NCDR at AHA
NCDR ACTION Registry-GWTG™
Congrats, You Hit Your Goals!
So, Why the MI?
Goals are great, but the gold star you get for
reaching them is no shield against events. Or is it?
Investigators used the ACTION Registry- Get With
the Guidelines (GWTG_ to analyze 443,117 acute
MI patients from January 2007 to November 2013
to see what shape they and their risk factors were
in when the heart attack hit.
Among participants without prior CVD or
diabetes, only 14% were classified as high risk by
Framingham Risk Score. At presentation, 67% of
MI patients had LDL at goal, 67% had non-HDL at
goal, 64% were not current smokers, and 65% of
patients with prior CVD were on aspirin.
What gives? Well, while two-thirds of patients
looked good when analyzing individual risk factors,
overall risk factor control prior to MI was suboptimal: only 36% of patients met all four risk factor
control metrics. Remembering the guidelines in place
during the period studied (Adult Treatment Panel
III), overall statin eligibility prior to MI was 61% but
only 61% of statin-eligible patients were receiving
them. In contrast, in an exploratory analysis utilizing
the 2013 ACC/AHA guidelines, statin eligibility prior
to MI presentation was estimated to be 90%.
So, the investigators concluded that among patients
presenting with acute MI who did not have diabetes
or prior CVD, few would be classified as high risk and
many would not have met ATP III statin eligibility criteria prior to MI. These findings support both the need
for more liberal treatment thresholds as recommended
in the 2013 AHA/ACC guidelines as well as greater
adherence to existing prevention targets.
NCDR PINNACLE Registry®
Impact of New Guidelines
There are two sets of recent guidelines that were
the subject of new papers presented at AHA and
subsequently published in JACC.
Cholesterol
The potential impact of the 2013 cholesterol guidelines on current US cardiovascular practice is unknown. Because cardiologists typically treat patients
at the highest risk for cardiac events, optimizing cholesterol management based on these new guidelines
would be expected to make a big difference.
The new guidelines recommended a “treat to risk”
strategy using fixed-dose statins, rather than the previous ATP III “treat to LDL-C target” strategy. The new
document also does not recommend use of nonstatin
therapies nor, given the lack of targets, is there a need
for repeated on-treatment cholesterol testing.
Given such substantial changes, there is going to
be a need to quantify expected shifts in care and subsequent implications for statin use, nonstatin use, and
38 CardioSource WorldNews
LDL-C testing among risk groups. To get a baseline,
investigators analyzed data on a cohort of 1.2 million
patients (from 2008 to 2012), nearly all of whom
(96.1%) were statin-eligible (for 91.2%, their eligibility was based on their atherosclerotic cardiovascular
disease [ASCVD]).1 However, there were 377,311
patients (32.4%) not receiving statin therapy and a
little more than a quarter million (22.6%) receiving
nonstatin therapies. Of the study patients, 20.8% had
two or more LDL-C assessments during the study
period and 7.0% had more than four assessments.
The authors concluded that meeting the new
cholesterol guidelines in patients treated in US
cardiovascular practices would result in significant
increases in statin use, as well as significant reductions in nonstatin therapies and laboratory testing.
Impact of New Blood Pressure
Guidelines
The new blood pressure guidelines represent another
major shift in treatment. The primary difference
between the last Joint National Committee guidelines
(JNC7) and the 2014 panel recommendations was
the raising of some blood pressure treatment targets,
including revised targets of <150/90 mm Hg for patients age 60 years and older and <140/90 mm Hg for
those with diabetes and/or chronic kidney disease.
There has been concern expressed about the
public health impact of these less aggressive recommendations on efforts to prevent cardiovascular
disease. Thus, investigators used NCDR PINNACLE Registry data to assess 1.2 million patients,
706,859 (59.6%) of whom achieved the 2003 JNC7
goals.2 Using the 2014 recommendations, 880,378
(74.3%) patients were at goal. Among the 173,519
(14.6%) for whom goal achievement changed,
40,323 (23.2%) had a prior stroke or transient ischemic attack, and 112,174 (64.6%) had coronary
artery disease.
