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ObjectiveOlder, relatively small studies identified female sex as a risk factor for adverse events after catheter ablation for atrial fibrillation (AF). We aimed to assess contemporary sex-based differences in baseline and procedural characteristics, adverse events, and quality of life among adults undergoing catheter ablation for AF.MethodsIn this observational cohort study, we evaluated those enrolled in the National Cardiovascular Data Registry AFib Ablation Registry between January 2016 and September 2020. Using logistic regression, we analysed the association between patient sex and in-hospital adverse events.ResultsAmong 58 960 adults (34.6% women) from 150 centres undergoing AF ablation by 706 physicians, women were older (68 vs 64 years, p<0.001), had more comorbidities, and had lower AF-related quality of life at the time of ablation (mean Atrial Fibrillation Effect on QualiTy-of-life Questionnaire) score: 51.8 vs 62.2, p<0.001). Women had a higher risk of hospitalisation >1 day (adjusted OR (aOR) 1.41 (95% CI 1.33 to 1.49)), major adverse event (aOR 1.60 (95% CI 1.33 to 1.92)) and any adverse event (aOR 1.57 (95% CI 1.41 to 1.75)). Women had a higher risk of bradycardia requiring pacemaker, phrenic nerve damage, pericardial effusion, bleeding and vascular injury, but had no differences in death or acute pulmonary vein isolation.ConclusionsAmong almost 60 000 patients in the largest prospective registry of AF ablation procedures, female sex was independently associated with a higher risk of hospitalisation >1 day, adverse events, and reduced quality of life, although there were no differences in death or acute pulmonary vein isolation.

Objective. To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements. Data Sources. In-depth interviews, hospital surveys, and Health Quality Alliance data. Study Design. We conducted a qualitative study using in-depth interviews with clinical and administrative staff (N=99) at hospitals reporting strong influence (n = 6) as well as hospitals reporting limited influence (n = 6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data. Data Collection Methods. In-depth, open-ended interviews; hospital survey. Principal Findings. Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes. Conclusions. The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals. Key Words. Quality improvement, campaigns, hospitals, acute myocardial infarction, Amid persistent evidence that many patients do not receive guideline-based care, national quality campaigns have developed to motivate widespread adoption of evidence-based practices to improve quality of care. Recent examples [...]

Percutaneous left atrial appendage (LAA) occlusion is increasingly performed in patients with atrial fibrillation and long-term contraindications for anticoagulation. Our aim was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of the LAA orifice and assess its impact on the adjacent left upper pulmonary vein (LUPV) hemodynamics. We included 50 patients who underwent percutaneous LAA occlusion with the Watchman device and had acceptable three-dimensional transesophageal echocardiography images of LAA pre- and post-device placement. We measured offline the LAA orifice diameters in the long axis, and the minimum and maximum diameters, circumference, and area in the short axis view. Eccentricity index was calculated as maximum/minimum diameter ratio. The LUPV peak S and D velocities pre- and post-procedure were also measured. Patients were elderly (mean age 76 ± 8 years), 30 (60%) were men. There was a significant increase of all LAA orifice dimensions following LAA occlusion: diameter 1 (pre-device 18.1 ± 3.2 vs. post-device 21.5 ± 3.4 mm, p < 0.001), diameter 2 (20.6 ± 3.9 vs. 22.1 ± 3.6 mm, p < 0.001), minimum diameter (17.6 ± 3.1 vs. 21.3 ± 3.4 mm, p < 0.001), maximum diameter (21.5 ± 3.9 vs. 22.4 ± 3.6 mm, p = 0.022), circumference (63.6 ± 10.7 vs. 69.6 ± 10.5 mm, p < 0.001), and area (3.1 ± 1.1 vs. 3.9 ± 1.2 cm2, p < 0.001). Eccentricity index decreased after procedure (1.23 ± 0.16 vs. 1.06 ± 0.06, p < 0.001). LUPV peak S and D velocities did not show a significant difference (0.29 ± 0.15 vs. 0.30 ± 0.14 cm/s, p = 0.637; and 0.47 ± 0.19 vs. 0.48 ± 0.20 cm/s, p = 0.549; respectively). LAA orifice stretches significantly and it becomes more circular following LAA occlusion without causing a significant impact on the LUPV hemodynamics.

