Publications by authors named "Tracy Y Wang"

326 Publications

Prophylactic Mechanical Circulatory Support Use in Elective Percutaneous Coronary Intervention for Patients With Stable Coronary Artery Disease.

Circ Cardiovasc Interv 2022 May 17;15(5):e011534. Epub 2022 May 17.

Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.).

Background: Mechanical circulatory support (MCS) devices can be used in high-risk percutaneous coronary intervention (PCI). Our objective was to describe trends and outcomes of prophylactic MCS use in elective PCI for patients with stable coronary artery disease in the American College of Cardiology National Cardiovascular Data Registry's CathPCI registry.

Methods: Among 2 108 715 consecutive patients with stable coronary artery disease undergoing elective PCI in the CathPCI registry between 2009 and 2018, we examined patterns of prophylactic use of MCS. Propensity score models with inverse probability of treatment weighting compared effectiveness (in-hospital death, cardiogenic shock, or new heart failure) and safety (stroke, tamponade, major bleeding, or vascular complication requiring treatment) between patients treated with intra-aortic balloon pump versus other MCS (Impella or extracorporeal membrane oxygenation).

Results: Overall, 6905 (0.3%) patients underwent elective PCI with prophylactic MCS. MCS use trended up from 0.2% of elective PCIs in 2009 to 0.6% in 2018 (<0.0001), driven by other MCS (<0.0001), whereas intra-aortic balloon pump use remained low and constant (=0.12). In-hospital major adverse cardiac events and cardiovascular complications occurred in 7.1% and 18.8% of elective PCI patients with prophylactic MCS use and 0.5% and 2.3% of patients without prophylactic MCS use. Intra-aortic balloon pump use was associated with a higher risk of major adverse cardiac events (9.6% versus 6.0%, adjusted odds ratio, 1.59 [95% CI, 1.32-1.91]) but lower risk of complications (18.2% versus 19.1%, adjusted odds ratio, 0.88 [95% CI, 0.77-0.99]) than use of other MCS.

Conclusions: The use of prophylactic MCS has increased over time for elective PCI in patients with stable coronary artery disease. Intra-aortic balloon pump was associated with higher major adverse cardiac events but lower risk of procedural complications compared with other MCS.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.121.011534DOI Listing
May 2022

Mentorship and the Leaky Pipeline in Academic Cardiology.

Authors:
Tracy Y Wang

Circ Cardiovasc Qual Outcomes 2022 May 13:101161CIRCOUTCOMES122009218. Epub 2022 May 13.

Duke Clinical Research Institute, Duke University, Durham NC.

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http://dx.doi.org/10.1161/CIRCOUTCOMES.122.009218DOI Listing
May 2022

Sex Differences in Management and Outcomes of Acute Myocardial Infarction Patients Presenting With Cardiogenic Shock.

JACC Cardiovasc Interv 2022 03;15(6):642-652

Section of Cardiology, Baylor School of Medicine, Houston, Texas, USA.

Objectives: The aim of this study was to examine the sex differences in the risk profile, management, and outcomes among patients presenting with acute myocardial infarction cardiogenic shock (AMI-CS).

Background: Contemporary clinical data regarding sex differences in the management and outcomes of AMI patients presenting with CS are scarce.

Methods: Patients admitted with AMI-CS from the National Cardiovascular Data Registry Chest Pain-MI registry between October 2008 to December 2017 were included. Sex differences in baseline characteristics, in-hospital management, and outcomes were compared. Patients ≥65 years of age with available linkage data to Medicare claims were included in the analysis of 1-year outcomes. Multivariable logistic regression and Cox proportional hazards models adjusting for patient and hospital-related covariates were used to estimate sex-specific differences in in-hospital and 1-year outcomes, respectively.

Results: Among 17,195 patients presenting with AMI-CS, 37.3% were women. Women were older, had a higher prevalence of comorbidities, and had worse renal function at presentation. Women were less likely to receive guideline-directed medical therapies within 24 hours and at discharge, undergo diagnostic angiography (85.0% vs 91.1%), or receive mechanical circulatory support (25.4% vs 33.8%). Women had higher risks of in-hospital mortality (adjusted OR: 1.10; 95% CI: 1.02-1.19) and major bleeding (adjusted OR: 1.23; 95% CI: 1.12-1.34). For patients ≥65 years of age, women did not have a higher risk of all-cause mortality (adjusted HR: 0.98; 95% CI: 0.88-1.09) and mortality or heart failure hospitalization (adjusted HR: 1.01; 95% CI: 0.91-1.12) at 1 year compared with men.

Conclusions: In this large nationwide analysis of patients with AMI-CS, women were less likely to receive guideline recommended care, including revascularization, and had worse in-hospital outcomes than men. At 1 year, there were no sex differences in the risk of mortality. Efforts are needed to address sex disparities in the initial care of AMI-CS patients.
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http://dx.doi.org/10.1016/j.jcin.2021.12.033DOI Listing
March 2022

Point-of-Care Ultrasonography: Clearly More Than a Pretty Picture-Reply.

JAMA Intern Med 2022 05;182(5):568

Duke Clinical Research Institute, Duke University, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamainternmed.2022.0073DOI Listing
May 2022

Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association.

Circ Cardiovasc Qual Outcomes 2022 03 22;15(3):e000105. Epub 2022 Feb 22.

Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system-, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.
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http://dx.doi.org/10.1161/HCQ.0000000000000105DOI Listing
March 2022

Ten-Year Trends in Patient Characteristics, Treatments, and Outcomes in Myocardial Infarction From National Cardiovascular Data Registry Chest Pain-MI Registry.

Circ Cardiovasc Qual Outcomes 2022 01 18;15(1):e008112. Epub 2022 Jan 18.

Virginia Commonwealth University, Richmond, VA (M.C.K.).

Background: The Chest Pain-MI registry affords a 10-year perspective of the acute myocardial infarction (MI) patient characteristics, management, and clinical outcomes in the United States. We report the changes in the treatment and cardiovascular outcomes of acute MI patients over 10 years.

Methods: Annual trends in patient characteristics, in-hospital treatment, and outcomes of 604 936 ST-segment-elevation MI (STEMI) and 933 755 non-ST-segment-elevation MI (NSTEMI) patients at 1230 hospitals from 2009 to 2018 were analyzed. Using the validated Acute Coronary Intervention and Outcomes Network mortality risk model, trends in in-hospital risk-adjusted mortality rates were tested between 2011 and 2018.

Results: Over 10 years, the prevalence of diabetes (22.8%-28.3% [STEMI] and 35.7%-41.3% [NSTEMI]) and atrial fibrillation (4.1%-6.1% and 9.4%-11.7%) increased, whereas the prevalence of smoking decreased (43.5%-37.9% and 30.2%-27.5%, <0.001 for all) in patients with STEMI and NSTEMI, respectively. Among eligible patients with STEMI, primary percutaneous coronary intervention use increased (82.3%-96.0%) with shorter median first medical contact to device time (90 to 82 minutes, <0.001). Among patients with NSTEMI, percutaneous coronary intervention use increased significantly (43.9%-54.5%, <0.001). Adherence to guideline-directed medical therapies improved in both groups. From 2011 to 2018, risk-adjusted mortality rate (2.8%-2.7%, =0.46) was stable in STEMI and declined significantly in patients with NSTEMI (1.9%-1.3%, =0.0001).

Conclusions: Risk factors of patients presenting with acute MI have changed modestly while treatment improved over time. Risk-adjusted mortality rates remained stable for patients with STEMI and declined significantly for patients with NSTEMI.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.121.008112DOI Listing
January 2022

Comfort Measures Only in Myocardial Infarction: Prevalence of This Status, Change Over Time, and Predictors From a Nationwide Study.

Circ Cardiovasc Qual Outcomes 2022 01 18;15(1):e007610. Epub 2022 Jan 18.

Section of Cardiovascular Medicine, Department of Internal Medicine (S.W.R., N.R.D.), Yale New Haven Hospital, New Haven, CT.

Background: Patients hospitalized with acute myocardial infarction (AMI) have a high mortality rate. Despite increasing recognition of the role for comfort focused care, little is known about the prevalence of comfort measures only (CMO) care among patients with AMI. The objective of this study was to investigate patient- and hospital-level patterns and predictors of CMO care among patients admitted with AMI.

Methods: This retrospective cohort study used the National Cardiovascular Data Registry Chest Pain-MI Registry, which contains data on patients admitted with AMI. Data were analyzed in 6-month increments from January 2015 to June 2018.

Results: Among 483 696 patients with AMI across 827 hospitals, 13 955 (2.9%) had CMO status at discharge (2.6% non-ST-segment-elevation myocardial infarction and 3.4% ST-segment-elevation myocardial infarction). There was a modest decline in CMO rates over time (3.0% to 2.8%). Independent patient characteristics associated with CMO status included male gender, White race, nonprivate insurance, frailty, and higher estimated bleeding and mortality risks. There was substantial variation in CMO rates across hospitals, with the proportion of CMO patients ranging from 0% to 17.1% and a median odds ratio of 1.59 (95% CI, 1.56-1.62). Among the 13 955 patients who were CMO by discharge, 8134 (58.3%) underwent diagnostic catheterization. This is despite significantly elevated risks predicted using precatheterization models, specifically the ACTION Registry GWTG in-hospital major bleeding and mortality risk scores. Patients who were initially managed invasively but later made CMO experienced high rates of procedural complications, including cardiogenic shock (38.3%), dialysis (10.1%), and bleeding (33.3%).

Conclusions: Most patients with AMI who were CMO by discharge had aggressive initial management and became CMO following in-hospital complications of their care. Early identification of high-risk patients and appropriate transition of such patients to CMO, if aligned with their values, remain important areas for future quality programs in AMI.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007610DOI Listing
January 2022

Atrial Fibrillation and Coronary Artery Disease: A Long-Term Perspective on the Need for Combined Antithrombotic Therapy.

Circ Cardiovasc Interv 2021 12 21;14(12):e011232. Epub 2021 Dec 21.

Duke Clinical Research Institute (S.L., G.M.-G., R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC.

Background: Older adults with atrial fibrillation (AF) are often treated with the shortest possible duration of antiplatelet/anticoagulant therapy after myocardial infarction (MI) or percutaneous coronary intervention (PCI) due to concern for bleeding. However, the risk of recurrent MI or PCI prompting antiplatelet therapy extension is unknown in this population.

Methods: Using the National Cardiovascular Data Registry linked to Medicare claims, we described the cumulative incidence of recurrent MI or PCI over a median of 7-year follow-up for patients ≥65 years old with AF discharged alive after acute MI between 2008 and 2017. We used pharmacy fill data to describe the proportion of patients filling prescriptions for both oral anticoagulants and P2Y inhibitors for ≥50% of the indicated duration after MI or PCI.

