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This study exploited both the magic of randomization and generalizability of real-world data by linking the patient-level data from the DAPT trial with real-world registry data. However, in subgroup analyses in reweighted data from patients with DAPT score >=2, the significant reduction in stent thrombosis in the group receiving prolonged DAPT was retained without significant impact on bleeding. A new strategy for discontinuation of dual antiplatelet therapy: the RESET Trial (REal Safety and Efficacy of 3-month dual antiplatelet Therapy following Endeavor zotarolimus-eluting stent implantation). [Extracted from the article]

Keywords: angiotensin receptor antagonists; drug recalls; drug utilization; health services research; hypertension EN angiotensin receptor antagonists drug recalls drug utilization health services research hypertension 411 413 3 04/20/20 20200204 NES 200204 On July 9, 2018, Health Canada announced a voluntary recall of 6 generic valsartan products because a known carcinogen N-nitrosodimethylamine was detected.[1] In total, more than 22 countries, including the United States, initiated recalls. Before the recall, 0.11% of the cohort had ED visits for hypertension per month, with no monthly change in the rate of ED visits for hypertension before the recall ( I P i =0.68). Angiotensin receptor antagonists, drug recalls, drug utilization, health services research, hypertension. [Extracted from the article]

Background--During the past decade, efforts focused intensely on improving the quality of care for people with, or at risk for, cardiovascular disease and stroke. We sought to quantify the changes in hospitalization rates and outcomes during this period. Methods and Results--We used national Medicare data to identify all Fee-for-Service patients ≥65 years of age who were hospitalized with unstable angina, myocardial infarction, heart failure, ischemic stroke, and all other conditions from 1999 through 2011 (2010 for 1-year mortality). For each condition, we examined trends in adjusted rates of hospitalization per patient-year and, for each hospitalization, rates of 30-day mortality, 30-day readmission, and 1-year mortality overall and by demographic subgroups and regions. Rates of adjusted hospitalization declined for cardiovascular conditions (38.0% for 2011 compared with 1999 [95% confidence interval (Cl), 37.2-38.8] for myocardial infarction, 83.8% [95% Cl, 83.3-84.4] for unstable angina, 30.5% [95% Cl, 29.3-31.6] for heart failure, and 33.6% [95% Cl, 32.9-34.4] for ischemic stroke compared with 10.2% [95% Cl, 10.1-10.2] for all other conditions). Adjusted 30-day mortality rates declined 29.4% (95% Cl, 28.1-30.6) for myocardial infarction, 13.1% (95% Cl, 1.1-23.7) for unstable angina, 16.4% (95% Cl, 15.1-17.7) for heart failure, and 4.7% (95% Cl, 3.0-6.4) for ischemic stroke. There were also reductions in rates o f 1-year mortality and 30-day readmission and consistency in declines among the demographic subgroups. Conclusions--Hospitalizations for acute cardiovascular disease and stroke from 1999 through 2011 declined more rapidly than for other conditions. For these conditions, mortality and readmission outcomes improved. [ABSTRACT FROM AUTHOR]

Background-Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know whether improvements in door-to-balloon times were shared equally among patient and hospital groups. Methods and Results-This analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention (acute myocardial infarction-8) inpatient measure from January 1, 2005, through September 30, 2010. For each calendar year, we summarized the characteristics of patients reported for the measure, including the number and percentage in each group, the median time to primary percutaneous coronary intervention, and the percentage with time to primary percutaneous coronary intervention within 75 minutes and within 90 minutes. Door-to-balloon time declined from a median of 96 minutes in the year ending December 31, 2005, to a median of 64 minutes in the 3 quarters ending September 30, 2010. There were corresponding increases in the percentage of patients who had times <90 minutes (44.2% to 91.4%) and <75 minutes (27.3% to 70.4%). The declines in median times were greatest among groups that had the highest median times during the first period: patients >75 years of age (median decline, 38 minutes), women (35 minutes), and blacks (42 minutes). Conclusion-National progress has been achieved in the timeliness of treatment of patients with ST-segment-elevation myocardial infarction who undergo primary percutaneous coronary intervention. [ABSTRACT FROM AUTHOR]

Background: In the past 2 decades, hypertension control in the US population has not improved and there are widening disparities. Little is known about progress in reducing hospitalizations for acute hypertension.Methods: We conducted serial cross-sectional analysis of Medicare fee-for-service beneficiaries age 65 years or older between 1999 and 2019 using Medicare denominator and inpatient files. We evaluated trends in national hospitalization rates for acute hypertension overall and by demographic and geographical subgroups. We identified all beneficiaries admitted with a primary discharge diagnosis of acute hypertension on the basis of International Classification of Diseases codes. We then used a mixed effects model with a Poisson link function and state-specific random intercepts, adjusting for age, sex, race and ethnicity, and dual-eligible status, to evaluate trends in hospitalizations.Results: The sample consisted of 397 238 individual Medicare fee-for-service beneficiaries. From 1999 through 2019, the annual hospitalization rates for acute hypertension increased significantly, from 51.5 to 125.9 per 100 000 beneficiary-years; the absolute increase was most pronounced among the following subgroups: adults ≥85 years (66.8-274.1), females (64.9-160.1), Black people (144.4-369.5), and Medicare/Medicaid insured (dual-eligible, 93.1-270.0). Across all subgroups, Black adults had the highest hospitalization rate in 2019, and there was a significant increase in the differences in hospitalizations between Black and White people from 1999 to 2019. Marked geographic variation was also present, with the highest hospitalization rates in the South. Among patients hospitalized for acute hypertension, the observed 30-day and 90-day all-cause mortality rates (95% CI) decreased from 2.6% (2.27-2.83) and 5.6% (5.18-5.99) to 1.7% (1.53-1.80) and 3.7% (3.45-3.84) and 30-day and 90-day all-cause readmission rates decreased from 15.7% (15.1-16.4) and 29.4% (28.6-30.2) to 11.8% (11.5-12.1) and 24.0% (23.5-24.6).Conclusions: Among Medicare fee-for-service beneficiaries age 65 years or older, hospitalization rates for acute hypertension increased substantially and significantly from 1999 to 2019. Black adults had the highest hospitalization rate in 2019 across age, sex, race and ethnicity, and dual-eligible strata. There was significant national variation, with the highest rates generally in the South. [ABSTRACT FROM AUTHOR]

