Patients with heart failure (HF) are at high risk of hospitalization or death. The objective of this study was to develop prediction models to identify patients with HF at highest risk for hospitalization or death. Using clinical and administrative databases, we identified 198,460 patients who received care from the Veterans Health Administration and had >= 1 primary or secondary diagnosis of HF that occurred within 1 year before June 1, 2009. We then tracked their outcomes of hospitalization and death during the subsequent 30 days and 1 year. Predictor variables chosen from 6 clinically relevant categories of sociodemographics, medical conditions, vital signs, use of health services, laboratory tests, and medications were used in multinomial regression models to predict outcomes of hospitalization and death. In patients who were in the >= 95th predicted risk percentile, observed event rates of hospitalization or death within 30 days and 1 year were 27% and 80% respectively, compared to population averages of 5% and 31%, respectively. The c-statistics for the 30-day outcomes were 0.82, 0.80, and 0.80 for hospitalization, death, and hospitalization or death, respectively, and 0.82, 0.76, and 0.77, respectively, for 1-year outcomes. In conclusion, prediction models using electronic health records can accurately identify patients who are at highest risk for hospitalization or death. This information can be used to assist care managers in selecting patients for interventions to decrease their risk of hospitalization or death. (C) 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;110:1342-1349)

Background:Statistical models that identify patients at elevated risk of death or hospitalization have focused on population subsets, such as those with a specific clinical condition or hospitalized patients. Most models have limitations for clinical use. Our objective was to develop models that identified high-risk primary care patients. Methods:Using the Primary Care Management Module in the Veterans Health Administration (VHA)’s Corporate Data Warehouse, we identified all patients who were enrolled and assigned to a VHA primary care provider on October 1, 2010. The outcome variable was the occurrence of hospitalization or death during the subsequent 90 days and 1 year. We extracted predictors from 6 categories: sociodemographics, medical conditions, vital signs, prior year use of health services, medications, and laboratory tests and then constructed multinomial logistic regression models to predict outcomes for over 4.6 million patients. Results:In the predicted 95th risk percentiles, observed 90-day event rates were 19.6%, 6.2%, and 22.6%, respectively, for hospitalization, death, and either hospitalization or death, compared with population averages of 2.7%, 0.7%, and 3.4%, respectively; 1-year event rates were 42.3%, 19.4%, and 51.3%, respectively, compared with population averages of 8.2%, 2.6%, and 10.8%, respectively. The C-statistics for 90-day outcomes were 0.83, 0.86, and 0.81, respectively, for hospitalization, death, and either hospitalization or death and were 0.81, 0.85, and 0.79, respectively, for 1-year outcomes. Conclusions:Prediction models using electronic clinical data accurately identified patients with elevated risk for hospitalization or death. This information can enhance the coordination of care for patients with complex clinical conditions.

Background: Patients with heart failure (HF) are at high risk of hospitalization and death. VHA has developed a population-based predictive model to identify high risk patients for case management. Methods: Using clinical and administrative databases, we identified all VA patients with a diagnosis of HF between June, 2008 and May, 2009, then followed the total of 194,062 HF patients for the subsequent 12 months. We used multinomial regression to model the outcome of hospitalization and death jointly. Candidates for predictor variables were related to demographics, medical history, vital status, health care utilization and medication. We randomly split the data 50% to 50% into a training sample and a validation sample. We derived the 30-day and 1-year predictive models from the training sample and validated the models on the other sample. Results: The C-statistics for 30-day and 1-year outcomes were 0.82 and 0.81 for hospitalization, 0.79 and 0.76 for hospitalization or death, respectively. Model calibration was excellent (Figure). For each outcome we stratified patients into 20 risk percentile categories. Risk stratification details were listed (Table). Conclusions: Predictive models can correctly stratify HF patients into risk categories for hospitalization and death. Table Risk Stratification by Outcomes 30-Day Outcomes 1-Year Outcomes Risk Hospitalized Hospitalized/Died Hospitalized Hospitalized/Died Category N (% * ) N (% * ) N (% * ) N (% * ) 1 5(0.05%) 36(0.4%) 51(0.5%) 535(5.5%) 2 9(0.1%) 72(0.7%) 121(1.2%) 824(8.5%) 3 21(0.2%) 99(1.0%) 223(2.3%) 1051(10.8%) 4 38(0.4%) 112(1.1%) 337(3.5%) 1254(12.9%) 5 51(0.5%) 117(1.2%) 472(4.9%) 1420(14.6%) 6 64(0.7%) 123(1.3%) 677(7.0%) 1628(16.9%) 7 93(1.0%) 185(1.9%) 907(9.3%) 1871(19.3%) 8 109(1.1%) 200(2.1%) 1105(11.4%) 2079(21.4%) 9 156(1.6%) 222(2.3%) 1397(14.4%) 2260(23.3%) 10 172(1.8%) 255(2.6%) 1664(17.1%) 2538(26.2%) 11 231(2.4%) 305(3.1%) 1980(20.4%) 2818(29.0%) 12 273(2.8%) 365(3.8%) 2306(23.8%) 3020(31.1%) 13 333(3.4%) 462(4.8%) 2589(26.7%) 3502(36.1%) 14 419(4.3%) 451(4.6%) 3057(31.5%) 3766(38.8%) 15 480(4.9%) 591(6.1%) 3423(35.3%) 4206(43.3%) 16 639(6.6%) 717(7.4%) 3989(41.1%) 4691(48.4%) 17 764(7.9%) 891(9.2%) 4446(45.8%) 5208(53.7%) 18 977(10.1%) 1126(11.6%) 5004(51.6%) 5819(60.0%) 19 1296(13.4%) 1458(15.0%) 5775(59.5%) 6619(68.2%) 20 2208(22.7%) 2580(26.6%) 6898(71.1%) 7812(80.5%) All 8338(4.3%) 10367(5.3%) 46421(23.9%) 62921(32.4%) *Observed event rate per risk category of the corresponding outcome