Results: Of 187 622 older patients discharged alive after MI, 50 539 (26.9%) had AF. Over a median of 7-year follow-up in patients with AF, the cumulative incidence was 14.5% for recurrent MI, 12.1% for PCI, 7.9% for stroke, and 9.5% for bleeding hospitalization. Among 7998 patients with AF and recurrent MI or PCI, 1668 (20.9%) had >1 MI or PCI during follow-up. Assuming each MI or PCI should be followed by 6 months of P2Y inhibitor therapy, patients with AF who had a recurrent MI/PCI had a median estimated indication for antiplatelet/anticoagulant treatment of 287 days (194, 358), but filled both P2Y inhibitor and oral anticoagulant for a median of 0 days (0, 21). In this cohort, 12.2% of patients filled prescriptions for both a P2Y inhibitor and oral anticoagulant for ≥50% of the indicated duration.

Conclusions: Older adults with AF and MI have high incidences of downstream recurrent MI or PCI requiring extended antiplatelet/anticoagulant therapy durations, yet many appear to be under-treated. These results highlight the need for better thrombosis prevention strategies in this group of patients.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.121.011232DOI Listing
December 2021

Racial Disparities in Invasive Management for Patients With Acute Myocardial Infarction With Chronic Kidney Disease.

Circ Cardiovasc Interv 2022 01 17;15(1):e011171. Epub 2021 Dec 17.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.

Background: Due to increased risks of contrast nephropathy, chronic kidney disease (CKD) can deter consideration of invasive management for patients with myocardial infarction (MI). Black patients have a higher prevalence of CKD. Whether racial disparities exist in the use of invasive MI management for patients with CKD presenting with MI is unknown.

Methods: We examined 717 012 White and 99 882 Black patients with MI treated from 2008 to 2017 at 914 hospitals in the National Cardiovascular Data Registry Chest Pain-MI Registry. CKD status was defined as estimated glomerular filtration rate (eGFR) ≥90 mL/(min·1.73 m; no CKD), eGFR <90 but ≥60 (mild), eGFR <60 but ≥30 (moderate), and eGFR <30 or dialysis (severe). We used multivariable logistic regression models to examine the interaction of race and CKD severity in invasive MI management.

Results: Among those with MI, Black patients were more likely than White patients to have CKD (eGFR <90; 61.4% versus 58.5%; <0.001). Among those with MI and CKD, Black patients were more likely than White patients to have severe CKD (21.2% versus 12.4%; <0.001). Patients with CKD were more likely than those without CKD to have diabetes or heart failure; Black patients with CKD were more likely to have these comorbidities when compared with White patients with CKD (all <0.0001). Black race and CKD were associated with a lower likelihood of invasive management (adjusted odds ratio, 0.78 [95% CI, 0.75-0.81]; adjusted odds ratio, 0.72 [95% CI, 0.70-0.74]; <0.001 for both). At eGFR levels ≥10, Black patients were significantly less likely than White patients to undergo invasive management.

Conclusions: Black patients with MI and mild or moderate CKD were less likely to undergo invasive management compared with White patients with similar CKD severity. National efforts are needed to address racial disparities that may remain in the invasive management of MI.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.121.011171DOI Listing
January 2022

Percutaneous Coronary Intervention Operator Profiles and Associations With In-Hospital Mortality.

Circ Cardiovasc Interv 2022 01 1;15(1):e010909. Epub 2021 Dec 1.

Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).

Background: Percutaneous coronary intervention is performed by operators with differing experience, technique, and case mix. It is unknown if operator practice patterns impact patient outcomes. We sought to determine if a cluster algorithm can identify distinct profiles of percutaneous coronary intervention operators and if these profiles are associated with patient outcomes.

Methods: Operators performing at least 25 annual procedures between 2014 and 2018 were clustered using an agglomerative hierarchical clustering algorithm. Risk-adjusted in-hospital mortality was compared between clusters.

Results: We identified 4 practice profiles among 7706 operators performing 2 937 419 procedures. Cluster 1 (n=3345) demonstrated case mix and practice patterns similar to the national median. Cluster 2 (n=1993) treated patients with lower clinical acuity and were less likely to use intracoronary diagnostics, atherectomy, and radial access. Cluster 3 (n=1513) had the lowest case volume, were more likely to work at rural hospitals, and cared for a higher proportion of patients with ST-segment-elevation myocardial infarction and cardiogenic shock. Cluster 4 (n=855) had the highest case volume, were most likely to treat patients with high anatomic complexity and use atherectomy, intracoronary diagnostics, and mechanical support. Compared with cluster 1, adjusted in-hospital mortality was similar for cluster 2 (estimated difference, -0.03 [95% CI, -0.10 to 0.04]), higher for cluster 3 (0.14 [0.07-0.22]), and lower for cluster 4 (-0.15 [-0.24 to -0.06]).

Conclusions: Distinct percutaneous coronary intervention operator profiles are differentially associated with patient outcomes. A phenotypic approach to physician assessment may provide actionable feedback for quality improvement.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.121.010909DOI Listing
January 2022

Hospital-Level Percutaneous Coronary Intervention Performance With Simulated Risk Avoidance.

J Am Coll Cardiol 2021 11;78(22):2213-2217

Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.

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http://dx.doi.org/10.1016/j.jacc.2021.09.862DOI Listing
November 2021

Nonfatal Myocardial Infarction-Poor Surrogate for Mortality.

