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Obstructive sleep apnea (OSA) is common in patients with atrial fibrillation (AF). Little is known about the impact of OSA on AF treatment and long-term outcomes. We studied whether patients with OSA have a greater likelihood of progressing to more persistent forms of AF or require more hospitalizations and/or worse outcomes compared with patients without OSA. A total of 10,132 patients were enrolled between June 2010 and August 2011 in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) and followed for up to 2 years. The prevalence of OSA and continuous positive airway pressure (CPAP) treatment was captured at baseline. The association between OSA and major cardiovascular outcomes was analyzed using multivariable hierarchical logistic regression modeling and Cox frailty regression model. Of the 10,132 patients with AF, 1,841 had OSA. Patients with OSA were more symptomatic (22% vs 16% severe/disabling symptoms; P < .0001) and more often on rhythm control therapy (35% vs 31%; P = .0037). In adjusted analyses, patients with OSA had higher risk of hospitalization (hazard ratio [HR], 1.12; 95% CI, 1.03-1.22; P = .0078), but no difference in the risks of death (HR, 0.94; 95% CI, 0.77-1.15; P = .54); the composite of CV death, myocardial infarction, and stroke/transient ischemic attack (HR, 1.07; 95% CI, 0.85-1.34; P = .57); major bleeding (HR, 1.18; 95% CI, 0.96-1.46; P = .11); or AF progression (HR, 1.06; 95% CI, 0.89-1.28; P = .51). Patients with OSA on CPAP treatment were less likely to progress to more permanent forms of AF compared with patients without CPAP (HR, 0.66; 95% CI, 0.46-0.94; P = .021). Compared with those without, AF patients with OSA have worse symptoms and higher risks of hospitalization, but similar mortality, major adverse cardiovascular outcome, and AF progression rates. Clinical Trial Registration: NCT01165710 (http://www.clinicaltrials.gov).

No consensus exists for heart transplant listing for patients who use cannabis. We conducted a web-based survey to assess knowledge, and practice patterns towards patients with heart failure who use cannabis referred for transplant. A total of 140 clinicians (cardiologists (41.4%, n = 58), surgeons (7.1%, n = 10), pharmacists (9.3%, n = 13), advanced practice providers and coordinators) responded and responses were grouped by whether they responded that cannabis is “illegal in my state” (illegal), or “legal for medical and recreational use in my state,” (legal). There was a statistically significant difference in responses between the groups in the frequency of cannabis use that should preclude a patient from HT listing p = 0.0330) with respondents where cannabis is legal tending to answer that higher frequencies were acceptable. The groups in the “legal group” responded that a validated cannabis screening questionnaire could evaluate HT eligibility (p = 0.0111). A majority in the illegal group responding “No” as to whether their program allows pre- or post-transplant patients to use prescribed cannabis products (p < 0.0001). A majority in the illegal group responding “No” while the majority in the legal group responded “Yes” to “Does your HT center’s current selection criteria policy address medical cannabis use in potential transplant candidates?” (p = 0.0001). Health care providers generally agreed that a validated cannabis use disorder screening questionnaire would be useful and that 6 months of abstinence from cannabis is sufficient prior to HT listing. Significant heterogeneity exists regarding cannabis use as it relates to heart transplantation.

Background Terror management theory (TMT) posits that people manage death-related anxiety through the meaning provided by their cultural world-views and the sense of personal value provided by self-esteem. While a large body of research has supported the core propositions of TMT, little research has focused on its application to individuals with terminal illness. If TMT can help healthcare providers better understand how belief systems adapt and change in life-threatening illness, and the role they play in managing death-related anxiety, it may provide guidance on how to improve communication around treatments near the end of life. As such, we set out to review the available research articles that focus on describing the relationship between TMT and life-threatening illness. Methods We reviewed PubMed, PsycINFO, Google Scholar, and EMBASE through May 2022 for original research articles focused on TMT and life-threatening illness. Articles were only deemed appropriate for inclusion if direct incorporation of the principles of TMT were made in reference to a population of interest whom had life-threatening illness Results were screened by title and abstract, followed by full review of candidate articles. References were also scanned. Articles were assessed qualitatively. Results Six relevant and original research articles were published which provide varied levels of support for TMT’s application in critical illness, each article detailed evidence of ideological changes consistent with what TMT would predict. Building self-esteem, enhancing the experience of life as meaningful, incorporating spirituality, engaging family members, and caring for patients at home where meaning and self-esteem can be better maintained are strategies supported by the studies and serve as starting points for further research. Conclusion These articles suggest that applying TMT to life-threatening illness can help identify psychological changes that may effectively minimize the distress from dying. Limitations of this study include a heterogenous group of relevant studies and qualitative assessment.