BACKGROUND: Left ventricular (LV) systolic dysfunction is associated with a >8-fold increased risk of heart failure and a 2-fold risk of premature death. The use of ECG signals in screening for LV systolic dysfunction is limited by their availability to clinicians. We developed a novel deep learning-based approach that can use ECG images for the screening of LV systolic dysfunction. METHODS: Using 12-lead ECGs plotted in multiple different formats, and corresponding echocardiographic data recorded within 15 days from the Yale New Haven Hospital between 2015 and 2021, we developed a convolutional neural network algorithm to detect an LV ejection fraction <40%. The model was validated within clinical settings at Yale New Haven Hospital and externally on ECG images from Cedars Sinai Medical Center in Los Angeles, CA; Lake Regional Hospital in Osage Beach, MO; Memorial Hermann Southeast Hospital in Houston, TX; and Methodist Cardiology Clinic of San Antonio, TX. In addition, it was validated in the prospective Brazilian Longitudinal Study of Adult Health. Gradient-weighted class activation mapping was used to localize class-discriminating signals on ECG images. RESULTS: Overall, 385 601 ECGs with paired echocardiograms were used for model development. The model demonstrated high discrimination across various ECG image formats and calibrations in internal validation (area under receiving operation characteristics [AUROCs], 0.91; area under precision-recall curve [AUPRC], 0.55); and external sets of ECG images from Cedars Sinai (AUROC, 0.90 and AUPRC, 0.53), outpatient Yale New Haven Hospital clinics (AUROC, 0.94 and AUPRC, 0.77), Lake Regional Hospital (AUROC, 0.90 and AUPRC, 0.88), Memorial Hermann Southeast Hospital (AUROC, 0.91 and AUPRC 0.88), Methodist Cardiology Clinic (AUROC, 0.90 and AUPRC, 0.74), and Brazilian Longitudinal Study of Adult Health cohort (AUROC, 0.95 and AUPRC, 0.45). An ECG suggestive of LV systolic dysfunction portended >27-fold higher odds of LV systolic dysfunction on transthoracic echocardiogram (odds ratio, 27.5 [95% CI, 22.3-33.9] in the held-out set). Class-discriminative patterns localized to the anterior and anteroseptal leads (V2 and V3), corresponding to the left ventricle regardless of the ECG layout. A positive ECG screen in individuals with an LV ejection fraction =40% at the time of initial assessment was associated with a 3.9-fold increased risk of developing incident LV systolic dysfunction in the future (hazard ratio, 3.9 [95% CI, 3.3-4.7]; median follow-up, 3.2 years). CONCLUSIONS: We developed and externally validated a deep learning model that identifies LV systolic dysfunction from ECG images. This approach represents an automated and accessible screening strategy for LV systolic dysfunction, particularly in low-resource settings. [ABSTRACT FROM AUTHOR]

Background: There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care.Methods: This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply.Results: Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]).Conclusions: Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes. [ABSTRACT FROM AUTHOR]

The article discusses a study by N.B. Allen and colleagues, published within the issue, which introduces a way for cost estimates for policymakers to make decisions on potential benefits of optimal cardiovascular health (CVH) in terms of reduced healthcare consumption. Topics include authors' finding of a delay in mortality risk due to optimal CVH; limitations of the study in terms of components of resource utilization; and importance of sustainable investments in primordial prevention.

Background--Acute kidney injury (AKI) after cardiac surgery is associated with poor outcomes and is difficult to predict. We conducted a prospective study to evaluate whether preoperative brain natriuretic peptide (BNP) levels predict postoperative AKI among patients undergoing cardiac surgery. ethods and Results--The Translational Research Investigating Biomarker Endpoints in Acute Kidney Injury (TRIBE-AKI) study enrolled 1139 adults undergoing cardiac surgery at 6 hospitals from 2007 to 2009 who were selected for high AKI risk. Preoperative BNP was categorized into quintiles. AKI was common with the use of Acute Kidney Injury Network definitions; at least mild AKI was a >0.3-mg/dL or 50% rise in creatinine (n=407, 36%), and severe AKI was either a doubling of creatinine or the requirement of acute renal replacement therapy (n=58, 5.1%). In analyses adjusted for preoperative characteristics, preoperative BNP was a strong and independent predictor of mild and severe AKI. Compared with the lowest BNP quintile, the highest quintile had significantly higher risk of at least mild AKI (risk ratio, 1.87; 95% confidence interval, 1.40-2.49) and severe AKI (risk ratio, 3.17; 95% confidence interval, 1.06-9.48). After adjustment for clinical predictors, the addition of BNP improved the area under the curve to predict at least mild AKI (0.67-0.69; P=0.02) and severe AKI (0.73-0.75; P=0.11). Compared with clinical parameters alone, BNP modestly improved risk prediction of AKI cases into lower and higher risk (continuous net reclassification index; at least mild AKI: risk ratio, 0.183; 95% confidence interval, 0.061-0.314; severe AKI: risk ratio, 0.231; 95% confidence interval, 0.067-0.506). onclusions--Preoperative BNP level is associated with postoperative AKI in high-risk patients undergoing cardiac-surgery. If confirmed in other types of patients and surgeries, preoperative BNP may be a valuable component of future efforts to improve preoperative risk stratification and discrimination among surgical candidates. [ABSTRACT FROM AUTHOR]

Background: Medication nonadherence is associated with worse outcomes in patients with atherosclerotic cardiovascular disease (ASCVD), a group who requires long-term therapy for secondary prevention. It is important to understand to what extent drug costs, which are potentially actionable factors, contribute to medication nonadherence.Methods: In a nationally representative survey of US adults in the National Health Interview Survey (2013-2017), we identified individuals ≥18 years with a reported history of ASCVD. Participants were considered to have experienced cost-related nonadherence (CRN) if in the preceding 12 months they reported skipping doses to save money, taking less medication to save money, or delaying filling a prescription to save money. We used survey analysis to obtain national estimates.Results: Of the 14 279 surveyed individuals with ASCVD, a weighted 12.6% (or 2.2 million [95% CI, 2.1-2.4]) experienced CRN, including 8.6% or 1.5 million missing doses, 8.8% or 1.6 million taking lower than prescribed doses, and 10.5% or 1.9 million intentionally delaying a medication fill to save costs. Age <65 years, female sex, low family income, lack of health insurance, and high comorbidity burden were independently associated with CRN, with >1 in 5 reporting CRN in these subgroups. Survey respondents with CRN compared with those without CRN had 10.8-fold higher odds of requesting low-cost medications and 8.9-fold higher odds of using alternative, nonprescription, therapies.Conclusions: One in 8 patients with ASCVD reports nonadherence to medications because of cost. The removal of financial barriers to accessing medications, particularly among vulnerable patient groups, may help improve adherence to essential therapy to reduce ASCVD morbidity and mortality. [ABSTRACT FROM AUTHOR]

Introduction: Access to high-quality health care for young women with acute myocardial infarction (AMI) lags behind that of men. Whether access to care varies based on the health care system remains unknown. We evaluated sex differences in pre-AMI access to care in young patients with AMI across countries. Methods: We utilized data from the GENESIS-PRAXY and VIRGO cohorts, which included young (< 55 yrs) AMI patients hospitalized in countries with public (Canada, Spain, Australia) or private (United States [US], Switzerland) health care systems (2009-13). We collected data on demographics, CV risk, and psychosocial factors. Pre-AMI access to care was defined as: having a primary health care provider, difficulties in access to primary/specialist care, primary health care visits/diagnostic tests for cardiac symptoms (12 months prior to AMI). Sex-stratified analysis by health care system was performed. Results: Among 4,689 AMI patients (58% women, mean age 47±6 yrs), 64% were from the US and 22% from Canada. Compared with men, women had more CV risk factors, higher rates of depression/stress and lower socioeconomic status (SES) (Table); more strikingly in the US. Across countries, 70% of patients had a primary health care provider. However, women experienced more difficulties accessing primary (21% vs. 15%) or specialist care (27% vs. 20%, all p<.001) versus men. Women in the US reported cost barriers (47% vs. 5%), whereas women from other countries had difficulties in contacting primary health care providers (91% vs. 46%, all p<.001). Nevertheless, compared with men, women reported more primary health care provider visits (46% vs. 37%) and tests for cardiac symptoms (66% vs. 50%), regardless of health care system. Conclusions: In both public and privately funded health care systems, one-fifth of young AMI patients had poor pre-AMI access to care, despite a high-risk factor burden - especially among women in the US. Young women of low SES should be targeted for primary prevention. [ABSTRACT FROM AUTHOR]

