Author + information
- Received July 30, 2007
- Revision received January 24, 2008
- Accepted January 29, 2008
- Published online April 29, 2008.
- Clyde W. Yancy, MD, FACC⁎,⁎ (, )
- William T. Abraham, MD, FACC†,
- Nancy M. Albert, PhD, RN‡,
- Robert Clare, MS§,
- Wendy Gattis Stough, PharmD∥,¶,
- Mihai Gheorghiade, MD, FACC#,
- Barry H. Greenberg, MD, FACC⁎⁎,
- Christopher M. O'Connor, MD, FACC††,
- Lilin She, PhD§,
- Jie Lena Sun, MS§,
- James B. Young, MD, FACC‡‡ and
- Gregg C. Fonarow, MD, FACC§§
- ↵⁎Reprint requests and correspondence:
Dr. Clyde W. Yancy, Baylor Heart and Vascular Institute, Baylor University Medical Center, 3500 Gaston Avenue, Suite H-030, Dallas, Texas 75246.
Objectives We sought to examine the characteristics, quality of care, and clinical outcomes for a large cohort of African-American patients hospitalized with heart failure (HF) in centers participating in a quality improvement initiative.
Background Heart failure in African Americans is characterized by variations in natural history, lesser response to evidence-based therapies, and disparate health care. We hypothesized that a performance improvement program will achieve similar adherence to quality measures in African Americans admitted with HF compared with non–African Americans.
Methods The OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry-based performance-improvement program includes a pre-specified 10% subgroup with 60- to 90-day follow-up. Data on quality of care measures and outcomes were analyzed for 8,608 African-American patients compared with 38,501 non–African-American patients.
Results African Americans were significantly younger and more likely to receive evidence-based medications but less likely to receive discharge instructions and smoking cessation counseling. In multivariable analyses, African-American race was an independent predictor of lower in-hospital mortality (odds ratio 0.71; 95% confidence interval 0.57 to 0.87; p < 0.001) but similar hospital length of stay. After multivariable adjustment, post-discharge outcomes were similar for American-American and non–African-American patients, but African-American race was associated with higher angiotensin-converting enzyme inhibitor prescription and left ventricular function assessment; no other HF quality indicators were influenced by race.
Conclusions In the context of a performance-improvement program, African Americans with HF received similar or better treatment with evidence-based medications, less discharge counseling, had better in-hospital survival, and similar adjusted risk of follow-up death/repeat hospital stay. (Organized Program to Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure [OPTIMIZE-HF]; NCT00344513)
Marked population differences exist in the prevalence, morbidity, and mortality associated with cardiovascular disease. In conjunction with biological risk factors, social and environmental determinants of cardiovascular disease might contribute to the treatment and outcome inequities seen in different populations (1). These differences have the potential to contribute to observed gaps in the overall life expectancy and quality of life and are felt to be partly responsible for health care disparities. African Americans are among those most seriously affected by disparate health care in the U.S. (2).
Recent statistics confirm that cardiovascular disease is the leading cause of death for African Americans (3,4). Heart failure (HF) is especially problematic for African Americans. Both the prevalence of HF and mortality due to chronic HF are increased in African Americans compared with the general population (4,5). The etiology of left ventricular dysfunction leading to HF in African Americans is also different, and the natural history is more aggressive than that seen in other populations. Among African-American patients with HF and left ventricular systolic dysfunction (LVSD), only one-fourth of patients have a known ischemic etiology of LVSD, with the remainder experiencing a putative nonischemic etiology of LVSD (6). In addition, HF occurs at an earlier age in African-American patients, with more advanced LVSD and worse clinical class at the time of diagnosis than seen in the population at large (7).
Despite being at high risk for cardiovascular morbidity and mortality, prior studies have indicated that African Americans are less likely than non-African Americans to receive guideline-recommended, evidence-based care such as diagnostic testing, drug therapy, and interventional procedures (8–10). The reasons for these disparities in health care are multifactorial, however, and might be related to access to care, patient preference, or bias (11). Recent studies also document that African-American patients are more likely to be treated at hospitals that provide poor quality of care with lower use of systematic processes, protocols, and evidence-based treatments (12–14). Moreover, even when treated at the same hospital, African-American patients might not receive the same standard of care delivered to white patients (12,15).
