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As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.

Background: Mental and behavioral health disorders (MBD) are associated with an increased risk of cardiovascular disease and with worse long-term outcomes after myocardial infarction (MI). Hypothesis: We hypothesized the prevalence of MBD among patients with acute MI is rising over time. Methods: Using National Inpatient Sample Database, we assessed temporal trends in the prevalence of MBD and in-hospital outcomes among patients hospitalized for acute MI in the US from 2008-2017. We used multiple logistic regression for in-hospital outcomes and examined yearly trends and estimated annual percent change (APC) in odds of MBD among MI patients. Results: We included a total of 6,117,804 patients with MI (ST elevation MI 30.4%) with a mean age of 67.2±0.04 and 39% females. Psychoactive substance use disorder (PSD) (24.9%) was the most common behavioral health disorder, and major depression (6.2%) and anxiety disorders (6.0%) were the most common mental health disorders, followed by bipolar disorder (0.9%), schizophrenia/psychotic disorders (0.8%) and post-traumatic stress disorder (PTSD) (0.3%). Between 2008 to 2018, the prevalence of PSD (23.7-25.0%, APC +0.6%), major depression (4.7-7.4%, APC +6.2%), anxiety disorders (3.2-8.9%, APC +13.5%), PTSD (0.2-0.6%, +12.5%) and bipolar disorder (0.7-1.0%, APC +4.0%) significantly increased over the time period. Major depression, bipolar disorder or schizophrenia/psychotic disorders were associated with a lower likelihood of coronary revascularization, although a co-diagnosis of MBD was associated with a lower risk of in-hospital mortality. Conclusion: MBD are common among patients with acute MI and there was a concerning increase in the prevalence of PSD, major depression, bipolar disorder, anxiety disorders and PTSD. Focused mental and behavioral health interventions and health care policy changes are warranted to address the increasing burden of comorbid MBD among acute MI.

The Cardiovascular Disease in Women Committee of the American College of Cardiology, in conjunction with interested parties (from the National Heart, Lung, and Blood Institute, American Heart Association, and European Society of Cardiology), convened a working group to develop a consensus on the syndrome of myocardial ischemia with no obstructive coronary arteries. In general, these patients have elevated risk for a cardiovascular event (including acute coronary syndrome, heart failure hospitalization, stroke, and repeat cardiovascular procedures) compared with reference subjects and appear to be at higher risk for development of heart failure with preserved ejection fraction. A subgroup of these patients also has coronary microvascular dysfunction and evidence of inflammation. This document provides a summary of findings and recommendations for the development of an integrated approach for identifying and managing patients with ischemia with no obstructive coronary arteries and outlines knowledge gaps in the area. Working group members critically reviewed available literature and current practices for risk assessment and state-of-the-science techniques in multiple areas, with a focus on next steps needed to develop evidence-based therapies. This report presents highlights of this working group review and a summary of suggested research directions to advance this field in the next decade.

To ensure that guidelines reflect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modified and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines (“Task Force”) has issued this focused update to revise guideline recommendations on the basis of recently published data. This update is not based on a complete literature review from the date of previous guideline publications, but it has been subject to rigorous, multilevel review and approval, similar to the full guidelines. For specific focused update criteria and additional methodological details, please see the ACC/AHA guideline methodology manual.1 ### Modernization In response to published reports from the Institute of Medicine2,3 and ACC/AHA mandates,4–7 processes have changed leading to adoption of a “knowledge byte” format. This entails delineation of recommendations addressing specific clinical questions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommodates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving technology (eg, smart phone apps), and supports the evolution of guidelines as “living documents” that can be …

Two guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and collaborating societies address the risk of aortic dissection in patients with bicuspid aortic valves and severe aortic enlargement: the “2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease” (Circulation. 2010;121:e266–e369) and the “2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease” (Circulation. 2014;129:e521–e643). However, the 2 guidelines differ with regard to the recommended threshold of aortic root or ascending aortic dilatation that would justify surgical intervention in patients with bicuspid aortic valves. The ACC and AHA therefore convened a subcommittee representing members of the 2 guideline writing committees to review the evidence, reach consensus, and draft a statement of clarification for both guidelines. This statement of clarification uses the ACC/AHA revised structure for delineating the Class of Recommendation and Level of Evidence to provide recommendations that replace those contained in Section 9.2.2.1 of the thoracic aortic disease guideline and Section 5.1.3 of the valvular heart disease guideline.

