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Myocardial infarction can be ruled out in patients with a single cardiac troponin measurement. Whether use of a uniform rule-out threshold has resulted in sex differences in care remains unclear. The purpose of this study was to evaluate implementation of a uniform rule-out threshold in females and males with possible myocardial infarction, and to derive and validate sex-specific thresholds. The implementation of a uniform rule-out threshold (<5 ng/L) with a high-sensitivity cardiac troponin I assay was evaluated in consecutive patients presenting with possible myocardial infarction. The proportion of low-risk patients discharged from the emergency department and incidence of myocardial infarction or cardiac death at 30 days were determined. Sex-specific thresholds were derived and validated, and proportion of female and male patients were stratified as low-risk compared with uniform threshold. In 16,792 patients (age 58 ± 17 years; 46% female) care was guided using a uniform threshold. This identified more female than male patients as low risk (73% vs 62%), but a similar proportion of low-risk patients were discharged from the emergency department (81% for both) with fewer than 5 (<0.1%) patients having a subsequent myocardial infarction or cardiac death at 30 days. Compared with a uniform threshold of <5 ng/L, use of sex-specific thresholds would increase the proportion of female (61.8% vs 65.9%) and reduce the proportion of male (54.8% vs 47.8%) patients identified as low risk. Implementation of a uniform rule-out threshold for myocardial infarction was safe and effective in both sexes. Sex-specific rule-out thresholds should be considered, but their impact on effectiveness and safety may be limited. [Display omitted] [ABSTRACT FROM AUTHOR]

There are limited data around sex differences in the risk profile, treatments and outcomes of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions in contemporary interventional practice. We investigated the impact of sex on clinical and procedural characteristics, complications and clinical outcomes in a national cohort. We created a longitudinal cohort (2006–2018, n = 30,605) of patients with stable angina who underwent CTO PCI in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographic, procedural and outcome data were analysed in two groups stratified by sex: male (n = 24,651), female (n = 5954). Female patients were older (68 vs 64 years, P < 0.001), had higher prevalence of diabetes mellitus (DM), hypertension (HTN) and prior stroke. Utilization of intravascular ultrasound (IVUS), drug eluting stents (DES), radial or dual access and enabling strategies during CTO PCI were higher in male compared to female patients. Following multivariable analysis, there was no significant difference in in-patient mortality (adjusted odds ratio (OR):1.40, 95 % CI: 0.75–2.61, P = 0.29) and major cardiovascular and cerebrovascular events (MACCE) (adjusted OR: 1.01, 95 % CI: 0.78–1.29, P = 0.96). The crude and adjusted rates of procedural complications (adjusted OR: 1.37, 95 % CI: 1.23–1.52, P < 0.001), coronary artery perforation (adjusted OR: 1.60, 95 % CI: 1.26–2.04, P < 0.001) and major bleeding (adjusted OR: 2.06, 95 % CI: 1.62–2.61, P < 0.001) were higher in women compared with men. Female patients treated by CTO PCI were older, underwent lesser complex procedures, but had higher adjusted risk of procedural complications with a similar adjusted risk of mortality and MACCE compared with male patients. • Limited data about clinical profile and outcomes of CTO PCI stratified by sex • In current study, women observed adjusted higher odds of procedural complications but similar odds of death & MACCE compared with men • Randomised control trial data are needed to validate these observational study findings. [ABSTRACT FROM AUTHOR]

There are concerns about the potential effect of social distancing used to control COVID-19 on the incidence of cardiovascular diseases (CVD). Retrospective cohort study. We examined the association between lockdown and CVD incidence in a Zero-COVID country, New Caledonia. Inclusion criteria were defined by a positive troponin sample during hospitalization. The study period lasted for 2 months, starting March 20, 2020 (strict lockdown: first month; loose lockdown: second month) compared with the same period of the three previous years to calculate incidence ratio (IR). Demographic characteristics and main CVD diagnoses were collected. The primary endpoint was the change in incidence of hospital admission with CVD during lockdown compared with the historical counterpart. The secondary endpoint included influence of strict lockdown, change in incidence of the primary endpoint by disease, and outcome incidences (intubation or death) analyzed with inverse probability weighting method. A total of 1215 patients were included: 264 in 2020 vs 317 (average of the historical period). CVD hospitalizations were reduced during strict lockdown (IR 0.71 [0.58–0.88]), but not during loose lockdown (IR 0.94 [0.78–1.12]). The incidence of acute coronary syndromes was similar in both periods. The incidence of acute decompensated heart failure was reduced during strict lockdown (IR 0.42 [0.24–0.73]), followed by a rebound (IR 1.42 [1–1.98]). There was no association between lockdown and short-term outcomes. Our study showed that lockdown was associated with a striking reduction in CVD hospitalizations, independently from viral spread, and a rebound of acute decompensated heart failure hospitalizations during looser lockdown. [ABSTRACT FROM AUTHOR]