The quality of care for African Americans admitted with HF has not been well studied in the context of an HF quality improvement program. The OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry provides an opportunity to capture quality indicators as a function of race and investigate their association with outcomes. The OPTIMIZE-HF program is designed to improve medical care and education for hospitalized HF patients and to accelerate use of evidence-based, guideline-recommended therapies by initiating them before hospital discharge. These process-of-care intervention strategies might standardize care for all patients with HF and test whether African Americans with HF who are treated similarly will experience the same outcomes as other HF populations (16). Our analyses investigated the influence of this quality-improvement initiative in a large African-American subgroup and the association with quality of care, post-discharge HF management, survival, and repeat hospital stay.
The study design and rationale of the OPTIMIZE-HF registry has been previously published (17–20). Briefly, OPTIMIZE-HF is a registry and performance-improvement program for patients hospitalized with HF. This nationwide patient registry was used to gather data on various patient characteristics with a web-based information system. Participating hospitals had the ability to view national aggregate hospital data as well as daily patient and performance data benchmarked with similar hospitals. The OPTIMIZE-HF process-of-care improvement program provided participating hospitals with materials for improving treatment and discharge plans for optimal patient management and included evidence-based best-practice algorithms (detailed algorithms on indications, contraindications, dosing, and monitoring steps for each evidence-based HF therapy) along with comprehensive patient education materials and resources. To be eligible for OPTIMIZE-HF, patients had to be adults hospitalized for an episode of HF as the primary cause of admission or with significant HF symptoms that developed during hospital stay with a primary discharge diagnosis of HF. With methodology similar to national cardiovascular registries and many randomized trials, race and ethnicity were collected for the purpose of evaluating subgroup differences. Admission and/or medical staff recorded race/ethnicity, usually as the patient was registered. Patients were assigned to race and ethnicity categories with options defined by the study protocol. A pre-specified subgroup (10%) had 60- to 90-day follow-up data collected. Participating sites had the option of participating in the hospital registry only or hospital registry and follow-up data collection. Site participation in the follow-up portion required obtaining informed consent. This follow-up cohort was demographically similar to patients in the overall registry (Online Table 1). Process-of-care improvement tool use was defined by use of either preprinted order sets or discharge checklists as documented in the medical record. Left ventricular systolic dysfunction was defined as a documented left ventricular ejection fraction (LVEF) <40% or qualitative assessment of moderate/severe dysfunction. The registry coordinating center was Outcome Sciences, Inc. (Cambridge, Massachusetts), which provided data collection, management, and source data verification.
Discrete data are reported as the number and frequency of eligible patients treated at the time of hospital discharge, excluding patients with documented intolerance/contraindications to specific therapies. The HF medication use and contraindications/intolerance were assessed at discharge from the index hospital stay and during follow-up. Race was analyzed according to African-American and non–African-American status. Patient characteristics and evidence-based treatments at hospital discharge were compared with the Pearson chi-square test for categorical variables and analysis of variance for continuous variables. Models of in-hospital mortality, mortality from hospital discharge to 90 days, and the combination of post-discharge mortality or repeat hospital stay have been developed to determine significant factors to use when applying adjusted models (Online Table 2) (19,20). Baseline clinical and treatment factors were applied to model selections. To model in-hospital mortality, 45 potential predictor variables were used in a logistic model. To model post-discharge mortality in the follow-up period, 19 potential predictor variables were used in a Cox proportional hazards model. To model repeat hospital stay and the combination of post-discharge mortality or repeat hospital stay, 69 variables were used in a logistic model. To model conformity with quality of care measures, 69 variables were considered, and those retained for each model are listed in Online Table 2. A p value of 0.05 was used as the criterion for variables to remain in the model. The assumption of linearity was checked in each model for the continuous variables by using restricted cubic splines. When the relationship was found to be nonlinear, appropriate transformations were applied. When the association between race and repeat hospital stay was examined, all variables from the post-discharge death or repeat hospital stay model were included. Generalized estimating equations were used to account for the correlation of data within the same hospital in the adjusted models. The SAS version 8.2 (SAS Institute, Cary, North Carolina) was used for all statistical analyses, which were performed independently at Duke Clinical Research Institute (Durham, North Carolina).
