Faculty Bibliography

IMPORTANCE/UNASSIGNED:Hypertension is often underrecognized, leading to preventable morbidity and mortality. Tailored data systems combined with care augmented by trained nonphysicians have the potential to improve cardiovascular care. OBJECTIVE/UNASSIGNED:To determine whether previously collected cardiovascular imaging data could be harnessed to improve the detection and treatment of hypertension through a system-level intervention. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:The NOTIFY-LVH trial was a 2-arm, pragmatic randomized clinical trial conducted from March 2023 through June 2024 within the Mass General Brigham health care system, a multi-institutional network serving the greater Boston, Massachusetts, area. The study included individuals with a Mass General Brigham primary care affiliation who had left ventricular hypertrophy (LVH) on a prior echocardiogram, had no established cardiomyopathy diagnosis, and were not being treated with antihypertensive medications. Patients were followed for 12 months postintervention. INTERVENTION/UNASSIGNED:Population health coordinators contacted clinicians of patients randomized to the intervention, notifying them of LVH and offering assistance with follow-up care. A clinical support pathway-including 24-hour ambulatory blood pressure monitoring or cardiology referrals-was provided to aid LVH evaluation. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the initiation of an antihypertensive medication. Secondary outcomes included new hypertension and cardiomyopathy diagnoses. RESULTS/UNASSIGNED:A total of 648 patients were randomized-326 to the intervention and 322 to the control. Mean (SD) patient age was 59.4 (10.8) years and 248 patients (38.3%) were female. A total of 102 patients (15.7%) had a baseline diagnosis of hypertension and 109 patients (20.1%) had a mean outpatient blood pressure of 130/80 mm Hg or higher. Over 12 months, 53 patients (16.3%) in the intervention arm were prescribed an antihypertensive medication vs 16 patients (5.0%) in the control arm (adjusted odds ratio [OR], 3.76; 95% CI, 2.09-6.75; P < .001). Individuals in the intervention group were also more likely to be diagnosed with hypertension (adjusted OR, 4.43; 95% CI, 2.36-8.33; P < .001). Cardiomyopathy diagnoses did not significantly differ between groups. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In the NOTIFY-LVH randomized clinical trial, a centralized population health coordinator-led notification and clinical support pathway for individuals with LVH on prior echocardiograms increased the initial treatment of hypertension. This work highlights the potential benefit of leveraging preexisting but potentially underutilized cardiovascular data to improve health care delivery through mechanisms augmenting the traditional ambulatory care system. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT05713916.

BACKGROUND:Results from national surveys indicate that many older adults reported delayed medical care during the acute phase of the COVID-19 pandemic, yet few studies have used objective data to characterize healthcare utilization among vulnerable older adults in that period. In this study, we characterized healthcare utilization during the acute pandemic phase (March 7-October 6, 2020) and examined risk factors for total disruption of care among older adults with multiple chronic conditions (MCC) in New York City. METHODS:This retrospective cohort study used electronic health record data from NYC patients aged ≥ 50 years with a diagnosis of either hypertension or diabetes and at least one other chronic condition seen within six months prior to pandemic onset and after the acute pandemic period at one of several major academic medical centers contributing to the NYC INSIGHT clinical research network (n=276,383). We characterized patients by baseline (pre-pandemic) health status using cutoffs of systolic blood pressure (SBP) < 140mmHg and hemoglobin A1C (HbA1c) < 8.0% as: controlled (below both cutoffs), moderately uncontrolled (below one), or poorly controlled (above both, SBP > 160, HbA1C > 9.0%). Patients were then assessed for total disruption versus some care during shutdown using recommended care schedules per baseline health status. We identified independent predictors for total disruption using logistic regression, including age, sex, race/ethnicity, baseline health status, neighborhood poverty, COVID infection, number of chronic conditions, and quartile of prior healthcare visits. RESULTS:Among patients, 52.9% were categorized as controlled at baseline, 31.4% moderately uncontrolled, and 15.7% poorly controlled. Patients with poor baseline control were more likely to be older, female, non-white and from higher poverty neighborhoods than controlled patients (P < 0.001). Having fewer pre-pandemic healthcare visits was associated with total disruption during the acute pandemic period (adjusted odds ratio [aOR], 8.61, 95% Confidence Interval [CI], 8.30-8.93, comparing lowest to highest quartile). Other predictors of total disruption included self-reported Asian race, and older age. CONCLUSIONS:This study identified patient groups at elevated risk for care disruption. Targeted outreach strategies during crises using prior healthcare utilization patterns and disease management measures from disease registries may improve care continuity.