JAMA Intern Med 2021 12;181(12):1588

Duke University, Duke Clinical Research Institute, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamainternmed.2021.5713DOI Listing
December 2021

Point-of-Care Ultrasonography: Visually Satisfying Medicine or Evidence-Based Medicine?

JAMA Intern Med 2021 12;181(12):1558-1559

Duke University, Duke Clinical Research Institute, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamainternmed.2021.5831DOI Listing
December 2021

Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention: JACC Review Topic of the Week.

J Am Coll Cardiol 2021 10;78(15):1550-1563

Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA. Electronic address:

Patients undergoing early surgery after coronary stent implantation are at increased risk for mortality from ischemic and hemorrhagic complications. The optimal antiplatelet strategy in patients who cannot discontinue dual antiplatelet therapy (DAPT) before surgery is unclear. Current guidelines, based on surgical and clinical characteristics, provide risk stratification for bridging therapy with intravenous antiplatelet agents, but management is guided primarily by expert opinion. This review summarizes perioperative risk factors to consider before discontinuing DAPT and reviews the data for intravenous bridging therapies. Published reports have included bridging options such as small molecule glycoprotein IIb/IIIa inhibitors (eptifibatide or tirofiban) and cangrelor, an intravenous P2Y inhibitor. However, optimal management of these complex patients remains unclear in the absence of randomized controlled data, without which an argument can be made both for and against the use of perioperative intravenous bridging therapy after discontinuing oral P2Y inhibitors. Multidisciplinary risk assessment remains a critical component of perioperative care.
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http://dx.doi.org/10.1016/j.jacc.2021.08.013DOI Listing
October 2021

Technology-Assisted Self-Selection of Candidates for Nonprescription Statin Therapy.

J Am Coll Cardiol 2021 09;78(11):1114-1123

Center for Cardiovascular Disease Prevention, Harvard Medical School, Boston, Massachusetts, USA.

Background: Although statins reduce cardiovascular morbidity and mortality, only about one-half of eligible patients receive treatment. Safe and appropriate consumer access to statins could have a significant positive public health impact.

Objectives: This study compares the concordance between a participant and clinician assessment of eligibility for statin therapy using a technology-assisted approach.

Methods: A total of 500 participants, 83 with limited literacy, completed an at-home Web-based application to assess appropriateness for treatment with rosuvastatin 5 mg. The Web application is designed to assess eligibility for a moderate-intensity statin based on current guidelines and deny access to individuals with contraindications to rosuvastatin. Subsequently, participants visited a research site where clinicians, blinded to the information the participant entered, performed an independent Web application assessment. The Web application is programmed for 1 of 3 rosuvastatin treatment outcomes: "OK to use," "not right for you," or "ask a doctor." The primary endpoint was the percent of participants whose self-selected eligibility for nonprescription rosuvastatin was concordant with clinician assessment.

Results: For the primary endpoint, participant selection for statin therapy was concordant with clinician selection in 481 (96.2%) of 500 participants (95% confidence interval: 94.1%-97.7%), of whom 23 (4.6%) were deemed appropriate and 458 (91.6%) were deemed inappropriate for treatment. Discordance was due to incorrect self-selection ("OK to use") in 3 cases, incorrect rejection ("not right for you") in 14 cases and an incorrect "ask a doctor" outcome in 2 cases.

Conclusions: The use of a technology-assisted approach to consumer self-selection for statin therapy resulted in participant self-selection that showed substantial agreement with clinician selection.
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http://dx.doi.org/10.1016/j.jacc.2021.06.048DOI Listing
September 2021

The Impact of American College of Cardiology Chest Pain Center Accreditation on Guideline Recommended Acute Myocardial Infarction Management.

Crit Pathw Cardiol 2021 12;20(4):173-178

Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA.

Background: Whether American College of Cardiology (ACC) Chest Pain Center (CPC) accreditation alters guidelines adherence rates is unclear.

Methods: We analyzed patient-level, hospital-reported, quality metrics for myocardial infarction (MI) patients from 644 hospitals collected in the ACC's Chest Pain-MI Registry from January 1, 2019, to December 31, 2020, stratified by CPC accreditation for >1 year.

Results: Of 192,374 MI patients, 67,462 (35.1%) received care at an accredited hospital. In general, differences in guideline adherence rates between accredited and nonaccredited hospitals were numerically small, although frequently significant. Patients at accredited hospitals were more likely to undergo coronary angiography (98.6% vs. 97.9%, P < 0.0001), percutaneous coronary intervention for NSTEMI (55.4% vs. 52.3%, P < 0.0001), have overall revascularization for NSTEMI (63.5% vs. 61.0%, P < 0.0001), and receive P2Y12 inhibitor on arrival (63.5% vs. 60.2%, P < 0.0001). Nonaccredited hospitals more ECG within 10 minutes (62.3% vs. 60.4%, P < 0.0001) and first medical contact to device activation ≤90 minutes (66.8% vs. 64.8%, P < 0.0001). Accredited hospitals had uniformly higher discharge medication guideline adherence, with patients more likely receiving aspirin (97.8% vs. 97.4%, P < 0.0001), angiotensin-converting enzyme inhibitor (46.7% vs. 45.3%, P < 0.0001), beta blocker (96.6% vs. 96.2%, P < 0.0001), P2Y12 inhibitor (90.3% vs. 89.2%, P < 0.0001), and statin (97.8% vs. 97.5%, P < 0.0001). Interaction by accredited status was significant only for length of stay, which was slightly shorter at accredited facilities for specific subgroups.