Background: The optimal management of patients with ST-segment elevation myocardial infarction (STEMI) presenting late->12 hours following symptom onset-is still under debate.Objectives: The purpose of this study was to describe characteristics, temporal trends, and impact of revascularization in a large population of latecomer STEMI patients.Methods: The authors analyzed the data of 3 nationwide observational studies from the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting between 12 and 48 hours after symptom onset were classified as latecomers.Results: A total of 6,273 STEMI patients were included in the 3 cohorts, 1,169 (18.6%) of whom were latecomers. After exclusion of patients treated with fibrinolysis and patients deceased within 2 days after admission, 1,077 patients were analyzed, of whom 729 (67.7%) were revascularized within 48 hours after hospital admission. At 30-day follow-up, all-cause death rate was significantly lower among revascularized latecomers (2.1% vs 7.2%; P < 0.001). After a median follow-up of 58 months, the rate of all-cause death was 30.4 (95% CI: 25.7-35.9) per 1,000 patient-years in the revascularized latecomers group vs 78.7 (95% CI: 67.2-92.3) per 1,000 patient-years in the nonrevascularized latecomers group (P < 0.001). In multivariate analysis, revascularization of latecomer STEMI patients was independently associated with a significant reduction of mortality occurrence during follow-up (HR: 0.65 [95% CI: 0.50-0.84]; P = 0.001).Conclusions: Coronary revascularization of latecomer STEMI patients is associated with better short and long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

We adopted a difference-in-difference (DID) design to evaluate the impact of a case-based payment pilot in Tianjin, China on hospital admission, utilization of varied therapeutic regimes, and the associated costs. We used claim data of all admissions of angina and acute myocardial infarction during July 2015 to June 2018, 18 months before and after the program. Our analyses were supported by convincing common trends tests and a couple of sensitivity analyses. As intended, for patients who received percutaneous coronary stenting (PCS) and were counted in the case-based payment system, we showed that the program decreased length-of-stay, per-admission spending, and out-of-pocket spending by 20.8%, 14.2%, and 95.5%, respectively, but did not increase readmissions. However, when considering all patients who suffered from the two types of coronary heart diseases, we found that the program otherwise increased per-admission spending by nearly 11%. As a result, the program took a perverse effect in increasing monthly spending for the health insurance scheme and the society by 1005.6 thousand USD (47·5%) and 1095·7 thousand USD (34·7%), respectively. Increases in hospital admissions, and proportion of performing PCS accounted for 66·7% and 39·2% of the rise, respectively. In addition, our analysis provided evidence of health providers' cream-skimming behaviors, including selecting younger patients with lower CCI in the case-based system, up-coding complications, and keeping higher cost patients in the fee-for-service payment system. We draw lessons that case-based payment may make an unintended impact that increases healthcare costs when incentives are not properly designed. • The case-based payment pilot decreased per-admission costs for case-mixes included. • For the specific diseases, the program however increased per-admission spending. • Admissions receiving high cost therapeutic regimes accounted for the rise. • The program decreased LOS and OOP costs but did not increase readmissions. • Patient selection and up-coding were profound. [ABSTRACT FROM AUTHOR]

The ageing of the population is leading to an increase in the number of elderly patients with acute myocardial infarction. These patients are at higher risk for complications and poor medication adherence, which in turn are associated with higher healthcare resource expenditures. Nursing programmes might help to improve adherence in these complex patients. The objective of this study was to assess the impact of a nursing intervention on therapeutic adherence in elderly patients after myocardial infarction compared to a control group. A single-blind, randomized controlled trial. Heart disease institute of a tertiary care hospital. Patients aged ≥75 years with myocardial infarction undergoing percutaneous coronary intervention. A comprehensive geriatric assessment was performed during the admission in all patients (N=143). Patients were randomly allocated to a nursing intervention group (n=68) or a usual care group (n=75). In patients from the intervention group, a nursing intervention programme was performed 3 months after admission based on education support and patient monitoring to improve therapeutic adherence. The main outcome measured was 12-months therapeutic adherence, as defined by a combination of measurement tools (Morisky-Green and Hayness-Sacket scales, attendance at visits and withdrawal of medication from the pharmacy). Therapeutic adherence was assessed by nurses blinded to the assignment group. The mean age was 82.2 years. The proportion of comorbidities was significant (diabetes mellitus 51/143 (35.7%), hypertension 110/143 (76.9%), prior stroke 22/143 (15.4%)). Likewise, the proportion of geriatric syndromes was noticeable (frailty 26/143 (18.2%), risk of malnutrition 38/143 (26.6%), cognitive impairment 28/143 (19.6%)). Most patients (92.3%) had a low educational level. A total of 119 patients achieved 12-month assessment adherence. Among these patients, the proportions of adherence were as follows: Morisky-Green test: 76/119 (63.9%), Haynes-Sackett test 99/119 (83.2%), medical visits compliance 95/119 (79.8%), and correct acquisition of drugs in the pharmacy 74/119 (62.2%). A total of 42/119 patients (35.3%) were adherent as defined by the combination of the 4 measures. Therapeutic adherence at 12 months was achieved in a significantly higher proportion of patients from the nursing intervention group (51.9% vs 21.5%, p<0.001). A significant proportion of elderly patients with myocardial infarction were non-adherent at 12 months. The proportion of adherent patients was highly variable according to the different tools used. A structured nursing intervention was independently associated with a higher adherence rate, as assessed by a multidimensional measurement, in this subset of complex high-risk elderly patients with myocardial infarction. Trial registration: Registered with www.clinicaltrials.gov (NCT04662762) [ABSTRACT FROM AUTHOR]