Charles Fox Sherrod

BACKGROUND: Although Kansas City Cardiomyopathy Questionnaire (KCCQ) domains independently quantify patients’ symptoms, physical and social functioning, and quality of life, the interrelationships between domains (eg, symptoms impacting physical limitations) have not been described, nor whether these vary by age or sex. METHODS: Cross-sectional data from adult outpatients with heart failure and reduced ejection fraction from 2 multicenter US registries, the Change the Management of Patients With Heart Failure Registry (2015–2017) and Cardiovascular Outcomes Research Consortium (2001–2002), were used to fit recursive path analysis models relating age, sex, and KCCQ domain scores. The interrelationships of these factors were quantified using unstandardized and standardized effect estimates. Unstandardized effects denote the linear effect of the independent variable on the dependent variable in units specific to both variables. Standardized effects are unitless and are obtained by multiplying the unstandardized effect by the ratio of the standard deviations of the dependent and independent variables. RESULTS: The analytic cohorts included 4839 patients from the Change the Management of Patients With Heart Failure Registry (mean age, 66.1±12.5 years, 29.3% women) and 547 patients from the Cardiovascular Outcomes Research Consortium (mean age, 66±12 years, 23.8% women). Standardized effect estimates revealed moderate to strong interrelationships among the KCCQ domains (effect size range, 0.34–0.70). Symptoms were strongly associated with all other domains (range, 0.61–0.70). Quality of life was most associated with symptoms and social limitations (range: 0.48–0.60), and less so with physical limitations (effect size=0.34). By comparison, the associations of age and sex with KCCQ domains were much smaller (effect sizes <0.2), and no interactions by age and sex were found. CONCLUSIONS: KCCQ domains were strongly interrelated, and these relationships did not differ appreciably by age or sex. These data enhance the interpretation of KCCQ domain scores in research and clinical practice; in particular, symptoms and social limitations may be key drivers of impaired quality of life in heart failure. Targeted interventions prioritizing these domains may most effectively improve patients’ overall health status.

Background: Survival after in‐hospital cardiac arrest has improved over the past 2 decades, yet prior studies have documented worse outcomes among Black compared with White patients. Although the racial survival gap narrowed through 2014, it remains unclear whether disparities persist in more recent years. Methods: We conducted an observational cohort study using in‐hospital cardiac arrest data from the Get With The Guidelines–Resuscitation registry from 2015 to 2022. Multivariable models using generalized estimating equations evaluated the association between patient race (White versus Black) and survival to hospital discharge, accounting for clustering by hospital. Secondary outcomes included return of spontaneous circulation and favorable neurological survival (ie, survival without severe neurologic disability). Models were adjusted for patient, arrest, and hospital characteristics. Results: Among 156 528 patients, 40 874 were Black and 115 654 were White. Black patients were younger, more often female, and had higher rates of diabetes, renal insufficiency, and respiratory insufficiency, whereas White patients had more prior myocardial infarctions. After adjustment, survival to discharge was similar between races (23.2% versus 20.0%; adjusted odds ratio [aOR], 1.03 [95% CI, 0.99–1.00], P =0.11), as were return of spontaneous circulation rates (68.1% versus 64.4%; aOR, 0.99 [95% CI, 0.97–1.02], P =0.62). However, White patients had higher favorable neurological survival (16.0% versus 12.6%; aOR, 1.10 [95% CI, 1.05–1.14], P <0.001). These findings remained consistent across years and were unchanged when adjusting for hospitals with high versus low proportions of Black patients. Conclusions: Although racial differences in survival to discharge have largely resolved, disparities in favorable neurological outcomes persist, suggesting potentially modifiable differences in postresuscitation care.

Background: Although they are fast‐growing populations in the United States, little is known about survival outcomes of Hispanic and Asian patients after in‐hospital cardiac arrest. Methods and Results: In Get With The Guidelines–Resuscitation, we identified Asian, Hispanic, and White adults with in‐hospital cardiac arrest during 2005 to 2023. Using multivariable models, we compared rates of survival to discharge separately for Asian and Hispanic patients versus White patients, as well as rates of sustained return of spontaneous circulation for ≥20 minutes and favorable neurologic survival as secondary outcomes. Of 189 557 in‐hospital cardiac arrests, 167 640 (88.4%), 16 800 (8.9%), and 5117 (2.7%) patients were White, Hispanic, and Asian, respectively. Compared with the survival rate to discharge for White patients (22.0%), rates were lower for Hispanic (19.4%; adjusted odds ratio [OR], 0.93 [95% CI, 0.89–0.97]; P P =0.008), and these differences were attenuated after accounting for the hospital at which patients received care (adjusted OR: Hispanic patients, 0.95 [95% CI, 0.91–1.00]; Asian patients, 0.91 [95% CI, 0.84–0.99]). Although there were no differences in rates of return of spontaneous circulation between White (68.7%), Hispanic (69.0%), and Asian patients (69.7%), both Asian and Hispanic patients were less likely to have favorable neurologic survival (White: 18.3%; Hispanic: 15.4%; adjusted OR, 0.88 [95% CI, 0.84–0.93]; Asian: 13.2%; adjusted OR, 0.80 [95% CI, 0.73–0.87]). These differences were also attenuated after accounting for hospital site. Conclusions: Compared with White patients, Hispanic and Asian patients with in‐hospital cardiac arrest had lower rates of overall survival and favorable neurologic survival. Some of these differences were associated with the hospital at which patients received care.

