Publications by Year: 2026

BACKGROUND: The real-world uptake of the 2021 Kidney Disease: Improving Global Outcomes (KDIGO) blood pressure (BP) guideline, which lowered the systolic BP target to <120 mmHg for patients with chronic kidney disease (CKD), is poorly understood. We examined the adoption of the 2021 KDIGO systolic BP target in clinical practice and its association with clinical outcomes.

METHODS: The study was based on data from the Mass General Brigham healthcare network, an integrated healthcare system spanning primary to tertiary care in New England. In serial cross-sectional analysis, we identified ∼50 000 patients with CKD stage 3-4 in each year from 2020 to 2024 and assessed the annual proportion of patients within the 2021 KDIGO systolic BP target. In longitudinal analysis, we identified 18 996 patients with incident CKD stage 3-4 in 2014-2019 and evaluated the association between systolic BP above vs. within the target and clinical outcomes.

RESULTS: In serial cross-sectional analysis, 18.3% of patients with CKD had systolic BP within the 2021 KDIGO target in 2020 (pre-guideline). The proportion changed only marginally after the guideline's publication-18.0% in 2021 (absolute difference, -0.3% [95% CI, -1.2 to 1.3]), 19.3% in 2022 (absolute difference, 1.0% [95% CI, -0.1 to 2.0]), 20.0% in 2023 (absolute difference, 1.7% [95% CI, 0.2 to 3.1]), and 21.9% in 2024 (absolute difference, 3.6% [95% CI, 1.9 to 5.3]). In longitudinal analysis, patients with systolic BP above the 2021 KDIGO target exhibited higher risks of cardio-kidney end points, lower risk of hypotension, and no differences in other safety end points compared to those within the target.

CONCLUSIONS: Adoption of the 2021 KDIGO BP guideline remained limited in real-world practice. As of 2024, nearly 4 in 5 patients with CKD had systolic BP above the new guideline target.

BACKGROUND: Catheter-based interventions for acute pulmonary embolism (PE) have transformed the therapeutic landscape over the past decade despite a lack of high-quality, randomized data demonstrating clinical benefit. In addition, multicenter data describing their real-world diffusion, patient selection, and outcomes remain limited.

OBJECTIVES: This study sought to characterize national trends, patient and imaging characteristics, and institutional variation in the use of catheter-directed thrombolysis (CDT) and mechanical thrombectomy (MT) across the Pulmonary Embolism Response Team (PERT) Consortium Registry from 2016 to 2024.

METHODS: The authors analyzed 2,958 patients with intermediate- or high-risk PE treated with advanced therapies from 48 U.S. institutions in the prospective PERT registry. Temporal trends in use of systemic thrombolysis, CDT, and MT were evaluated using mixed-effects Poisson models; factors associated with MT vs CDT were identified using mixed-effects logistic regression with site-level random intercepts. Patients were stratified by the European Society of Cardiology 2019 risk categories. The Composite Pulmonary Embolism Score (CPES) was used to further assess patient acuity.

RESULTS: Of the 2,958 patients who received advanced therapies, 75.9% had intermediate-risk PE and 24.1% high-risk PE. The use of MT increased by 18% per year (incident rate ratio [IRR]: 1.18; 95% CI: 1.14-1.23), surpassing CDT use by 2021, whereas the use of CDT and systemic thrombolysis declined by 13% and 12% per year, respectively. MT was independently associated with older age (≥70 years; OR: 1.37; 95% CI: 1.04-1.81), male sex (OR: 1.54; 95% CI: 1.19-1.99), vasopressor use, extracorporeal membrane oxygenation support, and saddle embolus or clot in transit, whereas CDT was more often used in younger female patients and in the presence of cardiorespiratory symptoms. The proportion of high-risk patients treated increased as did the mean CPES over the study period, reflecting treatment of progressively higher-acuity patients with catheter-based intervention.

CONCLUSIONS: Over the past decade, MT has rapidly replaced CDT as predominant catheter-based therapy for acute PE, reflecting both technological innovation and evolving operator confidence. The PERT registry captures this diffusion of innovation across institutions and patient profiles, revealing a shift toward treating sicker patients and greater procedural integration across specialties. These findings highlight the need for randomized evidence to define optimal patient selection and comparative outcomes across device classes.

