Person: Bhatt, Deepak
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Bhatt
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Deepak
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Bhatt, Deepak
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Publication Association of Chronic Renal Insufficiency With In-Hospital Outcomes After Percutaneous Coronary Intervention(John Wiley & Sons, Ltd, 2015) Gupta, Tanush; Paul, Neha; Kolte, Dhaval; Harikrishnan, Prakash; Khera, Sahil; Aronow, Wilbert S; Mujib, Marjan; Palaniswamy, Chandrasekar; Sule, Sachin; Jain, Diwakar; Ahmed, Ali; Cooper, Howard A; Frishman, William H; Bhatt, Deepak; Fonarow, Gregg C; Panza, Julio ABackground: The association of chronic renal insufficiency with outcomes after percutaneous coronary intervention (PCI) in the current era of drug-eluting stents and modern antithrombotic therapy has not been well characterized. Methods and Results: We queried the 2007–2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent PCI. Multivariable logistic regression was used to compare in-hospital outcomes among patients with chronic kidney disease (CKD), patients with end-stage renal disease (ESRD), and those without CKD or ESRD. Of 3 187 404 patients who underwent PCI, 89% had no CKD/ESRD; 8.6% had CKD; and 2.4% had ESRD. Compared to patients with no CKD/ESRD, patients with CKD and patients with ESRD had higher in-hospital mortality (1.4% versus 2.7% versus 4.4%, respectively; adjusted odds ratio for CKD 1.15, 95% CI 1.12 to 1.19, P<0.001; adjusted odds ratio for ESRD 2.29, 95% CI 2.19 to 2.40, P<0.001), higher incidence of postprocedure hemorrhage (3.5% versus 5.4% versus 6.0%, respectively; adjusted odds ratio for CKD 1.21, 95% CI 1.18 to 1.23, P<0.001; adjusted odds ratio for ESRD 1.27, 95% CI 1.23 to 1.32, P<0.001), longer average length of stay (2.9 days versus 5.0 days versus 6.4 days, respectively; P<0.001), and higher average total hospital charges ($60 526 versus $77 324 versus $97 102, respectively; P<0.001). Similar results were seen in subgroups of patients undergoing PCI for acute coronary syndrome or stable ischemic heart disease. Conclusions: In patients undergoing PCI, chronic renal insufficiency is associated with higher in-hospital mortality, higher postprocedure hemorrhage, longer average length of stay, and higher average hospital charges.Publication Initiation, Continuation, or Withdrawal of Angiotensin‐Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction(John Wiley and Sons Inc., 2017) Gilstrap, Lauren G.; Fonarow, Gregg C.; Desai, Akshay; Liang, Li; Matsouaka, Roland; DeVore, Adam D.; Smith, Eric E.; Heidenreich, Paul; Hernandez, Adrian F.; Yancy, Clyde W.; Bhatt, DeepakBackground: Guidelines recommend continuation or initiation of guideline‐directed medical therapy, including angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), in hospitalized patients with heart failure with reduced ejection fraction. Methods and Results: Using the Get With The Guidelines‐Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided ACEi/ARB‐eligible patients into 4 categories based on admission and discharge ACEi/ARB use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between ACEi/ARB category and outcomes. Most, 90.5%, were discharged on ACEi/ARB (59.6% continued and 30.9% newly started). Of those discharged without ACEi/ARB, 1.9% were discontinued, and 7.5% were eligible but not started. Thirty‐day mortality was 3.5% for patients continued and 4.1% for patients started on ACEi/ARB. In contrast, 30‐day mortality was 8.8% for patients discontinued (adjusted hazard ratio [HR adj] 1.92; 95% CI 1.32‐2.81; P<0.001) and 7.5% for patients not started (HR adj 1.50; 95% CI 1.12‐2.00; P=0.006). The 30‐day readmission rate was lowest among patients continued or started on therapy. One‐year mortality was 28.2% for patients continued and 29.7% for patients started on ACEi/ARB compared to 41.6% for patients discontinued (HR adj 1.35; 95% CI 1.13‐1.61; P<0.001) and 41.7% (HR adj 1.28; 95% CI 1.14‐1.43; P<0.001) for patients not started on therapy. Conclusions: Compared with continuation, withdrawal of ACEi/ARB during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.Publication Transcatheter and Doppler waveform correlation in transcatheter aortic valve replacement(BMJ Publishing Group, 