Background: Noninferiority trials are increasingly being performed. However, little is known about their methodological quality. We sought to characterize noninferiority cardiovascular trials published in the highest-impact journals, features that may bias results toward noninferiority, features related to reporting of noninferiority trials, and the time trends.Methods: We identified cardiovascular noninferiority trials published in JAMA, Lancet, or New England Journal of Medicine from 1990 to 2016. Two independent reviewers extracted the data. Data elements included the noninferiority margin and the success of studies in achieving noninferiority. The proportion of trials showing major or minor features that may have affected the noninferiority inference was determined. Major factors included the lack of presenting the results in both intention-to-treat and per-protocol/as-treated cohorts, α>0.05, the new intervention not being compared with the best alternative, not justifying the noninferiority margin, and exclusion or loss of ≥10% of the cohort. Minor factors included suboptimal blinding, allocation concealment, and others.Results: From 2544 screened studies, we identified 111 noninferiority cardiovascular trials. Noninferiority margins varied widely: risk differences of 0.4% to 25%, hazard ratios of 1.05 to 2.85, odds ratios of 1.1 to 2.0, and relative risks of 1.1 to 1.8. Eighty-six trials claimed noninferiority, of which 20 showed superiority, whereas 23 (21.1%) did not show noninferiority, of which 8 also demonstrated inferiority. Only 7 (6.3%) trials were considered low risk for all the major and minor biasing factors. Among common major factors for bias, 41 (37%) did not confirm the findings in both intention-to-treat and per-protocol/as-treated cohorts and 4 (3.6%) reported discrepant results between intention-to-treat and per-protocol analyses. Forty-three (38.7%) did not justify the noninferiority margin. Overall, 27 (24.3%) underenrolled or had >10% exclusions. Sixty trials (54.0%) were open label. Allocation concealment was not maintained or unclear in 11 (9.9%). Publication of noninferiority trials increased over time (P<0.001). Fifty-two (46.8%) were published after 2010 and had a lower risk of methodological or reporting limitations for major (P=0.03) and minor factors (P=0.002).Conclusions: Noninferiority trials in highest-impact journals commonly conclude noninferiority of the tested intervention, but vary markedly in the selected noninferiority margin, and frequently have limitations that may impact the inference related to noninferiority. [ABSTRACT FROM AUTHOR]

The NBA, the WNBA, and the NHL have shown how detailedprotocolsandtestingmandatescankeepgroupssafe and enable them to function at a high level when complementedbycontacttracingandtheisolationofpositivecases from the start. Downloaded from http://journals.lww.com/jbjsjournal by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60EtgtdlLYrLzSPu+hUapVK5dvms8 on 02/09/2021 Downloaded from http://journals.lww.com/jbjsjournal by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60EtgtdlLYrLzSPu+hUapVK5dvms8 on 02/09/2021 the Orthopaedic forum What's Important: Reopening Lessons from the Big Leagues' Experiences with COVID-19 Robby Sikka, MD, Andrew E. Lincoln, ScD, MS, Blythe J.S. Adamson, PhD, MPH,Jonathan A. Epstein, MD, and Harlan M. Krumholz, MD, SM, on behalf of the COVID-19 Sports and Society Working Group As Major League Baseball (MLB), the National Basketball Association (NBA), the National Hockey League (NHL), and the Women's National Basketball Association (WNBA) bring their seasons to a close 1, there remains no consensus ontheperfectwaytoplaysportsduringapandemic. [Extracted from the article]

Background: Some studies report that women are less likely to present with chest pain for acute myocardial infarction (AMI). Information on symptom presentation, perception of symptoms, and care-seeking behaviors is limited for young patients with AMI.Methods: We interviewed 2009 women and 976 men aged 18 to 55 years hospitalized for AMI at 103 US hospitals participating in the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Structured patient interviews during the index AMI hospitalization were used to collect information on symptom presentation, perception of symptoms, and care-seeking behaviors. We compared patient characteristics and presentation information by sex. Multivariable hierarchical logistic regression was used to evaluate the association between sex and symptom presentation.Results: The majority of women (87.0%) and men (89.5%) presented with chest pain (defined as pain, pressure, tightness, or discomfort). Women were more likely to present with ≥3 associated symptoms than men (eg, epigastric symptoms, palpitations, and pain or discomfort in the jaw, neck, arms, or between the shoulder blades; 61.9% for women versus 54.8% for men, P<0.001). In adjusted analyses, women with an ST-segment-elevation AMI were more likely than men to present without chest pain (odds ratio, 1.51; 95% confidence interval, 1.03-2.22). In comparison with men, women were more likely to perceive symptoms as stress/anxiety (20.9% versus 11.8%, P<0.001) but less likely to attribute symptoms to muscle pain (15.4% versus 21.2%, P=0.029). Approximately 29.5% of women and 22.1% of men sought medical care for similar symptoms before their hospitalization (P<0.001); however, 53% of women reported that their provider did not think these symptoms were heart-related in comparison with 37% of men (P<0.001).Conclusions: The presentation of AMI symptoms was similar for young women and men, with chest pain as the predominant symptom for both sexes. Women presented with a greater number of additional non-chest pain symptoms regardless of the presence of chest pain, and both women and their healthcare providers were less likely to attribute their prodromal symptoms to heart disease in comparison with men. [ABSTRACT FROM AUTHOR]

The author reflects on concerns regarding the safety of recombinant bone morphogenetic protein-2 (rhBMP-2), weakness of evidence-based medicine, financial conflict of interest, bias in conduct and dissemination of clinical research, and incomplete report of adverse events. Medtronic has allowed Yale University Open Data Access Project to use its data transparency model to advance open science and stewardship of clinical trial data which will benefit patients and physicians in decision making.

Background: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity.Objectives: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines.Methods: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review.Results: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews).Conclusion: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation. [ABSTRACT FROM AUTHOR]

Background: Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI.Methods: We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction.Results: One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women.Conclusions: Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference. [ABSTRACT FROM AUTHOR]

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction. [ABSTRACT FROM AUTHOR]

Background: Current classification schemes for acute myocardial infarction (AMI) may not accommodate the breadth of clinical phenotypes in young women.Methods and Results: We developed a novel taxonomy among young adults (≤55 years) with AMI enrolled in the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study. We first classified a subset of patients (n=600) according to the Third Universal Definition of MI using a structured abstraction tool. There was heterogeneity within type 2 AMI, and 54 patients (9%; including 51 of 412 women) were unclassified. Using an inductive approach, we iteratively grouped patients with shared clinical characteristics, with the aims of developing a more inclusive taxonomy that could distinguish unique clinical phenotypes. The final VIRGO taxonomy classified 2802 study participants as follows: class 1, plaque-mediated culprit lesion (82.5% of women; 94.9% of men); class 2, obstructive coronary artery disease with supply-demand mismatch (2a: 1.4% women; 0.9% men) and without supply-demand mismatch (2b: 2.4% women; 1.1% men); class 3, nonobstructive coronary artery disease with supply-demand mismatch (3a: 4.3% women; 0.8% men) and without supply-demand mismatch (3b: 7.0% women; 1.9% men); class 4, other identifiable mechanism (spontaneous dissection, vasospasm, embolism; 1.5% women, 0.2% men); and class 5, undetermined classification (0.8% women, 0.2% men).Conclusions: Approximately 1 in 8 young women with AMI is unclassified by the Universal Definition of MI. We propose a more inclusive taxonomy that could serve as a framework for understanding biological disease mechanisms, therapeutic efficacy, and prognosis in this population. [ABSTRACT FROM AUTHOR]