Conclusions: ACC CPC accreditation was associated with small consistent improvement in adherence to guideline-based treatment recommendations of catheter-based care (catheterization and PCI) for NSTEMI and discharge medications, and shorter hospital stays.
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http://dx.doi.org/10.1097/HPC.0000000000000266DOI Listing
December 2021

Geographic and Socioeconomic Disparities in Major Lower Extremity Amputation Rates in Metropolitan Areas.

J Am Heart Assoc 2021 09 25;10(17):e021456. Epub 2021 Aug 25.

Penn Cardiovascular Outcomes, Quality and Evaluative Research Center University of Pennsylvania Philadelphia PA.

Background Rates of major lower extremity amputation in patients with peripheral artery disease are higher in rural communities with markers of low socioeconomic status, but most Americans live in metropolitan areas. Whether amputation rates vary within US metropolitan areas is unclear, as are characteristics of high amputation rate urban communities. Methods and Results We estimated rates of major lower extremity amputation per 100 000 Medicare beneficiaries between 2010 and 2018 at the ZIP code level among ZIP codes with ≥100 beneficiaries. We described demographic characteristics of high and low amputation ZIP codes, and the association between major amputation rate and 3 ZIP code-level markers of socioeconomic status-the proportion of patients with dual eligibility for Medicaid, median household income, and Distressed Communities Index score-for metropolitan, micropolitan, and rural ZIP code cohorts. Between 2010 and 2018, 188 995 Medicare fee-for-service patients living in 31 391 ZIP codes with ≥100 beneficiaries had a major lower extremity amputation. The median (interquartile range) ZIP code-level number of amputations per 100 000 beneficiaries was 262 (75-469). Though nonmetropolitan ZIP codes had higher rates of major amputation than metropolitan areas, 78.2% of patients undergoing major amputation lived in metropolitan areas. Compared with ZIP codes with lower amputation rates, top quartile amputation rate ZIP codes had a greater proportion of Black residents (4.4% versus 17.5%, <0.001). In metropolitan areas, after adjusting for clinical comorbidities and demographics, every $10 000 lower median household income was associated with a 4.4% (95% CI, 3.9-4.8) higher amputation rate, and a 10-point higher Distressed Communities Index score was associated with a 3.8% (95% CI, 3.4%-4.2%) higher amputation rate; there was no association between the proportion of patients eligible for Medicaid and amputation rate. These findings were comparable to the associations identified across all ZIP codes. Conclusions In metropolitan areas, where most individuals undergoing lower extremity amputation live, markers of lower socioeconomic status and Black race were associated with higher rates of major lower extremity amputation. Development of community-based tools for peripheral artery disease diagnosis and management targeted to communities with high amputation rates in urban areas may help reduce inequities in peripheral artery disease outcomes.
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http://dx.doi.org/10.1161/JAHA.121.021456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649262PMC
September 2021

Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis.

J Am Heart Assoc 2021 08 13;10(16):e020490. Epub 2021 Aug 13.

Duke Clinical Research Institute Duke University School of Medicine Durham NC.

Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011-2016). Multilevel, multivariable Fine-Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1-year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th-75th percentiles, 13.3%-47.0%]). The odds of receiving AVR varied >2-fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14-2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1-year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13-1.33). Conclusions Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.
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http://dx.doi.org/10.1161/JAHA.120.020490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475044PMC
August 2021

Repeated cross-sectional analysis of hydroxychloroquine deimplementation in the AHA COVID-19 CVD Registry.

Sci Rep 2021 07 23;11(1):15097. Epub 2021 Jul 23.

Center for Innovation and Value at Parkland, University of Texas Southwestern Medical Center, Dallas, TX, USA.

There is little data describing trends in the use of hydroxychloroquine for COVID-19 following publication of randomized trials that failed to demonstrate a benefit of this therapy. We identified 13,957 patients admitted for active COVID-19 at 85 U.S. hospitals participating in a national registry between March 1 and August 31, 2020. The overall proportion of patients receiving hydroxychloroquine peaked at 55.2% in March and April and decreased to 4.8% in May and June and 0.8% in July and August. At the hospital-level, median use was 59.4% in March and April (IQR 48.5-71.5%, range 0-100%) and decreased to 0.3% (IQR 0-5.4%, range 0-100%) by May and June and 0% (IQR 0-1.3%, range 0-36.4%) by July and August. The rate and hospital-level uniformity in deimplementation of this ineffective therapy for COVID-19 reflects a rapid response to evolving clinical information and further study may offer strategies to inform deimplementation of ineffective clinical care.
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http://dx.doi.org/10.1038/s41598-021-94203-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302649PMC
July 2021

Differential modulation of polyunsaturated fatty acids in patients with myocardial infarction treated with ticagrelor or clopidogrel.

Cell Rep Med 2021 06 4;2(6):100299. Epub 2021 Jun 4.

Faculty of Medicine, Université de Montréal, Montréal, QC, Canada.