With the more permissive 2014 blood pressure targets, patients meeting the new goals had
significantly higher cardiovascular risk than those
meeting the 2003 guidelines. Specifically, the patients for whom the recommendations changed had
an average 10-year risk of myocardial infarction or
death of 8.5%, and, when stroke risk was included,
it rose to 28%.
The investigators noted that while the 2014
panel recommendations are based on randomizedcontrolled trial data, if these recommendations are
adopted by practitioners treating real-world populations of high-risk patients such as those in their
study, close monitoring will be necessary. Clinical
registries, for example, would help ensure that
improvements in cardiovascular event rates seen
in the last few decades, particularly stroke rates –
where an almost linear epidemiologic relationship
exists between blood pressure and stroke risk – do
not reverse course.
References:
1. Maddox TM, Borden WB, Tang F, et al. Implications of
the 2013 ACC/AHA Cholesterol Guidelines for Adults
in Contemporary Cardiovascular Practice: Insights
2.
From the NCDR PINNACLE Registry. J Am Coll Cardiol.
2014;64:2183-92.
Borden WB, Maddox TM, Tang F, et al. Impact of the
2014 Expert Panel Recommendations for Management
of High Blood Pressure on Contemporary Cardiovascular Practice: Insights From the NCDR PINNACLE
Registry. J Am Coll Cardiol. 2014;64:2196-203.
Co$t$ and Care
Rivaroxaban vs. Warfarin
Target-specific oral anticoagulants (e.g., rivaroxaban,
dabigatran, apixaban) have been approved for reducing the risk of stroke among patients with nonvalvular AF. They have the advantage of not requiring INR
monitoring compared to warfarin and there have
been indications that patients using these newer
agents have shorter hospital length of stays.
Laliberté et al. used insurance claims from the
Humana® database for May 2011 to December 2012
in order to do a cost analysis of rivaroxiban versus
warfarin. They used a retrospective matched-cohort
design to ensure that both cohorts were well balanced with each rivaroxaba n user matched 1:1 with
warfarin users based on propensity score.
Rivaroxaban use was associated with a significantly lower total number of hospitalization days (p
= 0.032) compared with warfarin plus significantly
fewer outpatient visits (p <0.001) and AF-related
hospitalizations (p = 0.022), but a higher number
of emergency room visits (p = 0.114). Despite
higher anticoagulant cost, overall total all-cause and
AF-related cost remained comparable due to cost
offset from less use of hospitalization ($5,411 vs.
$7,427; p = 0.0468).
Urban (Financial) Pain Centers
Big city hospitals have been severely penalized for
readmission of patients with MI, HF, or pneumonia. In 2013, 2,200 hospitals forfeited more than
$280 million in Medicare funds due to readmission
penalties stipulated by the Affordable Care Act.
“Major urban hospitals serving poorer, underemployed and under-educated patients are affected
the most by the penalties for readmission,” according to Arshad Javed, MD, chief author of the study
and chief medical resident at the John D. Dingell
V.A. Medical Center, Detroit, Michigan.
Researchers used census figures and other
indicators to evaluate the socioeconomic status of
the patient population in the large hospitals. Detroit
and Newark have the nation’s highest average readmission penalties. Chicago is one of eight Northern
cities with significantly higher readmission penalties compared to hospitals in the rest of the state.
Cuts in Medicare payments for safety net hospitals could lead to more reduced access to care,
said Dr. Javed. The researchers think readmission
penalties should be adjusted for the socioeconomic
status of the patient population. Hospital-to-home
initiatives may improve patient care and outcomes
more than a penalty system.
(For more on this topic, see our CardioSource
WorldNews cover story for August 2013 on why 30-day
readmission rates may be a lousy quality metric.) ■
December 2014