Publications

OBJECTIVE: Chronic limb threatening ischaemia (CLTI) requires timely and comprehensive management to improve limb salvage and survival rates. Socioeconomic disparities, including individual wealth, are critical determinants of healthcare access and outcomes.

METHODS: In this study, 333 173 Medicare beneficiaries who underwent CLTI revascularisation from 2016 - 2023 were analysed. Patients were stratified by dual enrolment in Medicaid, a marker of socioeconomic disadvantage, and outcomes were assessed using Kaplan-Meier methods and multivariable Cox proportional hazards models. The primary endpoint was a composite of major amputation or death. The study period was divided into pre-COVID-19 (January 2016 - March 2020), during COVID-19 (March 2020 - December 2021), and post-COVID-19 (December 2021 - December 2023) phases to evaluate pandemic related impacts on outcomes. Healthcare utilisation was compared between groups.

RESULTS: Among 333 173 Medicare beneficiaries who underwent endovascular revascularisation for CLTI, 26.2% were dual eligible (DE) patients. DE patients were younger, more often female, and had a higher burden of comorbidities compared with Medicare only beneficiaries. The crude cumulative incidence of the primary composite outcome was 80.1% for DE patients and 79.7% for Medicare only beneficiaries (unadjusted hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.06 - 1.08; p < .001), but this difference was not statistically significant after adjustment (adjusted HR 1.00, 95% CI 0.99 - 1.01; p = .98). DE patients experienced higher rates of major amputation (17.8% vs. 12.7%; adjusted HR 1.10, 95% CI 1.07 - 1.12; p < .001), but no statistically significant differences in adjusted rates of repeat revascularisation (adjusted HR 1.00, 95% CI 0.99 - 1.01; p = .99) or all cause mortality (adjusted HR 0.99, 95% CI 0.98 - 1.00; p = .067). During the COVID-19 period, the adjusted HR for the primary outcome was statistically significantly elevated among DE vs. non-DE patients (adjusted HR 1.05, 95% CI 1.02 - 1.08; p < .001), while risks were similar pre-COVID (adjusted HR 1.00, 95% CI 0.98 - 1.02; p = .88) and post-COVID (adjusted HR 1.01, 95% CI 0.97 - 1.04; p = .67).

CONCLUSION: DE patients represent a socioeconomically disadvantaged group with higher baseline comorbidity burdens and slightly higher unadjusted risks of adverse outcomes.

BACKGROUND: The dissemination of novel procedures should attempt to strike a balance between access and procedure quality. This study aimed to evaluate the temporal trends and geographic dispersion of mitral transcatheter edge-to-edge repair (M-TEER) sites and to examine the associations of site volume and site-to-population density with patient outcomes.

METHODS: We used the Medicare administrative databases in the United States to identify sites performing M-TEER in patients aged 65 to 99 years from 2017 to 2020 and examined the annualized volume and site-to-population density (per million beneficiaries in each corresponding hospital referral region). A hierarchical Cox regression analysis accounting for site-level clustering was performed to assess the association of site volume and density with 30-day and 1-year all-cause mortality.

RESULTS: We identified 456 sites performing M-TEER in 16 810 patients (median [interquartile range] age, 81 [75-86] years; female, 47%). The case number of M-TEER increased by 54% from 3125 in 2017 to 4820 in 2020, while sites performing M-TEER increased by 71% from 252 in 2017 to 432 in 2020, corresponding to a decline in the median patient-to-site distances from 37.1 kilometers (interquartile range, 14.4-105.0) to 28.6 kilometers (interquartile range, 12.8-74.9). Higher site volume (every 10 cases/y) was associated with lower 30-day (adjusted hazard ratio, 0.94 [95% CI, 0.91-0.99]) and 1 year (adjusted hazard ratio, 0.98 [95% CI, 0.96-1.00]) mortality, while there was insufficient evidence to determine the association between higher site density (every 1 site/million-beneficiaries) and 30-day (adjusted hazard ratio, 1.00 [95% CI, 0.99-1.02]) and 1-year (adjusted hazard ratio, 1.00 [95% CI, 0.99-1.01]) mortality.

CONCLUSIONS: Although sites performing M-TEER have been rapidly expanding, we did not find associations between higher regional site density and patient mortality. Continuous careful planning in disseminating M-TEER while ensuring adequate procedure volume per site may optimize patient outcomes.

BACKGROUND: Cardiovascular disease (CVD) and cancer share multiple risk factors and are the leading causes of morbidity and death worldwide. This study aims to examine historical and projected trends of the combined CVD-cancer global estimates and their shared risk factors.

METHODS: Death and disability-adjusted life years (DALYs) associated with CVDs, cancers, and their risk factors were obtained from the GBD (Global Burden of Disease) 2021 study. Historical estimates from 1990 to 2021 and forecast data from 2025 to 2050 were examined across age groups, regions, sociodemographic index, and sex.

