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We sought to determine if the absence of hypertension in older adults can be used to identify those at lower risk of atherosclerotic cardiovascular disease (ASCVD). We identified participants ≥75 years old free of cardiovascular disease (CVD) in the National Institutes of Health Pooled Cohorts with and without hypertension. We assessed the association between systolic blood pressure (BP), diastolic BP, and cardiovascular events using multivariable modeling. The association between predicted ASCVD risk and observed events was compared. Of 2667 adults aged ≥75 years, 67.9% had hypertension. Lower systolic BP correlated with lower CVD event rates. ASCVD predicted risk score and systolic BP were both independently associated with ASCVD event rates. Among adults with similar ASCVD predicted risk estimates, those without (vs. with) hypertension had lower observed event rates across the predicted risk spectrum. The absence of hypertension may help refine the risk stratification of older adults, particularly those with intermediate predicted risk.

Triglyceride (TG) levels encompass several lipoproteins that have been implicated in atherogenic pathways. Whether TG levels independently associate with cardiovascular disease both overall and, in particular among patients with established coronary artery disease (CAD) and type 2 diabetes (T2DM), remains controversial. Data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial was used to evaluate patients with T2DM and CAD. Cox proportional hazards models were used to determine the association between TG levels and outcomes. Stepwise adjustment was performed for demographics, clinical factors, lipid profile and statin treatment. The primary composite outcome was time to CV death, myocardial infarction (MI), or stroke and secondary outcome was CV death. Among 2,307 patients with T2DM and CAD, the mean (±SD) TG levels were 181 (±136) with a median (Q1-Q3) 148mg/dL (104-219). Overall, 51% of patients had TG150 mg/dL, 18% 150-199 mg/dL, 28% 200-499 mg/dL and 3% ≥500 mg/dL. Participants with elevated TG levels (≥150 mg/dL) were younger (61 vs 63 years, p0.001), had higher BMI (32 vs 30 kg/m

The TOPCAT trial investigated spironolactone vs placebo in patients with heart failure with preserved ejection fraction (HFpEF). Although the primary endpoint was not statistically significant, treatment with spironolactone did reduce heart failure hospitalizations compared with placebo. TOPCAT's impact on prescribing patterns in the United States is not well-characterized. We performed a retrospective analysis of discharge prescribing data in the Get With The Guidelines-Heart Failure Registry among patients with left ventricular ejection fraction ≥50% discharged between January 2009 and December 2016 to assess prescribing trends upon dissemination of TOPCAT results. Of 142,201 patients included in the study, 18,581 (13.1%) were prescribed mineralocorticoid receptor antagonists (MRAs) at discharge. Compared with those not prescribed MRAs, patients discharged on MRAs were generally younger (75 vs 78 years), and report white race (76.7% vs 72.0%), more likely to have had prior heart failure hospitalizations (75.5% vs 65.7%), lower brain natriuretic peptide levels (492 vs 545 pg/mL), but similar serum creatinine levels (1.2 vs 1.2 mg/dL) upon admission. MRA prescribing modestly increased over time (p

Systolic blood pressure (SBP) and its association with clinical outcomes in atrial fibrillation (AF) patients in community practice are poorly characterized. In patients with AF, we sought to (1) examine the prevalence of baseline uncontrolled hypertension and the overall change in SBP control, (2) identify predictors of uncontrolled SBP over 2 years of follow-up, and (3) determine the relation between SBP and clinical outcomes. We analyzed 10,132 patients with AF at 176 clinics in the ORBIT-AF registry between 2010 and 2014, classified as: (1) no history of hypertension; (2) controlled hypertension (baseline SBP140 mm Hg); (3) and uncontrolled hypertension (baseline SBP140 mm Hg). Predictors of SBP140 mm Hg at baseline or in follow-up were identified with pooled logistic regression. Random effects Cox regression models were used to compare cardiovascular outcomes and major bleeding as a function of continuous, time-dependent SBP. Overall 8,383 (83%) of patients with AF had hypertension. Of these, 24.2% (n = 2032) had uncontrolled baseline SBP, with little change over 2 years. Predictors of elevated follow-up SBP included uncontrolled baseline SBP, females, previous percutaneous coronary intervention, and diabetes. For every 5 mm Hg increase in follow-up SBP, the adjusted risk of stroke or systemic embolism or transient ischemic attack (adjusted hazard ratio [aHR] 1.05, 95% confidence interval [CI] 1.01 to 1.08, p = 0.01), myocardial infarction (aHR 1.05, 95% CI 1.00 to 1.11, p = 0.04), and major bleeding (aHR 1.03, 95% CI 1.00 to 1.06, p = 0.04) increased modestly. In conclusion, in patients with AF, higher SBP was associated with increasing adverse events; therefore, more rigorous blood pressure control should be emphasized.

Lipoprotein (a) [Lp(a)] is associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). As directed therapy for Lp(a) emerges, it is important to understand patterns of Lp(a) testing in routine clinical practice. We set out to characterize Lp(a) testing across a large academic health system. Using electronic health record (EHR) data from 2014 to 2019, we compared patients who underwent Lp(a) testing to date-matched peers who had low density lipoprotein (LDL-C) assessment alone. We analyzed ordering provider characteristics and rates of initiation of new lipid lowering therapy (LLT) within 12 months after testing. Of 1,296 adults with Lp(a) test results, 629 (48.5%) had prior history of ASCVD and 667 (51.4%) did not. Compared with those with LDL-C testing alone, individuals who underwent Lp(a) testing were more like to have a myocardial infarction or ischemic stroke at a young age and multiple prior cardiovascular events. Though the majority of Lp(a) tests were ordered in outpatient encounters, a higher proportion of Lp (a) tests compared with LDL-C tests were performed in the inpatient setting. Neurology and psychiatry were the most common specialty to order Lp(a) tests in our cohort. There was a significantly increased initiation of LLT after Lp(a) testing compared with LDL-C testing across all medication types. Consistent with guidelines, Lp(a) testing is used in those with early onset ASCVD, and among those with multiple cardiovascular events. Lp (a) testing is associated with more aggressive LLT in following year. Further research is needed to characterize Lp(a) testing across larger populations.

The aim of this study was to quantify time in therapeutic range (TTR) before and after a temporary interruption of warfarin due to an intervention in the Outcomes Registry for Better Informed Treatment of atrial fibrillation (AF). AF patients on warfarin who had a temporary interruption followed by resumption were identified. A nonparametric method for estimating survival functions for interval censored data was used to examine the first therapeutic International Normalized Ratio (INR) after interruption. TTR was compared using Wilcoxon signed rank test. Cox proportional hazards model was used to investigate the association between TTR in the first 3 months after interruption and subsequent outcomes at 3 to 9 months. Of 9,749 AF patients, 71% were on warfarin. Over a median (IQR) follow-up of 2.6 (1.8 to 3.1) y, 33% of patients had a total of 3,022 temporary interruptions. The first therapeutic INR was recorded within 1 week in 35.0% (95% confidence interval 32.6% to 37.4%), 2 weeks in 54.6% (52.2% to 57.0%), 30 days in 70.0% (67.9% to 72.1%) and 90 days in 91.3% (90.0% to 92.5%) of patients. Compared with pre-interruption, TTR 3 months after interruption was significantly lower (61.1% [36.6% to 85.0%] vs 67.6% [50.0% to 81.3%], p0.0001). A 10 unit increment in the TTR in the first 3 months after interruption was associated with a lower risk of major bleeding [Hazard ratio 0.91 (0.85 to 0.97), p = 0.005]. This association was noted in patients who received bridging anticoagulation, but not in those who did not. In conclusion, temporary interruption of warfarin is common, and nearly half of these patients had subtherapeutic INR after 2 weeks. Lower TTR in the first 3 months after interruption was associated with higher incidence of major bleeding in patients who received bridging anticoagulation.