BACKGROUND: Endovascular therapy is a cornerstone for chronic limb-threatening ischaemia (CLTI), yet the optimal device strategy remains uncertain.

AIMS: Our objective was to compare the clinical and economic outcomes between plain balloon angioplasty±bare metal stents (PBA±BMS), drug-coated balloons (DCBs)±BMS, and drug-eluting stents (DES) in a national real-world CLTI cohort.

METHODS: Medicare beneficiaries aged ≥66 years who underwent femoropopliteal revascularisation for CLTI between 2016 and 2023 were included. Patients were grouped by index device. Outcomes included a composite of all-cause mortality or major amputation, as well as major adverse limb events (MALE) and reintervention. Patients were followed from the index procedure until death, loss to follow-up, or the end of the study period. Time-to-event and cost outcomes were analysed using multivariable Cox and gamma regression models, respectively.

RESULTS: Among 108,304 CLTI patients, 52.5% received PBA±BMS, 30.7% DCBs, and 16.8% DES. At 2 years, the composite outcome occurred in 50.54% (PBA±BMS), 43.08% (DCB±BMS), and 43.71% (DES); at 5 years, it occurred in 75.69%, 71.19%, and 71.71%, respectively. Compared with PBA±BMS, DCB±BMS (hazard ratio [HR] 0.92, 95% confidence interval [CI]: 0.90-0.93) and DES (HR 0.93, 95% CI: 0.92-0.95) were associated with a lower risk of the composite outcome. DCBs were associated with reduced major amputation (HR 0.87, 95% CI: 0.84-0.91), mortality (HR 0.93, 95% CI: 0.91-0.94), MALE (HR 0.96, 95% CI: 0.94-0.98), and reintervention (HR 0.97, 95% CI: 0.96-0.99) compared with PBA±BMS. The proportion of BMS use was 10.1% in the PBA±BMS group and 3.1% in the DCB±BMS group.

CONCLUSIONS: In this national CLTI cohort, drug-coated devices were associated with reduced amputation and mortality. Data from this study suggest that DCBs may offer consistent benefit without increased costs.

BACKGROUND: Despite improving abdominal aortic aneurysm (AAA) outcomes in the United States, significant disparities exist. Smaller studies found that women experienced worse outcomes after endovascular aortic aneurysm repair (EVAR), yet few larger analyses have confirmed this. This study aimed to characterize sex-related differences in outcomes among patients who underwent infrarenal EVAR.

METHODS: Medicare fee-for-service beneficiaries ⩾ 66 years old who underwent infrarenal EVAR for intact AAA between January 1, 2011 and December 31, 2019 were included in this retrospective cohort study. The primary outcome was a composite of late aneurysm rupture, aortic reintervention, conversion to open repair, or all-cause mortality. Cox regression and Fine-Gray models were used.

RESULTS: Among 111,381 patients, the mean age was 76.63 ± 6.60 years, 92.88% were White, and 21.19% were women. The maximum follow-up was 3283 days. The hazard of the primary outcome was higher in women in the adjusted model (p = 0.013). When mortality was excluded, the association with sex persisted (p < 0.0010 [adjusted subdistribution model]; p < 0.0010 [adjusted cause-specific model]). Women experienced a lower frequency of postprocedural office visits, but a higher frequency of emergency department visits and hospital readmissions.

CONCLUSION: Women undergoing EVAR had a greater risk of adverse outcomes and unexpected healthcare utilization. Further investigation is warranted to determine the drivers of these outcomes.

BACKGROUND: Resistant hypertension is associated with adverse cardiovascular outcomes and mortality. In the past decade, management guidelines have shifted to target lower blood pressures (BP). Current prevalence and prescribing patterns among adults with resistant hypertension are not well characterized.

METHODS: We used data from the National Health and Nutrition Examination Survey from 2003 to 2020. Apparent treatment-resistant hypertension (aTRH) was defined as patients on a diuretic, either with a systolic BP ≥130 or diastolic BP ≥80 mm Hg while on 3 medications or those on ≥4 medications regardless of BP. Medications were identified through pill bottle review.