2018) Kalra, Ankur; Makkar, Raj R; Bhatt, Deepak; Khera, Sahil; Kleiman, Neal S; Reardon, Michael J; Kern, Morton JTranscatheter aortic valve replacement (TAVR) has become the preferred therapy for treatment of severe aortic stenosis in patients at intermediate to high risk of perioperative mortality following surgical aortic valve replacement. Haemodynamic assessment is an integral part of the procedure, and it is crucial for the operator to have an in-depth understanding of the haemodynamic alterations that occur during balloon aortic valvuloplasty and transcatheter valve deployment. Comprehension of the haemodynamic tracings is also pivotal for early recognition of periprocedural complications. With expanding indications for TAVR, it is imperative for members of the structural heart team to have an in-depth, nuanced understanding of transcatheter haemodynamic waveforms and their correlation with echocardiographic Doppler waveforms that are obtained periprocedurally during TAVR. This review provides a collection of transcatheter haemodynamic tracings and their corresponding Doppler echocardiography correlates that are demonstrative of physiological alterations and pathological lesions (complications) that occur during TAVR.Publication Association of Electronic Health Record Use With Quality of Care and Outcomes in Heart Failure: An Analysis of Get With The Guidelines—Heart Failure(John Wiley and Sons Inc., 2018) Selvaraj, Senthil; Fonarow, Gregg C.; Sheng, Shubin; Matsouaka, Roland A.; DeVore, Adam D.; Heidenreich, Paul A.; Hernandez, Adrian F.; Yancy, Clyde W.; Bhatt, DeepakBackground: Adoption of electronic health record (EHR) systems has increased significantly across the nation. Whether EHR use has translated into improved quality of care and outcomes in heart failure (HF) is not well studied. Methods and Results: We examined participants from the Get With The Guidelines—HF registry who were admitted with HF in 2008 (N=21 222), using various degrees of EHR implementation (no EHR, partial EHR, and full EHR). We performed multivariable logistic regression to determine the relation between EHR status and several in‐hospital quality metrics and outcomes. In a substudy of Medicare participants (N=8421), we assessed the relation between EHR status and rates of 30‐day mortality, readmission, and a composite outcome. In the cohort, the mean age was 71±15 years, 49% were women, and 64% were white. The mean ejection fraction was 39±17%. Participants were admitted to hospitals with no EHR (N=1484), partial EHR (N=13 473), and full EHR (N=6265). There was no association between EHR status and several quality metrics (aside from β blocker at discharge) or in‐hospital outcomes on multivariable adjusted logistic regression (P>0.05 for all comparisons). In the Medicare cohort, there was no association between EHR status and 30‐day mortality, readmission, or the combined outcome. Conclusions: In a large registry of hospitalized patients with HF, there was no association between degrees of EHR implementation and several quality metrics and 30‐day postdischarge death or readmission. Our results suggest that EHR may not be sufficient to improve HF quality or related outcomes.Publication Safety and efficacy of dual vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of randomized clinical trials(Oxford University Press, 2018) Golwala, Harsh B; Cannon, Christopher; Steg, Ph Gabriel; Doros, Gheorghe; Qamar, Arman; Ellis, Stephen G; Oldgren, Jonas; ten Berg, Jurrien M; Kimura, Takeshi; Hohnloser, Stefan H; Lip, Gregory Y H; Bhatt, DeepakAbstract Aims Of patients with atrial fibrillation (AF), approximately 10% undergo percutaneous coronary intervention (PCI). We studied the safety and efficacy of dual vs. triple antithrombotic therapy (DAT vs. TAT) in this population. Methods and results A systematic review and meta-analysis was conducted using PubMed, Embase, EBSCO, Cochrane database of systematic reviews, Web of Science, and relevant meeting abstracts for Phase 3, randomized trials that compared DAT vs. TAT in patients with AF following PCI. Four trials including 5317 patients were included, of whom 3039 (57%) received DAT. Compared with the TAT arm, Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding showed a reduction by 47% in the DAT arm [4.3% vs. 9.0%; hazard ratio (HR) 