BACKGROUND/UNASSIGNED:Digital health technologies have been proposed as a potential solution to improving maternal cardiovascular (CV) health in the postpartum (PP) period. In this context we performed a systematic scoping review of digital health interventions designed to improve PP CV health. METHODS/UNASSIGNED:We conducted a systematic review of PubMed/MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library. We included studies of PP women, with an intervention involving digital or mobile health (wearable devices, telemedicine, or remote monitoring). We included studies that measured an outcome related to CV health. RESULTS/UNASSIGNED:= 27 studies) showed no significant benefit in terms of lowered caloric intake and/or weight loss up to 1 year PP. 6 studies examined improvements in cardiometabolic markers such as lipids and glucose levels, of which the majority showed no benefit. CONCLUSION/UNASSIGNED:The majority of studies we reviewed found that digital health interventions such as mobile health, telemonitoring and wearable devices were feasible and had mixed effectiveness in improving postpartum CV health in the postpartum period.

BACKGROUND:Disruption of ambulatory healthcare in New York City (NYC) during the COVID-19 pandemic was common, but the impact on the cardiometabolic health of vulnerable patient groups is unknown. Therefore, we estimated the effect of total care disruption (TCD) on blood pressure (BP) control among older NYC residents with hypertension and at least one other chronic condition, and examined whether neighborhood poverty moderated this impact. METHODS:From the INSIGHT Clinical Research Network, we identified NYC residents ≥50 years of age with hypertension and at least one other chronic condition. TCD was defined as no ambulatory or telehealth visit during the pandemic. We contrasted the change in prevalence of controlled BP (BP <140/90) before and after the pandemic among those with and without TCD via an inverse probability weighted (IPW) difference-in-difference regression model. RESULTS:Among 212,673 eligible individuals, mean age was 69.5 years (SD: 10.2 years) and 15.1% experienced TCD. BP control declined from 52.4% to 45.9% among those with TCD and from 53.6% to 48.9% among those without TCD. After IPW adjustment, a larger decline in BP control was noted among those with TCD (adjusted difference-in-difference = 1.13 percentage points (95% CI 0.32-1.94, p-value=0.0058)). There was no consistent difference in the relationship between TCD and post-pandemic BP control across neighborhood poverty levels. CONCLUSION/CONCLUSIONS:COVID-19-related TCD was associated with a modest decline in BP control among older adults with hypertension in NYC; this was not moderated by neighborhood poverty level.