Background: Guidelines for heart failure (HF) recommend prescription of guideline-directed medical therapy before hospital discharge; some of these therapies are included in publicly reported performance measures. The burden of new medications for individual patients has not been described.Methods and Results: We used Get With The Guidelines-HF registry data from 2008 to 2013 to characterize prescribing, indications, and contraindications for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, aldosterone antagonists, hydralazine/isosorbide dinitrate, and anticoagulants. The difference between a patient's medication regimen at hospital admission and that recommended by HF quality measures at discharge was calculated. Among 158 922 patients from 271 hospitals with a primary discharge diagnosis of HF, initiation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was indicated in 18.1% of all patients (55.5% of those eligible at discharge were not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers at admission), β-blockers in 20.3% (50.5% of eligible), aldosterone antagonists in 24.1% (87.4% of eligible), hydralazine/isosorbide dinitrate in 8.6% (93.1% of eligible), and anticoagulants in 18.0% (58.0% of eligible). Cumulatively, 0.4% of patients were eligible for 5 new medication groups, 4.1% for 4 new medication groups, 9.4% for 3 new medication groups, 10.1% for 2 new medication groups, and 22.7% for 1 new medication group; 15.0% were not eligible for new medications because of adequate prescribing at admission; and 38.4% were not eligible for any medications recommended by HF quality measures. Compared with newly indicated medications (mean, 1.45 ± 1.23), actual new prescriptions were lower (mean, 1.16 ± 1.00).Conclusions: A quarter of patients hospitalized with HF need to start >1 medication to meet HF quality measures. Systems for addressing medication initiation and managing polypharmacy are central to HF transitional care. [ABSTRACT FROM AUTHOR]

Background: Previous studies have been unable to disentangle the negative associations of black race and low socioeconomic status (SES) with long-term outcomes of patients after acute myocardial infarction (AMI). Such information could assist in efforts to address both racial and socioeconomic disparities.Methods and Results: We used data from the Cooperative Cardiovascular Project, a prospective cohort study of Medicare beneficiaries hospitalized with AMI with 17 years of follow-up, to evaluate the relationship between race, area-level SES (measured by zip code-level median household income), and life expectancy after AMI. Life expectancy was estimated by using Cox proportional hazards regression with extrapolation using exponential models. Of the 141 095 patients with AMI, 6.3% were black and 6.8% resided in low-SES areas; 26% of black patients lived in low-SES areas in comparison with 5.7% of white patients. Post-myocardial infarction life expectancy estimates were shorter for black patients than for white patients across all socioeconomic levels in patients ≤ 75 years of age. After adjustment for patient and treatment characteristics, the association between race and life expectancy persisted but was attenuated. Younger black patients (<68 years) had shorter life expectancies than white patients, whereas older black patients had longer life expectancies. The largest white-black gap in life expectancy occurred in patients residing in high- and medium-SES areas (P=0.02 interaction).Conclusions: Black and white patients residing in low-SES areas have similar life expectancies after AMI, which are lower than those living in higher-SES areas. Racial disparities were most prominent among patients living in high-SES areas. [ABSTRACT FROM AUTHOR]

Acute myocardial infarction (AMI) and stroke are unanticipated major healthcare events that require emergent and expensive care. Given the potential financial implications of AMI and stroke among uninsured patients, we sought to evaluate rates of catastrophic healthcare expenditures (CHEs), defined as expenses beyond financial means, in a period before the implementation of insurance expansion and protections in the Affordable Care Act.1. [ABSTRACT FROM AUTHOR]

Background—Young women (<65 years) experience a 2- to 3-fold greater mortality risk than younger men after an acute myocardial infarction. However, it is unknown whether they are at higher risk for 30-day readmission, and if this association varies by age. We examined sex differences in the rate, timing, and principal diagnoses of 30-day readmissions, including the independent effect of sex following adjustment for confounders. Methods and Results—We included patients aged 18 to 64 years with a principal diagnosis of acute myocardial infarction. Data were used from the Healthcare Cost and Utilization Project-State Inpatient Database for California (07-09). Readmission diagnoses were categorized by using an aggregated version of the Centers for Medicare and Medicaid Services' Condition Categories, and readmission timing was determined from the day after discharge. Of 42 518 younger patients with acute myocardial infarction (26.4% female), 4775 (11.2%) had at least 1 readmission. The 30-day all-cause readmission rate was higher for women (15.5% versus 9.7%, P<0.0001). For both sexes, readmission risk was highest on days 2 to 4 after discharge and declined thereafter, and women were more likely to present with noncardiac diagnoses (44.4% versus 40.6%, P=0.01). Female sex was associated with a higher rate of 30-day readmission, which persisted after adjustment (hazard ratio, 1.22; 95% confidence interval, 1.15-1.30). There was no significant interaction between age and sex on readmission. Conclusions—In comparison with men, younger women have a higher risk for readmission, even after the adjustment for confounders. The timing of 30-day readmission was similar in women and men, and both sexes were susceptible to a wide range of causes for readmission. [ABSTRACT FROM AUTHOR]

Background: Despite the excess risk of mortality in young women (≤55 years of age) after acute myocardial infarction (AMI), little is known about young women's health status (symptoms, functioning, quality of life) during the first year of recovery after an AMI. We examined gender differences in health status over time from baseline to 12 months after AMI.Methods and Results: A total of 3501 AMI patients (67% women) 18 to 55 years of age were enrolled from 103 US and 24 Spanish hospitals. Data were obtained by medical record abstraction and patient interviews at baseline hospitalization and 1 and 12 months after AMI. Health status was measured by generic (Short Form-12) and disease-specific (Seattle Angina Questionnaire) measures. We compared health status scores at all 3 time points and used longitudinal linear mixed-effects analyses to examine the independent effect of gender, adjusting for time and selected covariates. Women had significantly lower health status scores than men at each assessment (all P values <0.0001). After adjustment for time and all covariates, women had Short Form-12 physical/mental summary scores that were -0.96 (95% confidence interval [CI], -1.59 to -0.32) and -2.36 points (95% CI, -2.99 to -1.73) lower than those of men, as well as worse Seattle Angina Questionnaire physical limitations (-2.44 points lower; 95% CI, -3.53 to -1.34), more angina (-1.03 points lower; 95% CI, -1.98 to -0.07), and poorer quality of life (-3.51 points lower; 95% CI, -4.80 to -2.22).Conclusion: Although both genders recover similarly after AMI, women have poorer scores than men on all health status measures, a difference that persisted throughout the entire year after discharge. [ABSTRACT FROM AUTHOR]