0.53, 95% credible interval (CrI) 0.36–0.85, I2 = 42.9%]. In addition, there was no difference in the trial-defined major adverse cardiac events (MACE) (10.4% vs. 10.0%, HR 0.85, 95% CrI 0.48–1.29, I2 = 58.4%), or in individual outcomes of all-cause mortality, cardiac death, myocardial infarction, stent thrombosis, or stroke between the two arms. Conclusion: Compared with TAT, DAT shows a reduction in TIMI major or minor bleeding by 47% with comparable outcomes of MACE. Our findings support the concept that DAT may be a better option than TAT in many patients with AF following PCI.Publication The management of antiplatelet therapy in acute coronary syndrome patients with thrombocytopenia: a clinical conundrum(Oxford University Press, 2017) McCarthy, Cian; Steg, Gabriel; Bhatt, DeepakPublication A practical clinical approach to utilize cardiopulmonary exercise testing in the evaluation and management of coronary artery disease: a primer for cardiologists(Lippincott Williams and Wilkins, 2018) Chaudhry, Sundeep; Arena, Ross; Bhatt, Deepak; Verma, Subodh; Kumar, NareshPurpose of review There is growing clinical interest for the use of cardiopulmonary exercise testing (CPET) to evaluate patients with or suspected coronary artery disease (CAD). With mounting evidence, this concise review with relevant teaching cases helps to illustrate how to integrate CPET data into real world patient care. Recent findings CPET provides a novel and purely physiological basis to identify cardiac dysfunction in symptomatic patients with both obstructive-CAD and nonobstructive-CAD (NO-CAD). In many cases, abnormal cardiac response on CPET may be the only objective evidence of potentially undertreated ischemic heart disease. When symptomatic patients have NO-CAD on coronary angiogram, they are still at increased risk for cardiovascular events. This problem appears to be more common in women than men and may warrant more aggressive risk factor modification. As the main intervention is lifestyle (diet, smoking cessation, exercise) and medical therapy (statins, angiotensin-converting enzyme inhibitors, beta-blockers), serial CPET testing enables close surveillance of cardiovascular function and is responsive to clinical status. Summary CPET can enhance outpatient evaluation and management of CAD. Diagnostically, it can help to identify physiologically significant obstructive-CAD and NO-CAD in patients with normal routine cardiac testing. CPET may be of particular value in symptomatic women with NO-CAD. Prognostically, precise quantification of improvements in exercise capacity may help to improve long-term lifestyle and medication adherence for this chronic condition.Publication Healthcare Resource Availability, Quality of Care, and Acute Ischemic Stroke Outcomes(John Wiley and Sons Inc., 2017) O'Brien, Emily C.; Wu, Jingjing; Zhao, Xin; Schulte, Phillip J.; Fonarow, Gregg C.; Hernandez, Adrian F.; Schwamm, Lee; Peterson, Eric D.; Bhatt, Deepak; Smith, Eric E.Background: Healthcare resources vary geographically, but associations between hospital‐based resources and acute stroke quality and outcomes remain unclear. Methods and Results: Using Get With The Guidelines‐Stroke and Dartmouth Atlas of Health Care data, we examined associations between healthcare resource availability, stroke care, and outcomes. We categorized hospital referral regions with high‐, medium‐, or low‐resource levels based on the 2006 national per‐capita availability median of 6 relevant acute stroke care resources. Using multivariable logistic regression, we examined healthcare resource level and in‐hospital quality and outcomes. Of 1 480 308 admitted ischemic stroke patients (2006–2013), 28.8% were hospitalized in low‐, 44.4% in medium‐, and 26.9% in high‐resource hospital referral regions. Quality‐of‐care/timeliness metrics, adjusted length of stay, and in‐hospital mortality were similar across all resource levels. Conclusions: Significant variation exists in regional availability of healthcare resources for acute ischemic stroke treatment, yet among Get With the Guidelines‐Stroke hospitals, quality of care and in‐hospital outcomes did not differ by regional resource availability.Publication Influence of healthy candidate bias in assessing clinical effectiveness for implantable cardioverter-defibrillators: cohort study