Warfarin reduces thromboembolic risks in atrial fibrillation (AF), but therapeutic durability remains a concern. We used clinical data from ORBIT-AF, a nationwide outpatient AF registry conducted at 176 sites with follow-up data at 6 and 12 months, to examine longitudinal patterns of warfarin discontinuation. We estimated associations between patient and provider characteristics and report of any warfarin discontinuation using discrete time proportional odds models. Of 10,132 AF patients enrolled in ORBIT-AF from June 2010 to August 2011, 6,110 (60.3%) were prescribed warfarin, had follow-up data, and were not switched to an alternative oral anticoagulant enrolled from June 2010 to August 2011. Over 1 year, 617 patients (10.1% of baseline warfarin users) discontinued warfarin therapy. Among incident warfarin users (starting therapy within 1 year of baseline survey), warfarin discontinuation rates rose to 17.1%. The most commonly reported reasons for warfarin discontinuation were physician preference (47.7%), patient refusal/preference (21.1%), bleeding event (20.2%), frequent falls/frailty (10.8%), high bleeding risk (9.8%), and patient inability to adhere to/monitor therapy (4.7%). In multivariable analysis, the factors most strongly associated with warfarin discontinuation were bleeding hospitalization during follow-up (odds ratio 10.91, 95% CI 7.91-15.03), prior catheter ablation (1.83, 1.37-2.45), noncardiovascular/nonbleeding hospitalization (1.77, 1.40-2.24), cardiovascular hospitalization (1.64, 1.33-2.03), and permanent AF (0.25, 0.17-0.36). Discontinuation of warfarin is common among patients with AF, particularly among incident users. Warfarin is most commonly discontinued because of physician preference, patient refusal, and bleeding events.

We conducted this secondary analysis to assess whether greater engagement with a text messaging intervention was associated with improved cardiovascular medication adherence at 12 months. International Registered Report Identifier (IRRID) RR2-10.1186/s13063-021-05453-9

Women are less likely to receive left ventricular assist devices and are more likely to experience poor outcomes. However, how gender impacts LVAD decision-making regarding LVAD implantation and the effects of that decision remains unknown.BACKGROUNDWomen are less likely to receive left ventricular assist devices and are more likely to experience poor outcomes. However, how gender impacts LVAD decision-making regarding LVAD implantation and the effects of that decision remains unknown.We performed a sub-group analysis from the stepped-wedge DECIDE-LVAD trial, which tested a decision-support intervention for patients considering LVAD therapy.METHODSWe performed a sub-group analysis from the stepped-wedge DECIDE-LVAD trial, which tested a decision-support intervention for patients considering LVAD therapy.Excluding 9 patients who withdrew from assessments, of the 239 patients analyzed, 203 (85%) were men and 36 (15%) were women. More men received LVADs (70%) than women (61%) and more men were alive at 6 months compared to women, both among those who received LVADs (87% vs 82%) and those who did not (74% vs 50%) (p = 0.002). Compared to men, women were more likely to have decision regret, depressive symptoms and perceived stress at baseline but not at follow-up. At 6-month follow-up, men experience improvements in decisional conflict, acceptance of illness, struggle with illness, and perceived stress-none of those improvements were noted amongst women. Compared to men who received LVADs, women receiving LVADs had worse decision regret and depressive symptoms at baseline and worse acceptance of illness and perceived stress at six months. Men who received LVADs experienced improvement in decisional conflict and perceived stress, while women did not experience these improvements. Both men and women who received LVADs experienced improvement in depressive symptoms. Quality of life as assessed by EuroQol visual analog scale improved for both men and women who received LVADs but not for those who did not receive LVADs; no gender differences in quality of life were noted.RESULTSExcluding 9 patients who withdrew from assessments, of the 239 patients analyzed, 203 (85%) were men and 36 (15%) were women. More men received LVADs (70%) than women (61%) and more men were alive at 6 months compared to women, both among those who received LVADs (87% vs 82%) and those who did not (74% vs 50%) (p = 0.002). Compared to men, women were more likely to have decision regret, depressive symptoms and perceived stress at baseline but not at follow-up. At 6-month follow-up, men experience improvements in decisional conflict, acceptance of illness, struggle with illness, and perceived stress-none of those improvements were noted amongst women. Compared to men who received LVADs, women receiving LVADs had worse decision regret and depressive symptoms at baseline and worse acceptance of illness and perceived stress at six months. Men who received LVADs experienced improvement in decisional conflict and perceived stress, while women did not experience these improvements. Both men and women who received LVADs experienced improvement in depressive symptoms. Quality of life as assessed by EuroQol visual analog scale improved for both men and women who received LVADs but not for those who did not receive LVADs; no gender differences in quality of life were noted.Women require greater decisional support at time of decision to undergo LVAD implantation and subsequently might benefit from more intensive psychosocial support.CONCLUSIONWomen require greater decisional support at time of decision to undergo LVAD implantation and subsequently might benefit from more intensive psychosocial support.

