Steiger, Kyle

Background Valvular heart disease contributes to symptomatic heart failure, but its prevalence and prognostic significance in advanced heart failure is not well understood. Methods This retrospective population‐based cohort study included adult residents of Olmsted County, Minnesota, with advanced heart failure (2007–2018). Patients were classified by echocardiographic regurgitation and stenosis of aortic, mitral, tricuspid, and pulmonic valves at the time of advanced heart failure. We examined the associations of aortic stenosis, mitral regurgitation, and tricuspid regurgitation with risks of cardiovascular and all‐cause death through 2023 using Cox proportional hazards models. Results There were 936 patients with advanced heart failure (mean age, 76.9 years; 44.5% women, 43.4% with heart failure with preserved ejection fraction). Moderate or greater regurgitation was observed in 2.8% (n=26) of aortic, 26% (n=244) of mitral, 42% (n=389) of tricuspid, and 4.3% (n=40) of pulmonic valves, while moderate or greater stenosis was observed in 9.7% (n=91) of aortic and 1.8% (n=17) of mitral valves. No patients had clinically significant tricuspid or pulmonic stenosis. After adjustment for age, sex, left ventricular ejection fraction, right ventricular function, serum sodium, Charlson comorbidity index, body mass index, and systolic blood pressure, moderate and severe aortic stenosis were associated with increased cardiovascular death compared with patients without aortic stenosis (hazard ratio [HR], 1.42 [95% CI, 1.01–2.01]; and HR, 1.55 [95% CI, 1.02–2.36]), respectively. Conclusions Tricuspid regurgitation, mitral regurgitation, and aortic stenosis were the most observed valvular pathologies of moderate or greater severity in advanced heart failure. Only moderate or greater aortic stenosis was independently associated with cardiovascular death in advanced heart failure.

Introduction: Psychological resilience is the ability to adapt to significant adversity. Higher resilience has been associated with better quality of life in HF, but its association with outcomes is not known. Herein, we characterize resilience and its association with outcomes in HF. Research Questions/Hypothesis: Greater resilience is associated with better health status and outcomes in high-risk HF. Methods: In a prospective study, adult residents of 11 counties in Southeastern Minnesota with HF who had been hospitalized with decompensated HF or ventricular arrhythmia (“high-risk HF”) in the preceding 1 year were mailed a survey that included questionnaires to assess resilience (Connor Davidson resilience scale, CD-RISC2), health status (KCCQ-12), and other psychosocial constructs in March 2022. Patients were divided into tertiles by resilience scores, and association with outcomes (survival and hospitalization) were examined using Cox proportional hazard regression and Andersen-Gill models, respectively. Results: Among 649 respondents (mean age 76 ± 11.5 years, 40% women, 64.3% HFpEF), patients with greater resilience were older ( p=0.015 ), had lower BMI ( p=0.003 ) and were more often retired or employed (vs disabled or unemployed, p<0.001 ). Greater resilience was moderately correlated with better health status (r=0.33), social support (r=0.27), and health literacy (r=-0.30); and lower treatment burden (r=-0.42), symptom burden (r=-0.41), and fewer depressive symptoms (r=-0.41) ( p<0.001 for all ). At 1-year follow up, patients with the lowest resilience (lowest tertile) were at a significantly increased risk for HF hospitalizations (adjusted HR 2.09, 95% CI 1.06-4.11) and CV mortality (adjusted HR 1.90, 95% CI 1.01-2.57) compared to those with highest resilience. There was no statistically significant association of resilience with risks of all-cause mortality or all-cause hospitalizations after adjustment ( Figures 1A-D ). Conclusion: Higher resilience is associated with better health status and psychosocial profile. Patients with low resilience are at increased risk for HF hospitalizations and CV mortality. Impact of resilience on long term outcomes and response to interventions must be tested in future studies.