The degree to which clinical outcomes are worsened in patients with atrial fibrillation (AF) with heart failure (HF) compared with those without HF is not well described. This study aimed to determine the impact of HF on clinical outcomes in patients with AF. We analyzed data from Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, a national registry of 10,135 patients with AF to determine associations between HF and left ventricular ejection fraction (LVEF) and outcomes, including stroke, mortality, and hospitalization using Cox multivariable modeling. Atrial Fibrillation Effect on Quality-of-Life Questionnaire (AFEQT) scores between groups were also compared. Overall, 33% (n = 3,203) of patients had HF; of these 33% (n = 985) had LVEF ≤40%. Oral anticoagulation was prescribed more commonly in patients with HF (81% vs 74%). Compared with patients without HF, those with HF had similar rate of stroke (1.28 vs 0.88 per 100-patient years, hazard ratio [HR] 1.11, confidence interval [CI] 0.83 to 1.48, p = 0.47) but higher mortality (HR 1.69, CI 1.49 to 1.92, p0.001) and hospitalization (HR 1.31, CI 1.23 to 1.39, p0.0001). Patients with LVEF ≤40% had similar stroke risk (HR 1.06, CI 0.67 to 1.67) but higher mortality (HR 2.06, CI 1.74 to 2.44) and hospitalization (HR 1.38, CI 1.25 to 1.51). AFEQT overall score was significantly lower (76.9 vs 83.3, p0.0001) in patients with HF. In conclusion, HF was associated with increased risk of death and hospitalization and worse quality of life, but similar rates of thromboembolism regardless of LVEF among patients with AF. These findings highlight the need to develop therapeutic strategies targeting functional status and survival for patients with HF and AF.

Asymptomatic atrial fibrillation (AF) is being increasingly diagnosed via implantable devices, screening, and inpatient telemetry. Management of asymptomatic AF is controversial, in part, because the associated risks have not been well described. We examined the incidence of major adverse outcomes in patients with asymptomatic versus symptomatic AF using Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, a nationwide US registry of AF patients. We compared stroke and/or non-central nervous system (CNS) embolism, major adverse cardiovascular and neurologic events, bleeding, and death in 9,319 asymptomatic (defined by European Heart Rhythm Association score = 1 or “no symptoms”) versus symptomatic patients. Overall, median (interquartile) age was 75 (67 to 82) years, 3,944 (42%) were women, and 38% versus 37% were asymptomatic based on physician versus patient-reported symptoms. Compared with those with symptoms, physician-defined asymptomatic patients were less likely to be woman (35%/47%) or be on an antiarrhythmic agent (22%/33%), but were more likely to have permanent and/or persistent AF (51%/40%). CHA2DS2-VASc scores did not vary by symptom status. After adjustment, risk of first stroke and/or non-CNS embolism (hazard ratio [HR] 0.85 [95% confidence interval {CI} 0.63 to 1.16], p = 0.32), major adverse cardiovascular and neurologic events (HR 0.88 [95% CI 0.76 to 1.03], p = 0.11), bleeding (HR 0.85 [95% CI 0.72 to 1.00], p = 0.05), and death (HR 0.99 [95% CI 0.87 to 1.13], p = 0.88) were similar in asymptomatic (European Heart Rhythm Association = 1) and symptomatic AF, respectively. Prospective, randomized studies are needed to further define associated adverse events and delineate optimal prophylactic therapies in patients with asymptomatic AF.

There is increasing emphasis on optimizing evidence-based medication (EBM) persistence as a means to improve longitudinal patient outcomes after acute myocardial infarction (MI); yet it is unknown whether differences in medication persistence exist between patients discharged from academic versus nonacademic hospitals. We linked Medicare pharmacy claims data with 3,184 patients with none–ST-segment elevation MI >65 years of age who were treated in 2006 at 253 hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology and American Heart Association guidelines registry. Using multivariate regression, we compared persistent filling of β blockers, angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, clopidogrel, and statins at 90 days and 1 year postdischarge between patients discharged from academic and nonacademic hospitals. Patients treated at academic hospitals were more frequently nonwhite (19% vs 8%, p 65 years old treated at academic versus nonacademic hospitals; however, persistence rates are low both early and late postdischarge, highlighting a continued need for quality improvement efforts to optimize post-MI management.

Non–vitamin K antagonist oral anticoagulants (NOACs) are effective at preventing stroke in patients with atrial fibrillation (AF). However, little is known about the management of bleeding in contemporary, clinical use of NOACs. We aimed to assess the frequency, management, and outcomes of major bleeding in the setting of community use of NOACs. Using the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II registry, we analyzed rates of International Society on Thrombosis and Haemostasis major bleeding and subsequent outcomes in patients treated with NOACs versus warfarin. Outcomes of interest included acute and chronic bleeding management, recurrent bleeding, thromboembolic events, and death. In total, 344 patients with atrial fibrillation experienced major bleeding events over a median follow-up of 360 days follow-up: n = 273 on NOAC (3.3 per 100 patient-years) and n = 71 on warfarin (3.5 per 100 patient-years). Intracranial bleeding was uncommon but similar (0.34 per 100 patient-years for NOAC vs 0.44 for warfarin, p = 0.5), as was gastrointestinal bleeding (1.8 for NOAC vs 1.3 for warfarin, p = 0.1). Blood products and correction agents were less commonly used in NOAC patients with major bleeds compared with warfarin-treated patients (53% vs 76%, p = 0.0004 for blood products; 0% vs 1.5% for recombinant factor; p = 0.0499); no patients received pharmacologic hemostatic agents (aminocaproic acid, tranexamic acid, desmopressin, aprotinin). Within 30 days, 23 NOAC-treated patients (8.4%) died versus 5 (7.0%) on warfarin (p = 0.7). At follow-up, 126 NOAC-treated (46%) and 29 warfarin-treated patients (41%) were not receiving any anticoagulation. In conclusion, rates of major bleeding are similar in warfarin and NOAC-treated patients in clinical practice. However, NOAC-related bleeds require less blood product administration and rarely require factor replacement.

Previous studies have suggested that patients with coronary artery disease (CAD) in rural areas may have worse outcomes due to limited availability of specialists, fewer resources, and less institutional funding. Data were collected from hospitals participating in the Get With the Guidelines-Coronary Artery Disease Program (GWTG-CAD) from January 2000 to December 2008. In-hospital outcomes and quality of care were stratified by care at rural versus urban hospitals. Multivariate logistic regression analysis was used to determine the association of rural locale with in-hospital mortality, length of stay, and compliance with the GWTG-CAD performance measurements including (1) early aspirin use, (2) smoking cessation counseling and discharge prescriptions of (3) aspirin, (4) angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers for left ventricular systolic dysfunction, (5) beta-blockers, and (6) lipid-lowering therapy and a composite of all 6 measurements. Data were collected from 22,096 patients at 71 rural centers and 329,938 patients at 477 urban centers. Unadjusted rates of compliance with performance measurements were lower in rural (range 82.4% to 90.5%) compared to urban (range 81.3% to 95.0%) hospitals including the composite (74.7% vs 80.6%, p0.0001). In multivariate analysis, rural status was not independently associated with lower compliance with any of the performance measurements. Unadjusted mortality rates were higher in rural versus urban hospitals (5.7% vs 4.4%, p0.0001), but this was not significant in multivariate analysis (odds ratio 1.05, 95% confidence interval 0.87 to 1.26). In conclusion, within the GWTG-CAD quality improvement initiative, patients with CAD treated at rural hospitals receive similar quality of care and have similar outcomes as those at urban centers.

According to several medical registries, there is a need to improve the care of post-myocardial infarction (MI) patients, especially those with left ventricular dysfunction (LVD) and heart failure. This can potentially be achieved by implementing disease management programs, which include critical pathways, patient education, and multidisciplinary hospital teams. Currently, algorithms for critical pathways, including discharge processes, are lacking for post-MI LVD patients. Such schemes can increase the use of evidence-based medicines proved to reduce mortality. Educational programs are aimed at increasing patients' awareness of their condition, promoting medication compliance, and encouraging the adoption of healthy behaviors; such programs have been shown to be effective in improving outcomes of post-MI LVD patients. Reductions in all-cause hospitalizations and medical costs as well as improved survival rates have been observed when a multidisciplinary team (a nurse, a pharmacist, and a hospitalist) is engaged in patient care. In addition, the use of the "pay for performance" method, which can be advantageous for patients, physicians, and hospitals, may potentially improve the care of post-MI patients with LVD.