IMPORTANCE/UNASSIGNED:Among older adults with ischemic heart disease, participation in traditional ambulatory cardiac rehabilitation (CR) remains low. While mobile health CR (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments to technology use may limit uptake, and efficacy data are currently lacking. OBJECTIVE/UNASSIGNED:To test whether mHealth-CR improves functional capacity in older adults. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:The RESILIENT phase 2, multicenter, randomized clinical trial recruited patients aged 65 years or older with ischemic heart disease (defined as a hospital visit for myocardial infarction or coronary revascularization) from 5 academic hospitals in New York, Connecticut, and Massachusetts between January 9, 2020, and April 22, 2024. INTERVENTION/UNASSIGNED:Participants were randomized 3:1 to mHealth-CR or usual care. mHealth-CR consisted of commercially available software delivered on a tablet computer, coupled with remote monitoring and weekly exercise therapist telephone calls, delivered over a 3-month duration. As RESILIENT was a trial conducted in a routine care setting to inform decision-making, participants in both arms were also allowed to receive traditional CR at their cardiologist's discretion. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was change from baseline to 3 months in functional capacity, measured by 6-minute walk distance (6MWD). Secondary outcomes were health status (12-Item Short Form Health Survey [SF-12]), residual angina, and impairment in activities of daily living. RESULTS/UNASSIGNED:A total of 400 participants (median age, 71.0 years [range, 65.0-91.0 years]; 291 [72.8%] male) were randomized to mHealth-CR (n = 298) or usual care (n = 102) and included in the intention-to-treat analysis. Of those, 356 participants (89.0%) returned in person for 6MWD assessment at 3 months. For the primary outcome, there was no adjusted difference in 6MWD between participants receiving mHealth-CR vs usual care (15.6 m; 95% CI, -0.3 to 31.5 m; P = .06). Among subgroups, there was an improvement in 6MWD among women (36.6 m; 95% CI, 8.7-64.4 m). There were no differences in any secondary outcomes between groups (eg, adjusted difference in SF-12 physical component scores at 3 months: -1.9 points; 95% CI, -3.9 to 0.2 points). Based on inverse propensity score weighting, there was no effect of mHealth-CR on 6MWD among those who did not attend traditional CR (25.7 m; 95% CI, -8.7 to 60.2 m). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this randomized clinical trial of mHealth-CR vs usual care, mHealth-CR did not significantly increase 6MWD or result in improvements in secondary outcomes. The findings suggest the older adult population may require more age-tailored mHealth strategies to effectively improve outcomes. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03978130.

PURPOSE/OBJECTIVE:Cardiac rehabilitation (CR) is beneficial in heart transplant and left ventricular assist device (LVAD) recipients, but patterns of attendance remain poorly understood. We describe CR adherence and cessation in this population. METHODS:We performed a retrospective review of heart transplant and LVAD recipients who attended ≥1 CR session at a tertiary medical center (2013-2022). Complete adherence was defined as attending 36 sessions. Primary reasons for cessation before 36 sessions were recorded. We compared post-operative complications, duration of hospitalization, and readmissions between participants with and without complete adherence using logistic and linear regressions. Among participants with complete adherence, we compared changes in metabolic equivalent of task (MET), exercise time, and peak oxygen uptake using paired sample t tests. RESULTS:There were 137 heart transplant and LVAD recipients (median age 56.9 years, 74% male) who attended CR. Among them, 91% either completed 36 CR sessions or <24 sessions. Among those without complete adherence (n = 74), 72% reported medical reasons, and 15% reported personal reasons for cessation. Compared to those who completed CR, those without complete adherence experienced more post-operative complications (44% vs 24%, P = .02) and major bleeding (23% vs 7%, P = .02) prior to CR. Participants with complete adherence experienced significant improvements in exercise time (142.5 seconds), MET (0.4), and peak oxygen uptake (1.4 mL/kg/min). CONCLUSIONS:Nearly half of heart transplant and LVAD recipients in CR completed all 36 sessions. Those with complete adherence experienced significant improvements in exercise measures, underscoring the important benefits of CR in this population.

PURPOSE/OBJECTIVE:Hypertension (HTN) is common and represents a major modifiable risk factor for ischemic heart disease in older adults. While home blood pressure monitoring (HBPM) is important in HTN management, patterns of HBPM engagement in older adults undergoing mobile health cardiac rehabilitation (mHealth-CR) are unknown. We aimed to identify patterns of adherence to HBPM in a cohort of older adults undergoing mHealth-CR to optimize HBPM use in the future. METHODS:We used interim data from the ongoing Rehabilitation using Mobile Health for Older Adults with Ischemic Heart Disease in the Home Setting (RESILIENT) randomized trial, in which intervention arm participants (adults ≥ 65 years with ischemic heart disease) were instructed to monitor blood pressure (BP) at least weekly. Engagement groups were determined by latent class analysis and compared using ANOVA or Chi-Square tests. Longitudinal mixed effect modeling determined the associations between weekly HBPM and baseline covariates including uncontrolled HTN, obesity, diabetes, depression, alcohol, and tobacco use. RESULTS:Of the 111 participants, the mean age was 71.9 ± 5.6 years, and 83% had HTN. Over the 12-week study, mean HBPM engagement was 2.3 ± 2.3 d/wk. We observed 3 distinct patterns of engagement: high engagement (22%), gradual decline (10%), and sustained baseline engagement (68%). HBPM adherence decreased in two of the engagement groups over time. Of the covariates tested, only depression was associated with weekly HBPM after adjusting for relevant covariates (OR 9.09, P  = .03). CONCLUSIONS:In this older adult cohort undergoing mHealth-CR, we found three main engagement groups with declining engagement over time in two of the three groups. These patterns can inform future mHealth-CR interventions.