RESULTS: In 2021, CVD-cancer resulted in age-standardized DALY rates of 8009 per 100 000 population (63% contributed by CVD) and age-standardized mortality rates of 352 per 100 000 population (67% by CVD) globally. While age-standardized DALYs of the CVD-cancer burden declined by 30% (33% in CVD and 26% in cancer), crude DALYs increased by 46% from 1990 to 2021. CVD-cancer resulted in higher age-standardized DALY rates in men (9654 per 100 000 population) than women (6556 per 100 000 population). While low-middle sociodemographic index regions had the highest CVD-related age-standardized DALY rates (6744 per 100 000 population), high-middle sociodemographic index regions had the highest cancer-related rates (3388 per 100 000) in 2021. The top risk factors driving CVD-cancer morbidity burden in 2021 were high systolic blood pressure (largely CVD contribution), dietary risks (89% by CVD), and tobacco (60% by CVD), persisting to 2050.

CONCLUSIONS: Global improvements in CVD-cancer age-standardized morbidity will be offset by the ever-rising crude CVD-cancer morbidity burden. Preventive efforts should prioritize key shared risk factors of hypertension, dietary risks, and tobacco.

BACKGROUND: Lower-extremity peripheral vascular interventions (PVIs) are increasingly used for treatment of peripheral artery disease. However, the relationship between hospital and operator PVI volume with in-hospital major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) is not well established.

METHODS: We used the NCDR PVI (National Cardiovascular Data Registry) registry, including procedural data from April 1, 2014, to December 31, 2019, assessing in-hospital MALEs and MACEs during hospitalization for PVI. Annualized PVI volumes were categorized on the basis of operator or site volume. Generalized linear mixed models assessed volume-outcome relationships after adjustment of covariates.

RESULTS: Between 2014 and 2019, 55 785 PVI procedures were performed at 97 hospitals by 555 operators. Adjusted analysis showed no statistically significant association between hospital volume and MALEs (highest versus lowest volume: odds ratio, 0.91 [95% CI, 0.74-1.11]; P=0.35) or hospital volume and MACEs (highest versus lowest volume: odds ratio, 1.23 [95% CI, 0.95-1.16]; P=0.12). Notably, undergoing PVI with high-volume operators was associated with lower odds of in-hospital MALEs (odds ratio, 0.73 [95% CI, 0.55-0.97]; P=0.03) and MACEs (odds ratio, 0.64 [95% CI, 0.44-0.95]; P=0.03). Female sex and comorbidities including dyslipidemia, prior percutaneous coronary intervention, heart failure, and acute or chronic limb ischemia were associated with higher MALE risk. Older age and comorbidities including hypertension, dyslipidemia, end-stage renal disease requiring dialysis, severe lung disease, prior myocardial infarction, heart failure, and acute limb ischemia were associated with greater MACE risk.

CONCLUSIONS: In contemporary practice, a significant relationship was observed between operator volume and adjusted PVI outcomes. Highest-volume operators had lower rates of in-hospital MALEs and MACEs compared with lowest-volume operators.

BACKGROUND: It remains unclear whether drug-coated balloons (DCBs) and drug-eluting stents are comparable in the treatment of coronary artery disease (CAD) and whether limus versus paclitaxel DCBs yield similar clinical outcomes. We aimed to assess the clinical efficacy of limus and paclitaxel DCBs in patients with CAD through a network meta-analysis.

METHODS: We comprehensively searched multiple databases for randomized controlled trials comparing the following 4 strategies: limus DCB, paclitaxel DCB, second-generation or newer drug-eluting stent, and plain old balloon angioplasty. The primary outcome was trial-defined major adverse cardiovascular events (MACEs), typically a composite of death, myocardial infarction, and target lesion revascularization. Secondary outcomes included individual components of MACE. We performed subgroup analyses for in-stent restenosis, small-vessel (<3 mm) CAD, and other de novo CAD, such as large vessel and ST-segment-elevation myocardial infarction.

RESULTS: We identified 39 randomized controlled trials including 10 219 patients. There was no significant difference in MACE between limus and paclitaxel DCBs (relative risk, 1.22 [95% CI, 0.86-1.73]). There were no significant differences in MACE between limus or paclitaxel DCB and second-generation or newer drug-eluting stents. Plain old balloon angioplasty had an increased risk of MACE compared with others. These results were consistent across subgroup analyses for in-stent restenosis, small-vessel CAD, and other de novo CAD.

CONCLUSIONS: No significant differences were observed in MACE or its components between limus and paclitaxel DCBs, albeit with limited statistical power. Furthermore, DCB and second-generation or newer drug-eluting stents yielded similar outcomes though power was limited, especially for other de novo CAD.

REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD420250654276.