Drug-eluting stents (DESs) are used in >80% of percutaneous coronary intervention (PCI) procedures; however, up to 2/3 are used for off-label indications. Factors associated with DES use in patients with ST-elevation myocardial infarction (STEMI) are not known in contemporary clinical practice. We analyzed temporal trends, geographic patterns, and sociodemographic factors associated with off-label use of DESs in patients undergoing primary PCI for STEMI from July 2004 to March 2006 in the National Cardiovascular Data Registry (NCDR). The main outcome of this study was receipt of any DES, and the candidate independent variables were sociodemographic, hospital, clinical, and procedural variables. We also analyzed temporal trends and geographic patterns for use of DESs. A total of 30,235 patients with STEMI underwent primary PCI with use of DESs (84%) or bare metal stents (16%). Adoption of DESs was rapid but varied widely as a function of geographic location. After adjusting for clinical and procedural variables, older age was associated with lower use (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.91 to 0.98), whereas white race (OR 1.14, 95% CI 1.03 to 1.27), commercial insurance (OR 1.22, 95% CI 1.11 to 1.34), and the west census region (OR 1.37, 95% CI 1.04 to 1.81) were associated with higher use of DESs. In conclusion, adoption of DESs was rapid in patients with STEMI, but geographic location and sociodemographic and hospital factors were associated with the use DESs.

Elevated B-type natriuretic peptide (BNP) levels are associated with increased risk for mortality in patients with non–ST-segment-elevation (NSTE) acute coronary syndromes (ACS). However, the optimal use of BNP measurement for the risk stratification of these patients remains unclear. This study was conducted to analyze patterns of, and factors associated with, BNP measurement in patients with NSTE ACS from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines? (CRUSADE) quality improvement initiative from 2003 through 2006. The association of degree of BNP elevation with in-hospital mortality in patients with measured BNP levels across risk categories was also analyzed. A total of 16,323 of 77,071 patients (21.2%) from 486 hospitals had BNP levels measured; the rate of BNP measurement by quarter increased from 5.1% to 27.7% during this analysis. Factors most strongly associated with BNP measurement included signs of heart failure on presentation, older age, previous heart failure, faster presenting heart rate, and higher body mass index. The adjusted risk for mortality was higher in patients who had BNP levels measured than in those who did not (adjusted odds ratio 1.14, 95% confidence interval 1.03 to 1.25). In patients with BNP levels measured, a higher degree of BNP elevation was associated with incrementally higher in-hospital mortality rates across risk categories. BNP levels were measured in approximately 1/5 of patients with NSTE ACS in contemporary practice. BNP was most frequently measured in patients presenting with high-risk characteristics, but the association of incremental increases in BNP levels with higher mortality rates was similar across risk categories. In conclusion, more widespread measurement of BNP levels for risk stratification of patients with NSTE ACS may be warranted.

Previous studies of hospitalized patients have suggested an "obesity paradox" with lower short-term mortality as weight increases. We hypothesized that some of this difference might be related to more aggressive management. To evaluate the effect of body mass index (BMI) on treatments and outcomes in patients with coronary artery disease (CAD), the Get With The Guidelines database was investigated. From 409 United States hospitals, 130,139 hospitalizations for CAD were identified with documented height and weight. Patients were stratified by BMI, with 3,305 (2.5%) underweight (BMI18.5 kg/m(2)), 34,697 (27%) of healthy weight (BMI 18.5 to 24.9 kg/m(2)), 47,883 (37%) overweight (BMI 25 to 29.9 kg/m(2)), 37,686 (29%) obese (BMI 30 to 39.9 kg/m(2)), and 6,568 (5%) extremely obese (BMIor =40 kg/m(2)). As BMI increased, patients were significantly younger but more likely to be men and have hypertension, diabetes, and hyperlipidemia. Unadjusted in-hospital mortality was highest in the underweight group (10.4%) and significantly lower in the healthy-weight (5.4%), overweight (3.1%), obese (2.4%), and extremely obese (2.9%) patients. Higher BMI was associated with increased use of standard medical therapies such as aspirin, beta blockers, inhibitors of the renin-angiotensin system, and lipid-lowering therapy in the hospital and at discharge. In adjusted analyses, compared with the healthy-weight group, overweight and obese patients were more likely to undergo invasive procedures and had lower mortality (p0.01 for all odds ratios). In conclusion, increasing BMI appears to be associated with better use of guideline-recommended medical treatment and invasive management of CAD, which may explain the observed lower rates of in-hospital mortality.

Fibrinolytic therapy is the most common reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), particularly in smaller centers. Previous studies evaluated the relation between time to treatment and outcomes when few patients were treated within 30 minutes of hospital arrival and many did not receive modern adjunctive medications. To quantify the impact of a delay in door-to-needle time on mortality in a recent and representative cohort of patients with STEMI, a cohort of 62,470 patients with STEMI treated using fibrinolytic therapy at 973 hospitals that participated in the National Registry of Myocardial Infarction from 1999 to 2002 was analyzed. Hierarchical models were used to evaluate the independent effect of door-to-needle time on in-hospital mortality. In-hospital mortality was lower with shorter door-to-needle times (2.9% foror =30 minutes, 4.1% for 31 to 45 minutes, and 6.2% for45 minutes; p0.001 for trend). Compared with those experiencing door-to-needle timesor =30 minutes, adjusted odd ratios (ORs) of dying were 1.17 (95% confidence interval [CI] 1.04 to 1.31) and 1.37 (95% CI 1.23 to 1.52; p for trend0.001) for patients with door-to-needle times of 31 to 45 and45 minutes, respectively. This relation was particularly pronounced in those presenting within 1 hour of symptom onset to presentation time (OR 1.25, 95% CI 1.01 to 1.54; OR 1.54, 95% CI 1.27 to 1.87, respectively; p for trend0.001). In conclusion, timely administration of fibrinolytic therapy continues to significantly impact on mortality in the modern era, particularly in patients presenting early after symptom onset.

Since the introduction of drug-eluting stents (DESs), patterns of revascularization strategies for patients with non-ST-segment elevation acute coronary syndromes have not been assessed. We studied 82,924 patients from the CRUSADE Initiative who presented with non-ST-segment elevation acute coronary syndromes and underwent coronary angiography at 365 United States hospitals that had capabilities for surgical (coronary artery bypass grafting [CABG]) and percutaneous (percutaneous coronary intervention [PCI]) revascularization from January 2002 to June 2005. Temporal trends in the use of PCI, CABG, and medical management without revascularization were analyzed with respect to the introduction of DESs. In total, 73,577 patients (89%) had50% stenosis inor =1 coronary artery, and there was a significant increase in the use of PCI (vs CABG or medical management without revascularization) during the study period (38.3% vs 52.5%). By quarter 2 of 2005, 80% of patients who underwent PCI received a DES. In total, 18,462 of 25,068 patients (73.6%) with 3-vessel disease (3VD) underwent revascularization and use of CABG decreased for these patients (48.9% to 39.9%, p0.001), whereas use of PCI increased (51.1% to 60.1%, p0.001). Factors significantly associated with use of PCI for patients with 3VD who underwent any revascularization included previous PCI, previous CABG, cardiology inpatient care, care at an academic hospital, renal insufficiency, and previous congestive heart failure. In conclusion, coinciding with the introduction of DESs, there has been a significant increase in the use of PCI and, in those patients with 3VD, a decrease in the use of CABG with a shift toward increasing use of PCI. Long-term implications of this shift remain uncertain, especially in patients with 3VD.

Previous studies of non-ST-segment elevation acute coronary syndromes (NSTE ACSs) complicated by heart failure (HF) have focused primarily on patients with left ventricular systolic dysfunction defined by an ejection fraction (EF)40%. Little is known about HF with preserved systolic function (EFor =40%) in the NSTE ACS population. We identified high-risk patients with NSTE ACS (ischemic electrocardiographic changes and/or positive cardiac markers) from the CRUSADE quality improvement initiative who had an EF recorded and who had information on HF status. Management and outcomes were analyzed and compared based on the presence or absence of HF and whether left ventricular EF wasor =40%. Of 94,558 patients with NSTE ACS, 21,561 (22.8%) presented with signs of HF, and most had HF with preserved systolic function (n = 11,860, 55%). Mortality rates were 10.7% for HF/systolic dysfunction, 5.8% for HF/preserved systolic function, 5.7% for no HF/systolic dysfunction, and 1.5% for no HF/preserved systolic function. Use of guideline-recommended medical therapies and interventions was frequently significantly lower in those with HF regardless of EF compared with those without HF, except for use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In conclusion, NSTE ACS complicated by HF with preserved systolic function is common and associated with a 2.3-fold higher mortality compared with NSTE ACS without HF or systolic dysfunction. Guideline-recommended therapies and interventions are under-utilized in patients with NSTE ACS and HF, with and without preserved systolic function, compared with those without HF.