Background--Despite the excess risk of mortality in young women (=55 years of age) after acute myocardial infarction (AMI), little is known about young women's health status (symptoms, functioning, quality of life) during the first year of recovery after an AMI. We examined gender differences in health status over time from baseline to 12 months after AMI. Methods and Results--A total of 3501 AMI patients (67% women) 18 to 55 years of age were enrolled from 103 US and 24 Spanish hospitals. Data were obtained by medical record abstraction and patient interviews at baseline hospitalization and 1 and 12 months after AMI. Health status was measured by generic (Short Form-12) and disease-specific (Seattle Angina Questionnaire) measures. We compared health status scores at all 3 time points and used longitudinal linear mixed-effects analyses to examine the independent effect of gender, adjusting for time and selected covariates. Women had significantly lower health status scores than men at each assessment (all P values <0.0001). After adjustment for time and all covariates, women had Short Form-12 physical/mental summary scores that were -0.96 (95% confidence interval [CI], -1.59 to -0.32) and -2.36 points (95% CI, -2.99 to -1.73) lower than those of men, as well as worse Seattle Angina Questionnaire physical limitations (-2.44 points lower; 95% CI, -3.53 to -1.34), more angina (-1.03 points lower; 95% CI, -1.98 to -0.07), and poorer quality of life (-3.51 points lower; 95% CI, -4.80 to -2.22). Conclusion--Although both genders recover similarly after AMI, women have poorer scores than men on all health status measures, a difference that persisted throughout the entire year after discharge. [ABSTRACT FROM AUTHOR]

Background: The extent to which articles are cited is a surrogate of the impact and importance of the research conducted; poorly cited articles may identify research of limited use and potential wasted investments. We assessed trends in the rates of poorly cited articles and journals in the cardiovascular literature from 1997 to 2007.Methods and Results: We identified original articles published in cardiovascular journals and indexed in the Scopus citation database from 1997 to 2007. We defined poorly cited articles as those with ≤5 citations in the 5 years following publication and poorly cited journals as those with >75% of journal content poorly cited. We identified 164 377 articles in 222 cardiovascular journals from 1997 to 2007. From 1997 to 2007, the number of cardiovascular articles and journals increased by 56.9% and 75.2%, respectively. Of all the articles, 75 550 (46.0%) were poorly cited, of which 25 650 (15.6% overall) had no citations. From 1997 to 2007, the proportion of poorly cited articles declined slightly (52.1%-46.2%, trend P<0.001), although the absolute number of poorly cited articles increased by 2595 (trend P<0.001). At a journal level, 44% of cardiovascular journals had more than three-fourths of the journal's content poorly cited at 5 years.Conclusion: Nearly half of all peer-reviewed articles published in cardiovascular journals are poorly cited 5 years after publication, and many are not cited at all. The cardiovascular literature and the number of poorly cited articles both increased substantially from 1997 to 2007. The high proportion of poorly cited articles and journals suggests inefficiencies in the cardiovascular research enterprise. [ABSTRACT FROM AUTHOR]

Background—The extent to which articles are cited is a surrogate of the impact and importance of the research conducted; poorly cited articles may identify research of limited use and potential wasted investments. We assessed trends in the rates of poorly cited articles and journals in the cardiovascular literature from 1997 to 2007. Methods and Results—We identified original articles published in cardiovascular journals and indexed in the Scopus citation database from 1997 to 2007. We defined poorly cited articles as those with ≤5 citations in the 5 years following publication and poorly cited journals as those with >75% of journal content poorly cited. We identified 164 377 articles in 222 cardiovascular journals from 1997 to 2007. From 1997 to 2007, the number of cardiovascular articles and journals increased by 56.9% and 75.2%, respectively. Of all the articles, 75 550 (46.0%) were poorly cited, of which 25 650 (15.6% overall) had no citations. From 1997 to 2007, the proportion of poorly cited articles declined slightly (52.1%-46.2%, trend P<0.001), although the absolute number of poorly cited articles increased by 2595 (trend P<0.001). At a journal level, 44% of cardiovascular journals had more than three-fourths of the journal's content poorly cited at 5 years. Conclusion—Nearly half of all peer-reviewed articles published in cardiovascular journals are poorly cited 5 years after publication, and many are not cited at all. The cardiovascular literature and the number of poorly cited articles both increased substantially from 1997 to 2007. The high proportion of poorly cited articles and journals suggests inefficiencies in the cardiovascular research enterprise. [ABSTRACT FROM AUTHOR]

Background: Sex disparities in reperfusion therapy for patients with acute ST-segment-elevation myocardial infarction have been documented. However, little is known about whether these patterns exist in the comparison of young women with men.Methods and Results: We examined sex differences in rates, types of reperfusion therapy, and proportion of patients exceeding American Heart Association reperfusion time guidelines for ST-segment-elevation myocardial infarction in a prospective observational cohort study (2008-2012) of 1465 patients 18 to 55 years of age, as part of the US Variations in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study at 103 hospitals enrolling in a 2:1 ratio of women to men. Of the 1238 patients eligible for reperfusion, women were more likely to be untreated than men (9% versus 4%, P=0.002). There was no difference in reperfusion strategy for the 695 women and 458 men treated. Women were more likely to exceed in-hospital and transfer time guidelines for percutaneous coronary intervention than men (41% versus 29%; odds ratio, 1.65; 95% confidence interval, 1.27-2.16), more so when transferred (67% versus 44%; odds ratio, 2.63; 95% confidence interval, 1.17-4.07); and more likely to exceed door-to-needle times (67% versus 37%; odds ratio, 2.62; 95% confidence interval, 1.23-2.18). After adjustment for sociodemographic, clinical, and organizational factors, sex remained an important factor in exceeding reperfusion guidelines (odds ratio, 1.72; 95% confidence interval, 1.28-2.33).Conclusions: Young women with ST-segment-elevation myocardial infarction are less likely to receive reperfusion therapy and more likely to have reperfusion delays than similarly aged men. Sex disparities are more pronounced among patients transferred to percutaneous coronary intervention institutions or who received fibrinolytic therapy. [ABSTRACT FROM AUTHOR]

Background—Sex disparities in reperfusion therapy for patients with acute ST-segment-elevation myocardial infarction have been documented. However, little is known about whether these patterns exist in the comparison of young women with men. Methods and Results—We examined sex differences in rates, types of reperfusion therapy, and proportion of patients exceeding American Heart Association reperfusion time guidelines for ST-segment-elevation myocardial infarction in a prospective observational cohort study (2008-2012) of 1465 patients 18 to 55 years of age, as part of the US Variations in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study at 103 hospitals enrolling in a 2:1 ratio of women to men. Of the 1238 patients eligible for reperfusion, women were more likely to be untreated than men (9% versus 4%, P=0.002). There was no difference in reperfusion strategy for the 695 women and 458 men treated. Women were more likely to exceed in-hospital and transfer time guidelines for percutaneous coronary intervention than men (41% versus 29%; odds ratio, 1.65; 95% confidence interval, 1.27-2.16), more so when transferred (67% versus 44%; odds ratio, 2.63; 95% confidence interval, 1.17-4.07); and more likely to exceed door-to-needle times (67% versus 37%; odds ratio, 2.62; 95% confidence interval, 1.23-2.18). After adjustment for sociodemographic, clinical, and organizational factors, sex remained an important factor in exceeding reperfusion guidelines (odds ratio, 1.72; 95% confidence interval, 1.28-2.33). Conclusions—Young women with ST-segment-elevation myocardial infarction are less likely to receive reperfusion therapy and more likely to have reperfusion delays than similarly aged men. Sex disparities are more pronounced among patients transferred to percutaneous coronary intervention institutions or who received fibrinolytic therapy. [ABSTRACT FROM AUTHOR]

