Browsing by Author "Giczewska, Anna"

Now showing 1 - 4 of 4
  • Thumbnail Image
    ItemOpen Access
    Association Between Age and Outcomes of Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: Results From the CABANA Trial.
    (Circulation, 2022-03) Bahnson, Tristram D; Giczewska, Anna; Mark, Daniel B; Russo, Andrea M; Monahan, Kristi H; Al-Khalidi, Hussein R; Silverstein, Adam P; Poole, Jeanne E; Lee, Kerry L; Packer, Douglas L; CABANA Investigators

    Background

    Observational data suggest that catheter ablation may be safe and effective to treat younger and older patients with atrial fibrillation. No large, randomized trial has examined this issue. This report describes outcomes according to age at entry in the CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation).

    Methods

    Patients with atrial fibrillation ≥65 years of age, or <65 with ≥1 risk factor for stroke, were randomly assigned to catheter ablation versus drug therapy. The primary outcome was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Secondary outcomes included all-cause mortality, the composite of mortality or cardiovascular hospitalization, and recurrence of atrial fibrillation. Treatment effect estimates were adjusted for baseline covariables using proportional hazards regression models.

    Results

    Of 2204 patients randomly assigned in CABANA, 766 (34.8%) were <65 years of age, 1130 (51.3%) were 65 to 74 years of age, and 308 (14.0%) were ≥75 years of age. Catheter ablation was associated with a 43% reduction in the primary outcome for patients <65 years of age (adjusted hazard ratio [aHR], 0.57 [95% CI, 0.30-1.09]), a 21% reduction for 65 to 74 years of age (aHR, 0.79 [95% CI, 0.54-1.16]), and an indeterminate effect for age ≥75 years of age (aHR, 1.39 [95% CI, 0.75-2.58]). Four-year event rates for ablation versus drug therapy across age groups, respectively, were 3.2% versus 7.8%, 7.8% versus 9.6%, and 14.8% versus 9.0%. For every 10-year increase in age, the primary outcome aHR increased (ie, less favorable to ablation) an average of 27% (interaction P value=0.215). A similar pattern was seen with all-cause mortality: for every 10-year increase in age, the aHR increased an average of 46% (interaction P value=0.111). Atrial fibrillation recurrence rates were lower with ablation than with drug therapy across age subgroups (aHR 0.47, 0.58, and 0.49, respectively). Treatment-related complications were infrequent for both arms (<3%) regardless of age.

    Conclusions

    We found age-based variations in clinical outcomes for catheter ablation compared with drug therapy, with the largest relative and absolute benefits of catheter ablation in younger patients. No prognostic benefits for ablation were seen in the oldest patients. No differences were found by age in treatment-related complications or in the relative effectiveness of catheter ablation in preventing recurrent atrial arrhythmias.

    Registration

    URL: https://www.

    Clinicaltrials

    gov; Unique identifier: NCT00911508.
  • Thumbnail Image
    ItemOpen Access
    Association Between Sex and Treatment Outcomes of Atrial Fibrillation Ablation Versus Drug Therapy: Results From the CABANA Trial.
    (Circulation, 2021-02) Russo, Andrea M; Zeitler, Emily P; Giczewska, Anna; Silverstein, Adam P; Al-Khalidi, Hussein R; Cha, Yong-Mei; Monahan, Kristi H; Bahnson, Tristram D; Mark, Daniel B; Packer, Douglas L; Poole, Jeanne E; CABANA Investigators

    Background

    Among patients with atrial fibrillation (AF), women are less likely to receive catheter ablation and may have more complications and less durable results. Most information about sex-specific differences after ablation comes from observational data. We prespecified an examination of outcomes by sex in the 2204-patient CABANA trial (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation).

    Methods

    CABANA randomized patients with AF age ≥65 years or <65 years with ≥1 risk factor for stroke to a strategy of catheter ablation with pulmonary vein isolation versus drug therapy with rate/rhythm control agents. The primary composite outcome was death, disabling stroke, serious bleeding, or cardiac arrest, and key secondary outcomes included AF recurrence.

    Results

    CABANA randomized 819 (37%) women (ablation 413, drug 406) and 1385 men (ablation 695, drug 690). Compared with men, women were older (median age, 69 years versus 67 years for men), were more symptomatic (48% Canadian Cardiovascular Society AF Severity Class 3 or 4 versus 39% for men), had more symptomatic heart failure (42% with New York Heart Association Class ≥II versus 32% for men), and more often had a paroxysmal AF pattern at enrollment (50% versus 39% for men) (P<0.0001 for all). Women were less likely to have ancillary (nonpulmonary vein) ablation procedures performed during the index procedure (55.7% versus 62.2% in men, P=0.043), and complications from treatment were infrequent in both sexes. For the primary outcome, the hazard ratio for those who underwent ablation versus drug therapy was 1.01 (95% CI, 0.62-1.65) in women and 0.73 (95% CI, 0.51-1.05) in men (interaction P value=0.299). The risk of recurrent AF was significantly reduced in patients undergoing ablation compared with those receiving drug therapy regardless of sex, but the effect was greater in men (hazard ratio, 0.64 [95% CI, 0.51-0.82] for women versus hazard ratio, 0.48 [95% CI, 0.40-0.58] for men; interaction P value=0.060).