Data on the impact of residual peri-device leak after left atrial appendage occlusion (LAAO) are limited.

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IMPORTANCE: Left atrial appendage occlusion (LAAO) has emerged as an alternative to anticoagulation for select patients with atrial fibrillation; however, women have been underrepresented in clinical trials of LAAO, and sex-specific subanalyses are limited. OBJECTIVE: To evaluate the sex differences in the baseline characteristics of patients undergoing LAAO implant and in the in-hospital outcomes after LAAO implant. DESIGN, SETTING, AND PARTICIPANTS: A total of 49 357 patients in the National Cardiovascular Data Registry LAAO Registry undergoing LAAO with the Watchman device between January 1, 2016, and June 30, 2019, were included in this study. EXPOSURE: Female or male sex. MAIN OUTCOMES AND MEASURES: The primary outcomes were aborted or canceled procedure, major adverse event, any adverse event, prolonged hospital stay longer than 1 day, and death. Unadjusted and multivariable adjusted logistic regression analyses were performed to assess sex differences in in-hospital adverse events. RESULTS: In this cohort study of 49 357 patients (mean [SD] age, 76.1 [8.0] years), 20 388 women (41.3%) and 28 969 (58.7%) men underwent LAAO. Compared with men, women were older and had a higher prevalence of paroxysmal atrial fibrillation, prior stroke, and uncontrolled hypertension but a lower prevalence of congestive heart failure, diabetes, and coronary artery disease. After multivariable adjustment, there were no differences in aborted or canceled procedures between women and men (613 [3.0%] vs 851 [2.9%]; odds ratio [OR] 1.01, 95% CI, 0.90-1.13). Women were more likely than men to experience any adverse event (1284 [6.3%] vs 1144 [3.9%]; P &lt; .001; OR, 1.63; 95% CI, 1.49-1.77; P &lt; .001) or major adverse event (827 [4.1%] vs 567 [2.0%]; P &lt; .001; OR, 2.06; 95% CI, 1.82-2.34; P &lt; .001) owing to pericardial effusion requiring drainage (241 [1.2%] vs 144 [0.5%]) or major bleeding (349 [1.7%] vs 244 [0.8%]). Women were also more likely than men to experience a hospital stay longer than 1 day (3272 [16.0%] vs 3355 [11.6%]; P &lt; .001; adjusted OR, 1.46; 95% CI, 1.38-1.54; P &lt; .001) or death (adjusted OR, 2.01; 95% CI, 1.31-3.09; P = .001), although death was rare and absolute differences were minimal (58 [0.3%] vs 37 [0.1%]; P &lt; .001). CONCLUSIONS AND RELEVANCE: This study suggests that, compared with men, women have a significantly higher risk of in-hospital adverse events after LAAO. Further research aimed at risk reduction, particularly strategies to reduce the risk of pericardial effusion and major bleeding, in women undergoing LAAO is warranted.