The OPTIMIZE-HF registry enrolled patients from March 1, 2003 through December 31, 2004 and included 48,612 patients from 259 hospitals, with pre-specified follow-up data available from 91 centers and 5,791 patients. Race was available for 47,190 (97.1%) patients. Of these, 8,608 (17.7%) were African Americans; follow-up data were collected from 1,044 African-American patients. Patient characteristics are detailed in Table 1. The characteristics of African Americans hospitalized for HF differed from those of non–African Americans in the registry. African-American patients tended to be female and younger and were more likely to have systolic dysfunction and renal insufficiency. Systolic blood pressure (SBP), B-type natriuretic peptide (BNP), and admission weight were all higher in hospitalized African Americans. Additionally, the presumed etiology of HF differed significantly between African-American and non–African-American patients. Whereas HF etiology in African-American patients was more likely to be hypertensive (39.2% vs. 19.3%; p < 0.0001), in non–African-American patients it was more likely to be ischemic (49.4% vs. 29.5%; p < 0.0001). Etiology attributable to other causes (postpartum, valvular, familial, alcohol/other drug, chemotherapy, viral, unknown/idiopathic, and other) did not differ between African-American and non–African-American patients (31.3% for each group). Importantly, 70.5% of the African-American patients with HF had a nonischemic etiology, either related to hypertension or causes other than ischemic heart disease. The mean LVEF was significantly lower in African-American patients (35.4% vs. 39.7%; p < 0.0001), and the percentage of African-American patients with LVSD was significantly higher than that observed in non–African-American patients (56.9% vs. 47.1%; p < 0.0001).
Quality of care
Comparison of the use of process-of-care measures between racial populations analyzed in this study demonstrated significant differences. African-American patients were significantly less likely to receive complete discharge instructions and smoking cessation advice, but they were more likely to receive LVEF assessment and a prescription for angiotensin-converting enzyme (ACE) inhibitors in the absence of contraindications and intolerance (Fig. 1). At discharge, eligible African Americans with LVSD were more likely to be prescribed ACE inhibitors or angiotensin receptor blocker drugs (ARBs) (p < 0.0001), aldosterone antagonists (p < 0.0001), and hydralazine (p < 0.0001) but just as likely as other patients to be prescribed beta-blocker drugs, warfarin, and nitrates (p = 0.225, p = 0.118, and p = 0.674, respectively) (Fig. 2). African Americans were less likely to receive statin therapy. Whereas African Americans were more likely to be prescribed hydralazine, the percentage of African Americans with LVSD that received a combination of hydralazine/isosorbide dinitrate was only 4.5%. There was documented use of the process-of-care improvement tools in 39.5% of African-American patients compared with 46.9% non–African-American patients (p < 0.0001).
Hospital stay and mortality
In unadjusted analyses, African-American HF patients experienced a modestly shorter length of stay (5.58 days vs. 5.71 days; p < 0.001), significantly lower in-hospital mortality (2.2% vs. 4.1%; p < 0.0001), and lower follow-up mortality (6.5% vs. 9.1%; p = 0.009) (Table 2). However, this patient population had similar readmission events (31.7% vs. 29.3%; p = 0.12) and similar death/repeat hospital stay events (35.3% vs. 36.6%; p = 0.44). In multivariable analyses, African-American race was an independent predictor of lower in-hospital mortality (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.57 to 0.87, p < 0.001) but was not predictive of follow-up mortality (hazard ratio 1.12, 95% CI 0.80 to 1.58, p = 0.50), follow-up repeat hospital stay (OR 1.14, 95% CI 0.93 to 1.40, p = 0.22), or death/repeat hospital stay (OR 1.02, 95% CI 0.86 to 1.22, p = 0.79) (Table 2).