The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative is a prospective, rapid-cycle quality-improvement initiative that focuses on improving both the diagnostic evaluation of patients with non–ST-segment elevation (NSTE) acute coronary syndromes (ACS; defined as ischemic ST-segment changes and/or positive cardiac markers) and the use of treatments recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for management of NSTE ACS. The ultimate goal of the CRUSADE initiative is to improve the quality of care among high-risk patients with NSTE ACS. At the same time, the CRUSADE initiative provides the unique opportunity to evaluate the pattern of NSTE ACS management in a large-scale, routine practice setting in the United States. Cumulatively, the CRUSADE initiative has collected data from >165,000 patients with NSTE ACS admitted at >400 US hospitals since 2001. This article reviews the major results from the CRUSADE initiative on risk stratification, gaps in guidelines adherence, paradoxical care, and the association of guideline adherence with outcomes.

We evaluated temporal trends in the use of early (

In the case of non-ST-segment elevation acute coronary syndromes (NSTE-ACSs), the acute use of certain antiplatelet agents is complicated by concerns about perioperative bleeding risks in patients requiring coronary artery bypass grafting (CABG) during the index hospitalization. As a result, clinicians often withhold potentially useful agents, such as clopidogrel, before determining patients' coronary anatomy. An accurate predictive model could allow for a better balance of this safety concern with the demonstrated benefits of agents such as clopidogrel. To create an accurate decision-making tool that would assess, at hospital presentation, the need for CABG in patients with NSTE-ACSs, we studied 61,974 high-risk patients with NSTE-ACS admitted to 311 CABG-capable hospitals participating in Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) from 2001 to 2003. A total of 8,395 patients (14%) underwent CABG during their initial hospital stay. A multivariate model was developed and identified 13 presenting clinical characteristics significantly associated with the likelihood of CABG (previous CABG, male gender, previous heart failure, diabetes, hyperlipidemia, renal insufficiency, ST depression and transient ST elevation, ageor = 75 years, previous percutaneous coronary intervention, family history of coronary artery disease, hypertension, trends in CABG rates, and previous stroke). This model had only modest predictive accuracy and calibration (c-index = 0.67). In conclusion, although certain presenting clinical features are associated with an increased likelihood of CABG in patients with NSTE-ACSs during the index hospitalization, it remains difficult to reliably identify, before diagnostic angiography, those who will subsequently undergo surgical revascularization.

Limited data are available on the off-label use of drug-eluting stents (DESs) in clinical practice. We used data from the American College of Cardiology National Cardiovascular Data Registry to describe the rates and outcomes of DES use in 4 common off-label situations: ST-elevation myocardial infarction, in-stent restenosis, coronary artery bypass grafts, and chronic total occlusions. The rates of in-hospital adverse events for each off-label situation were determined and compared with the expected rates calculated from a validated model. From approval of DESs to the end of 2004, a total of 408,033 procedures involved placement of a DES. The use of DESs increased from 19.7% at the start of the study to 78.2% by the end of fourth quarter of 2004. Off-label use of DESs occurred in 24.1% of procedures. The rates of in-hospital adverse events with DES use in ST-elevation myocardial infarction, in-stent restenosis, coronary artery bypass grafting, and chronic total occlusions were lower than expected from the validated model. In conclusion, off-label use of DESs is common and is associated with a low rate of short-term adverse events. Randomized clinical trials are needed to confirm the efficacy of DESs in these clinical and angiographic settings. These data also highlight the importance of multicenter registries in tracking new technologies.

Elevated low-density lipoprotein cholesterol (LDL-C) is associated with increased risk of myocardial infarction and is a target for disease prevention. The association between initial LDL-C and statin treatment in patients with non-ST-segment elevation myocardial infarction (NSTEMI)/unstable angina pectoris (UAP) has not been well characterized. We explored detailed LDL-C levels and statin treatment in 22,938 patients with NSTEMI/UAP enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines Registry (2003 to 2006). Patients reporting home statin use or previous cardiovascular disease were excluded. We examined statin receipt at discharge across 4 categories of baseline LDL-C: very low (70 mg/dl), low (70 to 99 mg/dl), high (100 to 129 mg/dl), and very high (≥130 mg/dl). The largest proportion of patients had LDL-C ≥130 mg/dl (32.6%), followed by LDL-C 100 to 129 mg/dl (32.1%), LDL-C 70 to 99 mg/dl (24.9%), and LDL-C70 mg/dl (10.4%). Compared with high LDL-C categories, patients in the lowest LDL-C category had their first NSTEMI/UAP event at a significantly older age and had higher rates of other cardiovascular risk factors (including hypertension and diabetes) but were less likely to have a family history of coronary artery disease. Overall, 80.3% of eligible patients with NSTEMI/UAP received statins at discharge, ranging from 63.8% in those with very low LDL-C (70 mg/dl) to 88.1% in those with very high LDL-C (130 mg/dl). In conclusion,1/3 of patients with NSTEMI/UAP had an LDL-C level100. Those with low LDL-C were older, had more co-morbidities, and were less likely to be prescribed a statin at discharge than those with higher LDL-C.

Public reporting has been proposed as a strategy to improve health care quality. Percutaneous coronary interventions (PCIs) performed in the United States from July 1, 2009, to June 30, 2011, included in the CathPCI Registry were identified (n = 1,340,213). Patient characteristics and predicted and observed in-hospital mortality were compared between patients treated with PCI in states with mandated public reporting (Massachusetts, New York, Pennsylvania) and states without mandated public reporting. Most PCIs occurred in states without mandatory public reporting (88%, n = 1,184,544). Relative to patients treated in nonpublic reporting states, those who underwent PCI in public reporting states had similar predicted in-hospital mortality (1.39% vs 1.37%, p = 0.17) but lower observed in-hospital mortality (1.19% vs 1.41%, adjusted odds ratio [OR(adj)] 0.80; 95% confidence interval [CI] 0.74, 0.88; p

Previous studies have shown that blacks have worse long-term outcomes than whites who have systolic heart failure. The reasons for these racial differences remain unclear. We investigated the effect of race and etiology of heart failure on outcomes of patients who had left ventricular (LV) systolic dysfunction. We studied records of 1,977 patients (27% black) who underwent cardiac catheterization who had New York Heart Association class II to IV symptoms and a LV ejection fraction40%. Adjusted Cox's proportional hazards regression models were examined for the end points of mortality, rehospitalization, and a composite of the 2. Black versus white patients were younger (median age 56 vs 63 years, p0.01), more often were women (49% vs 33%, p0.01), had diabetes (37% vs 31%, p = 0.02), and hypertension (75% vs 56%, p0.01). Black patients were less likely to have significant coronary artery disease by angiography (41% vs 69%, p0.01). Race was not an independent predictor of mortality (hazard ratio 1.09, 95% confidence interval 0.93 to 1.28, p = 0.27). After adjusted survival curves were stratified by race and etiology, the estimates indicated that among those patients who had nonischemic LV dysfunction, blacks appeared to have worse survival than whites. Thus, we found no racial differences in the long-term mortality risk of patients who had symptomatic LV systolic dysfunction. In conclusion, after stratifying by ischemic and nonischemic etiologies, we found decreased survival in blacks who had a nonischemic etiology compared with whites. There were no racial differences in rehospitalization between patients who had ischemic LV systolic dysfunction and those who did not.