IMPORTANCE: After disparate results from observational and small randomized studies, the COMPLETE trial demonstrated superiority of multivessel (MV) percutaneous coronary intervention (PCI) over culprit-only PCI for ST-elevation myocardial infarction (STEMI). OBJECTIVE: To describe temporal trends and institutional variation of MV PCI use for STEMI in the United States to inform how new evidence may influence clinical practice. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included STEMI admissions involving MV disease from 1598 institutions in the National Cardiovascular Data Registry CathPCI Registry from the third quarter of 2009 to the first quarter of 2018. An MV PCI was defined as a PCI to a nonculprit lesion within 45 days of the index procedure. EXPOSURES: Multivessel PCI, defined as placement of coronary stents in 2 or more major epicardial vessels or the staged placement of 1 or more coronary stents in a major epicardial vessel distinct from the index culprit vessel, within 45 days of the index PCI. MAIN OUTCOMES AND MEASURES: Outcomes included the proportional use of MV PCI among STEMI admissions with MV disease, and the timing of MV PCI (an index procedure, a staged procedure during index hospitalization, or a postdischarge procedure within 45 days). RESULTS: Among 359 879 admissions with STEMI and MV disease, MV PCI was performed in 38.5% (n = 138 380; mean [SD] age of patients, 62.3 [12.3] years; 102 266 men [73.9%]) within 45 days. Of those receiving MV PCIs, 30.8% (n = 42 629) had a procedure performed during the index procedure, 31.6% (n = 43 696) as a staged procedure during the index hospitalization, and 37.6% (n = 52 055) within 45 days of discharge. Complete revascularization of all diseased arteries was performed in 76.2% (n = 105 389). From the third quarter of 2009 to the second quarter of 2013, MV PCI use declined by 10%, from 42.7% (3230 of 7572 cases) to a nadir of 32.7% (3386 of 10 342 cases), followed by an increase to 44.0% (5062 of 11 497 cases) by the fourth quarter of 2017. During this time, there was a 13.6% decline in use of postdischarge staged MV PCI (from 23.4% of STEMI cases [1772 of 7572 cases] in the third quarter of 2009 to 9.9% [1094 of 11 171 cases] in the fourth quarter of 2014) and an 12.5% increase in MV PCI performed during the index admission (from 19.3% [1458 of 7572 cases] in the third quarter of 2009 to 31.8% [3557 of 11 171 cases] in the first quarter of 2018). Multivessel PCI use varied substantially across institutions, with a median use of 37.9% (interquartile range, 30.0%-46.5%). CONCLUSIONS AND RELEVANCE: In this large, nationwide analysis, MV PCI use for patients with STEMI has been increasing through early 2018 but was used in the minority of patients and with wide variability across US institutions. The adoption of new trial results into guidelines and practice may further promote the growth of MV PCI.

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IMPORTANCE: Cardiogenic shock after acute myocardial infarction (AMI) is associated with high mortality, particularly among patients with multivessel coronary artery disease. Recent evidence suggests that use of multivessel percutaneous coronary intervention (PCI) may be associated with harm. However, little is known about recent patterns of care and outcomes for this patient population. OBJECTIVE: To evaluate patterns in the use of multivessel PCI vs culprit-vessel PCI in AMI and cardiogenic shock and outcomes in the US from 2009 to 2018. DESIGN, SETTING, AND PARTICIPANTS: This cohort study identified all patients in the CathPCI Registry) with AMI and cardiogenic shock who had multivessel coronary artery disease and underwent PCI between July 1, 2009, and March 31, 2018. EXPOSURES: Multivessel or culprit-vessel PCI for AMI and shock. PRIMARY OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality. Temporal trends and hospital variation in PCI strategies were evaluated, while accounting for differences in case mix using hierarchical models. As a secondary outcome, the association of PCI strategy with postdischarge outcomes was evaluated in the subset of patients who were Medicare beneficiaries. RESULTS: Of 64 301 patients (mean [SD] age, 66.4 [12.5] years; 20 366 [31.7%] female; 54 538 [84.8%] White) with AMI and shock at 1649 US hospitals, 34.9% had primary multivessel PCI. In the subgroup of 48 943 patients with ST-segment elevation myocardial infarction (STEMI), 31.5% underwent multivessel PCI. Between 2009 and 2018, this percentage increased by 6.7% per year for AMI and 5.8% for STEMI. Overall, multivessel PCI was associated with a greater adjusted risk of in-hospital complications (odds ratio [OR], 1.18; 95% CI, 1.14-1.23) and with greater in-hospital mortality in patients with STEMI (OR, 1.11; 95% CI, 1.06-1.16). Among Medicare beneficiaries, multivessel PCI use was not associated with postdischarge 1-year mortality (51.5% vs 49.8%; risk-adjusted OR, 0.97; 95% CI, 0.90-1.04; P = .37). Significant hospital variation was found in the use of multivessel PCI, with a higher multivessel PCI rate for similar patients across hospitals (median OR, 1.37; 95% CI, 1.33-1.41). Patients at hospitals with high rates of PCI in STEMI use had higher risk-adjusted in-hospital mortality (highest vs lowest hospital multivessel PCI quartile: OR, 1.10; 95% CI, 1.02-1.19). CONCLUSIONS AND RELEVANCE: This cohort study found that multivessel PCI was increasingly used as the revascularization strategy in AMI and shock and that hospitals that used multivessel PCI more, especially among patients with STEMI, had worse outcomes. With recent evidence suggesting harm with this strategy, there appears to be an urgent need to change practice and improve outcomes in this high-risk population.