RESULTS: Of 24 579 adults with hypertension, 1939 had aTRH (42.4% male, 19.9% Black), corresponding to a weighted total of 6 989 821 US patients. Among hypertensive adults, the prevalence of aTRH was 6.41% (95% CI, 5.97%-6.88%) and remained stable over time. Over the study duration, aTRH prevalence among adults on treatment decreased from 17.7% to 12.6%. The overall prevalence of hypertension rose from 50.1% to 54.0%, while the prevalence of uncontrolled BP decreased from 75.0% to 68.7%. Over time, use of 3 drug regimens for aTRH decreased (57.8%-42.9%), while 4 drug regimens increased (34.0%-51.8%). aTRH was most strongly associated with older patients, those of Black race, higher body mass index, and more advanced cardiovascular comorbidities.

CONCLUSION: The prevalence of aTRH has remained stable over the past 2 decades despite the rising incidence of hypertension. Use of multidrug treatment regimens has increased, aligning with national guidelines. However, uncontrolled hypertension remains high.

Background: Angiography-derived fractional flow reserve (Angio-FFR) is an emerging tool for guiding percutaneous coronary intervention (PCI). Its uptake and outcomes compared to pressure wire (PW)-based assessment in the US are unknown. Methods: We conducted a cohort study of US Medicare beneficiary data from 1 January 2019 to 31 December 2024. Propensity score matching (1:3) of Angio-FFR to PW was performed in patients who underwent PCI during the same procedure, and separately among those who did not undergo PCI during the same procedure. The primary outcome was the cumulative incidence of major adverse cardiovascular events (MACE) through 2 years, including all-cause death, myocardial infarction (MI) and repeat revascularization. Secondary outcomes included individual MACE components, 30-day acute kidney injury and 30-day major bleeding. Falsification endpoints (hospitalization for pneumonia and hip fracture) were used to assess unmeasured confounding. Results: Of 466,535 angiograms that included intra-procedural physiologic assessment, 1.00% (N=4,672) used Angio-FFR. Annual use increased from 0.47% in 2019 to 3.85% in 2024. Among PCI patients, 1,591 Angio-FFR and 4,773 PW matched PCI patients had similar MACE rates through 2 years (24.8% vs 23.5%; HR 1.01, 95% CI 0.85 - 1.20). Secondary outcomes and falsification endpoints were not significantly different. In non-PCI patients, 2,532 Angio-FFR and 7,596 PW matched patients also had similar MACE through 2 years (24.1% vs 23.9%; HR 0.97, 95% CI 0.84 - 1.11). Conclusions: Angio-FFR usage in the US is modest but increasing. Angio-FFR guidance during angiography versus PW was associated with comparable outcomes through 2 years.

Rule-based natural language processing (NLP) tools can identify pulmonary embolism (PE) via radiology reports. However, their external validity remains uncertain.In this cross-sectional study, 1,712 hospitalized patients (with and without PE) at Mass General Brigham (MGB) hospitals (2016-2021) were analyzed. Two previously published NLP algorithms were applied to radiology reports to identify PE. Chart review by two physicians was the reference standard. We tested three approaches: (A) NLP applied to all patients; (B) NLP limited to radiology reports of patients with principal or secondary International Classification of Diseases 10th revision (ICD-10) PE discharge codes; and (C) NLP applied to patients with PE discharge codes or a Present-on-Admission (POA) indicator ("Y") for PE. All others were assumed PE-negative in Approaches B and C to minimize NLP false positives. Weighted estimates were derived from the MGB hospitalized cohort (n = 381,642) to calculate F1 scores (as the harmonic mean of sensitivity and positive predictive value [PPV]).In Approach A, both NLP tools showed high sensitivity (82.5%, 93.0%) and specificity (98.9%, 98.7%) but low PPV (60.3%, 59.6%). Approach B improved PPV (95.2%, 94.9%) but reduced sensitivity (74.1%, 76.2%), while Approach C preserved both high sensitivity (82.5%, 93.0%) and PPV (95.6%, 95.8%). Approach C demonstrated the best performance, yielding significantly higher F1 scores for both NLP tools (88.6%, 94.4%) compared with Approach A (69.7%, 72.6%) and Approach B (83.3%, 84.5%) (P < 0.001).The accuracy of PE detection improves when rule-based NLP algorithms are operationalized using administrative claims data in addition to radiology reports.