A subgroup analysis revealed African-American patients with LVSD experienced a shorter length of stay, significantly lower in-hospital mortality, and similar follow-up mortality but more readmission events (Figs. 3A and 3B). Analysis of African-American patients without systolic dysfunction revealed that this group also had lower in-hospital mortality but similar length of stay, repeat hospital stay, and post-discharge mortality compared with that experienced by non–African-American patients (Figs. 4A and 4B).
Race as an independent predictor of quality of care
Additional multivariable analyses were performed to assess the association between African-American race and conformity with the American College of Cardiology/American Heart Association (ACC/AHA) performance measures and other quality indicators for patients hospitalized with HF. African-American race was independently associated with higher ACE inhibitor prescription and left ventricular function assessment; all other HF quality indicators were not influenced by race (Table 3).
The OPTIMIZE-HF is a registry-based performance improvement program that enables quality care for patients with HF through performance improvement tools and feedback on patient characteristics, treatments, quality measures, and clinical events. Our findings from this OPTIMIZE-HF analysis of African Americans with HF demonstrate that, among participating hospitals, provision of most but not all quality measures were similar to other races. Furthermore, when treated similarly, African-American patients have a lower risk-adjusted inpatient mortality but a similar adjusted 60- to 90-day post-discharge morbidity and mortality risk due to HF.
Process-of-care quality-improvement strategies represent one potential mechanism for addressing and reversing racial disparities in cardiovascular care and outcomes (21–23). The results of the current study suggest that process-of-care intervention programs might benefit African-American as much as non–African-American patients, with similar use of certain evidence-based therapies for HF. Importantly, within the context of a performance-improvement program, patient race did not influence the quality of HF care delivered. This is an important observation in light of recent findings suggesting that patients with HF or acute myocardial infarction treated at hospitals that disproportionately treat African-American patients are at high risk for adverse outcomes and lower quality of care (24,25). Although not designed to improve disparate health care, it is plausible that OPTIMIZE-HF or other similar performance improvement programs might represent a unique tool to address health care disparities in HF.
Given a higher cardiovascular risk profile as measured by several clinical variables, including a lower mean LVEF, higher BNP levels, and greater incidence of renal insufficiency, African-American patients in the OPTIMIZE-HF registry might have been expected to fare less well. However, African Americans with HF had lower rates of in-hospital mortality, regardless of systolic function. Although this might reflect the younger age of African-American patients, these findings persisted after multivariable adjustment, although the OR for in-hospital mortality moved from 0.49 to 0.71 after adjustment for observed covariates. Residual confounding by measured variables and confounding by unmeasured variables must still be considered in accounting for these observations. It is also notable that African-American patients hospitalized with HF were on average 11 years younger than non–African-American patients. This finding underscores the need for increased HF prevention efforts in this population. Uncertain differences in the pathophysiology of HF in African Americans remain a potential explanation for these differences in presentation and are perhaps driven by subtle biological differences including certain genomic variances (26).
Prior studies have shown higher rates of hospital stay in African Americans with HF, but the data on mortality rates have varied. Analysis of the SOLVD (Studies of Left Ventricular Dysfunction) treatment trial suggested that African Americans with chronic systolic dysfunction HF have increased mortality risk (5). Deswal et al. (27), examining 4,901 African-American and 17,093 Caucasian Veterans Affairs patients discharged from the hospital for HF, found a lower risk-adjusted OR for mortality at 30 days and 2 years in African Americans with similar readmission rates. A study of 29,372 Medicare beneficiaries hospitalized with HF in 1998 and 1999 also revealed higher repeat hospital stay rates but lower mortality in African-American patients compared with Caucasians (28). Because a substantial proportion of African-American patients hospitalized with HF are younger than 65 years of age, Medicare datasets might not be sufficient to characterize the demographic status, quality of care, and outcomes for this patient population.