CONTEXT:Prior mechanistic studies reported that omeprazole decreases the platelet inhibitory effects of clopidogrel, yet the clinical significance of these findings is not clear.OBJECTIVE:To assess outcomes of patients taking clopidogrel with or without a proton pump inhibitor (PPI) after hospitalization for acute coronary syndrome (ACS).DESIGN, SETTING, AND PATIENTS:Retrospective cohort study of 8205 patients with ACS taking clopidogrel after discharge from 127 Veterans Affairs hospitals between October 1, 2003, and January 31, 2006. Vital status information was available for all patients through September 30, 2006.MAIN OUTCOME MEASURES:All-cause mortality or rehospitalization for ACS.RESULTS:Of 8205 patients taking clopidogrel after discharge, 63.9% (n = 5244) were prescribed PPI at discharge, during follow-up, or both and 36.1% (n = 2961) were not prescribed PPI. Death or rehospitalization for ACS occurred in 20.8% (n = 615) of patients taking clopidogrel without PPI and 29.8% (n = 1561) of patients taking clopidogrel plus PPI. In multivariable analyses, use of clopidogrel plus PPI was associated with an increased risk of death or rehospitalization for ACS compared with use of clopidogrel without PPI (adjusted odds ratio [AOR], 1.25; 95% confidence interval [CI], 1.11-1.41). Among patients taking clopidogrel after hospital discharge and prescribed PPI at any point during follow-up (n = 5244), periods of use of clopidogrel plus PPI (compared with periods of use of clopidogrel without PPI) were associated with a higher risk of death or rehospitalization for ACS (adjusted hazard ratio, 1.27; 95% CI, 1.10-1.46). In analyses of secondary outcomes, patients taking clopidogrel plus PPI had a higher risk of hospitalizations for recurrent ACS compared with patients taking clopidogrel without PPI (14.6% vs 6.9%; AOR, 1.86 [95% CI, 1.57-2.20]) and revascularization procedures (15.5% vs 11.9%; AOR, 1.49 [95% CI, 1.30-1.71]), but not for all-cause mortality (19.9% vs 16.6%; AOR, 0.91 [95% CI, 0.80-1.05]). The association between use of clopidogrel plus PPI and increased risk of adverse outcomes also was consistent using a nested case-control study design (AOR, 1.32; 95% CI, 1.14-1.54). In addition, use of PPI without clopidogrel was not associated with death or rehospitalization for ACS among patients not taking clopidogrel after hospital discharge (n = 6450) (AOR, 0.98; 95% CI, 0.85-1.13).CONCLUSION:Concomitant use of clopidogrel and PPI after hospital discharge for ACS was associated with an increased risk of adverse outcomes than use of clopidogrel without PPI, suggesting that use of PPI may be associated with attenuation of benefits of clopidogrel after ACS.