Despite the established benefit of drug-eluting stents (DESs) in improving clinical and angiographic outcomes in pivotal, randomized trials, relatively little is known regarding the frequency and patterns of DES use in clinical practice. To characterize DES use in a broad, unselected high-risk non-ST-segment elevation acute coronary syndrome population, we evaluated the frequency, patterns, and predictors of DES use among patients in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Quality Improvement Initiative who were selected to undergo percutaneous coronary intervention. Of 8,852 patients with high-risk non-ST-segment elevation acute coronary syndromes who underwent percutaneous revascularization at 262 hospitals between October 2003 and June 2004, 5,858 (66.2%) were treated with DESs and 2,994 (33.8%) were not. During a 9-month period, DES use increased considerably from 52.6% of cases in October 2003 to 78.5% in June 2004. Compared with the bare metal stent cohort, patients receiving DESs were more likely to be women and to have private insurance, but were less likely to present with positive cardiac markers or ST-segment depression. In adjusted analysis, death and recurrent infarction were significantly lower among the patients with a DES, yet early revascularization and treatment with guideline-recommended therapies were less frequent. In a multivariate model, significant (p0.05) predictors of DES use included hyperlipidemia, elevated systolic blood pressure, private insurance, and treatment at a larger hospital. In conclusion, these findings not only identified differences in the selection and treatment of patients receiving bare metal stents versus DESs, but also demonstrated the increasing use of DESs in higher risk patients who have previously been excluded from randomized, pivotal trials.

Sotalol is a commonly prescribed antiarrhythmic drug (AAD) used for maintaining sinus rhythm in patients with atrial fibrillation (AF). Although randomized studies have found that sotalol can significantly delay time to AF recurrence, its association with mortality is less clear, particularly among those with coronary artery disease. We examined outcomes of 2,838 patients with coronary artery disease and AF. Using Cox proportional hazards modeling, landmark analysis, and time-dependent covariates for drug therapy, we compared cumulative survival among patients treated with sotalol (n = 226), amiodarone (n = 856), or no AAD (n = 1,756). Median follow-up was 4.2 years (interquartile range [IQR] 2.0-7.4). The median age was 68 years (IQR 60-75). Compared with those treated with amiodarone or no AAD, patients treated with sotalol were less likely to be black (6% vs 13% vs 13%) and have a previous myocardial infarction (35% vs 51% vs 48%) or a left ventricular ejection fraction40% (13% vs 26% vs 21%). In follow-up, persistence of sotalol was limited; 97% of patients treated with sotalol were treated for25% of the follow-up period. In adjusted analysis accounting for time on therapy, sotalol use was associated with an increased risk of all-cause death compared with no drug (hazard ratio 1.53, 95% confidence interval 1.19 to 1.96, p = 0.0009), but a decreased risk of death compared with amiodarone (hazard ratio 0.72, 95% confidence interval 0.55 to 0.91, p = 0.0141). In conclusion, sotalol therapy was more frequently used in patients with fewer co-morbidities, often discontinued early in follow-up, and was associated with increased mortality compared with no AAD but decreased mortality relative to amiodarone.

We assessed the relation of abnormal predischarge non-invasive test results to outcomes in postmyocardial infarction patients. We included series published from 1980 to 1995 containing only myocardial infarction patients, enrolling most patients after 1980, testing within 6 weeks of infarction, having follow-up rates > 80%, and having 2 x 2 frequency outcome rates for test results, that were the latest of multiple reports. Sensitivity, specificity, and predictive values were calculated for test results for 1-year outcomes (cardiac death, cardiac death or reinfarction). Univariable and summary odds were calculated for test results. Reports (n = 54) included a total of 19,874 patients and were primarily retrospective (76%) and small series (35% of reports included < 5 deaths). One-year mortality ranged from 2.5% for pharmacologic stress echocardiography to 9.3% for exercise radionuclide angiography. Positive predictive values for most noninvasive risk markers were < 0.10 for cardiac death and < 0.20 for death or reinfarction. Electrocardiographic, symptomatic, and scintigraphic risk markers of ischemia (ST-segment depression, angina, a reversible defect) were less sensitive (< or = 44%) for identifying morbid and fatal outcomes than markers of left ventricular dysfunction or heart failure (exercise duration, impaired systolic blood pressure response, and peak left ventricular ejection fraction). The positive predictive value of predischarge noninvasive testing is low. Markers of left ventricular dysfunction appear to be better predictors than markers of ischemia. Limitations of the literature-small samples and widely varying event rates-impede our ability to discern the accuracy of pre-discharge noninvasive testing. More rigorous, controlled trials are required to elucidate the relative value of these tests for risk stratification.

Risk of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is high, yet the effectiveness of guideline-recommended preoperative prophylaxis in clinical practice remains uncertain. We determined the utilization and variation of preoperative AF prevention and assessed the comparative effectiveness of alternative drugs using the Society of Thoracic Surgeons multicenter Contemporary Analysis of Perioperative Cardiovascular Surgical Care (CAPS-Care) registry. Among 2,177 patients who underwent high-risk CABG and/or valve surgery, the mean age was 71 ± 9, 66% were men, 26% had chronic lung disease, and 21% had cerebrovascular disease. Overall use of AF prophylaxis was 84% and varied across sites (range 52% to 100%). The most common preventive agents were beta blockers (72%), followed by calcium antagonists (17%). Postoperatively, 30% (n = 646) developed AF at a median of 2 (25th to 75th percentiles: 1 to 3) days after surgery. Increasing age, height, white race, body mass index35, New York Heart Association class IV heart failure, preoperative dialysis, and concomitant aortic valve replacement were associated with greater odds of postoperative AF (p0.05 for all). Preoperative amiodarone use was associated with a trend to reduction of postoperative AF (26%, adjusted odds ratio 0.72 [95% confidence interval 0.51 to 1.00], p = 0.052). After adjustment, the odds of postoperative AF were not statistically different across agents. In conclusion, use of AF prophylaxis before surgery varied significantly. In this high-risk population, we were unable to demonstrate that any of the commonly used preventive agents were associated with lower rates of AF compared with alternatives or no treatment.

Concern has been raised that Asian-Americans may have a higher bleeding risk than Caucasian-Americans when treated with fibrinolytic and antithrombotic agents. To date there is limited evidence to support or refute this hypothesis or evaluate bleeding risk and its related outcomes in Caucasian-Americans versus Asian-Americans with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions (PPCI). We evaluated Asian-Americans and Caucasian-Americans with STEMI receiving reperfusion therapy in the National Registry of Myocardial Infarction (NRMI) 4 and 5 (n = 90,317). We studied risk-adjusted major bleeding and in-hospital mortality. Major bleeding rates after fibrinolysis were similar in Asian-Americans (n = 705) and Caucasian-Americans (n = 42,243, 11.1% vs 10.3%, adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.69 to 1.36, p = 0.5002). Although the observed major bleeding rate was higher in Asian-Americans (n = 1,037) compared to Caucasian-Americans (n = 46,332) treated with PPCI (10.3% vs 7.8%, p = 0.0036), these rates differed only marginally after adjusting for baseline clinical variables (OR 1.24, 95% CI 0.97 to 1.59). Overall adjusted mortality was similar in Asian-Americans and Caucasian-Americans when treated with fibrinolysis (OR 0.96, 95% CI 0.56 to 1.65) or with PPCI (OR 1.35, 95% CI 0.85 to 2.13). Major bleeding after PPCI or fibrinolysis was associated with similar increased risks for mortality in these ethic groups. In conclusion, despite suggestions to the contrary, Asian-Americans with STEMI treated with fibrinolysis or PPCI had similar bleeding and bleeding-related mortality risks compared to Caucasian-Americans. Given the genotypic and phenotypic differences between the 2 cohorts, similar studies in the rapidly growing Asian-American population are needed to confirm our findings and to understand the safety and effectiveness of newer potent antiplatelet and antithrombotic agents in patients with coronary syndromes.

Early physician follow-up after a heart failure (HF) hospitalization is associated with lower risk of readmission. However, factors associated with early physician follow-up are not well understood. We identified 30,136 patients with HF ≥65 years at 225 hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE) registry or the Get With The Guidelines–Heart Failure (GWTG-HF) registry from January 1, 2003 through December 31, 2006. We linked these clinical data to Medicare claims data for longitudinal follow-up. Using logistic regression models with site-level random effects, we identified predictors of physician follow-up within 7 days of hospital discharge. Overall 11,420 patients (37.9%) had early physician follow-up. Patients residing in hospital referral regions with higher physician concentration were significantly more likely to have early follow-up (odds ratio 1.29, 95% confidence interval 1.12 to 1.48, for highest vs lowest quartile). Patients in rural areas (0.84, 0.78 to 0.91) and patients with lower socioeconomic status (0.79, 0.74 to 0.85) were less likely to have early follow-up. Women (0.87, 0.83 to 0.91) and black patients (0.84, 0.77 to 0.92) were less likely to receive early follow-up. Patients with greater co-morbidity were less likely to receive early follow-up. In conclusion, physician follow-up within 7 days after discharge from a HF hospitalization varied according to regional physician density, rural location, socioeconomic status, gender, race, and co-morbid conditions. Strategies are needed to ensure access among vulnerable populations to this supply-sensitive resource.