Background--Younger age and female sex are both associated with greater mental stress in the general population, but limited data exist on the status of perceived stress in young and middle-aged patients presenting with acute myocardial infarction. Methods and Results--We examined sex difference in stress, contributing factors to this difference, and whether this difference helps explain sex-based disparities in 1-month recovery using data from 3572 patients with acute myocardial infarction (2397 women and 1175 men) 18 to 55 years of age. The average score of the 14-item Perceived Stress Scale at baseline was 23.4 for men and 27.0 for women (P<0.001). Higher stress in women was explained largely by sex differences in comorbidities, physical and mental health status, intrafamily conflict, caregiving demands, and financial hardship. After adjustment for demographic and clinical characteristics, women had worse recovery than men at 1 month after acute myocardial infarction, with mean differences in improvement score between women and men ranging from -0.04 for EuroQol utility index to -3.96 for angina-related quality of life (P<0.05 for all). Further adjustment for baseline stress reduced these sex-based differences in recovery to -0.03 to -3.63, which, however, remained statistically significant (P<0.05 for all). High stress at baseline was associated with significantly worse recovery in angina-specific and overall quality of life, as well as mental health status. The effect of baseline stress on recovery did not vary between men and women. Conclusions--Among young and middle-aged patients, higher stress at baseline is associated with worse recovery in multiple health outcomes after acute myocardial infarction. Women perceive greater psychological stress than men at baseline, which partially explains women's worse recovery. [ABSTRACT FROM AUTHOR]

Background--United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients' experience with counseling about sexual activity after AMI. Methods and Results--The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07; 95% confidence interval, 1.03-1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02-1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08-1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk; 1.36, 95% confidence interval, 1.11-1.66). Conclusions--Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines. [ABSTRACT FROM AUTHOR]

Background: United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients' experience with counseling about sexual activity after AMI.Methods and Results: The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07; 95% confidence interval, 1.03-1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02-1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08-1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk; 1.36, 95% confidence interval, 1.11-1.66).Conclusions: Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines.Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT00597922. [ABSTRACT FROM AUTHOR]

The article presents a scientific statement from the American Heart Association concerning approaches to improving radiation safety in cardiovascular imaging. It highlights the importance of cardiac imaging to the diagnosis and management of heart disease. It enumerates several major approaches to enhancing radiation safety in medical imaging. A list is also presented of publicly available sources of information on radiation exposure from medical or cardiac imaging.

The article discusses the depression treatment and health status outcomes in young patients with acute myocardial infarction (AMI) and presents study on same. Topics include continued antidepressant medications and depression counseling received by patients; measuring treatment effects with random effects for marital status, diabetes mellitus, and heart failure; and higher depression rates in women among AMI survivors.

Background: Studies of sex differences in long-term mortality after acute myocardial infarction have reported mixed results. A systematic review is needed to characterize what is known about sex differences in long-term outcomes and to define gaps in knowledge.Methods and Results: We searched the Medline database from 1966 to December 2012 to identify all studies that provided sex-based comparisons of mortality after acute myocardial infarction. Only studies with at least 5 years of follow-up were reviewed. Of the 1877 identified abstracts, 52 studies met the inclusion criteria, of which 39 were included in this review. Most studies included fewer than one-third women. There was significant heterogeneity across studies in patient populations, methodology, and risk adjustment, which produced substantial variability in risk estimates. In general, most studies reported higher unadjusted mortality for women compared with men at both 5 and 10 years after acute myocardial infarction; however, many of the differences in mortality became attenuated after adjustment for age. Multivariable models varied between studies; however, most reported a further reduction in sex differences after adjustment for covariates other than age. Few studies examined sex-by-age interactions; however, several studies reported interactions between sex and treatment whereby women have similar mortality risk as men after revascularization.Conclusions: Sex differences in long-term mortality after acute myocardial infarction are largely explained by differences in age, comorbidities, and treatment use between women and men. Future research should aim to clarify how these differences in risk factors and presentation contribute to the sex gap in mortality. [ABSTRACT FROM AUTHOR]

Background--Studies of sex differences in long-term mortality after acute myocardial infarction have reported mixed results. A systematic review is needed to characterize what is known about sex differences in long-term outcomes and to define gaps in knowledge. Methods and Results--We searched the Medline database from 1966 to December 2012 to identify all studies that provided sex-based comparisons of mortality after acute myocardial infarction. Only studies with at least 5 years of follow-up were reviewed. Of the 1877 identified abstracts, 52 studies met the inclusion criteria, of which 39 were included in this review. Most studies included fewer than one-third women. There was significant heterogeneity across studies in patient populations, methodology, and risk adjustment, which produced substantial variability in risk estimates. In general, most studies reported higher unadjusted mortality for women compared with men at both 5 and 10 years after acute myocardial infarction; however, many of the differences in mortality became attenuated after adjustment for age. Multivariable models varied between studies; however, most reported a further reduction in sex differences after adjustment for covariates other than age. Few studies examined sex-by-age interactions; however, several studies reported interactions between sex and treatment whereby women have similar mortality risk as men after revascularization. Conclusions--Sex differences in long-term mortality after acute myocardial infarction are largely explained by differences in age, comorbidities, and treatment use between women and men. Future research should aim to clarify how these differences in risk factors and presentation contribute to the sex gap in mortality. [ABSTRACT FROM AUTHOR]

Background: Little is known about the variation in complication rates among U.S. hospitals that perform elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures. The purpose of this study was to use National Quality Forum (NQF)-endorsed hospital-level risk-standardized complication rates to describe variations in, and disparities related to, hospital quality for elective primary THA and TKA procedures performed in U.S. hospitals. Methods: We conducted a cross-sectional analysis of national Medicare Fee-for-Service data. The study cohort included 878,098 Medicare fee-for-service beneficiaries, sixty-five years or older, who underwent elective THA or TKA from 2008 to 2010 at 3479 hospitals. Both medical and surgical complications were included in the composite measure. Hospitalspecific complication rates were calculated from Medicare claims with use of hierarchical logistic regression to account for patient clustering and were risk-adjusted for age, sex, and patient comorbidities. We determined whether hospitals with higher proportions of Medicaid patients and black patients had higher risk-standardized complication rates. Results: The crude rate of measured complications was 3.6%. The most common complications were pneumonia (0.86%), pulmonary embolism (0.75%), and periprosthetic joint infection or wound infection (0.67%). The median risk-standardized complication rate was 3.6% (range, 1.8% to 9.0%). Among hospitals with at least twenty-five THA and TKA patients in the study cohort, 103 (3.6%) were better and seventy-five (2.6%) were worse than expected. Hospitals with the highest proportion of Medicaid patients had slightly higher but similar risk-standardized complication rates (median, 3.6%; range, 2.0% to 7.1%) compared with hospitals in the lowest decile (3.4%; 1.7% to 6.2%). Findingswere similar for the analysis involving the proportion of black patients. Conclusions: There was more than a fourfold difference in risk-standardized complication rates across U.S. hospitals in which elective THA and TKA are performed. Although hospitals with higher proportions of Medicaid and black patients had rates similar to those of hospitals with lower proportions, there is a continued need to monitor for disparities in outcomes. These findings suggest there are opportunities for quality improvement among hospitals in which elective THA and TKA procedures are performed. [ABSTRACT FROM AUTHOR]

