Hospitals for which crude composite acute myocardial infarction performance was in the bottom quintile (n = 89) were smaller nonacademic institutions that treated a higher percentage of patients from racial or ethnic minority groups and also patients with greater comorbidities than hospitals ranked in the top quintile (n = 90). Although there was overall agreement on hospital rankings based on observed vs adjusted composite scores (weighted kappa, 0.74), individual hospital ranking changed with adjustment (median, 22 ranks; range, 0-214; interquartile range, 9-40). Additionally, 16.5% of institutions (n = 74) changed pay-for-performance financial status categories after accounting for patient and treatment opportunity mix. CONCLUSION: Our findings suggest that accounting for hospital differences in patient characteristics and treatment opportunities is associated with modest changes in hospital performance rankings and eligibility for financial benefits in pay-for-performance programs for treatment of myocardial infarction.

Potential unintended financial consequences of pay-for-performance on the quality of care for minority patients.

OBJECTIVES: The purpose of this study was to determine whether pay-for-performance (PFP) increases existing racial care disparities. BACKGROUND: Medicare's PFP program provides financial rewards to hospitals whose care performance ranks in the highest quintile relative to peers and reduces funding to hospitals that rank in the lowest quintile. Pay-for-performance is designed to improve care but may disproportionately penalize hospitals caring for large minority populations. METHODS: Using Medicare data, 3449 US hospitals were ranked by performance on PFP process measures for acute myocardial infarction (AMI), community-acquired pneumonia (CAP), and heart failure (HF). These rankings were compared with the percentage of African American (AA) patients in a center. We determined the eligibility for financial bonus (highest quintile ranking) or penalty (lowest quintile) among centers treating large AA populations (> or = 20%) versus not after adjusting for hospital facility (catheterization, percutaneous coronary intervention, surgery), academic status, number of hospital beds, location, patient volume, and region. RESULTS: The percentage of AA patients treated by a center was inversely associated with performance for AMI and CAP (P < .01) but not HF (P = .06). Relative to hospitals with < 20% AA, those with > or = 20% AA were less likely eligible for financial bonuses and more likely to face penalties: for AMI, adjusted odds ratio (OR) 0.7 (95% CI 0.5-1.0) and 1.8 (1.4-2.4), respectively; for CAP, OR 0.5 (95% CI 0.3-0.6) and 2.3 (1.8-2.9), respectively; for HF, OR 1.0 (95% CI 0.7-1.2) and 1.2 (0.9-1.5), respectively. CONCLUSIONS: Hospitals with large minority populations may be at financial risk under PFP. Thus, PFP may worsen existing racial care disparities.

Deletion of the mouse alpha-calcitonin gene-related peptide gene increases the vulnerability of the heart to ischemia-reperfusion injury.

Calcitonin gene-related peptide (CGRP), a potent vasodilator released from capsaicin-sensitive C-fiber and Adelta-fiber sensory nerves, has been suggested to play a beneficial role in myocardial ischemia-reperfusion (I/R) injury. Because most previous studies showing a cardioprotective role of CGRP employed pharmacological experiments, the purpose of this study was to utilize a genetic approach by using mice with a targeted deletion of the alpha-CGRP gene to determine whether this neuropeptide had a modulatory function on the severity of I/R injury. To accomplish this goal, isolated, perfused hearts from alpha-CGRP knockout (KO) and wild-type (WT) mice were subjected to 30 min of ischemia followed by 5, 15, and 30 min of reperfusion. Cardiac functional parameters, including coronary flow rates, left ventricular developed pressure, maximum rates of pressure development, and left ventricular end-diastolic pressure, were measured before and after I/R injury, as were levels of creatine kinase, to assess myocardial damage, and malonaldehyde, to assess oxidative stress. Following I/R injury, cardiac performance was significantly reduced in the hearts from the alpha-CGRP KO mice compared with their WT counterparts. The marked reduction in myocardial function in the alpha-CGRP KO hearts compared with WT hearts after I/R injury was associated with a significant elevation in creatine kinase release into the perfusates and malonaldehyde production in the cardiac tissue. Therefore, these data indicate that, in this in vitro setting, deletion of alpha-CGRP makes the heart more vulnerable to I/R injury, possibly due, at least in part, to increased oxidative stress.

Acute ST-segment elevation myocardial infarction: critical care perspective.

More than 1.2 million patients suffer from new or recurrent ischemic events occur annually. This includes an estimated 565,000 cases of first and 300,000 cases of recurrent myocardial infarction (MI). Although mortality from acute MI has declined in recent years, it still remains high at 25% to 30%. Despite its high mortality, prognosis can be improved with timely and effective use of evidence-based treatment in the acute setting. This review outlines the critical care management strategies for ST-segment MI (STEMI).