Ensuring reliability of Large Language Models (LLMs) in clinical tasks is crucial. Our study assesses two state-of-the-art LLMs (ChatGPT and LlaMA-2) for extracting clinical information, focusing on cognitive tests like MMSE and CDR. Our data consisted of 135,307 clinical notes (Jan 12th, 2010 to May 24th, 2023) mentioning MMSE, CDR, or MoCA. After applying inclusion criteria 34,465 notes remained, of which 765 underwent ChatGPT (GPT-4) and LlaMA-2, and 22 experts reviewed the responses. ChatGPT successfully extracted MMSE and CDR instances with dates from 742 notes. We used 20 notes for fine-tuning and training the reviewers. The remaining 722 were assigned to reviewers, with 309 each assigned to two reviewers simultaneously. Inter-rater-agreement (Fleiss' Kappa), precision, recall, true/false negative rates, and accuracy were calculated. Our study follows TRIPOD reporting guidelines for model validation. For MMSE information extraction, ChatGPT (vs. LlaMA-2) achieved accuracy of 83% (vs. 66.4%), sensitivity of 89.7% (vs. 69.9%), true-negative rates of 96% (vs 60.0%), and precision of 82.7% (vs 62.2%). For CDR the results were lower overall, with accuracy of 87.1% (vs. 74.5%), sensitivity of 84.3% (vs. 39.7%), true-negative rates of 99.8% (98.4%), and precision of 48.3% (vs. 16.1%). We qualitatively evaluated the MMSE errors of ChatGPT and LlaMA-2 on double-reviewed notes. LlaMA-2 errors included 27 cases of total hallucination, 19 cases of reporting other scores instead of MMSE, 25 missed scores, and 23 cases of reporting only the wrong date. In comparison, ChatGPT's errors included only 3 cases of total hallucination, 17 cases of wrong test reported instead of MMSE, and 19 cases of reporting a wrong date. In this diagnostic/prognostic study of ChatGPT and LlaMA-2 for extracting cognitive exam dates and scores from clinical notes, ChatGPT exhibited high accuracy, with better performance compared to LlaMA-2. The use of LLMs could benefit dementia research and clinical care, by identifying eligible patients for treatments initialization or clinical trial enrollments. Rigorous evaluation of LLMs is crucial to understanding their capabilities and limitations.

BACKGROUND:Because of advances in medical treatment of heart failure, patients are living longer than in previous eras and may approach the need for advanced therapies, including heart transplantation, at older ages. This study assesses practices surrounding heart transplant in older adults (> 70 years) and examines short- and medium-term outcomes. METHODS AND RESULTS/RESULTS:This study is a retrospective analysis using the United Network for Organ Sharing (UNOS) database from 2010 to 2021. The absolute number of older adults being transplanted is increasing. Older adults were more likely to have had a prior malignancy or ischemic cardiomyopathy and less likely to be on extra-corporeal membrane oxygenation or have a high UNOS status prior to transplant. Mortality at 1-year was higher for older adults (27.8% vs. 23.4%), but at 5 years there was no significant difference (22.3% vs. 19.4%.). Older adults were more likely to die of malignancy or infection. Adults under 70 were more likely to die of cardiovascular causes or graft failure. There was less rejection in older adults. Mortality has not changed for older adults transplanted before versus after the 2018 UNOS allocation change. CONCLUSIONS:Carefully selected older adults may be considered for heart transplantation, given similar intermediate-term mortality.