At every national and international cardiology meeting, there is at least 1 obligate dualistic debate on whether duration of dual antiplatelet therapy (DAPT) in all patients treated with coronary stent implantation should be short or long. This binary approach is similarly played out in the literature. Although we recognize the usefulness of different intellectual perspectives, as well as the entertainment value of such debates, we believe that the time for debating has passed. Rather, it is time to acknowledge that some patients may best be treated with a short duration of DAPT, some with a standard duration of DAPT, and some with a longer or prolonged duration of DAPT. We should now direct our energies toward identifying these subgroups. Decisions on DAPT duration for any individual patient must be based not on dogmatic or blind adherence to a study result, meta-analysis, or even guideline recommendation but on a thoughtful and informed ongoing assessment of the benefits and risks of DAPT for that particular patient (Figure), as well as patient preference. Figure. Factors associated with an increased risk of ischemia (stent thrombosis, spontaneous myocardial infarction [MI]) and bleeding. ACS indicates acute coronary syndrome; CAD, coronary artery disease; NSAID, nonsteroidal anti-inflammatory drugs; OAT, oral anticoagulant therapy; and PCI, percutaneous coronary intervention. This dualistic short versus long debate ignores the fact that many patients with comparable ischemic and bleeding risk may best be treated by a …

Androgen-deprivation therapy (ADT) is a widely used treatment for prostate cancer. Recently, several studies have reported an association between ADT and an increased risk of cardiovascular events, including myocardial infarction and cardiovascular mortality.1–5 These reports have led to increased interest and discussion regarding the metabolic effects of ADT and its possible association with increased cardiovascular risk. In addition, likely as a result of these reports, internists, endocrinologists, and cardiologists are now being consulted regarding the evaluation and management of patients in whom ADT is being initiated. Most of these physicians are not aware of the possible effects of ADT on cardiovascular risk factors or the issues regarding ADT and cardiovascular disease. Therefore, this multidisciplinary writing group has been commissioned to review and summarize the metabolic effects of ADT, to evaluate the data regarding a possible relationship between ADT and cardiovascular events in patients with prostate cancer, and to generate suggestions regarding the evaluation and management of patients, both with and without known cardiac disease, in whom ADT is being initiated. The writing group emphasizes that the purpose of this advisory is strictly informative. This advisory should thus not be construed as dictating clinical practice or superseding the clinical judgment of physicians, and it should not be used for medicolegal purposes. Androgens, produced mainly in the testicles, stimulate prostate cancer cells to grow. Lowering androgen levels can eliminate prostate cancer cells that require androgens to survive.6 ADT reduces levels of androgens in circulation, with the goal of improving outcomes in men with prostate cancer. Gonadotropin-releasing hormone (GnRH) agonists (eg, leuprolide, goserelin, and triptorelin) currently are the most common form of ADT and have largely supplanted the use of bilateral orchiectomy. Antiandrogens (eg, flutamide and bicalutamide) are a form of prostate cancer therapy that blocks the binding of androgen to …

Advances in magnetic resonance (MR) imaging over the past 2 decades have led to MR becoming an increasingly attractive imaging modality. With the growing number of patients treated with permanent implanted or temporary cardiovascular devices, it is becoming ever more important to clarify safety issues in regard to the performance of MR examinations in patients with these devices. Extensive, although not complete, ex vivo, animal, and clinical data are available from which to generate recommendations regarding the safe performance of MR examination in patients with cardiovascular devices, as well as to ascertain caveats and contraindications regarding MR examination for such patients. Safe MR imaging involves a careful initial patient screening, accurate determination of the permanent implanted or temporary cardiovascular device and its properties, a thoughtful analysis of the risks and benefits of performing the examination at that time, and, when indicated, appropriate physician management and supervision. This scientific statement is intended to summarize and clarify issues regarding the safety of MR imaging in patients with cardiovascular devices.