The adequacy of medical therapy is often impugned as an explanation for racially disparate outcomes. In the OPTIMIZE-HF registry the differences between African-American and non–African-American patients cannot be explained by medication prescription, because appropriate evidence-based therapies were prescribed at similar levels at the time of hospital discharge. Actual medication compliance, however, might have impacted repeat hospital stays. African-American patients were less likely to receive complete discharge instructions and smoking cessation advice at discharge. Several studies have shown that pre-discharge programs that enhance patient education and consultation and conduct follow-up reminders for medical adherence are associated with fewer readmissions and with reductions in HF symptoms (29–31).
The OPTIMIZE-HF performance-improvement program was associated with remarkably high ACE inhibitor/ARB and beta-blocker prescription rates at hospital discharge, regardless of race. Notably, African Americans were more likely to be prescribed ACE inhibitors and ARBs than non–African Americans in this registry, and this might have been responsible in part for better inpatient and short-term outcomes in African Americans with HF than previously observed. In addition to ACE inhibitor usage, clinical trials and other registries have shown the importance of beta-blocker use in the African-American population with HF. In the community-based COHERE (Carvedilol Heart Failure Registry), carvedilol treatment produced similar results, reducing hospital stays, HF, and mortality in African-American and Caucasian patients (32). The most recent update of the ACC/AHA clinical practice guidelines for the management of chronic HF recommends that the African-American population receive the same application of evidence-based therapies as the general population (33). Our findings would support that statement. The A-HeFT (African-American Heart Failure Trial) study tested isosorbide dinitrate/hydralazine as adjunctive therapy for HF in African Americans and demonstrated a substantial 43% mortality benefit and a 33% reduction in hospital stays for HF over background therapy with ACE inhibitor/ARB and beta-blocker drugs (6). Despite these substantial benefits, only 4.5% of African Americans in the OPTIMIZE-HF registry were treated with isosorbide dinitrate/hydralazine. Recent guidelines from the Heart Failure Society of America give the adjunctive use of isosorbide dinitrate/hydralazine the highest-tier recommendation, with expectations that outcomes for African-American patients will improve with adherence to guideline-based care (34). Given the poor adoption of isosorbide dinitrate/hydralazine, further opportunities remain to improve care for African-American HF patients (6).
Although the OPTIMIZE-HF registry represents an opportunity to study HF patients in a real-world setting, there are several limitations to a registry-based study that call for careful interpretation of results. Data were collected by medical chart review and are dependent upon the accuracy and completeness of documentation and abstraction. Race was not a self-reported variable but rather was determined as that documented in the medical record, thus errors in racial determination could have occurred. Because of the large number of patients in the registry, some small differences that might be of little clinical relevance have p values indicating a high degree of statistical significance. These findings might not apply to hospitals that differ in patient characteristics or care patterns from OPTIMIZE-HF hospitals. The 60- to 90-day follow-up data are only in a subset of patients in the overall registry and might not be representative of the entire aggregate in the database. Medication use was as reported by patients and as documented in the medical record. Actual adherence rates might have been lower than reported, and compliance with medical therapy is not a certainty. Decreased compliance with medical therapy due to access of care issues affecting the African-American cohort might well have been a contributing factor to the readmission experiences noted in the OPTIMIZE-HF registry. Contraindications and intolerance were as documented in the medical record, but a proportion of patients reported to be eligible for treatment but not treated might have had contraindications or intolerance that were present but not documented. There were no direct measures of socioeconomic status or bias in OPTIMIZE-HF, thus the contribution of certain elements affecting similar or disparate health care can only be inferred but not proven with these data. This study was not a prospective randomized trial, and residual measured and unmeasured confounders might have influenced clinical outcomes. Prospective randomized studies will be required to further test the influence of performance-improvement programs on markers of health care disparities.
African-American HF patients, when exposed to a process-of-care improvement initiative, had better-than-previously observed treatment with evidence-based therapies. Furthermore, African-American HF patients when treated according to guidelines had similar or better outcomes compared with non–African-American patients. In adjusted analyses, patient race did not influence hospital-based delivery of high-quality care, as defined by current ACC/AHA HF performance measures. Further research is required to test the benefit of a performance-improvement program on narrowing evidence of health care disparities in African Americans with cardiovascular disease. In the interim, all appropriate evidence-based therapies should be employed to improve outcomes in all patients with HF. The OPTIMIZE-HF program suggests that an in-hospital process-of-care improvement program might help to achieve similar conformity with quality measures for African Americans with HF.