Untargeted metabolomics is used to refine the development of biomarkers for the diagnosis of cardiovascular disease. Myocardial infarction (MI) has major individual and societal consequences for patients, who remain at high risk of secondary events, despite advances in pharmacological therapy. To monitor their differential response to treatment, we performed untargeted plasma metabolomics on 175 patients from the platelet inhibition and patient outcomes (PLATO) trial treated with ticagrelor and clopidogrel, two common PY inhibitors. We identified a signature that discriminates patients, which involves polyunsaturated fatty acids (PUFAs) and particularly the omega-3 fatty acids docosahexaenoate and eicosapentaenoate. The known cardiovascular benefits of PUFAs could contribute to the efficacy of ticagrelor. Our work, beyond pointing out the high relevance of untargeted metabolomics in evaluating response to treatment, establishes PUFA metabolism as a pathway of clinical interest in the recovery path from MI.
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http://dx.doi.org/10.1016/j.xcrm.2021.100299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8233657PMC
June 2021

Patient perceptions and use of non-statin lipid lowering therapy among patients with or at risk for atherosclerotic cardiovascular disease: Insights from the PALM registry.

Clin Cardiol 2021 Jun 18;44(6):863-870. Epub 2021 May 18.

Duke Clinical Research Institute, Durham, North Carolina, USA.

Background: Non-statin lipid lowering therapies (LLTs) provide additional treatment options for patients. Use patterns and patient perceptions of non-statin LLT remain incompletely described.

Hypothesis: The guideline-recommended statin intensity remains underutilized in patients treated with and without non-statin LLT.

Methods: The PALM Registry collected LLT information on patients with or at risk of ASCVD treated at 125 US clinics in 2015. We compared patient perceptions, lipid levels and statin use among patients treated with and without non-statin LLT.

Results: Among 7720 patients, 1930 (25.0%) were treated with a non-statin LLT (1249 fish oil, 417 fibrates, 329 ezetimibe, 196 niacin). Concurrent statin treatment occurred in 73.7%, of which 45.4% were dosed under the guideline-recommended intensity. Compared with patients on statin alone, patients receiving both a statin and non-statin LLT (n = 1423) were more likely to be male, white race and to perceive themselves as higher risk of ASCVD compared with their peers (38.5% vs. 34.9%, p = .047). Only 27.4% of patients treated with non-statin LLT alone perceived themselves at higher risk. Most (75.7%) patients treated with a non-statin LLT alone reported never being treated with a statin, despite ASCVD in 30.8% of these patients. Among those previously treated with a statin, 59.3% reported being willing to try a statin again.

Conclusions: Non-statin LLT is used in one in four patients with or at risk for ASCVD; its use is frequently in place of statin therapy or in the absence of guideline-recommended statin intensity. More work is needed to establish statins as first line therapy.
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http://dx.doi.org/10.1002/clc.23625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207979PMC
June 2021

Differences in Preferences Between Clinicians and Patients for the Use and Dosing of Direct Oral Anticoagulants for Atrial Fibrillation.

J Am Heart Assoc 2021 06 15;10(11):e020697. Epub 2021 May 15.

Division of Cardiology Duke University Medical Center Durham NC.

Background Direct oral anticoagulants (DOACs) are effective in reducing the stroke risk for patients with nonvalvular atrial fibrillation if prescribed at the labeled dose, yet underdosing is frequent. Little is known about clinician knowledge and patient or clinician preferences for DOAC dosing. Methods and Results From April 2019 to March 2020, 240 clinicians and 343 patients with atrial fibrillation completed an assessment of anticoagulation knowledge/preferences. Clinician knowledge of DOAC dosing was tested with 4 hypothetical patient scenarios. Patients and clinicians were asked to grade the importance of 25 factors in anticoagulation decision making. Among clinicians, the median age was 55 years, and 23% were primary care clinicians. In scenarios of a patient indicated for full-dose DOAC, 41.2% of clinicians underdosed apixaban and 17.6% underdosed rivaroxaban. In scenarios of a patient indicated for reduced-dose DOAC, 64.6% and 71.7% of clinicians chose to use reduced-dose apixaban and rivaroxaban, respectively. Only 35.0% of clinicians correctly answered all 4 scenarios with the label-indicated dose; this knowledge gap was similar between clinicians who did and did not underdose. Among patients with atrial fibrillation, the median age was 65 years, and 89% were currently anticoagulated. Patients and clinicians ranked stroke prevention and avoiding severe bleeding as very important to anticoagulation decision making. Patients were more likely than clinicians to rank the ability to reduce anticoagulation dose if needed as very important (70.5% versus 43.6%; <0.001). Conclusions There are considerable knowledge gaps regarding DOAC dosing in clinicians treating patients with atrial fibrillation, as well as significant differences in treatment dosing preferences between clinicians and patients.
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http://dx.doi.org/10.1161/JAHA.120.020697DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483523PMC
June 2021

Trends in Patient Characteristics and COVID-19 In-Hospital Mortality in the United States During the COVID-19 Pandemic.

JAMA Netw Open 2021 05 3;4(5):e218828. Epub 2021 May 3.

Division of Cardiology, Department of Medicine, University of Washington, Seattle.

Importance: In-hospital mortality rates from COVID-19 are high but appear to be decreasing for selected locations in the United States. It is not known whether this is because of changes in the characteristics of patients being admitted.

Objective: To describe changing in-hospital mortality rates over time after accounting for individual patient characteristics.

Design, Setting, And Participants: This was a retrospective cohort study of 20 736 adults with a diagnosis of COVID-19 who were included in the US American Heart Association COVID-19 Cardiovascular Disease Registry and admitted to 107 acute care hospitals in 31 states from March through November 2020. A multiple mixed-effects logistic regression was then used to estimate the odds of in-hospital death adjusted for patient age, sex, body mass index, and medical history as well as vital signs, use of supplemental oxygen, presence of pulmonary infiltrates at admission, and hospital site.

