Circulation
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Multicenter Study
Predictors of outcomes in low-flow, low-gradient aortic stenosis: results of the multicenter TOPAS Study.
Patients with low-flow, low-gradient aortic stenosis have a poor prognosis with conservative therapy but a high operative mortality if treated surgically. Recently, we proposed a new index of aortic stenosis severity derived from dobutamine stress echocardiography, the projected aortic valve area at a normal transvalvular flow rate, as superior to other conventional indices to differentiate true-severe from pseudosevere aortic stenosis. The objective of this study was to identify the determinants of survival, functional status, and change in left ventricular ejection fraction during follow-up of patients with low-flow, low-gradient aortic stenosis. ⋯ In patients with low-flow, low-gradient aortic stenosis, the most significant risk factors for poor outcome were (1) impaired functional capacity as measured by Duke Activity Status Index or 6-minute walk test distance; (2) more severe valve stenosis as measured by projected aortic valve area at a normal transvalvular flow rate; and (3) reduced peak stress left ventricular ejection fraction, a composite measure accounting for both resting left ventricular function and contractile reserve.
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Randomized Controlled Trial Multicenter Study
Ambrisentan for the treatment of pulmonary arterial hypertension: results of the ambrisentan in pulmonary arterial hypertension, randomized, double-blind, placebo-controlled, multicenter, efficacy (ARIES) study 1 and 2.
Ambrisentan is a propanoic acid-based, A-selective endothelin receptor antagonist for the once-daily treatment of pulmonary arterial hypertension. ⋯ Ambrisentan improves exercise capacity in patients with pulmonary arterial hypertension. Improvements were observed for several secondary end points in each of the studies, although statistical significance was more variable. Ambrisentan is well tolerated and is associated with a low risk of aminotransferase abnormalities.
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Multicenter Study
Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.
The goal of this study was to determine the relationship between all-cause, risk-adjusted, in-hospital mortality after coronary artery bypass graft surgery and the proportion of preventable in-hospital deaths as a measure of quality of care at an institution level. ⋯ Approximately one third of in-hospital coronary artery bypass graft deaths were judged preventable by surgeon reviewers. All-cause risk-adjusted mortality rates are convenient measures of institutional quality of care but were not correlated with preventable mortality in our jurisdiction. Providers should conduct detailed adverse event audits to drive meaningful improvements in quality.
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Multicenter Study Comparative Study
Comparison of "risk-adjusted" hospital outcomes.
A frequent challenge in outcomes research is the comparison of rates from different populations. One common example with substantial health policy implications involves the determination and comparison of hospital outcomes. The concept of "risk-adjusted" outcomes is frequently misunderstood, particularly when it is used to justify the direct comparison of performance at 2 specific institutions. ⋯ Risk-adjusted outcomes, commonly the focus of public report cards, have a specific interpretation. Using indirect standardization, these outcomes reflect a provider's performance for its specific case mix relative to the expected performance of an average provider for that same case mix. Unless study design or post hoc adjustments have resulted in reasonable overlap of case-mix distributions, such risk-adjusted outcomes should not be used to directly compare one institution with another.
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Multicenter Study Comparative Study
Impact of ethnicity and gender differences on angiographic coronary artery disease prevalence and in-hospital mortality in the American College of Cardiology-National Cardiovascular Data Registry.
Although populations referred for coronary angiography are increasingly diverse, there is limited information on coronary artery disease (CAD) prevalence and in-hospital mortality other than for predominately white male patients. ⋯ The likelihood for significant CAD at coronary angiography and for in-hospital mortality varied significantly by ethnicity and gender. Future clinical practice guidelines should be tailored to gender subsets of the population, in particular for black women, to improve the efficient use of angiographic laboratories and to target at-risk populations of women and men.