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The strong association between the functional impairment and the use of beta-blockers after acute myocardial infarction in the elderly patients are studied. The survival benefits are observed in the patients, who are using beta-blockers, with and without functional impairments.

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IMPORTANCE: Although physician visual assessment (PVA) of stenosis severity is a standard clinical practice to support decisions for coronary revascularization, there are concerns about its accuracy. OBJECTIVE: To compare PVA with quantitative coronary angiography (QCA) as a means of assessing stenosis severity among patients undergoing percutaneous coronary intervention (PCI) in China. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study (2012-2013) of a random subset of 1295 patients from the China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) Prospective PCI Study was carried out. The PEACE Prospective PCI study recruited a consecutive sample of patients undergoing PCI at 35 hospitals in 18 provinces of China. The coronary angiograms of this subset of participants were reviewed using QCA by 2 independent core laboratories blinded to PVA readings. MAIN OUTCOMES AND MEASURES: Differences between PVA and QCA assessments of stenosis severity for lesions for which PCI was performed and variation of these differences among hospitals and physicians, stratified by the diagnosis of acute myocardial infarction (AMI). RESULTS: In patients without AMI, the mean (SD) age was 62 (10) years, and 217 (31.5%) were women; in patients with AMI, the mean (SD) age was 60 (11) years, and 153 (25.2%) were women. The mean (SD) percent diameter stenosis by PVA was 16.0% (11.5%) greater than that by QCA in patients without AMI and 10.2% (12.3%) in those with AMI (P &lt; .001 for both comparisons). In patients without AMI, of 837 lesions with 70% or more stenosis by PVA, 427 (50.6%) were less than 70% by QCA; in patients with AMI, similar patterns were observed to a lesser extent. Among patients without AMI, only 4 (0.47%) lesions were additionally assessed with fractional flow reserve. Among 30 hospitals, the difference between PVA and QCA readings of stenosis severity varied from 7.6% (95% CI, 0.4%-14.7%) to 21.3% (95% CI, 17.1%-24.9%) among non-AMI patients. Across 57 physicians, this difference varied from 6.9% (95% CI, −1.4%-15.3%) to 26.4% (95% CI, 21.5%-31.4%). CONCLUSIONS AND RELEVANCE: For coronary lesions treated with PCI in China, PVA reported substantially higher readings of stenosis severity than QCA, with large variation across hospitals and physicians. These findings highlight the need to improve the accuracy of information used to guide treatment decisions in catheterization laboratories.

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Observational studies and in vivo experiments have raised concern that the cardioprotective effects of taking aspirin are blocked by ibuprofen, a non-steroidal anti-inflammatory drug that competitively inhibits aspirins binding site […]

This analysis evaluated temporal trends and factors associated with the use of dual-coil implantable cardioverter-defibrillator (ICD) leads.