Background: Previous studies have reported conflicting findings regarding how the incidence of heart failure (HF) after acute myocardial infarction (AMI) has changed over time, and data on contemporary national trends are sparse.Methods and Results: Using a complete national sample of 2 789 943 AMI hospitalizations of Medicare fee-for-service beneficiaries from 1998 through 2010, we evaluated annual changes in the incidence of subsequent HF hospitalization and mortality using Poisson and survival analysis models. The number of patients hospitalized for HF within 1 year after AMI declined modestly from 16.1 per 100 person-years in 1998 to 14.2 per 100 person years in 2010 (P<0.001). After adjusting for demographic factors, a relative 14.6% decline for HF hospitalizations after AMI was observed over the study period (incidence risk ratio, 0.854; 95% confidence interval, 0.809-0.901). Unadjusted 1-year mortality following HF hospitalization after AMI was 44.4% in 1998, which decreased to 43.2% in 2004 to 2005, but then increased to 45.5% by 2010. After adjusting for demographic factors and clinical comorbidities, this represented a 2.4% relative annual decline (hazard ratio, 0.976; 95% confidence interval, 0.974-0.978) from 1998 to 2007, but a 5.1% relative annual increase from 2007 to 2010 (hazard ratio, 1.051; 95% confidence interval, 1.039-1.064).Conclusions: In a national sample of Medicare beneficiaries, HF hospitalization after AMI decreased from 1998 to 2010, which may indicate improvements in the management of AMI. In contrast, survival after HF following AMI remains poor, and has worsened from 2007 to 2010, demonstrating that challenges still remain for the treatment of this high-risk condition after AMI. [ABSTRACT FROM AUTHOR]

Background—Previous studies have reported conflicting findings regarding how the incidence of heart failure (HF) after acute myocardial infarction (AMI) has changed over time, and data on contemporary national trends are sparse. Methods and Results—Using a complete national sample of 2789943 AMI hospitalizations of Medicare fee-for-service beneficiaries from 1998 through 2010, we evaluated annual changes in the incidence of subsequent HF hospitalization and mortality using Poisson and survival analysis models. The number of patients hospitalized for HF within 1 year after AMI declined modestly from 16.1 per 100 person-years in 1998 to 14.2 per 100 person years in 2010 (P<0.OOl). After adjusting for demographic factors, a relative 14.6% decline for HF hospitalizations after AMI was observed over the study period (incidence risk ratio, 0.854; 95% confidence interval, 0.809–0.901). Unadjusted 1-year mortality following HF hospitalization after AMI was 44.4% in 1998, which decreased to 43.2% in 2004 to 2005, but then increased to 45.5% by 2010. After adjusting for demographic factors and clinical comorbidities, this represented a 2.4% relative annual decline (hazard ratio, 0.976; 95% confidence interval, 0.974–0.978) from 1998 to 2007, but a 5.1% relative annual increase from 2007 to 2010 (hazard ratio, 1.051; 95% confidence interval, 1.039–1.064). Conclusions—In a national sample of Medicare beneficiaries, HF hospitalization after AMI decreased from 1998 to 2010, which may indicate improvements in the management of AMI. In contrast, survival after HF following AMI remains poor, and has worsened from 2007 to 2010, demonstrating that challenges still remain for the treatment of this high-risk condition after AMI. [ABSTRACT FROM AUTHOR]

The article offers the authors' discussion on the existence of variation in admission rates to intensive care units (ICU) for patients with heart failure (HF) throughout hospitals in the U.S. They describe the patterns of using such units and their application for handling the disease. They also note their anticipation of similarity in overall in-hospital risk-standardized mortality rates (RSMRs) regardless of triage patterns.

The article provides an executive summary of the 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guideline for the Management of ST-Elevation Myocardial Infarction, a report of the ACCF/AHA Task Force on Practice Guidelines. It says that the practice guidelines aim to assist healthcare providers in clinical decision making. It mentions that the guidelines also attempt to determine the practices needed by most patients.

The article discusses the need of shared decision making (SDM) ability in cases related to advanced heart failure. It mentions that the SDM mandate the need of fully informing the patients about the risks and benefits of the treatments. It allows the clinicians and patients to share information with each other for proper treatment of the disease. Communication in case of heart failure is quiet important as it fully informs patient about the severity, outcomes and treatment of the disease.

Background--Clinical trials have shown that statin therapy reduces cardiovascular morbidity and mortality in patients with coronary artery disease (CAD), even among patients with low-density lipoprotein cholesterol levels <100 mg/dL. We sought to determine the extent to which patients with obstructive CAD in routine outpatient care are treated with statins, nonstatins, or no lipid-lowering therapy. Methods and Results--Within the American College of Cardiology's Practice Innovation and Clinical Excellence (PINNACLE) outpatient registry, we examined rates of treatment with statin and nonstatin medications in 38 775 outpatients with obstructive CAD (history of myocardial infarction or coronary revascularization) and without documented contraindications to statin therapy. Among these patients, 30 160 (77.8%) were prescribed statins, 2042 (5.3%) were treated only with nonstatin lipid-lowering medications, and 6573 (17.0%) were untreated. Lack of medical insurance was associated with no statin treatment, and male sex, coexisting hypertension, and a recent coronary revascularization were associated with statin treatment. Among those not on any lipid-lowering therapy, low-density lipoprotein cholesterol levels were available for 51.2% (3365/6573). Among these untreated patients, low-density lipoprotein cholesterol levels were < 100 mg/dL in 1794 patients (53.3%) and ≥100 mg/dL in 1571 patients (46.7%). Conclusions--Despite robust clinical trial evidence, a substantial number of patients with obstructive CAD remain untreated with statins. A small proportion were treated with nonstatin therapy, and 1 in 6 patients was simply untreated; half of the untreated patients had low-density lipoprotein cholesterol values <100 mg/dL. These findings illustrate important opportunities to improve lipid management in outpatients with obstructive CAD. [ABSTRACT FROM AUTHOR]

Despite substantial improvement in recent years in hospital performance in many quality measures for acute myocardial infarction (AMI), national performance lags in a key publicly reported quality indicator for AMI--door-to-balloon time, the period from patient (with ST-segment elevation myocardial infarction or STEMI) arrival to provision of percutaneous coronary intervention or balloon angioplasty. Previous research has elucidated distinguishing features of hospitals that routinely achieved recommended door-to-balloon times for patients with STEMI. However, what has not been fully explored is how top-performing hospitals handle setbacks during the improvement process. In this study, we used qualitative methods to characterize the range of setbacks in door-to-balloon improvement efforts and the strategies used to address these barriers among hospitals that were ultimately successful in reducing door-to-balloon time to meet clinical guidelines. Setbacks included (1) failure to anticipate and address implications of initial changes in door-to-balloon processes for the system as a whole; (2) tension between and within departments and disciplines, which needed to gain consensus about how to reduce door-to-balloon time; and (3) waning attention to door-to-balloon performance as a top priority after the perceived goal of reducing treatment times had been reached. Our findings demonstrate key aspects of technical capacity, organizational culture, and environmental conditions that were factors in maintaining improvement efforts despite setbacks and hence may be critical to sustaining top performance. Understanding how top-performing hospitals recognize and respond to setbacks can help senior management promote organizational resiliency, leading to an environment in which learning, growth, and quality improvement can be sustained. [ABSTRACT FROM AUTHOR]

Explores the roles of senior management in quality improvement efforts in providing health services. Occurrence of quality problems and medical errors in healthcare organizations; Organization of the roles and activities of managers in quality improvement efforts. INSET: PRACTITIONER APPLICATION.