Dr. Yancy reported that he has received research grants from GlaxoSmithKline, Medtronic, NitroMed, and Scios, Inc. He is also a consultant or on the Speakers' Bureau for AstraZeneca, GlaxoSmithKline, Medtronic, NitroMed, Novartis, and Scios, Inc. He was previously on the advisory board for CHF Solutions. He currently serves on the Food and Drug Administration (FDA) cardiovascular device panel and study section for the National Institutes of Health (NIH). He has received honoraria from AstraZeneca, GlaxoSmithKline, Medtronic, Novartis, and Scios, Inc. He reports editorial board involvement for American Heart Journal, American Journal of Cardiology (Associate Editor), Circulation (Guest Editor), Congestive Heart Failure, Current Heart Failure Reports, Journal of Acute Cardiac Care, and Journal of Urban Cardiology. Dr. Abraham reported that he has received a research grant from Amgen, Biotronik, CHF Solutions, GlaxoSmithKline, HFSA, Medtronic, Myogen, NIH, Orqis Medical, Otsuka Maryland Research Institute, Paracor, and Scios, Inc. He is/has been a consultant/is on the Speakers' Bureau for Amgen, AstraZeneca, Boehringer-Ingelheim, CHF Solutions, GlaxoSmithKline, Guidant, Medtronic, Merck, Pfizer, ResMed, Respironics, Scios, Inc., and St. Jude Medical. He is on the advisory board of CardioKine, CardioKinetix Inc., CHF Solutions, Department of Veterans Affairs Cooperative Studies Program, Inovise, NIH, and Savacor, Inc. He has received honoraria from AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Guidant, Medtronic, Merck, Pfizer, ResMed, Respironics, Scios, Inc., and St. Jude Medical. He reports editorial board involvement with Congestive Heart Failure, Current Cardiology Reviews, Current Heart Failure Reports, Expert Review of Cardiovascular Therapy, Journal Watch Cardiology, PACE—Pacing and Clinical Electrophysiology, The American Heart Hospital Journal, and The Journal of Heart Failure. Dr. Albert reported that she is a consultant for GlaxoSmithKline and Medtronic. She is also on the Speakers' Bureau for GlaxoSmithKline, Medtronic, NitroMed, and Scios, Inc., and is employed by the Cleveland Clinic Foundation. She reports editorial board involvement for Progress in Cardiovascular Nursing (Senior Editor), Journal of Cardiovascular Nursing, and Critical Care Nurse. Mr. Clare is an employee of DCRI. Dr. Stough reported that she has received research grants from Actelion, GlaxoSmithKline, Medtronic, Otsuka, and Pfizer. She is a consultant or on the Speakers' Bureau for Abbott, AstraZeneca, GlaxoSmithKline, Medtronic, Novacardia, Otsuka, Protein Design Labs, RenaMed, Sigma Tau, and Scios, Inc. She has received honoraria from Abbott, AstraZeneca, GlaxoSmithKline, Medtronic, and Pfizer. Dr. Gheorghiade reported that he has received research grants from the NIH, Otsuka, Sigma Tau, Merck, and Scios, Inc. He is/has been a consultant for Debbio Pharm, Errekappa Terapeutici, GlaxoSmithKline, Protein Design Labs, and Medtronic. He has received honoraria from Abbott, AstraZeneca, GlaxoSmithKline, Medtronic, Otsuka, Protein Design Labs, Scios, Inc., and Sigma Tau. He reports editorial board involvement with Acute Cardiac Care Journal (Associate Editor), American Heart Journal, American Journal of Therapeutics (Associate Editor), Archives for Chest Disease (Associate Editor), Current Cardiology Reviews, Expert Review of Cardiovascular Therapy, Heart Disease: A Journal of Cardiovascular Medicine, Heart Failure Reviews, Heart International, Journal of Cardiac Failure, Journal of the American College of Cardiology, Italian Heart Journal, The American Journal of Cardiology, The Journal of Heart Disease, and The Journal of Heart