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IMPORTANCE: Cardiac resynchronization therapy (CRT) reduces the risk for mortality and heart failure–related events in select patients. Little is known about the use of CRT in combination with an implantable cardioverter defibrillator (ICD) in patients who are eligible for this therapy in clinical practice. OBJECTIVE: To (1) identify patient, clinician, and hospital characteristics associated with CRT defibrillator (CRT-D) use and (2) determine the extent of hospital-level variation in the use of CRT-D among guideline-eligible patients undergoing ICD placement. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort from 1428 hospitals participating in the National Cardiovascular Data Registry ICD Registry between April 1, 2010, and June 30, 2014. Adult patients meeting class I or IIa guideline recommendations for CRT at the time of device implantation were included in this study. MAIN OUTCOMES AND MEASURES: Implantation of an ICD with or without CRT. RESULTS: A total of 63 506 eligible patients (88.6%) received CRT-D at the time of device implantation. The mean (SD) ages of those in the ICD and CRT-D groups were 67.9 (12.2) years and 68.4 (11.5) years, respectively. In hierarchical multivariable models, black race was independently associated with lower use of CRT-D (odds ratio [OR], 0.77; 95% CI, 0.71-0.83) as was nonprivate insurance (OR, 0.90; 95% CI, 0.85-0.95 for Medicare and OR, 0.73; 95% CI, 0.65-0.82 for Medicaid). Clinician factors associated with greater CRT-D use included clinician implantation volume (OR, 1.01 per 10 additional devices implanted; 95% CI, 1.01-1.01) and electrophysiology training (OR, 3.13 as compared with surgery-boarded clinicians; 95% CI, 2.50-3.85). At the hospital level, the overall median risk-standardized rate of CRT-D use was 79.9% (range, 26.7%-100%; median OR, 2.08; 95% CI, 1.99-2.18). CONCLUSIONS AND RELEVANCE: In a national cohort of patients eligible for CRT-D at the time of device implantation, nearly 90% received a CRT-D device. However, use of CRT-D differed by race and implanting operator characteristics. After accounting for these factors, the use of CRT-D continued to vary widely by hospital. Addressing disparities and variation in CRT-D use among guideline-eligible patients may improve patient outcomes.

Aims Despite the benefits of regular physical activity participation following acute myocardial infarction, little is known about gender differences in physical activity among patients after acute myocardial infarction. We described, by gender, physical activity trajectories pre- and post-acute myocardial infarction, and determined whether gender was independently associated with physical activity.Methods and results The Variation in Recovery: Role of Gender on Outcomes of Young AMI patients (VIRGO) study, conducted at 103 US, 24 Spanish, and three Australian hospitals, was designed, in part, to evaluate gender differences in lifestyle behaviors following acute myocardial infarction. We used baseline, one-month, and 12-month data collected from patients aged 18–55 years (n= 3572). Patients were assigned to American Heart Association-defined levels of physical activity. A generalized estimating equation model was used to account for repeated measures within the same individual over time. Men were more active (≥150 min/wk moderate or ≥75 min/wk vigorous activity) than women at baseline (42% vs 34%), one month (45% vs 34%), and 12 months (48% vs 36%) (all p< 0.0001). Men engaged in a significantly longer duration of activity at each time point. When controlling for all other factors, women had 1.37 times the odds of being less active than men from pre-acute myocardial infarction to 12-months post-acute myocardial infarction (95% confidence interval: 1.21–1.55). Non-white race, non-active workplaces, smoking, diabetes, hypertension, and obesity were also associated independently with being less active over time (all p< 0.05).Conclusions Although activity increased modestly over time, women recovering from acute myocardial infarction were less likely to meet physical activity recommendations than were men. By identifying factors associated with low levels of activity during acute myocardial infarction recovery, targeted interventions can be introduced prior to hospital discharge.

