Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator.

Background And Purpose: There are few validated models for prediction of risk of symptomatic intracranial hemorrhage (sICH) after intravenous tissue-type plasminogen activator treatment for ischemic stroke. We used data from Get With The Guidelines-Stroke (GWTG-Stroke) to derive and validate a prediction tool for determining sICH risk.

Methods: The population consisted of 10 242 patients from 988 hospitals who received intravenous tissue-type plasminogen activator within 3 hours of symptom onset from January 2009 to June 2010.

Comparison of 30-day mortality models for profiling hospital performance in acute ischemic stroke with vs without adjustment for stroke severity.

Context: There is increasing interest in reporting risk-standardized outcomes for Medicare beneficiaries hospitalized with acute ischemic stroke, but whether it is necessary to include adjustment for initial stroke severity has not been well studied.

Objective: To evaluate the degree to which hospital outcome ratings and potential eligibility for financial incentives are altered after including initial stroke severity in a claims-based risk model for hospital 30-day mortality for acute ischemic stroke.

Design, Setting, And Patients: Data were analyzed from 782 Get With The Guidelines-Stroke participating hospitals on 127,950 fee-for-service Medicare beneficiaries with ischemic stroke who had a score documented for the National Institutes of Health Stroke Scale (NIHSS, a 15-item neurological examination scale with scores from 0 to 42, with higher scores indicating more severe stroke) between April 2003 and December 2009.

Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke.

Background: The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stroke are time-dependent. Emergency medical services (EMS) hospital prenotification of an incoming patient with potential stroke may provide a means of reducing evaluation and treatment times and improving treatment rates; yet, available data are limited.

Methods And Results: We examined 371 988 patients with acute ischemic stroke transported by EMS and enrolled in Get With The Guidelines-Stroke from April 1, 2003, to March 31, 2011.

Troponin I in acute decompensated heart failure: insights from the ASCEND-HF study.

Aims: We examined the prognostic importance of cardiac troponin I (cTnI) in a cohort of patients enrolled in the ASCEND-HF study of nesiritide in acute decompensated heart failure (ADHF). Circulating troponins are a prognostic marker in patients with ADHF. Contemporary assays with greater sensitivity require reassessment of the significance of troponin elevation in HF.

Trends in smoking cessation counseling: experience from American Heart Association-get with the guidelines.

Background: Successful smoking cessation in stroke and coronary artery disease (CAD) patients is important, as smoking contributes to significant morbidity and mortality. The American Heart Association developed Get With The Guidelines (GWTG) to improve compliance with national guideline recommendations for cardiovascular care. Using data from GWTG, we examined trends associated with the smoking-cessation counseling (SCC) performance measure.

Age and gender differences in quality of care and outcomes for patients with ST-segment elevation myocardial infarction.

Background: Young patients (aged≤45 years) presenting with ST-segment elevation myocardial infarction present unique challenges. The quality of care and in-hospital outcomes may differ from their older counterparts.

Methods: A total of 31,544 patients presenting with ST-segment elevation myocardial infarction and enrolled in the American Heart Association's Get With the Guidelines Coronary Artery Disease registry were analyzed.

Reperfusion strategies and quality of care in 5339 patients age 80 years or older presenting with ST-elevation myocardial infarction: analysis from get with the guidelines-coronary artery disease.

Background: Data regarding reperfusion strategies, adherence to national guidelines, and in-hospital mortality in ST-elevation myocardial infarction (STEMI) patients age ≥80 years are limited. The aim of this study was to determine current reperfusion trends, medical treatment, and in-hospital mortality during STEMI in older adults.

Hypothesis: Among patients aged 80 or above presenting with STEMI, adherence to guidelines, length of stay, and in-hospital mortality would be better in those receiving reperfusion versus those who did not.

Quality of care and outcomes among patients with acute myocardial infarction by level of kidney function at admission: report from the get with the guidelines coronary artery disease program.

Background: Many patients admitted for acute myocardial infarction (AMI) have chronic renal insufficiency. We studied the impact of chronic renal insufficiency on mortality and quality of inpatient care for AMI from the American Heart Association's Get With The Guidelines-Coronary Artery Disease Program.

Hypothesis: We hypothesized that mortality and quality of inpatient care would not vary with renal function.

Risks of intracranial hemorrhage among patients with acute ischemic stroke receiving warfarin and treated with intravenous tissue plasminogen activator.