Clinical decision support (CDS) is one strategy to increase evidence-based practices by clinicians. Despite its potential, CDS tools produce mixed results and are often disliked by clinicians. Principles from behavioral economics such as \"nudges\" may improve the effectiveness and clinician satisfaction of CDS tools. This paper outlines a pragmatic approach grounded in implementation science to identify and prioritize how to incorporate different types of nudges into CDS tools. The purpose of this paper is to describe a systematic and pragmatic approach grounded in implementation science to identify and prioritize how best to incorporate different types of nudges into CDS tools. We provide a case example of how this systematic approach was applied to design a CDS tool to improve guideline-concordant prescribing of mineralocorticoid receptor antagonists for patients with heart failure and reduced ejection fraction. We applied the Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments, and Ego nudge framework and the Practical, Robust Implementation and Sustainability Model implementation science framework to systematically and pragmatically identify and prioritize different types of nudges for CDS tools. To illustrate how these frameworks can be applied in a real-life scenario, we use a case example of a CDS tool to improve guideline-concordant prescribing for patients with heart failure. We describe a process of how these frameworks can be used pragmatically by clinicians and informaticists or more technical CDS builders to apply nudge theory to CDS tools. We defined four iterative steps guided by the Practical, Robust Implementation and Sustainability Model: (1) engage partners for user-centered design, (2) develop a shared understanding of the nudge types, (3) determine the overarching CDS format, and (4) brainstorm and prioritize nudge types to address each modifiable contextual issue. These steps are iterative and intended to be adapted to align with the local resources and needs of various clinical scenarios and settings. We provide illustrative examples of how this approach was applied to the case example, including who we engaged, details of nudge design decisions, and lessons learned. We present a pragmatic approach to guide the selection and prioritization of nudges, informed by implementation science. This approach can be used to comprehensively and systematically consider key issues when designing CDS to optimize clinician satisfaction, effectiveness, equity, and sustainability while minimizing the potential for unintended consequences. This approach can be adapted and generalized to other health settings and clinical situations, advancing the goals of learning health systems to expedite the translation of evidence into practice.

Oral anticoagulation (OAC) therapy reduces the risk of thromboembolic events associated with atrial fibrillation (AF), yet a substantial proportion of patients with AF are not prescribed OAC. The aim of this study is to describe the frequencies of and factors associated with OAC contraindications in contemporary clinical practice. We analyzed data from the ORBIT-AF study, a national, prospective, outpatient registry of incident and prevalent AF. Oral anticoagulation contraindications were uniformly collected at enrollment by site personnel using a predefined list. Baseline patient and provider characteristics were compared between participants with and without documented OAC contraindications. From June 2010 to August 2011, 10,130 patients 18 years or older with electrocardiographically documented AF were enrolled at 176 practices. Of these, 1,330 (13.1%) had contraindications documented at the baseline visit: prior bleed (27.7%), patient refusal/preference (27.5%), high bleeding risk (18.0%), frequent falls/frailty (17.6%), need for dual antiplatelet therapy (10.4%), unable to adhere/monitor warfarin (6.0%), comorbid illness (5.3%), prior intracranial hemorrhage (5.0%), allergy (2.4%), occupational risk (0.8%), pregnancy (0.2%), and other (12.6%). Among patients with reported contraindications, 30.3% were taking warfarin or dabigatran, as compared with 83.0% of those without reported contraindications. Besides “patient refusal/preference,” being labeled as having frequent falls or being frail was associated with the lowest OAC use among patients with high stroke risk. Contraindications to OAC therapy among patients with AF are common but subjective. Many patients with reported contraindications were receiving OAC, suggesting that the perceived benefit outweighed the potential harm posed by the relative contraindication.