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IMPORTANCE: Trends and in-hospital outcomes associated with early adoption of the subcutaneous implantable cardioverter defibrillator (S-ICD) in the United States have not been described. OBJECTIVES: To describe early use of the S-ICD in the United States and to compare in-hospital outcomes among patients undergoing S-ICD vs transvenous (TV)-ICD implantation. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of 393 734 ICD implants reported to the National Cardiovascular Data Registry ICD Registry, a nationally representative US ICD registry, between September 28, 2012 (US Food and Drug Administration S-ICD approval date), and March 31, 2015, was conducted. A 1:1:1 propensity-matched analysis of 5760 patients was performed to compare in-hospital outcomes among patients with S-ICD with those of patients with single-chamber (SC)–ICD and dual-chamber (DC)–ICD. MAIN OUTCOMES AND MEASURES: Analysis of trends in S-ICD adoption as a function of total ICD implants and comparison of in-hospital outcomes (death, complications, and defibrillation threshold [DFT] testing) among S-ICD and TV-ICD recipients. RESULTS: Of the 393 734 ICD implants evaluated during the study period, 3717 were S-ICDs (0.9%). A total of 109 445 (27.8%) of the patients were female; the mean (SD) age was 67.03 (13.10) years. Use of ICDs increased from 0.2% during the fourth quarter of 2012 to 1.9% during the first quarter of 2015. Compared with SC-ICD and DC-ICD recipients, those with S-ICDs were more often younger, female, black, undergoing dialysis, and had experienced prior cardiac arrest. Among 2791 patients with S-ICD who underwent DFT testing, 2588 (92.7%), 2629 (94.2%), 2635 (94.4%), and 2784 (99.7%) were successfully defibrillated (≤65, ≤70, ≤75, and ≤80 J, respectively). In the propensity-matched analysis of 5760 patients, in-hospital complication rates associated with S-ICDs (0.9%) were comparable to those of SC-ICDs (0.6%) (P = .27) and DC-ICD rates (1.5%) (P = .11). Mean (SD) length of stay after S-ICD implantation was comparable to that after SC-ICD implantation (1.1 [1.5] vs 1.0 [1.2] days; P = .77) and less than after DC-ICD implantation (1.1 [1.5] vs 1.2 [1.5] days; P &lt; .001). CONCLUSIONS AND RELEVANCE: The use of S-ICDs is rapidly increasing in the United States. Early adoption has been associated with low complication rates and high rates of successful DFT testing despite frequent use in patients with a high number of comorbidities.

Introduction:Pre-procedure cardiac computed tomography (CT) or magnetic resonance imaging (MRI) prior to percutaneous left atrial appendage occlusion (LAAO) has many theoretical benefits but data on its association with periprocedural safety and effectiveness is limited.Hypothesis:Pre-procedure imaging has the potential to improve the safety and effectiveness of LAAO.Methods:We evaluated patients in the NCDR LAAO Registry who underwent LAAO between 1/2016 and 6/2021 to compare the safety and effectiveness of LAAO procedures by use vs. non-use of pre-procedural CT/MRI. Study outcomes included implant success (deployment and release of device), device success (device released with peri-device leak <5mm), and procedure success [device released with peri-device leak <5mm and no in-hospital MAE (major adverse effects)]. Multivariable logistic regression was used to assess the relationship between pre-procedure imaging and outcomes.Results:Pre-procedure CT/MRI was used for 18.2% (n=20,851) of the 114,384 procedures in this study and significant variability was noted by hospital (Figure). CT/MRI use was more common among government and university hospitals, larger hospitals, non-teaching hospitals, and hospitals in the Midwest and south, and was less common among patients with uncontrolled hypertension, abnormal renal function, and no prior thromboembolism. Overall rates of implant success, device success, and procedure success were 93.4%, 91.2%, and 89.4%. Pre-procedure CT/MRI was independently associated with an increased likelihood of implant success (OR 1.08, CI 1.00-1.17), device success (OR 1.10, CI 1.04-1.16), and procedural success (OR 1.07, CI 1.02-1.13) There was no significant difference in risk for MAE (OR 1.02, 0.92-1.12).Conclusions:Pre-procedure CT/MRI was used 1 in 5 LAAO procedures and was independently associated with higher likelihood of implant success, device success, and procedure success, but no difference in MAE.