of older patients with heart failure(BMJ Publishing Group Ltd., 2014) Setoguchi, Soko; Warner Stevenson, Lynne; Stewart, Garrick C; Bhatt, Deepak; Epstein, Andrew E; Desai, Manisha; Williams, Lauren A; Chen, Chih-YingObjective: To assess the potential contribution of unmeasured general health status to patient selection in assessments of the clinical effectiveness of implantable cardioverter-defibrillator (ICD) therapy. Design: Retrospective cohort study. Setting: Linked data from an ICD registry, heart failure registry, and Medicare claims data for ICDs implanted in 2005 through 2009. Participants: 29 426 patients admitted to hospital with heart failure aged 66 years or older and eligible for ICD therapy for primary prevention. Main outcome measures Non-traumatic hip fracture, admission to a skilled nursing facility, and 30 day mortality—outcomes unlikely to be improved by ICD therapy. Results: Compared with 17 853 patients without ICD therapy, 11 573 patients with ICD therapy were younger and had lower ejection fraction and more cardiac admissions to hospital but fewer non-cardiac admissions to hospital and comorbid conditions. Patients with ICD therapy had greater freedom from unrelated events after adjusting for age and sex: hip fracture (hazard ratio 0.77, 95% confidence interval 0.64 to 0.92), skilled nursing facility admission (0.53, 0.50 to 0.55), and 30 day mortality (0.12, 0.10 to 0.15). Conclusions: Lower risks of measured outcomes likely reflect unmeasured differences in comorbidity and frailty. The findings highlight potential pitfalls of observational comparative effectiveness research and support physician consideration of general health status in selecting patients for ICD therapy.Publication Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials(BMJ Publishing Group Ltd., 2013) Gloy, Viktoria L; Briel, Matthias; Bhatt, Deepak; Kashyap, Sangeeta R; Schauer, Philip R; Mingrone, Geltrude; Bucher, Heiner C; Nordmann, Alain JObjective: To quantify the overall effects of bariatric surgery compared with non-surgical treatment for obesity. Design: Systematic review and meta-analysis based on a random effects model. Data sources Searches of Medline, Embase, and the Cochrane Library from their inception to December 2012 regardless of language or publication status. Eligibility criteria Eligible studies were randomised controlled trials with ≥6 months of follow-up that included individuals with a body mass index ≥30, compared current bariatric surgery techniques with non-surgical treatment, and reported on body weight, cardiovascular risk factors, quality of life, or adverse events. Results: The meta-analysis included 11 studies with 796 individuals (range of mean body mass index at baseline 30-52). Individuals allocated to bariatric surgery lost more body weight (mean difference −26 kg (95% confidence interval −31 to −21)) compared with non-surgical treatment, had a higher remission rate of type 2 diabetes (relative risk 22.1 (3.2 to 154.3) in a complete case analysis; 5.3 (1.8 to 15.8) in a conservative analysis assuming diabetes remission in all non-surgically treated individuals with missing data) and metabolic syndrome (relative risk 2.4 (1.6 to 3.6) in complete case analysis; 1.5 (0.9 to 2.3) in conservative analysis), greater improvements in quality of life and reductions in medicine use (no pooled data). Plasma triglyceride concentrations decreased more (mean difference −0.7 mmol/L (−1.0 to −0.4) and high density lipoprotein cholesterol concentrations increased more (mean difference 0.21 mmol/L (0.1 to 0.3)). Changes in blood pressure and total or low density lipoprotein cholesterol concentrations were not significantly different. There were no cardiovascular events or deaths reported after bariatric surgery. The most common adverse events after bariatric surgery were iron deficiency anaemia (15% of individuals undergoing malabsorptive bariatric surgery) and reoperations (8%). Conclusions: Compared with non-surgical treatment of obesity, bariatric surgery leads to greater body weight loss and higher remission rates of type 2 diabetes and metabolic syndrome. However, results are limited to two years of follow-up and based on a small number of studies and individuals. Systematic review registration PROSPERO CRD42012003317 (www.crd.york.ac.uk/PROSPERO).