Main Outcomes And Measures: In-hospital death adjusted for exposures for 4 periods in 2020.

Results: The registry included 20 736 patients hospitalized with COVID-19 from March through November 2020 (9524 women [45.9%]; mean [SD] age, 61.2 [17.9] years); 3271 patients (15.8%) died in the hospital. Mortality rates were 19.1% in March and April, 11.9% in May and June, 11.0% in July and August, and 10.8% in September through November. Compared with March and April, the adjusted odds ratios for in-hospital death were significantly lower in May and June (odds ratio, 0.66; 95% CI, 0.58-0.76; P < .001), July and August (odds ratio, 0.58; 95% CI, 0.49-0.69; P < .001), and September through November (odds ratio, 0.59; 95% CI, 0.47-0.73).

Conclusions And Relevance: In this cohort study, high rates of in-hospital COVID-19 mortality among registry patients in March and April 2020 decreased by more than one-third by June and remained near that rate through November. This difference in mortality rates between the months of March and April and later months persisted even after adjusting for age, sex, medical history, and COVID-19 disease severity and did not appear to be associated with changes in the characteristics of patients being admitted.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.8828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094014PMC
May 2021

Harnessing Mobile Health Technology for Secondary Cardiovascular Disease Prevention in Older Adults: A Scientific Statement From the American Heart Association.

Circ Cardiovasc Qual Outcomes 2021 05 1;14(5):e000103. Epub 2021 Apr 1.

Secondary prevention of cardiovascular disease (CVD), the leading cause of morbidity and mortality, is critical to improving health outcomes and quality of life in our aging population. As mobile health (mHealth) technology gains universal leverage and popularity, it is becoming more user-friendly for older adults and an adjunct to manage CVD risk and improve overall cardiovascular health. With the rapid advances in mHealth technology and increasing technological engagement of older adults, a comprehensive understanding of the current literature and knowledge of gaps and barriers surrounding the impact of mHealth on secondary CVD prevention is essential. After a systematic review of the literature, 26 studies that used mHealth for secondary CVD prevention focusing on lifestyle behavior change and medication adherence in cohorts with a mean age of ≥60 years were identified. Improvements in health behaviors and medication adherence were observed, particularly when there was a short message service (ie, texting) component involved. Although mobile technologies are becoming more mainstream and are starting to blend more seamlessly with standard health care, there are still distinct barriers that limit implementation particularly in older adults, including affordability, usability, privacy, and security issues. Furthermore, studies on the type of mHealth that is the most effective for older adults with longer study duration are essential as the field continues to grow. As our population ages, identifying and implementing effective, widely accepted, cost-effective, and time-efficient mHealth interventions to improve CVD health in a vulnerable demographic group should be a top health priority.
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http://dx.doi.org/10.1161/HCQ.0000000000000103DOI Listing
May 2021

Electronic Health Record Integration of Predictive Analytics to Select High-Risk Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction for Intensive Care Unit Admission.

Circ Cardiovasc Qual Outcomes 2021 04 24;14(4):e007602. Epub 2021 Mar 24.

Cardiovascular Medicine Division, Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (A.C.F.).

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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007602DOI Listing
April 2021

Sex disparities in patients with symptomatic severe aortic stenosis.

Am Heart J 2021 07 17;237:116-126. Epub 2021 Mar 17.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. Electronic address:

Background: We evaluated whether there is equitable distribution across sexes of treatment and outcomes for aortic valve replacement (AVR), via surgical (SAVR) or transcatheter (TAVR) methods, in symptomatic severe aortic stenosis (ssAS) patients.

Methods: Using de-identified data, we identified 43,822 patients with ssAS (2008-2016). Multivariate competing risk models were used to determine the likelihood of any AVR, while accounting for the competing risk of death. Association between sex and 1-year mortality, stratified by AVR status, was evaluated using multivariate Cox regression models with AVR as a time-dependent variable.

Results: Among patients with ssAS, 20,986 (47.9%) were female. Females were older (median age 81 vs. 78, P<0.001), more likely to have body mass index <20 (8.5% vs. 3.5%), and home oxygen use (4.4% vs. 3.4%, P<0001 for all). Overall, 12,129 (27.7%) patients underwent AVR for ssAS. Females were less likely to undergo AVR compared with males (24.1% vs. 31.0%, adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.77-0.83), but when treated, were more likely to undergo TAVR (37.9% vs. 30.9%, adjusted HR 1.21, 95% CI 1.15-1.27). Untreated females and males had similarly high rates of mortality at 1 year (31.1% vs. 31.3%, adjusted HR 0.98, 95% CI 0.94-1.03). Among those undergoing AVR, females had significantly higher mortality (10.2% vs. 9.4%, adjusted HR 1.24, 95% CI 1.10-1.41), driven by increased SAVR-associated mortality (9.0% vs. 7.6%, adjusted HR 1.43, 95% CI 1.21-1.69).

Conclusions: Treatment rates for ssAS patients remain suboptimal with disparities in female treatment.
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http://dx.doi.org/10.1016/j.ahj.2021.01.021DOI Listing
July 2021

Evolution of Clinical Thinking and Practice Regarding Aspirin: What Has Changed and Why?

Am J Cardiol 2021 04;144 Suppl 1:S10-S14

Duke Clinical Research Institute, Duke University, Durham, North Carolina.