OBJECTIVE To determine the relative hazards of acute and chronic diabetes complications among people with diabetes across the U.S. rural-urban continuum. RESEARCH DESIGN AND METHODS This retrospective cohort study used the OptumLabs Data Warehouse, a deidentified data set of U.S. commercial and Medicare Advantage beneficiaries, to follow 2,901,563 adults (age ≥18 years) with diabetes between 1 January 2012 and 31 December 2021. We compared adjusted hazard ratios (HRs) of diabetes complications in remote areas (population &lt;2,500), small towns (population 2,500–50,000), and cities (population &gt;50,000). RESULTS Compared with residents of cities, residents of remote areas had greater hazards of myocardial infarction (HR 1.06 [95% CI 1.02–1.10]) and revascularization (HR 1.04 [1.02–1.06]) but lower hazards of hyperglycemia (HR 0.90 [0.83–0.98]) and stroke (HR 0.91 [0.88–0.95]). Compared with cities, residents of small towns had greater hazards of hyperglycemia (HR 1.06 [1.02–1.10]), hypoglycemia (HR 1.15 [1.12–1.18]), end-stage kidney disease (HR 1.04 [1.03–1.06]), myocardial infarction (HR 1.10 [1.08–1.12]), heart failure (HR 1.05 [1.03–1.06]), amputation (HR 1.05 [1.02–1.09]), other lower-extremity complications (HR 1.02 [1.01–1.03]), and revascularization (HR 1.05 [1.04–1.06]) but a smaller hazard of stroke (HR 0.95 [0.94–0.97]). Compared with small towns, residents of remote areas had lower hazards of hyperglycemia (HR 0.85 [0.78–0.93]), hypoglycemia (HR 0.92 [0.87–0.97]), and heart failure (HR 0.94 [0.91–0.97]). Hazards of retinopathy and atrial fibrillation/flutter did not vary geographically. CONCLUSIONS Adults in small towns are disproportionately impacted by complications of diabetes. Future studies should probe for the reasons underlying these disparities.

Introduction While neurovascular surgeries have largely been performed by neurosurgeons, the advent of endovascular procedures has produced increasing involvement of other specialists in this arena (i.e. neurologists and radiologists).This study aims to analyzethe involvement of different specialties within theneuroendovascular workforce by characterizingthem by their primary specialty. Methods The Medicare Provider Utilization Database was queried from 2013 to 2019 for all primary Current Procedural Terminology (CPT) codes identified by the American Medical Association as pertaining to endovascular procedures of the nervous system (61623, 61624, 61630, 61635, 61626, 61645, and 61650). We counted the number of unique providers in respective fields (neurology, neurosurgery, and radiology) who performed these procedures. Statistical analyses, including data aggregation, exploratory analysis, and propensity adjustment, were performed using R, version 4.0.1 (The R Foundation, Vienna, Austria). The two‐sided Mann‐Kendall trend test, a non‐parametric statistical test that assesses for monotonic trends in either an upward or downward trend, was utilized to assess for trends over time. Within each year analyzed, a Chi‐squared test for trend in proportions was used. A significance level of 0.05 was used. Results In 2013, neurosurgeons comprised 45% of the workforce performing these procedures, neurologists were 9%, and radiologists were 47%. By 2019, neurosurgeons decreased to 34.5% of the workforce, while neurologists increased to 21.5%, and radiologists decreased slightly to 44%. Neurologists were the only field in which the proportional shift in providers was noted to have a significant change in trajectory (p:0.04), an upward trajectory. Overall proportional differences between respective specialists were statistically significant each year (p< 0.01). Conclusions Neurologists are increasingly performing endovascular procedures. Increased communication and coordination between specialties can improve disparities in care to ensure adequate access to neurovascular care across the US.

Introduction Endovascular procedures have become increasingly popular in recent years due to preference of minimally invasive approaches and technological advancement.This study aims to characterize the trends in procedural rates of common neuro‐endovascular procedures performed by neurologists, neurosurgeons, and radiologists. Methods The Medicare Provider Utilization Database was queried from 2013 to 2019 for all primary Current Procedural Terminology codes identified by the American Medical Association as pertaining to endovascular procedures of the nervous system (61623, 61624, 61630, 61635, 61626, 61645, and 61650). Statistical analyses, including data aggregation, exploratory analysis, and propensity adjustment, were performed using R, version 4.0.1 (The R Foundation, Vienna, Austria). The two‐sided Mann‐Kendall trend test, a non‐parametric statistical test that assesses for monotonic trends in either an upward or downward trend, was utilized to assess for trends over time. A significance level of 0.05 was used. Results Between 2013 to 2019 a total of 40,730 endovascular procedures were performed by neurosurgeons, neurologists and radiologists treating Medicare patients. When all codes were combined, there was a significant increase in the number of procedures done by all specialists: Radiology (2013:1080; 2019:4938; p:0.02), Neurosurgery (2013:1230; 2019:4508; p< 0.01), and Neurology (2013:205; 2019:2397; p:0.04). Significant increases in mechanical thrombectomy (CPT61645) were observed in all fields: Radiology (2016:1287, 2019:3542; p< 0.01), Neurosurgery (2016:610; 2019:2326; p< 0.01), Neurology (2016:569; 2019:1951; p< 0.01). Increases in transcatheter permanent occlusion (CPT61624) were observed in neurosurgery (2013:1230; 2019:2049; p:0.04). Increases in temporary balloon artery occlusion (CPT61623) were noted in neurology (2013:21; 2019:27; p:0.04). Conclusions Endovascular procedures have seen a dramatic rise in utilization over a short amount of time, particularly mechanical thrombectomy. Future investigation should include more inclusive datasets beyond the Medicare population.