Context: Intravenous tissue plasminogen activator (tPA) is known to improve outcomes in ischemic stroke; however, patients receiving long-term chronic warfarin therapy may face an increased risk for intracranial hemorrhage when treated with tPA. Although current guidelines endorse administering intravenous tPA to warfarin-treated patients if their international normalized ratio (INR) is 1.7 or lower, there are few data on safety of intravenous tPA in warfarin-treated patients in clinical practice.

B-type natriuretic peptide level and postdischarge thrombotic events in older patients hospitalized with heart failure: insights from the Acute Decompensated Heart Failure National Registry.

Background: Patients hospitalized with heart failure (HF) have elevated B-type natriuretic peptide (BNP) levels and increased risk for thromboembolic events. Associations between BNP level and thromboembolic events in patients with HF without atrial fibrillation (AF) are not well studied.

Methods: We linked data from the ADHERE registry for 2003 through 2006 with Medicare claims to identify patients ≥65 years who were hospitalized with HF, did not have AF, and did not receive warfarin at discharge.

Design and rationale of a retrospective clinical effectiveness study of aldosterone antagonist therapy in patients with heart failure.

Background: Despite demonstrated efficacy in randomized trials, aldosterone antagonist therapy is not used in many eligible patients with heart failure. Questions remain about its clinical effectiveness and safety for patients who are underrepresented in randomized trials and those at risk for hyperkalemia.

Methods: The proposed study will evaluate the effectiveness of aldosterone antagonist therapy in eligible Medicare beneficiaries ≥ 65 years old hospitalized for heart failure between 2005 and 2008.

Utilization of hospice and predicted mortality risk among older patients hospitalized with heart failure: findings from GWTG-HF.

Background: Guidelines recommend hospice care as a treatment option for end-stage heart failure (HF) patients. Little is known regarding utilization of hospice care in a contemporary cohort of patients hospitalized with HF and how this may vary by estimated mortality risk.

Methods: We analyzed HF patients ≥65 years (n = 58,330) from 214 hospitals participating in the Get With the Guidelines-HF program.

Trends in patients hospitalized with heart failure and preserved left ventricular ejection fraction: prevalence, therapies, and outcomes.

Background: Heart failure with preserved ejection fraction (EF) is a common syndrome, but trends in treatments and outcomes are lacking.

Methods And Results: We analyzed data from 275 hospitals in Get With the Guidelines-Heart Failure from January 2005 to October 2010. Patients were stratified by EF as reduced EF (EF <40% [HF-reduced EF]), borderline EF (40%≤EF<50% [HF-borderline EF]), or preserved (EF ≥50% [HF-preserved EF]).

International variation in use of oral anticoagulation among heart failure patients with atrial fibrillation.

Background: We sought to characterize patient factors and regional variations associated with vitamin K antagonist (VKA) use in patients with heart failure (HF) and atrial fibrillation (AF) in areas outside the United States and Europe.

Methods: The ADHERE-International registry enrolled patients with decompensated HF from 10 Asia Pacific and Latin American countries from December 2005 to January 2009. Rates of VKA use in patients with HF and either new-onset AF or a history of AF were determined and compared according to CHADS(2) scores.

Times from symptom onset to hospital arrival in the Get with the Guidelines--Stroke Program 2002 to 2009: temporal trends and implications.

Background And Purpose: Time from symptom onset to hospital arrival is the most important factor in determining eligibility for intravenous tissue-type plasminogen activator. We used data from a large contemporary nationwide study to determine temporal trends in the proportions of patients arriving within time windows for potential acute ischemic stroke therapies.

Methods: Trends in symptom onset to hospital arrival time ("onset-to-door time") for patients with acute ischemic stroke in the Get With The Guidelines-Stroke (GWTG-Stroke) program were analyzed between 2003 and 2009.

Pharmacotherapy in Medicare beneficiaries with atrial fibrillation.

Background: There are limited data regarding national patterns of pharmacotherapy for atrial fibrillation (AF) among older patients. Drug exposure data are now captured for Medicare beneficiaries enrolled in prescription drug plans.

Objective: To describe pharmacotherapy for AF among Medicare beneficiaries.

Assessment of dyspnea in acute decompensated heart failure: insights from ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) on the contributions of peak expiratory flow.

Objectives: This study hypothesized that peak expiratory flow rate (PEFR) would increase with acute heart failure (AHF) treatment over the first 24 h, related to a Dyspnea Index (DI) change and treatment effect.