Patients with previous stroke are at high-risk for myocardial infarction (MI). Concern regarding increased risk of bleeding or recurrent stroke in this patient population might alter therapeutic decisions. Data were collected from 281 hospitals in the United States in the NCDR ACTION Registry. Patients with ST-segment elevation MI (STEMI; n = 15,997) or non-STEMI (NSTEMI; n = 25,514) entered into the registry from January 1, 2007 through December 31, 2007 were included. We assessed use of evidence-based medications and procedures in patients with and without previous stroke. Risk-adjusted odds ratio of death, major bleeding not related to coronary artery bypass grafting, and a composite outcome (major adverse cardiac events [MACEs], i.e., death/MI/stroke/cardiogenic shock/congestive heart failure) were calculated using logistic regression. Previous stroke was reported in 5.1% of patients with STEMI and 9.3% of those with NSTEMI. Of patients with STEMI eligible for reperfusion therapy, those with previous stroke were less likely to receive reperfusion therapy compared to patients without previous stroke. Patients with previous stroke had longer door-to-needle and door-to-balloon times. Of patients with STEMI and NSTEMI, those with previous stroke were less likely to receive evidence-based therapies. Death, MACEs, and major bleeding were more common with previous stroke. When adjusted for baseline risk, patients with previous stroke were at increased risk of death (only those with STEMI) and MACEs but not bleeding. In conclusion, patients with STEMI and previous stroke are at increased risk for death and patients with STEMI and NSTEMI are at increased risk of MACE. Despite this, previous stroke patients are less likely to receive guideline-based MI therapies.

Bleeding, a common complication of acute myocardial infarction (AMI) treatment, is associated with worse outcomes. A contemporary model for major bleeding associated with AMI treatment can stratify patients at elevated risk for bleeding and is needed to risk-adjust AMI practice and outcomes. Using the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines (ACTION Registry–GWTG) database, an in-hospital major bleeding risk model was developed in a population of patients with ST-segment elevation myocardial infarction and non–ST-segment elevation myocardial infarction. The model used only baseline variables and was developed (n = 72,313) and validated (n = 17,960) in patients with AMI (at 251 United States centers from January 2007 to December 2008). The 12 most statistically and clinically significant variables were incorporated into the final regression model. The calibration plots are shown, and the model discrimination is demonstrated in derivation and validation cohorts, as well as across key subgroups. The rate of major bleeding in the overall population was 10.8%. The 12 factors associated with major bleeding in the model were heart rate, baseline hemoglobin, female gender, baseline serum creatinine, age, electrocardiographic changes, heart failure or shock, diabetes, peripheral artery disease, body weight, systolic blood pressure, and home warfarin use. The risk model discriminated well in the derivation (C-statistic = 0.73) and validation (C-statistic = 0.71) cohorts. A risk score for major bleeding corresponded well with observed bleeding: very low risk (3.9%), low risk (7.3%), moderate risk (16.1%), high risk (29.0%), and very high risk (39.8%). In conclusion, the ACTION Registry–GWTG in-hospital major bleeding model stratifies risk for major bleeding using variables at presentation and enables risk-adjusted bleeding outcomes for quality improvement initiatives and clinical decision making.

Light-to-moderate alcohol consumption has been previously associated with a lower risk of acute myocardial infarction (AMI) and mortality. The association of changes in drinking behavior after an AMI with health status and long-term outcomes is unknown. Using a prospective cohort of patients with AMI evaluated with the World Health Organization's Alcohol Use Disorders Identification Test, we investigated changes in drinking patterns in 325 patients who reported moderate drinking at the time of their AMI. One-year alcohol consumption, disease-specific (angina pectoris and quality of life) and general (mental and physical) health status and rehospitalization outcomes, and 3-year mortality were assessed. Seattle Angina Questionnaire Angina Frequency and Quality of Life, Short Form-12 Mental and Physical Component Summary Scales were modeled using multivariable hierarchical linear models within site. Of the initial 325 moderate drinkers at baseline, 273 (84%) remained drinking and 52 (16%) quit. In fully adjusted models, Physical Component Scale scores (beta 6.47, 95% confidence interval 3.73 to 9.21, p0.01) were significantly higher during follow-up in those who remained drinking. Persistent moderate drinkers had a trend toward less angina (relative risk 0.65, 95% confidence interval 0.39 to 1.10, p = 0.11), fewer rehospitalizations (hazard ratio 0.79, 95% confidence interval 0.44 to 1.41, p = 0.42), lower 3-year mortality (relative risk 0.75, 95% confidence interval 0.23 to 2.51, p = 0.64), and better disease-specific quality of life (Seattle Angina Questionnaire Quality of Life, beta 3.88, 95% confidence interval -0.79 to 8.55, p = 0.10) and mental health (Mental Component Scale, beta 0.83, 95% confidence interval -1.62 to 3.27, p = 0.51) than quitters. In conclusion, these data suggest that there are no adverse effects for moderate drinkers to continue consuming alcohol and that they may have better physical functioning compared to those who quit drinking after an AMI.

Guidelines support percutaneous coronary intervention (PCI) of the noninfarct-related artery during primary PCI for ST-segment elevation myocardial infarction (STEMI) in patients with hemodynamic compromise; however, in patients without hemodynamic compromise, PCI of the noninfarct-related artery is given a class III recommendation. We analyzed the National Cardiovascular Data Registry (n = 708,481 admissions, 638 sites) to determine the prevalence, predictors, and in-hospital outcomes of primary multivessel PCI from 2004 to 2007. Patients with STEMI and multivessel coronary artery disease who were undergoing primary PCI were identified (n = 31,681). After excluding the patients treated with staged PCI (n = 2,745), 10.8% (n = 3,134) of the remaining population (n = 28,936) were treated with multivessel PCI. Patients undergoing multivessel PCI were at higher risk and were more likely to be in cardiogenic shock. The overall in-hospital mortality rates were greater in patients undergoing multivessel PCI (7.9% vs 5.1%, p

Use of evidence-based medicine (EBM) improves outcomes after acute coronary syndromes (ACS), yet patients often discontinue prescribed therapies after discharge. Although such discontinuation is well documented, patients' reasons for medication discontinuation have not been reported. MAINTAIN is a longitudinal follow-up registry of CRUSADE/ACTION, which enrolled patients during an ACS hospitalization from January 2006 to September 2007. All discharge medications were obtained from hospital charts. Patients were interviewed by telephone 3 months after discharge to determine if EBM classes prescribed at discharge were continued (aspirin, clopidogrel, beta blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and lipid-lowering medications). If discontinuation occurred, patients were asked if it was with provider knowledge/input or not (self-discontinuation). A multivariable logistic regression model was performed to identify factors associated with self-discontinuation of prescribed EBM. Of the 1,077 patients interviewed, 1,006 (93.4%) were discharged on aspirin, 816 (75.8%) on clopidogrel, 982 (91.2%) on beta blockers, 745 (69.2%) on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 968 (89.9%) on lipid-lowering medications. At 3-month follow-up, 304 patients (28.2%) had discontinuedor =1 of these prescribed EBM classes. Although many reported provider involvement, most discontinuation (61.5%) was self-determined. Factors independently associated with self-discontinuation were no pharmacy coinsurance, increasing number of medications, not using reminder tools (e.g., pillbox), lower education, and dialysis. In conclusion, 1/3 of patients with ACS discontinueor =1 of their prescribed EBMs within 3 months of hospital discharge, and most of this discontinuation is without provider involvement. Patient education, better prescription drug coverage, and reminder strategies may improve use of EBMs at 3 months after discharge from ACS admission.