Aspirin (ASA) is the original antiplatelet agent. Its routine use, long unquestioned for both primary and secondary prevention in cardiovascular disease, is under increasing scrutiny as the risk:benefit balance for ASA becomes less clear and other disease- and risk-modifying approaches are validated. It can be viewed as a significant advance in evidence-based medicine that the use of an inexpensive, readily available, long-validated therapy is being questioned in large, rigorous trials. In this overview we present the important questions surrounding a more informed approach to ASA therapy: duration of therapy, assessment of net clinical benefit, and timing of start and stop strategies. We also consider potential explanations for "breakthrough" thrombosis when patients are on ASA therapy. Other manuscripts in this Supplement address the specifics of primary prevention, secondary prevention, triple oral antithrombotic therapy, and the future of ASA in cardiovascular medicine.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.021DOI Listing
April 2021

Patient-Perceived Versus Actual Risk of Cardiovascular Disease and Associated Willingness to Consider and Use Prevention Therapy.

Circ Cardiovasc Qual Outcomes 2021 01 13;14(1):e006548. Epub 2021 Jan 13.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.M.N., T.Y.W., S.L., X.M., Z.L., E.D.P.).

Background: Cardiovascular prevention guidelines use estimated 10-year atherosclerotic cardiovascular disease (CVD) risk based on the pooled cohort equations to guide treatment decisions and engage patients in shared decision-making. We sought to determine patient perceived versus actual risk of atherosclerotic CVD and associations with willingness for preventive therapy.

Methods: We evaluated calculated and perceived CVD risk among 4187 patients across 124 sites in the Patient and Provider Assessment of Lipid Management Registry. Ten-year risk was assessed using the pooled cohort equations; risk relative-to-peers was determined based on age-, sex-, and race-based percentiles; and patient estimates of risk were assessed using patient surveys. Poisson regression models evaluated associations between risk estimates, statin use, and willingness to take prevention therapy.

Results: Overall, there was no correlation between patients' estimates of their 10-year CVD risk and calculated 10-year risk (ρ=-0.01, =0.46), regardless of age, sex, race, or socioeconomic status. The majority (72.2%) overestimated their 10-year CVD risk relative to the pooled cohorts equation (mean perceived 33.3% versus mean calculated 17.1%, <0.01). Patients' perceptions of their risk relative-to-peers were slightly correlated with standardized risk percentiles (ρ=0.19, <0.01), although most had overly optimistic views of how risk compared with their peers. Increasing perceived risk was not associated with current statin use (=0.18) but was associated with willingness to consider future prevention therapy (<0.01). Perceived risk relative-to-peers was associated with increased prevalent statin use (risk ratio 1.04 per category increase [95% CI, 1.02-1.06]) and reported willingness for prevention therapy (risk ratio 1.11 [95% CI, 1.07-1.16]).

Conclusions: When asked, most patients overestimate their 10-year risk but hold an optimistic bias of their risk relative to age-, race-, and sex-matched peers. Providing accurate absolute risk assessments to patients without proper context may paradoxically decrease many patients' perceived risk of CVD, thereby disincentivizing initiation of CVD risk reduction therapy.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.006548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855929PMC
January 2021

Difference in Medication Adherence Between Patients Prescribed a 30-Day Versus 90-Day Supply After Acute Myocardial Infarction.

J Am Heart Assoc 2021 01 21;10(1):e016215. Epub 2020 Dec 21.

Duke Clinical Research Institute Durham NC.

Background Evidence-based medication adherence rates after a myocardial infarction are low. We hypothesized that 90-day prescriptions are underused and may lead to higher evidence-based medication adherence compared with 30-day fills. Methods and Results We examined patients with myocardial infarction treated with percutaneous coronary intervention between 2011 and 2015 in the National Cardiovascular Data Registry. Linking to Symphony Health pharmacy data, we described the prevalence of patients filling 30-day versus 90-day prescriptions of statins, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and P2Y inhibitors after discharge. We compared 12-month medication adherence rates by evidence-based medication class and prescription days' supply and rates of medication switches and dosing changes. Among 353 259 patients with myocardial infarction treated with percutaneous coronary intervention, 90-day evidence-based medication fill rates were low: 13.0% (statins), 12.3% (β-blockers), 14.6% (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers), and 9.7% (P2Y inhibitors). Patients filling 90-day prescriptions were more likely older (median 69 versus 62 years) with a history of prior myocardial infarction (25.0% versus 17.9%) or percutaneous coronary intervention (30.3% versus 19.5%; <0.01 for all) than patients filling 30-day prescriptions. The 12-month adherence rates were higher for patients who filled 90-day versus 30-day supplies: statins, 83.1% versus 75.3%; β-blockers, 72.7% versus 62.9%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, 71.1% versus 60.9%; and P2Y inhibitors, 78.5% versus 66.6% (<0.01 for all). Medication switches and dosing changes within 12 months were infrequent for patients filling 30-day prescriptions-14.7% and 0.3% for 30-day P2Y inhibitor fills versus 6.3% and 0.2% for 90-day fills, respectively. Conclusions Patients who filled 90-day prescriptions had higher adherence and infrequent medication changes within 1 year after discharge. Ninety-day prescription strategies should be encouraged to improve post-myocardial infarction medication adherence.
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http://dx.doi.org/10.1161/JAHA.119.016215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955468PMC
January 2021
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