Introduction:The optimal ablation strategy beyond pulmonary vein isolation (PVI) for atrial fibrillation (AFib) is undefined. No prior study has been adequately powered to evaluate real-world safety outcomes in those receiving adjunctive (adj) ablation lesions. We sought to evaluate characteristics and in-hospital complications among patients undergoing AFib ablation with PVI with and without adj lesions.Hypothesis:PVI + adj will be more common in those with persistent AF (persAF) and be associated with adverse events.Methods:Patients enrolled in the National Cardiovascular Data Registry AFib Ablation Registry undergoing first-time ablation between 2016 and 2020 were stratified into paroxysmal (PAF) and persAF, and separated into PVI only, PVI+cavotricuspid isthmus (CTI) ablation alone, PVI+adj (SVC isolation, coronary sinus, vein of Marshall, atypical atrial flutter lines, other). In-hospital outcomes were compared using multivariable logistic regression.Results:A total of 50,937 patients were included. Among PAF, as compared to PVI only, both PVI+CTI and PVI+adj were associated with prolonged hospitalization after adjustment, while there were no differences in complications. In the persAF cohort, as compared to PVI only, PVI+adj was associated with a higher risk of any complication and major complication, while no differences were observed in PVI+CTI (Table). In-hospital death was rare with no differences across groups.Conclusion:Adjunctive lesions are commonly performed in real-world practice in both PAF and persAF with varied strategies. Among PAF, additional lesions were associated with prolonged hospitalization, although not complications. Among persAF, PVI+adj, but not PVI+CTI, was associated with a higher risk of complications. While additional CTI ablation may be considered safe in persAF, further efforts to determine optimal ablation strategies beyond PVI and mitigate risk are warranted.

Introduction:Patients with peripheral artery disease (PAD) are at high risk for adverse cardiovascular events, including acute myocardial infarction (AMI). Though AMI care has improved, in-hospital outcomes for patients experiencing an AMI with comorbid PAD are not well described in recent practice. We hypothesized that patients with PAD would have higher rates of bleeding and mortality during AMI hospitalization.Methods:We assessed clinical characteristics and in-hospital major bleeding and mortality rates of patients admitted with AMI and comorbid PAD at 646 hospitals in the NCDR Chest Pain MI Registry from 1/2019 to 9/2021. Major bleeding and mortality were compared for patients with vs. without PAD using multivariable logistic regression.Results:Compared with patients admitted for AMI without PAD (n = 307,550), those with PAD (n = 24,585) were older, had more comorbidities including tobacco use, diabetes, prior AMI and heart failure, and more frequently presented with NSTEMI vs. STEMI. Patients with PAD had higher crude rates of in-hospital major bleeding (9.7% vs. 6.3%) and mortality (8.1% vs. 4.7%); in exploratory analyses, rates of other adverse in-hospital events were also higher (Figure). After multivariable adjustment, PAD was associated with an increased risk of major bleeding (adjusted OR [aOR] 1.23 [95% CI 1.17-1.30]). PAD was also associated with greater risk of in-hospital mortality (aOR 1.28 [95% CI 1.21-1.37]), particularly among patients over age 65 (aOR 1.32 [95% CI 1.23-1.42] for ≥65 years vs. 1.06 [95% CI 0.96-1.18] for patients <65 years; interaction p = 0.02).Conclusions:Among patients hospitalized with AMI, those with PAD have greater comorbidity burden and increased risk of major bleeding. Patients with PAD, particularly those who are ≥65 years, also have increased risk of in-hospital death. These findings highlight a need for improved preventive efforts, tailored care pathways, and greater focus on AMI management in PAD patients.