Left ventricular (LV) dysfunction is associated with poor clinical outcomes in acute respiratory failure (ARF). This study evaluates the efficacy of LV strain in detecting LV dysfunction in ARF patients requiring invasive mechanical ventilation (IMV) compared to conventionally measured left ventricular ejection fraction (LVEF). ARF patients requiring IMV who had echocardiography performed during MICU admission were included. LV global longitudinal strain (LVGLS) and LVEF were measured retrospectively using speckle tracking (STE) and traditional transthoracic echocardiography (TTE), respectively, by investigators blinded to the status of IMV and clinical data. The cohort was divided into three groups: TTE during IMV (TTE-IMV), before IMV (TTE-bIMV), and after IMV (TTE-aIMV). Multivariable regression models, adjusted for illness severity score, chronic cardiac disease, acute respiratory failure etiology, body mass index, chronic obstructive pulmonary disease, and obstructive sleep apnea, evaluated associations between LV function parameters and the presence of IMV. Among 376 patients, TTE-IMV, TTE-bIMV, and TTE-aIMV groups constituted 223, 68, and 85 patients, respectively. The median age was 65 years (IQR: 56–74), with 53.2% male participants. Adjusted models showed significantly higher LVGLS in groups not on IMV at the time of TTE (TTE-bIMV: β = 4.19, 95% CI 2.31 to 6.08, p < 0.001; TTE-aIMV: β = 3.79, 95% CI 2.03 to 5.55, p < 0.001), while no significant differences in LVEF were observed across groups. In a subgroup analysis of patients with LVEF ≥55%, the significant difference in LVGLS among the groups remained (TTE-bIMV: β = 4.18, 95% CI 2.22 to 6.15, p < 0.001; TTE-aIMV: β = 3.45, 95% CI 1.50 to 5.40, p < 0.001), but was no longer present in those with LVEF < 55%. This suggests an association between IMV and lower LVGLS in ARF patients requiring IMV, indicating that LVGLS may be a more sensitive marker for detecting subclinical LV dysfunction compared to LVEF in this population. Future studies should track and assess serial echocardiography data in the same cohort of patients pre-, during, and post-IMV in order to validate these findings and prognosticate STE-detected LV dysfunction in ARF patients requiring IMV.

Right ventricular (RV) dysfunction is associated with poor prognosis in acute respiratory failure (ARF). Our study evaluates the efficacy of RV strain in detecting RV dysfunction in ARF patients requiring invasive mechanical ventilation (IMV) compared to tricuspid annular plane systolic excursion (TAPSE). In this retrospective study involving 376 patients diagnosed with ARF and requiring IMV, we extracted clinical and outcome data from patient records. RV global longitudinal strain (RVGLS), free wall longitudinal strain (FWLS), and TAPSE were measured retrospectively using speckle tracking echocardiography (STE) and traditional echocardiography, respectively. We divided the cohort into three groups: TTE during IMV (TTE-IMV, 223 patients), before IMV (TTE-bIMV, 68 patients), and after IMV (TTE-aIMV, 85 patients). Multivariable regression analysis, adjusted for covariates, revealed significantly higher RVGLS and FWLS in the groups not on IMV at the time of TTE compared to the TTE-IMV group. Specifically, the TTE-bIMV group showed higher RVGLS (β = 7.28, 95% CI 5.07, 9.48) and FWLS (β = 5.83, 95% CI 3.36, 8.31), while the TTE-aIMV group exhibited higher RVGLS (β = 9.39, 95% CI 6.10, 12.69) and FWLS (β = 7.54, 95% CI 4.83, 10.24). TAPSE did not reveal any significant differences across the groups. Our study suggests an association between IMV and lower RVGLS and FWLS in ARF patients, indicating that IMV itself may contribute to RV dysfunction. RVGLS and FWLS appear to be more sensitive than TAPSE in detecting changes in RV function that were previously subclinical in patients on IMV. Prospective studies with TTE before, during, and after IMV are necessary to assess the primary driver of RV dysfunction and to prognosticate STE-detected RV dysfunction in this population.

Background: Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. Methods: The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0–100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0–7), and modified HF Collaboratory (0–100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. Results: Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was −1.94 (17.8); HF collaborator, −0.11 (1.32); and modified HF Collaboratory, −1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. Conclusions: KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.

Aims: The discontinuation of oral anticoagulants (OACs) remains as a significant concern in the management of atrial fibrillation (AF). The discontinuation rate may vary depending on management strategy, and physicians may also discontinue OACs due to concerns about patient satisfaction with their care. We aimed to assess the incidence of OAC discontinuation and its relationship to patients’ health in an outpatient AF registry. Methods and Results: From a multicenter registry for newly recognized AF patients (n = 3313), we extracted 1647 (49.7%) patients with OACs and a CHA₂DS₂-Vasc score of ≥2. Discontinuation was defined as sustained cessation of OACs within a 1-year follow-up. We examined predictors associated with discontinuation and its relations to health status defined by the AFEQT questionnaire. Of the 1647 patients, 385 (23.6%) discontinued OACs after 1 year, with discontinuation rates varying across treatment strategies (15.3% for catheter ablation, 4.9% for rhythm control with antiarrhythmic drugs, and 3.0% for rate control). Successful rhythm control was associated with discontinuation in the catheter ablation (OR 6.61, 95% CI 3.00–14.6, p < 0.001) and antiarrhythmic drugs (OR 6.47, 95% CI 2.62–15.9, p < 0.001) groups, whereas the incidence of bleeding events within 1 year was associated with discontinuation in the rate control group. One-year AFEQT scores did not significantly differ between patients who discontinued OACs and those who did not in each treatment strategy group. Conclusions: OAC discontinuation was common among AF patients with significant stroke risk but varied depending on the chosen treatment strategy. This study also found no significant association between OAC discontinuation and patients’ health status.

By Anna Hardesty, Arun Muthiah & 5 more. Resident Project Winners