BACKGROUND: Suboptimal blood pressure (BP) control remains a major cardiovascular disease risk factor. Whether genetically predicted BP independently predicts long-term BP control is unknown. We examined the associations of BP polygenic scores (PGSs) with long-term BP control and treatment-resistant hypertension.

METHODS: We identified 22 456 Mass General Brigham Biobank participants with hypertension. Longitudinal BP control was defined as the percentage of time above-target systolic BP (SBP) ≥130 mm Hg or diastolic BP (DBP) ≥80 mm Hg over 5 years. Using multivariable regression, we assessed the associations of BP PGS with duration above-target BP and lifetime treatment-resistant hypertension incidence. Incremental prognostic utility of BP PGSs was assessed based on the discrimination C-index, Brier score, and net reclassification index. Validation was performed in the population-based UK Biobank cohort using the SBP/DBP ≥140/90 mm Hg threshold.

RESULTS: Among 10 853 (48.3%) were female, the mean SBP/DBP (SD) at index date was 132 (18)/75 (11) mm Hg, and 4126 (18.4%) developed treatment-resistant hypertension over lifetime. In reference to the low (<20th percentile) PGS group, the high (≥80th percentile) BP PGS was associated with 8.01 (95% CI, 6.68%-9.34%) longer duration with above-target SBP and 6.19 (95% CI, 5.05%-7.33%) with high DBP. Each high SBP and DBP PGS conferred 2.36 (95% CI, 2.07-2.68) and 1.75 (95% CI, 1.55-1.99)-fold higher odds of treatment-resistant hypertension. Adding BP PGSs to traditional risk factors improved treatment-resistant hypertension prediction from C-index (95% CI), 0.74 (0.73-0.75) to 0.78 (0.77-0.79). BP PGSs consistently predicted longitudinal BP management to a comparable extent in the UK Biobank.

CONCLUSIONS: Harnessing BP PGSs may inform anticipated trends in BP control to warrant vigilant monitoring and augment prioritization of intensive therapy.

Atherosclerotic renal artery stenosis (RAS) affects nearly 7% of adults over age 65 and is associated with increased cardiovascular and renal morbidity. Although early observational studies suggested benefit from renal artery stenting, subsequent randomized trials failed to show improvement in major clinical endpoints, contributing to substantial declines in procedural use. To characterize contemporary practice, we conducted a retrospective cohort study of Medicare beneficiaries older than 65 years who underwent renal artery stenting for atherosclerotic RAS between 2016 and 2020. Using Medicare claims data, we evaluated baseline characteristics, temporal utilization, and postprocedural outcomes, stratified by race, geographic region, and dual Medicare-Medicaid enrollment status. Among 19,130 patients, the mean age was 76.0 years (±6.4), 59.2% were female, and 90.3% were White; 84.2% had chronic kidney disease and 48.7% had heart failure. Procedural rates declined by 41.1% over the study period. Compared with White patients, Black patients had higher adjusted risks of hypertensive crisis hospitalization (aHR 1.45, 95% CI, 1.24-1.70) and dialysis initiation (aHR 1.78, 95% CI, 1.39-2.27); patients of Other races also had greater risk of dialysis initiation (aHR 1.98, 95% CI, 1.50-2.63). Patients in the South experienced higher unadjusted cardiovascular event rates (50.0%) but similar adjusted mortality compared with those in the Northeast (aHR 1.09, 95% CI, 0.98-1.21). Dual enrollment was associated with increased all-cause mortality (aHR 1.31, 95% CI, 1.20-1.43). In conclusion, renal artery stenting rates continued to decline in recent years, and contemporary recipients constitute an older, comorbid population with substantial cardiovascular risk. Outcomes differed markedly by race, socioeconomic status, and geography, highlighting the need for improved risk stratification and prospective evaluation of stenting in high-risk cohorts.