To improve hospital performance in door-to-balloon (DTB) times nationally, the American College of Cardiology D2B Alliance recently enrolled approximately 1,000 hospitals that perform percutaneous coronary intervention (PCI) across the United States in a large national quality improvement effort. We evaluated recent changes in DTB times in hospitals within the Get-With-The-Guidelines (GWTG) Coronary Artery Disease (CAD) program, a partner in the D2B Alliance. Within GWTG-CAD participating hospitals, we studied DTB in nontransferred patients with ST-elevation myocardial infarction treated with primary PCI from July 2006 to March 2008. We evaluated the percentage of patients treated within 90 minutes and used multivariable models with generalized estimating equations to examine trends over time after accounting for changes in patients' characteristics. A total of 5,801 patients at 167 hospitals were included in our analysis, with 3,567 patients at 98 hospitals that joined the D2B Alliance. From July to September 2006, 54.1% of patients received primary PCI within 90 minutes. This number increased significantly during the study period: 335 (74.1%) of 452 patients at GWTG-CAD participating hospitals were treated within 90 minutes from January to March 2008, including 229 of 304 patients (75.3%) treated at hospitals that joined the D2B Alliance and 106 of 148 patients (71.6%) treated at other GWTG-CAD participating hospitals (p

Age and chronic kidney disease are major risk factors for poor cardiovascular outcome; however, renal function is often estimated on the basis of serum creatinine levels, and advanced renal impairment may be hidden behind near normal creatinine levels. We assessed the impact of estimated glomerular filtration rate (GFR) on in-hospital mortality in young (65 years old), old (65 to 84 years old), and very old (or = 85 years old) patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction. The adjusted risk of death was calculated in 169,826 patients from the American College of Cardiology National Cardiovascular Data Registry undergoing primary PCI for acute myocardial infarction. Younger patients had fewer co-morbidities, higher estimated GFR, less frequent multivessel disease, and lower unadjusted mortality rates than older patients (p0.0001 for all comparisons). However, the adjusted risk of in-hospital mortality for patients with severe renal insufficiency (estimated GFR30 ml/min/1.73 m(2)) compared with those with normal renal function (estimated GFRor = 60 ml/min/1.73 m(2)) was higher in young patients (adjusted odds ratio = 7.58, 95% confidence interval 6.18 to 9.29) than old (adjusted odds ratio = 4.75, 95% confidence interval 4.14 to 5.45) and very old patients (adjusted odds ratio = 3.50, confidence interval 2.50 to 4.89). In conclusion, severe renal insufficiency is associated with a greater risk of in-hospital mortality in young than old and very old patients after primary PCI. Risk stratification for patients with acute myocardial infarction should incorporate an assessment of renal function with estimated GFR values rather than absolute serum creatinine levels as done in the currently utilized risk scoring algorithms.

We sought to determine the usage patterns and impact of upstream glycoprotein IIb/IIIa inhibitor and clopidogrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). We studied trends in the use of upstream glycoprotein IIb/IIIa inhibitors and clopidogrel in 3,895 patients with STEMI undergoing primary PCI at 124 hospitals in the United States participating in the CRUSADE initiative from March 2005 to December 2006. Administration of these agents15 minutes before PCI was considered pre-PCI use, and administrationor =15 minutes before, during, and after PCI was considered peri-PCI use. A total of 3,566 patients (91.6%) received glycoprotein IIb/IIIa inhibitors within 24 hours of presentation, of whom 1,225 (34.4%) received this medication before PCI. Similarly, 3,785 patients (97.2%) received clopidogrel within 24 hours of presentation, of whom 1,029 (27.2%) received this medication before PCI. From 2005 to 2006, pre-PCI glycoprotein IIb/IIIa inhibitor use decreased from 43.4% to 33.5%, whereas pre-PCI clopidogrel use increased from 21.2% to 31.5%. Clinical characteristics, risk of adverse outcomes, and bleeding events were similar in the pre- versus peri-PCI glycoprotein IIb/IIIa inhibitor and clopidogrel cohorts, respectively. In conclusion, most patients with STEMI undergoing primary PCI receive glycoprotein IIb/IIIa inhibitors and clopidogrel, but only (1/3) are treated upstream with these agents and this upstream use does not have a significant impact on outcomes. These results indicate that further studies are needed to determine the optimal dosing and timing of antiplatelet therapies for patients undergoing primary PCI.

Angina pectoris (AP) often responds to treatment, but in some, it becomes chronic or recurs over time. Identifying patients with continued AP is a necessary to understand its associations and implications. A baseline cohort with coronary disease and AP were surveyed 6 months and 1 year after catheterization for self-reported symptoms and quality of life. Patients were divided into 3 groups: chronic AP, recurrent AP, and AP free. Baseline characteristics, medications, revascularization, and quality of life are described. Regression analysis determined independent associations with chronic AP. Of the 1,109 patients with complete 1-year follow-up, 19% (n = 207) had chronic AP, 11% (n = 126) had recurrent AP, but most (70%, n = 776) were AP free. Patients with chronic and recurrent AP had similar cardiac histories, had more single vessel coronary disease, and underwent revascularization less often. Patients with recurrent AP had lower educational status and more often smoked. Patients with chronic AP were younger, were women, had higher body mass index, had more depression and lung disease, and had more frequent baseline AP. They also took more antianginals and other medications and had reduced physical function and health-related quality of life in relation to the persistence and frequency of symptoms (p

Outcomes are typically graded on the basis of diagnoses coded according to the International Classification of Diseases, Ninth Revision (ICD-9). To facilitate performance measurement, the ICD-9 codes for acute myocardial infarction changed in October 2005 to completely separate non-ST elevation myocardial infarction (NSTEMI; code 410.71) and ST elevation myocardial infarction (STEMI; all other codes 410.x), yet it is unclear whether these changes have been implemented by coders. Patients in the National Registry of Myocardial Infarction (NRMI), version 5, were categorized in 2 ways: by electrocardiographic (ECG) findings and ICD-9 codes. Agreement between ECG findings and ICD-9 codes for type of myocardial infarction (STEMI or NSTEMI) was assessed before and after ICD-9 revision. Mortality rates were measured in a subgroup of patients discharged without transfer after the coding change. There were 102,679 hospitalizations before October 2005 and 63,012 hospitalizations after the coding change, among which the mean age was 66.7 years. Previously, 81% of NSTEMIs (by ECG diagnosis) were coded ICD-9 410.71; after the reclassification of code 410.71 to reflect NSTEMI, 82% of NSTEMIs were coded 410.71 (p

Patients, physicians, and payers are facing a significant increase in cardiovascular (CV) imaging use, resulting in skyrocketing societal costs, without clear improvement in patient outcomes. The need for studies evaluating the effects of CV imaging that assess appropriate end points is critical to address continued concerns over the lack of well-designed clinical studies. Thus, the investigators propose a framework, using computed tomographic angiography as a model, that should be considered in the optimal design of future imaging research and would potentially provide payers with data to make appropriate reimbursement decisions. The inclusion of risk stratification, randomization, multiple-site participation, and multigeography site enrollment are key elements in the construction of such studies. Meaningful end points with regard to operating characteristics, downstream testing, CV event rates, outcomes, and costs are essential to appropriately evaluate any new imaging technology. Only once better level evidence is formed to support CV imaging can the central issues of quality and appropriateness of CV imaging truly be evaluated. If the CV community does not embrace this type of scientific evaluation of CV imaging modalities and fails to adequately identify the value in these techniques, it may ultimately lose the ability to use them to provide optimal care to its patients.

Elevated B-type natriuretic peptide (BNP) levels are associated with increased risk for mortality in patients with non-ST-segment-elevation (NSTE) acute coronary syndromes (ACS). However, the optimal use of BNP measurement for the risk stratification of these patients remains unclear. This study was conducted to analyze patterns of, and factors associated with, BNP measurement in patients with NSTE ACS from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines? (CRUSADE) quality improvement initiative from 2003 through 2006. The association of degree of BNP elevation with in-hospital mortality in patients with measured BNP levels across risk categories was also analyzed. A total of 16,323 of 77,071 patients (21.2%) from 486 hospitals had BNP levels measured; the rate of BNP measurement by quarter increased from 5.1% to 27.7% during this analysis. Factors most strongly associated with BNP measurement included signs of heart failure on presentation, older age, previous heart failure, faster presenting heart rate, and higher body mass index. The adjusted risk for mortality was higher in patients who had BNP levels measured than in those who did not (adjusted odds ratio 1.14, 95% confidence interval 1.03 to 1.25). In patients with BNP levels measured, a higher degree of BNP elevation was associated with incrementally higher in-hospital mortality rates across risk categories. BNP levels were measured in approximately 1/5 of patients with NSTE ACS in contemporary practice. BNP was most frequently measured in patients presenting with high-risk characteristics, but the association of incremental increases in BNP levels with higher mortality rates was similar across risk categories. In conclusion, more widespread measurement of BNP levels for risk stratification of patients with NSTE ACS may be warranted.