    Conclusions

    Clinically relevant treatment-related strategy differences in the primary and secondary clinical outcomes of CABANA were not seen between men and women, and there were no sex differences in adverse events. The CABANA trial results support catheter ablation as an effective treatment strategy for both women and men. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00911508.
  • Thumbnail Image
    ItemOpen Access
    Prevalence and predictors of no-shows to physical therapy for musculoskeletal conditions.
    (PloS one, 2021-01) Bhavsar, Nrupen A; Doerfler, Shannon M; Giczewska, Anna; Alhanti, Brooke; Lutz, Adam; Thigpen, Charles A; George, Steven Z

    Objectives

    Chronic pain affects 50 million Americans and is often treated with non-pharmacologic approaches like physical therapy. Developing a no-show prediction model for individuals seeking physical therapy care for musculoskeletal conditions has several benefits including enhancement of workforce efficiency without growing the existing provider pool, delivering guideline adherent care, and identifying those that may benefit from telehealth. The objective of this paper was to quantify the national prevalence of no-shows for patients seeking physical therapy care and to identify individual and organizational factors predicting whether a patient will be a no-show when seeking physical therapy care.

    Design

    Retrospective cohort study.

    Setting

    Commercial provider of physical therapy within the United States with 828 clinics across 26 states.

    Participants

    Adolescent and adult patients (age cutoffs: 14-117 years) seeking non-pharmacological treatment for musculoskeletal conditions from January 1, 2016, to December 31, 2017 (n = 542,685). Exclusion criteria were a primary complaint not considered an MSK condition or improbable values for height, weight, or body mass index values. The study included 444,995 individuals.

    Primary and secondary outcome measures

    Prevalence of no-shows for musculoskeletal conditions and predictors of patient no-show.

    Results

    In our population, 73% missed at least 1 appointment for a given physical therapy care episode. Our model had moderate discrimination for no-shows (c-statistic:0.72, all appointments; 0.73, first 7 appointments) and was well calibrated, with predicted and observed no-shows in good agreement. Variables predicting higher no-show rates included insurance type; smoking-status; higher BMI; and more prior cancellations, time between visit and scheduling date, and between current and previous visit.

    Conclusions

    The high prevalence of no-shows when seeking care for musculoskeletal conditions from physical therapists highlights an inefficiency that, unaddressed, could limit delivery of guideline-adherent care that advocates for earlier use of non-pharmacological treatments for musculoskeletal conditions and result in missed opportunities for using telehealth to deliver physical therapy.
  • Thumbnail Image
    ItemOpen Access
    Ultrafiltration in Acute Heart Failure: Implications of Ejection Fraction and Early Response to Treatment From CARRESS-HF.
    (Journal of the American Heart Association, 2020-12-08) Fudim, Marat; Brooksbank, Jeremy; Giczewska, Anna; Greene, Stephen J; Grodin, Justin L; Martens, Pieter; Ter Maaten, Jozine M; Sharma, Abhinav; Verbrugge, Frederik H; Chakraborty, Hrishikesh; Bart, Bradley A; Butler, Javed; Hernandez, Adrian F; Felker, G Michael; Mentz, Robert J
    Background Ultrafiltration is not commonly used because of higher incidence of worsening renal function without improved decongestion. We examined differential outcomes of high versus low fluid removal and preserved versus reduced ejection fraction (EF) in CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure). Methods and Results Baseline characteristics in the ultrafiltration arm were compared according to 24-hour ultrafiltration-based fluid removal above versus below the median. Patients were stratified by EF (≤40% or >40%). We compared clinical parameters of clinical decongestion during the hospitalization based on initial (≤24 hours) response to ultrafiltration. Cox-proportional hazards models were used to identify associations between fluid removal <24 hours and composite of death, hospitalization, or unscheduled outpatient/emergency department visit during study follow-up. The intention-to-treat analysis included 93 patients. Within 24 hours, median fluid removal was 1.89 L (Q1, Q3: 1.22, 3.16). The high fluid removal group had a greater urine output (9.08 versus 6.23 L, P=0.027) after 96 hours. Creatinine change from baseline to 96 hours was similar in both groups (0.10 mg/dL increase, P=0.610). The EF >40% group demonstrated larger increases of change in creatinine (P=0.023) and aldosterone (P=0.038) from baseline to 96 hours. Among patients with EF >40%, those with above median fluid removal (n=17) when compared with below median (n=17) had an increased rate of the combined end point (87.5% versus 47.1%, P=0.014). Conclusions In patients with acute heart failure, higher initial fluid removal with ultrafiltration had no association with worsening renal function. In patients with EF >40%, ultrafiltration was associated with worsening renal function irrespective of fluid removal rate and higher initial fluid removal was associated with higher rates of adverse clinical outcomes, highlighting variable responses to decongestive therapy.