Objective To evaluate the relationship between ABCD2 score and cerebrovacular stenosis of patients with transient ischemic attack(TIA).Methods We retrospectively reviewed the medical records of 88 patients with TIA;all of them were examined with the magnetic resonance angiography(MRA).All patients were divided into two groups according to cerebrovascular vascular stenosis ≥50% or not, and divided into two groups according to ABCD2 score ≥4 point or not.The relationship between ABCD2 score and cerebrovaculare vascular stenosis was analyzed.Results Group stenosis ≥50% were more likely to have ABCD2 score ≥4 compared with group stenosis 50%(74.4% vs 44.9%, OR=3.559, 95%CI 1.428-8.868, P=0.005).Group stenosis ≥50% were more likely to have stroke history than those stenosis 50%(33.3% vs 10.2%, OR=4.400, 95%CI 1.408～4.869, P=0.01).The stroke within 2 days after TIA is higher in group cerebrovascular stenosis ≥50% than that in group stenosis 50%(10.3% vs 0%, OR=0.417, 95%CI 0.324-0.537, P=0.04).Conclusion The patients with ABCD2 score≥4 show higher rate of cerebrovascular stenosis.Patients with previous stroke more likely to undergo cerebrovascular vascular stenosis.The stroke within 2 days after TIA is higher in patients with cerebrovascualr stenosis ≥50%.

CONTEXT:It is unknown whether patients are at increased short-term risk for adverse events following clopidogrel cessation.OBJECTIVE:To assess the rates of adverse events after stopping treatment with clopidogrel in a national sample of patients with acute coronary syndrome (ACS).DESIGN, SETTING, AND PATIENTS:Retrospective cohort study of 3137 patients with ACS discharged from 127 Veterans Affairs hospitals between October 1, 2003, and March 31, 2005, with posthospital treatment with clopidogrel.MAIN OUTCOME MEASURE:Rate of all-cause mortality or acute myocardial infarction (AMI) after stopping treatment with clopidogrel.RESULTS:Mean (SD) follow-up after stopping treatment with clopidogrel was 196 (152) days for medically treated patients with ACS without stents (n = 1568) and 203 (148) days for patients with ACS treated with percutaneous coronary intervention (PCI) (n = 1569). Among medically treated patients, mean (SD) duration of clopidogrel treatment was 278 [corrected] (169) [corrected] days and death or AMI occurred in 17.1% (n = 268) of patients, with 60.8% (n = 163) of events occurring during 0 to 90 days, 21.3% (n = 57) during 91 to 180 days, and 9.7% (n = 26) during 181 to 270 days after stopping treatment with clopidogrel. In multivariable analysis including adjustment for duration of clopidogrel treatment, the first 90-day interval after stopping treatment with clopidogrel was associated with a significantly higher risk of adverse events (incidence rate ratio [IRR], 1.98; 95% confidence interval [CI], 1.46-2.69 vs the interval of 91-180 days). Similarly, among PCI-treated patients with ACS, mean (SD) duration of clopidogrel treatment was 302 [corrected] (151) [corrected] days and death or AMI occurred in 7.9% (n = 124) of patients, with 58.9% (n = 73) of events occurring during 0 to 90 days, 23.4% (n = 29) during 91 to 180 days, and 6.5% (n = 8) during 181 to 270 days after stopping clopidogrel treatment. In multivariable analysis including adjustment for duration of clopidogrel treatment, the first 90-day interval after stopping clopidogrel treatment was associated with a significantly higher risk of adverse events (IRR, 1.82; 95% CI, 1.17-2.83).CONCLUSIONS:We observed a clustering of adverse events in the initial 90 days after stopping clopidogrel among both medically treated and PCI-treated patients with ACS, supporting the possibility of a clopidogrel rebound effect. Additional studies are needed to confirm the clustering of events after stopping clopidogrel, including associations with cardiovascular mortality and reasons for stopping clopidogrel, as well as to determine the mechanism of this phenomenon, and to identify strategies to reduce early events after clopidogrel cessation.