Age-adjusted sudden cardiac death rates are highest for black patients compared with other racial groups. The prophylactic implantation of an implantable cardioverter-defibrillator (ICD) provides a significant reduction in sudden cardiac death and overall mortality in patients after myocardial infarctions with significant left ventricular systolic dysfunction. The purpose of this study was to determine whether black patients with left ventricular systolic dysfunction were less likely than white patients to receive ICDs for the primary prevention of sudden cardiac death. Data from the National Registry to Advance Heart Health (ADVANCENT) were analyzed to determine which patients with histories of myocardial infarctions and ejection fractions

It has been suggested that Asians may respond differently to antithrombotic therapy, but contemporary management and outcomes of non-ST-segment elevation (NSTE) acute coronary syndromes (ACSs) in Asian patients have not been well characterized. Using data from the CRUSADE initiative, we compared baseline characteristics, treatment patterns, and in-hospital outcomes between 1,071 Asian and 72,513 non-Asian white patients hospitalized with NSTE ACS. Asian patients were more likely to have hypertension, diabetes, and renal insufficiency compared with non-Asian whites. Body mass index was lower in Asian patients (24.9 vs 27.8 kg/m(2), p0.0001). Use of acute medical therapies, cardiac catheterization, and percutaneous or surgical revascularization did not significantly differ between Asian and white groups after adjustment for patient and hospital characteristics. In-hospital mortality (5.0% vs 4.4%, adjusted odds ratio [OR] 1.24, 95% confidence interval [CI] 0.88 to 1.73) and reinfarction rates (2.0% vs 2.3%. adjusted OR 0.94, 95% CI 0.65 to 1.38) were also similar. In contrast, rates of major bleeding (13.4% vs 9.4%, p0.0001) and red blood cell transfusion (9.6% vs 6.6%, p = 0.0005) were significantly higher in the Asian population and this higher bleeding risk persisted after adjustment for bleeding risk factors and body mass index; adjusted ORs were 1.32 (95% CI 1.08 to 1.62) and 1.32 (95% CI 1.01 to 1.72), respectively. In conclusion, despite similar treatment, Asian patients with NSTE ACS have significantly higher bleeding risk even after adjustment for risk factors and body mass index. Further investigation is needed to explore the potential for ethnic variability in antithrombotic susceptibility.

Although glycoprotein (GP) IIb/IIIa inhibitors are recommended for patients with unstable angina and non-ST-segment elevation myocardial infarction who undergo percutaneous coronary intervention (PCI), the American College of Cardiology/American Heart Association guidelines do not specify optimal timing for their initiation. We compared patient characteristics and clinical outcomes in 30,830 patients with non-ST-segment elevation myocardial infarction included in the CRUSADE initiative (January 2001 to December 2004) who underwent PCI with upstream (1 hour before PCI) or periprocedural use of GP IIb/IIIa inhibitors. GP IIb/IIIa inhibitors were administered upstream in 43% of patients versus periprocedurally in 57%. Time from arrival to PCI was longer for patients who received GP IIb/IIIa inhibitors upstream (median 25.6 hours) compared with periprocedurally (18.2 hours). Unadjusted incidence of in-hospital death or reinfarction was lower with upstream GP IIb/IIIa inhibitor use (3.8% vs 4.3%, p = 0.046), but after adjusting for patient and hospital characteristics, this difference was not statistically significant. Treatment with upstream GP IIb/IIIa inhibitors was associated with a lower incidence of unadjusted death or reinfarction in patients who underwent PCI12 hours from hospital arrival. In conclusion, in this observational analysis, overall ischemic outcomes were similar between the 2 groups, but clinical trials are needed to solve the controversy over optional timing of GP IIb/IIIa inhibitor use.

Recent studies have suggested that low-dose aspirin has preserved benefit with less bleeding compared with standard-dose aspirin when given with or without clopidogrel in patients with high-risk non-ST-segment elevation acute coronary syndromes (NSTE ACSs). We evaluated 22,618 patients with NSTE ACSs and high-risk features (ischemic ST-segment changes and/or positive cardiac markers) from 369 hospitals included in the CRUSADE initiative from May 4, 2003 to September 30, 2004. We analyzed acute (24 hours of admission) and discharge aspirin doses in relation to concomitant clopidogrel use and other clinical predictors. Dosing of aspirin in the first 24 hours was as follows: 17.3% of patients (n = 3,911) received 81 mg, 13.5% (n = 3,062) received 162 mg, 67.4% (n = 15,247) received 325 mg, and 1.8% (n = 398) received325 mg. Use of lower dose aspirin increased at discharge: 40.2% (n = 7,524) received 81 mg, 3.1% (n = 579) received 162 mg, and 55.7% (n = 10,423) received 325 mg. In patients who received concomitant clopidogrel at discharge (n = 12,635), 37.6% received aspirin 81 mg and 58.5% received 325 mg. Compared with patients who did not receive concomitant discharge clopidogrel (n = 4,772), 44.0% received aspirin 81 mg and 51.2% received 325 mg. Use of aspirin 81 mg was significantly lower in patients undergoing percutaneous coronary intervention (31.5% vs 46.2%, p0.0001). In conclusion, most patients with high-risk NSTE ACSs in the United States continue to be treated with aspirin 325 mg at discharge with and without concomitant clopidogrel, despite recent studies that have shown a better safety profile with low-dose aspirin.

The presence of congestive heart failure (CHF) has been associated with treatment disparities and worse outcomes in patients with ST-segment elevation myocardial infarction, but the incidence and effect of CHF in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACSs) has not been well characterized. We evaluated 45,744 patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) who were treated at 424 hospitals in the CRUSADE Quality Improvement Initiative between March 2000 and March 2003. Treatment patterns and in-hospital outcomes in patients with signs of CHF on presentation and those who developed in-hospital CHF were compared with those in patients without CHF. In total, 10,398 patients (22.7%) had signs of CHF on presentation, and 1,664 patients (3.6%) later developed in-hospital CHF. Compared with patients without CHF, early (24 hours from presentation) medications and invasive cardiac procedures were used less often in patients with signs of CHF on presentation. Likewise, patients with in-hospital CHF were less likely than those without CHF to receive acute antiplatelet agents and undergo cardiac catheterization but more likely to receive acute beta blockers, angiotensin-converting enzyme inhibitors, and heparin and to undergo coronary artery bypass grafting. Adjusted mortality was higher in patients with signs of CHF on presentation (odds ratio 2.64, 95% confidence interval 2.31 to 3.01) and those with in-hospital CHF (odds ratio 4.93, 95% confidence interval 4.05 to 5.99) than in patients without CHF. In conclusion, CHF occurs frequently in patients with NSTE ACS but is associated with less aggressive treatment and a higher risk of mortality. Further study is needed to determine the causes of these treatment differences and the optimal therapeutic approach for patients with NSTE ACS and concomitant CHF.

We sought to determine the frequency of electrocardiographic (ECG) acquisition within 10 minutes of hospital arrival, factors associated with delayed ECG acquisition, and any relation among delayed ECG acquisition, treatment patterns, and clinical outcomes. We therefore analyzed data from 63,478 patients (26,615 women, 42%) with high-risk non-ST-segment elevation acute coronary syndromes (designated by positive cardiac markers and/or ischemic ST-segment changes) who were enrolled in the CRUSADE Quality Improvement Initiative from February 2001 to March 2004. Patients were categorized based on time to electrocardiography as delayed (>10 minutes from hospital arrival) or nondelayed (

We sought to characterize current patterns of care for lipid testing and management in a sample of patients in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines Quality Improvement Initiative and to determine the most important predictors of lipid testing and management at discharge. We evaluated data from >40,000 patients who had been hospitalized in United States hospitals from March 2000 to March 2003 and had a principal discharge diagnosis of unstable angina pectoris or non-ST-segment elevation acute myocardial infarction as part of the initiative.