Virtual care interventions have the potential to improve access to care and serial medication intensification for patients with chronic heart failure with reduced ejection fraction (HFrEF). However, concerns remain that these interventions might unintentionally create or widen existing disparities in care delivery and patient outcomes. This study aimed to characterize the health care use patterns of patients who have HFrEF, including specialty type and frequency of in-person and virtual visits. We conducted a retrospective cohort study of patients with HFrEF within a large health system. Inclusion criteria were patients alive with an ejection fraction ≤40% as of September 1, 2021, and at least one virtual or in-person outpatient visit to a primary care or cardiology clinician in the prior year. Descriptive statistics were used to evaluate baseline patient demographics and clinical use data and outcomes. Univariate analyses were performed both with virtual visits as a variable (received or did not receive) using the chi-square test for association and as a discrete outcome using the Wilcoxon rank-sum test to capture potentially important predictor variables that could influence use or frequency of using virtual visits. The primary outcome of interest was the odds of at least one virtual visit during the 1-year evaluation period from 2021 to 2022. Descriptive statistics were used to evaluate baseline patient demographics and care use. A logistic regression model was used to model at least one primary care or cardiology virtual visit. A total of 8481 patients were included in the analysis. The mean age was 65.9 years (SD 15.1), 5672 (66.9%) patients were male and 6608 (77.9%) patients were non-Hispanic White. The majority of patients had no cardiology (7938/8481, 93.6%) or primary care (7955/8481, 93.8%) virtual visits during the evaluation period. Multivariable logistic regression showed significantly higher odds of having at least one virtual visit for patients with certain digital access-for example, email on file (odds ratio [OR] 9.3, P≤.001), cell phone on file (OR 2.9, P≤.001), and active electronic health record patient portal (OR 2.8, P≤.001)-than those without. Age, race, ethnicity, rurality, and Social Vulnerability Index were not associated with virtual visits. Only a minority of patients with HFrEF were seen via virtual visits. Patients who regularly used digital technology were more likely to have virtual visits. Patients were more likely to be seen in a cardiology clinic than by a primary care provider. Although there was no evidence of an association between social determinants of health factors like race, ethnicity, or rurality with digital divide indicators, these findings should be interpreted with caution given the limitations of these data. Future studies should aim to replicate the findings of this study and explore ways to enhance the effective and equitable use of virtual visits.

Background Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive condition for which disease-modifying therapies are increasingly available. However, limited research has explored the patient experience with ATTR-CM and its impact on quality of life. Methods In this single-center qualitative study, we conducted semi-structured interviews with ten participants (either with ATTR-CM or at-risk family members). At-risk family members were defined as asymptomatic individuals with a clinically actionable TTR variant that were identified through cascade genetic testing. Interviews were recorded, transcribed, and analyzed using a hybrid deductive and inductive approach. Two independent experts assessed participants’ knowledge of ATTR-CM. Results Four exploratory themes emerged regarding the ATTR-CM patient journey. Participants demonstrated moderate to excellent knowledge of disease and an appropriate level of confidence. Diagnostic delays were a major source of frustration and were largely attributed to limited knowledge among non-specialist providers. While these providers often recognized that something was wrong, they struggled with appropriate diagnostic work-up and timely specialist referrals. Patients also noted disparities in ATTR-CM care based on geography, race, and socioeconomic status. Reactions to support groups were mixed, with concerns about re-traumatization being most prominent. Conclusions This qualitative study explores aspects of the ATTR-CM patient experience not captured through conventional clinical pathways. Diagnostic delays appeared to be driven by non-specialist provider knowledge gaps and systemic disparities in access to specialized care. These preliminary insights may inform the design of multidisciplinary care models that better reflect patient needs and priorities.