Search

This study sought to assess medical management of patients found to have nonobstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA) performed in the emergency department (ED). Contemporary recognition and management of nonobstructive CAD discovered on CCTA performed in the ED is unknown. Patients undergoing CCTA in the authors' hospital's ED between November 2013 and March 2018 who also received primary care within the authors' health system were studied. All patients with nonobstructive CAD, defined as 1% to 49% maximum luminal stenosis on CCTA, were included, along with a control group without CAD in a 1 case:1 control fashion. Ten-year atherosclerotic cardiovascular disease (ASCVD) risk prior to CCTA was estimated using the Pooled Cohort Equations. Management changes were recorded until 6 months after CCTA. Multivariate logistic regression tested the association between CCTA result and follow-up statin prescription, adjusting for cardiovascular risk factors and baseline statin use. The cohort included 510 patients with nonobstructive CAD and 510 controls. Prevalence of statin prescription increased from 38.8% to 56.1% among patients with nonobstructive CAD (p < 0.001) and 18.0% to 20.4% among controls (p = 0.01), representing a 7.1-fold relative difference (95% confidence interval [CI]: 4.4 to 23.0; p < 0.001) in multivariate analysis. However, 30.0% of patients with nonobstructive CAD and ≥20% 10-year ASCVD risk were not prescribed a statin at the end of follow-up. Cardiologist evaluation was independently associated with statin prescription after adjustment for ASCVD risk factors (odds ratio [OR] 4.4; 95% CI: 2.4 to 8.5; p < 0.001). A Coronary Artery Disease Reporting and Data System class 1 to 2 result was associated with lower low-density lipoprotein cholesterol by 12.1 mg/dl at mean 1.9-year follow-up (p < 0.001). Incidental subclinical atherosclerosis on CCTA performed in the ED increases the likelihood of statin prescription, but opportunities to improve allocation of indicated preventive therapies remain. [ABSTRACT FROM AUTHOR]

In the U.S. presidential election of 2016, communities with poorer public health shifted votes to the Republican party. Whether this trend has persisted beyond 2016 is unclear. We created a county-level measure of public health (the "unhealthy" component) by performing principal component analysis on 9 health statistics. We then estimated shifting of votes by defining "net vote shift" as the percentage of Republican votes in the 2018 U.S. House of Representatives election minus the percentage of Republican votes in the same election in 2016. Finally, we performed linear regression to assess the independent, county-level association of the unhealthy component with net vote shift after adjusting for county-level demographic factors. The mean county-level net vote shift was −6.4 percentage points (SD 12.6 percentage points), consistent with a mean net vote shift toward the Democratic party. After adjustment for demographic covariates, the unhealthy score was associated with higher net vote shift (17.7 percentage points shift toward Republican per unit unhealthy, p =.0323). In the 2018 congressional elections, despite an overall shift toward the Democratic Party there is evidence of ongoing shifting of community voting in unhealthy communities toward the Republican party. • Changes in U.S. Congressional voting are associated with public health. • These changes mirror prior changes in U.S. presidential voting. • Healthier communities are shifting toward Democratic voting. • Sicker communities are shifting toward Republican voting. • Analysis of contemporary political party realignment should consider public health. [ABSTRACT FROM AUTHOR]

Background: Patients with isolated tricuspid regurgitation (TR) in the absence of left-sided valvular dysfunction are often managed nonoperatively.Objectives: The purpose of this study was to assess the impact of surgery for isolated TR, comparing survival for isolated severe TR patients who underwent surgery with those who did not.Methods: A longitudinal echocardiography database was used to perform a retrospective analysis of 3,276 adult patients with isolated severe TR from November 2001 to March 2016. All-cause mortality for patients who underwent surgery versus those who did not was analyzed in the entire cohort and in a propensity-matched sample. To assess the possibility of immortal time bias, the analysis was performed considering time from diagnosis to surgery as a time-dependent covariate.Results: Of 3,276 patients with isolated severe TR, 171 (5%) underwent tricuspid valve surgery, including 143 (84%) repairs and 28 (16%) replacements. The remaining 3,105 (95%) patients were medically managed. When considering surgery as a time-dependent covariate in a propensity-matched sample, there was no difference in overall survival between patients who received medical versus surgical therapy (hazard ratio: 1.34; 95% confidence interval: 0.78 to 2.30; p = 0.288). In the subgroup that underwent surgery, there was no difference in survival between tricuspid repair versus replacement (hazard ratio: 1.53; 95% confidence interval: 0.74 to 3.17; p = 0.254).Conclusions: In patients with isolated severe TR, surgery is not associated with improved long-term survival compared to medical management alone after accounting for immortal time bias. [ABSTRACT FROM AUTHOR]