The role of endomyocardial biopsy (EMB) in the diagnosis and treatment of adult and pediatric cardiovascular disease remains controversial, and the practice varies widely even among cardiovascular centers of excellence. A need for EMB exists because specific myocardial disorders that have unique prognoses and treatment are seldom diagnosed by noninvasive testing.1 Informed clinical decision making that weighs the risks of EMB against the incremental diagnostic, prognostic, and therapeutic value of the procedure is especially challenging for nonspecialists because the relevant published literature is usually cited according to specific cardiac diseases, which are only diagnosed after EMB. To define the current role of EMB in the management of cardiovascular disease, a multidisciplinary group of experts in cardiomyopathies and cardiovascular pathology was convened by the American Heart Association (AHA), the American College of Cardiology (ACC), and the European Society of Cardiology (ESC). The present Writing Group was charged with reviewing the published literature on the role of EMB in cardiovascular diseases, summarizing this information, and making useful recommendations for clinical practice with classifications of recommendations and levels of evidence. The Writing Group identified 14 clinical scenarios in which the incremental diagnostic, prognostic, and therapeutic value of EMB could be estimated and compared with the procedural risks. The recommendations contained in the present joint Scientific Statement are derived from a comprehensive review of the published literature on specific cardiomyopathies, arrhythmias, and cardiac tumors and are categorized according to presenting clinical syndrome rather than pathologically confirmed disease. The ultimate intent of this document is to provide an understanding of the range of acceptable approaches for the use of EMB while recognizing that individual patient care decisions depend on factors not well reflected in the published literature, such as local availability of specialized facilities, cardiovascular pathology expertise, and operator experience. The use of EMB …

Preamble e346 1. Introduction e347 2. Overview of Acs e349 3. Initial Evaluation and Management e350 4. Early Hospital Care e359

Cardiovascular disease (CVD) is the leading cause of death in the United States.1 Despite efforts promoting primary and secondary CVD prevention,2–8 obesity and physical inactivity remain at epidemic proportions, with >60% of Americans adults overweight or obese and >50% not performing recommended levels of physical activity.9 Similarly, hypertension, hypercholesterolemia, and other CVD risk factors remain poorly controlled in many Americans. Despite numerous pharmacological and device-based advances in the management of patients with established CVD, morbidity and mortality associated with this condition remain substantial. Hence, a critical need exists for novel strategies and interventions that can potentially reduce the risk of CVD and its attendant morbidity and mortality. Numerous studies have explored the relationship between pet (primarily dog or cat) ownership and CVD, with many reporting beneficial effects, including increased physical activity, favorable lipid profiles, lower systemic blood pressure, improved autonomic tone, diminished sympathetic responses to stress, and improved survival after an acute coronary syndrome. Accordingly, the potential cardiovascular benefits of pet ownership have received considerable lay press and medical media coverage and attention from the Centers for Disease Control and Prevention10 and have been the focus of a meeting sponsored by the National Institutes of Health.11 The purpose of this American Heart Association Scientific Statement is to critically assess the data regarding the influence of pet ownership on the presence and reduction of CVD risk factors and CVD risk. Some, but not all, studies of pet ownership and systemic blood pressure have found an association between pet ownership and lower blood pressure. An Australian study of 5741 participants attending a free screening clinic found that pet owners had significantly ( P =0.03) lower systolic blood pressures than pet nonowners despite similar body mass index (BMI) and socioeconomic profiles.12 In a study of 240 married couples …

Granting clinical staff privileges to physicians is the primary mechanism institutions use to uphold quality care. The Joint Commission requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians themselves are charged with defining the