Cardiac implantable electronic devices (CIEDs) have increased the quality and duration of life for millions of patients. As their utilization continues to grow exponentially, clinicians need to diagnose and manage several device-associated complications that may arise during the CIED life cycle. This primer is tailored for the general internal medicine physician or hospitalist, who will inevitably take care of patients with CIEDs, to provide a contemporary update on the incidence and clinical manifestations of the 4 most common CIED complications, with the latest evidence to guide clinical management and expected outcomes. Specifically, this review focuses on: 1) generator/lead failure, which has decreased to less than 1% per year due to continuous advances in manufacturing and programming and is mostly managed conservatively with close monitoring; 2) CIED infections, which, while also rare at approximately 1% per year, carry a short-term mortality of 10% to 20%, thus requiring immediate diagnosis and often urgent treatment with lead extraction because antibiotic treatment is rarely effective; and 3) lead-related venous obstruction, which has highly variable incidence (5% to 30%) and manifestations, ranging from arm swelling to superior vena cava syndrome. Management options range from anticoagulation to balloon venoplasty, often with unsatisfying results. This review will also focus on 4) lead-related tricuspid regurgitation, which affects 20% to 30% of CIEDs and has become an area of intense interest with the development of percutaneous tricuspid treatments-where evidence is urgently needed to inform the need for lead extraction versus jailing during tricuspid interventions. The progressive adoption of leadless devices may significantly reduce many of these complications. Nonetheless, optimal management requires input from a multidisciplinary team of electrophysiologists and imaging, heart failure, and structural interventional specialists-who should be able to recognize and treat each complication promptly based on a rapidly evolving evidence base.

BACKGROUND: Chronic limb-threatening ischemia (CLTI) disproportionately affects racial minority populations, with Black patients experiencing higher amputation rates and reduced access to vascular care. Recent national campaigns have aimed to improve early screening and diagnosis of peripheral arterial disease (PAD), but it is unclear whether these efforts have improved outcomes.

OBJECTIVES: To assess temporal trends in treatment, outcomes, and healthcare utilization for Black versus White Medicare beneficiaries with CLTI undergoing endovascular revascularization.

METHODS: We conducted a retrospective cohort study using Medicare claims data for beneficiaries aged ≥66 years who underwent endovascular revascularization for CLTI from January 2016 to December 2023. The primary outcome was a composite of major amputation or death over 4 years, evaluated using Cox models. Healthcare utilization was assessed via adjusted rate ratios (aRRs) for vascular provider visits, emergency department use, and hospital admissions.

RESULTS: Among 303,906 patients, 17.2% (N=52,376) identified as Black. Black patients were younger, had more comorbidities, and more often presented with gangrene. They more frequently underwent angioplasty alone and less frequently received stents. Over a median 1.7 years of follow-up, Black patients had higher risk of major amputation (HR 1.49; 95% CI, 1.45-1.53) and lower mortality (HR 0.91; 95% CI, 0.90-0.93). They had fewer vascular visits before (aRR 0.91) and after (aRR 0.92) revascularization, but more ED visits (aRR 1.09) and hospital readmissions (aRR 1.28).

CONCLUSIONS: Despite national initiatives, Black patients with CLTI continue to face higher amputation risk and reduced access to longitudinal vascular care, underscoring the need for sustained, equity-focused interventions.

BACKGROUND: In recent years, there has been increasing utilization of catheter-based interventions (CBI) for the treatment of acute pulmonary embolism (PE). We aimed to investigate the trends and practice patterns associated with the utilization of CBI among older patients hospitalized with a PE in US hospitals.

METHODS: All Medicare fee-for-service beneficiaries hospitalized with a PE from June 1, 2018, to September 30, 2023, were identified. For outcomes analysis, a subset of patients hospitalized between June 1, 2018, and December 31, 2021, was identified to allow for follow-up to occur.

RESULTS: In total, 313,522 patients were hospitalized with a concomitant PE; of which, 9.12% (n = 28,597) underwent a CBI (4.76% [n = 14,914] catheter-directed thrombolysis and 4.76% [n = 14,918] mechanical thrombectomy). Utilization of CBI increased over time from 5.92% in 2018 to 14.1% in 2023, attributed to increases in mechanical thrombectomy. CBI was used more frequently at teaching hospitals (adjusted OR, 1.10; 95% CI, 1.04-1.15) and in male patients (adjusted OR, 1.15; 95% CI, 1.10-1.21), while less frequently at smaller institutions (adjusted OR, 0.14; 95% CI, 0.09-0.22) and in patients with Black race (adjusted OR, 0.90; 95% CI, 0.85-0.95) or dual enrollment (adjusted OR, 0.80; 95% CI, 0.76-0.86). Older age, Black race, geographic region, and distressed communities were associated with higher rates of death or periprocedural complications.

CONCLUSIONS: In this contemporary nationwide analysis of hospitalized patients with PE, we found that rates of CBI increased over time, although uptake of CBI remains heterogeneous. Our findings suggest that there are differences in access to advanced therapies and outcomes among particular populations following CBI for PE management.