Background: Readmissions among older adults hospitalized for acute myocardial infarction (AMI) are costly, disruptive, and difficult to predict. Aging-related functional impairments may improve risk prediction, but have not been measured in most studies. Our objective was therefore to develop a readmission risk model for older adults hospitalized for AMI that considered functional impairments. Methods: SILVER-AMI is a prospective cohort study of 3006 patients age ≥75 hospitalized with AMI at 96 U.S. hospitals. Participants underwent in-hospital assessment of functional impairments including cognition, vision, hearing, and mobility. Clinical variables traditionally associated with readmission risk, as well as patient reported health status, were also collected. The outcome was all-cause readmission at 30 days. We used backward selection and Bayesian model averaging to derive (N=2004) a risk model that was subsequently validated in a separate sample (N=1002). Model discrimination and calibration were respectively evaluated with the C-statistic and the Hosmer-Lemeshow test. Results: Mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. Within 30 days, 547 participants (18.2%) experienced readmission (61.0% cardiac cause). Participants who were readmitted were older, had more comorbidities, and had a higher prevalence of functional impairments including activity of daily living disability (17.0% vs. 13.0%, P=0.01), weak grip strength (64.4% vs. 59.2%, P<0.01), and impaired mobility measured by Timed Up and Go (TUG) (72.5% vs. 53.6%, P<0.001). The final readmission risk model contained 8 variables; mobility was the only functional impairment retained, but was the strongest predictor (Figure). The model was well calibrated (P value >0.05 for Hosmer-Lemeshow statistic) and had moderate discrimination (C-statistic: 0.65 derivation cohort, 0.63 validation cohort) across all multiply imputed datasets. Conclusion: In our final risk model, functional mobility was the strongest predictor of 30-day readmission among older adults after AMI. The modest C-statistic indicates that much of the variability in readmission among this older adult population remains unexplained by patient-level factors. [ABSTRACT FROM AUTHOR]

Background: The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guidelines recommended statin as the first-line lipid-lowering therapy (LLT) for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). We aim to examine the impact of the guidelineson statin use in the US. Methods: Using the2010-2015 Medical Expenditure Panel Survey (MEPS) data, we estimated trends in statin utilization in adults age 40-75 years in 4 defined groups: (1) All adults, adults with: (2) established ASCVD, (3) diabetes mellitus [DM] and no ASCVD and, (4) estimated 10-year risk >=7.5% in absence of ASCVD and DM. Joint-point regression (JPR) analysis was used to examine changes in statin use trend around the period of the guideline's publication. Results: We found no statistically significant change in statin use. (Figure) The use of any statin therapy in 2010-2012 ranged from 24.6 to 25.1%, and 24.6 to 25.1% in 2014-2015 among all adults. Statin use among those with ASCVD ranged from 58.8 to 56.6% (2010-2012) and 56.7-57.8% (2014-2015). Similar trends were noted in our two other study groups. However, a significantly higher proportion of statin users among established ASCVD patients reported use of high intensity doses: 34.3 to 38.1% post- versus 29.6 to 31.6% pre-guideline publication with an average annual percentage change (AAPC) of 4.9 (95% CI: 2.9-6.9). (Figure) Joint point regression showed no statistically significant inflection in the trend line of all and high-intensity statin use in any of the study groups after guideline publication. Conclusion: There was a mild increase in high-intensity statin use after the 2013 ACC/AHA guidelines release, but no impact on overall statin use in US two years after publication. Barriers to guideline adoption and opportunities to increase the impact of guidelines on clinical practice need to be investigated. [ABSTRACT FROM AUTHOR]

Introduction: Diabetes increases the risk of mortality after acute myocardial infarction (AMI). However, little is known about the association of diabetes and health status outcomes (symptoms, function, quality of life) after AMI in younger adults (≤55 years). Methods: We investigated the association between diabetes and health status over the first 12 months after AMI among 3501 adults with AMI (42.6% with diabetes) aged 18-55 years enrolled in the Variation in Recovery: Role of Gender on Outcomes of Young AMI patients (VIRGO) study. Health status was measured with the Seattle Angina Questionnaire (SAQ), 12-item Short-Form Health Survey (SF-12), and EuroQol-Visual Analogue Scale (EQ-VAS) at baseline (during hospitalization), 1-month, and 12-months post-AMI. We compared health status scores at the 3 time points between patients with and without diabetes, and performed statistical analyses using unadjusted and covariate-adjusted longitudinal linear-mixed effects (LME) models. Results: At baseline, young adults with diabetes had significantly worse scores on SAQ-angina frequency (81±22 vs. 86±19), SAQ-physical limitations (77±28 vs. 85±23), SAQ-quality of life (55±25 vs. 57±23), SF-12 mental (44±13 vs. 46±12)/physical functioning (41±12 vs. 46±12), and EQ-VAS (61±22 vs. 66±21) than those without diabetes (p ≤ 0.01 for all). Over time, both groups (with and without diabetes) improved considerably and the differences in health status scores progressively narrowed (except for SF-12 physical functioning). In the LME models that adjusted for socio-demographics, cardiovascular risk factors, comorbidities, clinical characteristics, psychosocial factors, health care utilization, and AMI treatment, diabetes was associated with worse health status at baseline but not after discharge, and the association did not vary by sex (p value for interactions diabetes*sex >0.05 for all). Conclusion: At baseline, young women and men with diabetes had poorer health status than those without diabetes. After AMI, however, they experienced significant improvement and diabetes was not associated with worse angina, SAQ-physical limitations, mental functioning and quality of life, after adjustment for baseline patient characteristics and treatment. [ABSTRACT FROM AUTHOR]

Background: Healthcare costs pose a major challenge for patients with atherosclerotic cardiovascular disease (ASCVD), particularly those without insurance. It is critical to evaluate whether the uninsured forgo or delay medical care for ASCVD due to costs. Methods: In the nationally representative Medical Expenditure Panel Survey (2005-2016), we identified all nonelderly adults (18-65 years) with ASCVD with and without insurance coverage during a year. We compared comorbidity-adjusted healthcare utilization between uninsured and insured using survey-specific logistic regression. Further, based on a validated questionnaire, we examined self-reported care-deferrals, defined as either being unable to receive or delaying required medical care or prescription medications due to cost. Results: There were 1739 uninsured and 8865 insured nonelderly ASCVD patients, representing respectively 1.3 million and 8.6 million US adults annually. The uninsured were younger (mean 49 vs 53 years) but had a similar distribution for gender and race. After accounting for demographic and clinical differences, the uninsured and insured had similar odds of ≥1 emergency visits (OR 1.05 [0.90, 1.24]), but the uninsured had lower odds of using outpatient (OR 0.56 [0.46, 0.67]) and inpatient care services (OR 0.69 [0.57, 0.84]). The uninsured were more likely to report both an inability to access required health care (21% vs 5%, OR 5.32 [4.31, 6.57]) and the need to delay care (17% vs 5%, OR 4.05 [3.24, 5.07]) due to the cost of healthcare services. Despite recent improvements, 1 in 5 uninsured patients with ASCVD continues to defer care due to costs (Figure). Conclusions: Among nonelderly adults with ASCVD, there was a relative underutilization of non-emergency healthcare services with 1 in 5 reporting deferral of healthcare services due to cost. Efforts to improve outcomes of uninsured ASCVD patients must target the substantial proportion that defers care due to costs. [ABSTRACT FROM AUTHOR]