Background: A prior report showed omeprazole decreases platelet inhibitory effects of clopidogrel (clopid). However, the clinical impact of these findings is unknown. We studied outcomes of patients taking clopid alone versus clopid and proton-pump inhibitor (PPI) after acute coronary syndrome (ACS) in a national VA registry. Methods: This was a retrospective cohort study of 3,311 ACS patients discharged from 127 VA hospitals on either clopid alone or clopid+PPI based on pharmacy dispensing data. The main outcome was AMI/death. Cox proportional hazards regression models assessed the association between drug use as a time varying covariate and outcomes. Mean follow-up was >1 year. During follow-up, patients could have gaps in their treatment and thus could be categorized as “no drugs” or “PPI-only” for short durations. Results: At discharge, 34% were prescribed clopid alone and 66% clopid+PPI. Baseline characteristics were quite similar (e.g. mean age 68.1 yrs for clopid vs 68.3 yrs for clopid+PPI) except clopid+PPI patients had less diabetes and more renal insufficiency. In multivariable analyses, clopid+PPI was associated with a higher risk of AMI/death risk compared to clopid alone (HR 1.28; 95% CI 1.07–1.53) (Figure ). Findings were consistent excluding patients with bleeding event during follow-up and using a nested case-control study design. Conclusion: Concomitant use of clopidogrel and PPI after ACS is associated with higher risk of adverse outcomes than clopidogrel use without PPI. These findings, coupled with the prior mechanistic study, suggest that concomitant PPI use attenuates the benefits of clopidogrel after ACS.

Background Little is known about the association between clopidogrel use and long-term outcomes after stent implantation for acute coronary syndromes (ACS) in clinical practice.Methods This retrospective cohort study included patients with ACS receiving drug-eluting stent (DES) or bare-metal stent (BMS) and discharged from all Veterans Health Administration hospitals from 2003 to 2004. Clopidogrel use was assessed by pharmacy dispensing data. Multivariable Cox regression assessed the association between clopidogrel discontinuation and outcomes with clopidogrel use as a time-varying covariate and adjusting for demographics, comorbidities, hospital presentation, and treatment variables. Median follow-up was 538 days.Results Of 1455 patients with ACS, 65.8% received BMS and 34.2% received DES. The median number of days of clopidogrel use was 299. In multivariable analysis, clopidogrel discontinuation was associated with higher all-cause mortality (hazard ratio [HR] 2.40, 95% confidence interval [Cl] 1.61-3.58). The findings were consistent for patients receiving BMS (HR 2.65, 95% Cl 1.59-4.42) or DES (HR 2.00, 95% Cl 1.06-3.75) and for the outcomes of acute myocardial infarction (AMI) and AMI or mortality. When follow-up was divided into 6-month intervals, the association between clopidogrel discontinuation and higher mortality remained consistent up to 18 months after hospital discharge. In secondary analysis of patients who were event-free at 6 months, clopidogrel discontinuation was associated with higher risk for AMI among patients receiving DES (HR 3.57, 95% Cl 1. 13-11.3) compared with BMS (HR 1.26, 95% Cl 0.58-2.74).Conclusion Clopidogrel discontinuation after extended use was still associated with increased mortality risk. Clinical trials are urgently needed to define the optimal duration of clopidogrel therapy after stent implantation for ACS.

Background Severe mental illness (SMI) has been associated with more medical co-morbidity and less cardiovascular procedure use for older patients with myocardial infarction. However, it is unknown whether SMI is associated with increased long term mortality risk among patients presenting with acute coronary syndromes (ACS). We tested the hypothesis that SMI is associated with higher one-year mortality following ACS hospitalization. Methods All ACS patients (n = 14,194) presenting to Veterans Health Administration (VHA) hospitals between October 2003 and September 2005 were included. Survival analysis evaluated the association between SMI and one-year all-cause mortality, adjusting for demographics, co-morbidities, in-hospital treatment, and discharge medications. Results Overall, 18.4 % of ACS patients had SMI. Patients with SMI were more likely female, younger, Caucasian race, have a history of alcohol abuse, liver disease, dementia, hypertension and more likely to be a current smoker; however, prior cardiac history was similar between the 2 groups. There were no significant differences in cardiac procedure use, including coronary angiogram (38.7% vs. 40.3%, p = 0.14) or coronary revascularization (31.0% vs. 32.3%, p = 0.19), and discharge medications between those with and without SMI. One-year mortality was lower for patients with SMI (15.8% vs. 19.1%, p < 0.001). However, in multivariable analysis, there were no significant differences in mortality (HR 0.91; 95% CI 0.81–1.02) between patients with and without SMI. Conclusion Among ACS patients in the VHA, SMI is prevalent, affecting almost 1 in 5 patients. However, patients with SMI were as likely to undergo coronary revascularization and be prescribed evidence-based medications at hospital discharge, and were not at elevated risk of adverse 1-year outcomes compared to patients without SMI.