A 62-year–old man presented with progressive exertional dyspnea and angina. His past medical history is notable for coronary artery disease, for which he underwent a coronary artery bypass graft surgery 8 years earlier. A few years afterward, he underwent aortic valve (AV) bypass (AVB) surgery for severe aortic stenosis (AS) using an apicoaortic conduit to the descending aorta consisting of a 16-mm connector and an 18-mm valved conduit (Hancock valve; Medtronic, Minneapolis, MN; Figures 1 and 2; online-only Data Supplement Movie I). After a period of initial improvement in symptoms, the patient developed progressive dyspnea and angina and was referred for additional cardiac workup. Figure 1. An ECG-gated thin-slice contrast-enhanced cardiac computed tomography scan showing a heavily calcified native aortic valve (AV), hypertrophied left ventricle (LV), and the apical LV insertion site of the apicoaortic valved conduit. Figure 2. A 3-dimensional cardiac computed tomography reconstruction image showing the apicoaortic valved conduit, extending from its apical insertion site into the left ventricle (LV) to its insertion site into the descending aorta. Arrow , Conduit valve. The patient underwent a bicycle ergometer test, which showed a diminished functional capacity and was stopped because of fatigue and a hypotensive response. He underwent a 2-dimensional transthoracic echocardiogram with gradual dobutamine infusion. He was found to have a heavily calcified AV (online-only Data Supplement Movie II) with a rest mean transvalvular gradient of 34 mm Hg and velocity of 3.5 m/s, which increased to 50 mm Hg and 4.8 m/s, respectively, at peak dobutamine dose (Figure 3). This corresponded with a …

Background In the setting of atherosclerosis, endothelial vasomotor function is abnormal. Increased oxidative stress has been implicated as one potential mechanism for this observation. We therefore hypothesized that an antioxidant, ascorbic acid, would improve endothelium-dependent arterial dilation in patients with coronary artery disease. Methods and Results Brachial artery endothelium-dependent dilation in response to hyperemia was assessed by high-resolution vascular ultrasound before and 2 hours after oral administration of either 2 g ascorbic acid or placebo in a total of 46 patients with documented coronary artery disease. Plasma ascorbic acid concentration increased 2.5-fold 2 hours after treatment (46±8 to 114±11 μmol/L, P =.001). In the prospectively defined group of patients with an abnormal baseline response (P =.003 for ascorbic acid versus placebo). Ascorbic acid had no effect on hyperemic flow or arterial dilation to sublingual nitroglycerin. Conclusions Ascorbic acid reverses endothelial vasomotor dysfunction in the brachial circulation of patients with coronary artery disease. These findings suggest that increased oxidative stress contributes to endothelial dysfunction in patients with atherosclerosis and that endothelial dysfunction may respond to antioxidant therapy.

Alice K. Jacobs, MD, FACC, FAHA, Chair Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect Nancy Albert, PhD, CCNS, CCRN, FAHA Mark A. Creager, MD, FACC, FAHA Steven M. Ettinger, MD, FACC Robert A. Guyton, MD, FACC Jonathan L. Halperin, MD, FACC, FAHA Judith S. Hochman, MD, FACC, FAHA

Arterial puncture and sheath insertion by use of the modified Seldinger technique has become the standard method by which invasive cardiovascular procedures are performed.1 With improvement in techniques and devices, a significant number of patients with atherosclerotic disease are undergoing invasive vascular procedures. Approximately 7 million invasive cardiovascular procedures are performed worldwide each year, and this number is expected to increase with the aging of the population. The vast majority of these procedures are performed with femoral arterial access. Because the number of cardiovascular procedures performed via the femoral artery approach continues to increase, effective arterial hemostasis techniques are essential to high-quality patient care. In fact, vascular access complications, reported to be as high as 6% in some series, remain the leading cause of morbidity after a cardiac catheterization procedure.2 Manual compression has been considered the traditional technique to achieve closure of the arteriotomy site, requiring close observation and immobilization for success. Arteriotomy closure devices (ACDs) were introduced in 1995 to decrease vascular complications and reduce the time to hemostasis and ambulation. Subsequently, several generations of passive and active ACDs have been introduced that incorporate suture, collagen plug, nitinol clip, and other mechanisms to achieve hemostasis. According to a new Life Science Intelligence report entitled “2008 Global Vascular Closure Device Markets: US, Europe, Rest of World,” the global market for vascular closure devices will reach nearly $1 billion in 2013.3 Despite this widespread use of both passive and active ACDs, there are incomplete data on their safety and efficacy. Additionally, there are few published recommendations regarding the indications for the use of these devices, their comparative effectiveness versus manual compression, and the end points of clinical interest for patients undergoing vascular closure. Therefore, the present scientific statement provides an overview of vascular access and patient risk for …