Failure. Dr. Greenberg reported that he has received research grant support from Amgen, Cardiodynamics, GlaxoSmithKline, Millennium, Novacardia, Otsuka, Pfizer, Sanofi-Aventis, and Titan. He is on the Speakers' Bureau/is a consultant for Amgen, AstraZeneca, GlaxoSmithKline, Guidant Corp., Medtronic, Merck & Co., NitroMed, Pfizer, Remon Medical Technologies, and Scios, Inc. He has served on advisory boards for CHF Solutions, GlaxoSmithKline, and NitroMed. He has received honoraria from AstraZeneca, GlaxoSmithKline, Medtronic, Merck & Co., NitroMed, Novartis, Pfizer, and Scios, Inc. He reports editorial board involvement for Congestive Heart Failure and Journal of the American College of Cardiology. Dr. O'Connor reported that he has received research grant support from the NIH. He is on the Speakers' Bureau and/or a consultant for Amgen, AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Guidant, Medtronic, Merck, NitroMed, Novartis, Otsuka, Pfizer, and Scios, Inc. He has received honoraria from GlaxoSmithKline, Pfizer, and Otsuka. Dr. She is an employee of DCRI. Ms. Sun is an employee of DCRI. Dr. Young reported that he has received research grants from Abbott, Acorn, Amgen, Artesion Therapeutics, AstraZeneca, Biosite, GlaxoSmithKline, Guidant, Medtronic, MicroMed, NIH, Scios, Inc., Vasogen, and World Heart. He is a consultant for Abbott, Acorn, Amgen, Biomax Canada, Biosite, Boehringer-Ingelheim, Bristol-Myers Squibb, Cotherix, Edwards Lifescience, GlaxoSmithKline, Guidant, Medtronic, MicroMed, Novartis, Paracor, Proctor & Gamble, Protemix, Scios, Inc., Sunshine, Thoratec, Transworld Medical Corporation, Vasogen, Viacor, and World Heart. He reports editorial board involvement for Journal of Heart and Lung Transplantation, Evidence-Based Medicine, Journal of the American College of Cardiology, American Heart Journal, Cleveland Clinic Journal of Medicine, Cardiology Today, Graft, TheHeart.org, Transplantation and Immunology Letter, and American Society of Transplantation Newsletter. Dr. Fonarow reported that he has received research grants from Amgen, Biosite, Bristol-Myers Squibb, Boston Scientific/Guidant, GlaxoSmithKline, Medtronic, Merck, Pfizer, Sanofi-Aventis, Scios, Inc., and the NIH. He is/has been on the Speakers' Bureau or has received honoraria in the past 5 years from Amgen, AstraZeneca, Biosite, Bristol-Myers Squibb, Boston Scientific/Guidant, GlaxoSmithKline, Kos, Medtronic, Merck, NitroMed, Pfizer, Sanofi-Aventis, Schering-Plough, Scios, Inc., St. Jude Medical, Takeda, and Wyeth. He is or has been a consultant for Biosite, Bristol-Myers Squibb, Boston Scientific/Guidant, GlaxoSmithKline, Medtronic, Merck, NitroMed, Orqis Medical, Pfizer, Sanofi-Aventis, Schering-Plough, Scios, Inc., and Wyeth. He reports editorial board involvement with American Heart Journal, Circulation, Journal of Cardiac Failure, Journal of the American College of Cardiology, and Reviews of Cardiovascular Medicine.
For supplementary tables, please see the online version of this article.
GlaxoSmithKline funded both the OPTIMIZE-HF registry and this analysis of registry data. For full author disclosures, please see the end of this paper. John R. Teerlink, MD, served as Guest Editor for this article.
- Abbreviations and Acronyms
- American College of Cardiology/American Heart Association
- angiotensin-converting enzyme
- angiotensin receptor blocker
- B-type natriuretic peptide
- confidence interval
- heart failure
- left ventricular ejection fraction
- left ventricular systolic dysfunction
- odds ratio
- Received July 30, 2007.
- Revision received January 24, 2008.
- Accepted January 29, 2008.
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