Background: Dyspnea is a key symptom and clinical trial endpoint in AHF, yet objective assessment is lacking.

Methods: In a clinical trial substudy, 421 patients (37 sites) underwent PEFR testing at baseline, 1, 6, and 24 h after randomization to nesiritide or placebo.

Update on aldosterone antagonists use in heart failure with reduced left ventricular ejection fraction. Heart Failure Society of America Guidelines Committee.

Aldosterone antagonists (or mineralocorticoid receptor antagonists [MRAs]) are guideline-recommended therapy for patients with moderate to severe heart failure (HF) symptoms and reduced left ventricular ejection fraction (LVEF), and in postmyocardial infarction patients with HF. The Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) trial evaluated the MRA eplerenone in patients with mild HF symptoms. Eplerenone reduced the risk of the primary endpoint of cardiovascular death or HF hospitalization (hazard ratio [HR] 0.

Sex differences in in-hospital mortality in acute decompensated heart failure with reduced and preserved ejection fraction.

Background: There are no sex-specific survival comparisons between patients with heart failure (HF) with reduced and those with preserved ejection fraction. Large registries noting women have better survival than men combined HF patients with reduced and preserved EF. Other registries that compared patients with reduced and preserved EF did not analyze their data by sex.

Data quality in the American Heart Association Get With The Guidelines-Stroke (GWTG-Stroke): results from a national data validation audit.

Background: Get With The Guidelines (GWTG)-Stroke is a national stroke registry and quality improvement program. We examined the accuracy and reliability of data entered in GWTG-Stroke.

Methods: Data entered by sites in the GWTG-Stroke database were compared with that abstracted from de-identified medical records by trained auditors.

Care and outcomes of Hispanic patients admitted with heart failure with preserved or reduced ejection fraction: findings from get with the guidelines-heart failure.

Background: Although individuals of Hispanic ethnicity are at high risk for developing heart failure (HF), little is known about differences between Hispanic HF patients stratified by left ventricular ejection fraction (EF). We compared characteristics, quality of care, and outcomes between Hispanic and non-Hispanic white patients hospitalized for HF with preserved EF (PEF) or reduced EF (REF).

Methods And Results: From 247 hospitals in Get With The Guidelines-Heart Failure between 2005-2010, 6117 Hispanics were compared with 71 859 non-Hispanic whites.

Presence of atrial fibrillation is independently associated with adverse outcomes in patients hospitalized with heart failure: an analysis of get with the guidelines-heart failure.

Background: It is unclear if the presence of atrial fibrillation (AF) on admission is associated with worse in-hospital outcomes in patients hospitalized with heart failure (HF). This study evaluated the clinical characteristics, management, length of stay, and mortality of HF patients with and without AF.

Methods And Results: We studied 99 810 patients from 255 sites admitted with HF enrolled in Get With The Guidelines-Heart Failure between January 1, 2005, and December 31, 2010.

Patient and hospital characteristics associated with traditional measures of inpatient quality of care for patients with heart failure.

Background: The purpose of this study was to determine patient and hospital characteristics associated with 4 measures of quality of inpatient heart failure care used by both the primary payer of heart failure care in the United States (Center for Medicare and Medicaid Services) and the main hospital accrediting organization (The Joint Commission).

Methods: We used data from Get With The Guidelines Program for patients hospitalized with heart failure. Eligibility for receiving care based on the Center for Medicare and Medicaid Services performance measures was determined for assessment of left ventricular ejection fraction (LVEF; n = 60,601), use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) if LVEF<40% and no contraindications (24,130), discharge instructions (49,383), and smoking cessation counseling (10,152).

Indications for cardiac resynchronization therapy: 2011 update from the Heart Failure Society of America Guideline Committee.

Cardiac resynchronization therapy (CRT) improves survival, symptoms, quality of life, exercise capacity, and cardiac structure and function in patients with New York Heart Association (NYHA) functional class II or ambulatory class IV heart failure (HF) with wide QRS complex. The totality of evidence supports the use of CRT in patients with less severe HF symptoms. CRT is recommended for patients in sinus rhythm with a widened QRS interval (≥150 ms) not due to right bundle branch block (RBBB) who have severe left ventricular (LV) systolic dysfunction and persistent NYHA functional class II-III symptoms despite optimal medical therapy (strength of evidence A).