Background:Despite recognition of the role of early ablation for favorable long-term outcomes in atrial fibrillation (AF), access to these services requires substantial resources and expertise. We investigated county-level variation in the availability of AF ablation care for the Medicare population.Methods:In Medicare physician claims from 2019 linked to AHRQ county characteristics, we evaluated the volume of AF ablation per 100,000 population over the age of 65 years across US counties. We examined county characteristics associated with local access to ablation care, evaluating county-level differences in population composition, cardiovascular risk factor burden, and access to primary care (number per 100,000 population).Results:A total of 64,055 beneficiaries received AF ablation care from 1,501 physicians across the US. Of 3,143 U.S. counties, 403 (12.8%) in 2019 had any ablation procedures. In counties with local ablation care, a median 182 beneficiaries per 100,000 persons ≥65 years of age underwent AF ablation, with a wide variation in volumes across counties - interquartile range 97 per 100,000 to 337 per 100,000 (Figure).Of the total estimated 49,238,690 persons ≥65 years of age across counties within the United States and District of Columbia, 18,639,381 (37.9%) resided in counties without AF ablation services in the same county. In adjusted analyses, counties without local AF ablation services did not differ in demographic characteristics or prevalence of cardiovascular risk factors but were characterized by lower access to primary care physicians and lower educational attainment among county residents (P<0.01 for both).Conclusions:Only 1 in 8 US counties has local AF ablation care, with over one-third of U.S. adults ≥65 years of age residing in counties without local services. Patient-centered care necessitates greater accessibility for many patients without proximity to AF ablation care, especially with expanding indications.

IMPORTANCE: The use of coronary catheterization and percutaneous coronary intervention (PCI) is increasing in China, but, to date, there are no nationally representative assessments of the quality of care and outcomes in patients undergoing these procedures. OBJECTIVE: To assess the quality of care and outcomes of patients undergoing coronary catheterization and PCI in China. DESIGN, SETTING, AND PARTICIPANTS: In a clinical observational study (China PEACE [Patient-Centered Evaluative Assessment of Cardiac Events]–Retrospective CathPCI Study), we used a 2-stage, random sampling strategy to create a nationally representative sample of 11 241 patients undergoing coronary catheterization and PCI at 55 urban Chinese hospitals in calendar years 2001, 2006, and 2011. Data analysis was performed from July 11, 2014, to November 20, 2015. MAIN OUTCOMES AND MEASURES: Patient characteristics, treatment patterns, quality of care, and outcomes associated with these procedures and changes over time. RESULTS: Of the 11 241 patients included in the study, the samples included, for 2001, 285 women (weighted percentage, 28.6%); for 2006, 826 women (weighted percentage, 32.2%), and for 2011, 2588 women (weighted percentage, 35.7%). Mean (SD) ages were 58 (8), 60 (11), and 61 (11) years, respectively. Between 2001 and 2011, estimated national rates of hospitalizations for coronary catheterization increased from 26 570 to 452 784 and for PCI, from 9678 to 208 954 (17-fold and 21-fold), respectively. More than half of stable patients undergoing coronary catheterization had nonobstructive coronary artery disease; this amount did not change significantly over time (2001: 60.3% [95% CI, 56.1%-64.5%]; 2011: 57.5% [95% CI, 55.8%-59.3%], P = .05 for trend). The proportion of PCI procedures performed via radial approach increased from 3.5% (95% CI, 1.7%-5.3%) in 2001 to 79.0% (95% CI, 77.7%-80.3%) in 2011 (P &lt; . 001 for trend). The use of drug-eluting stents (DESs) increased from 18.0% (95% CI, 14.2%-21.7%) in 2001 to 97.3% (95% CI, 96.9%-97.7%) in 2011 (P &lt; .001 for trend) largely owing to increased use of domestic DESs. The median length of stay decreased from 14 days (interquartile range [IQR], 9-20) in 2001 to 10 days (IQR, 7-14) in 2011 (P &lt; .001 for trend). In-hospital mortality did not change significantly, but both adjusted risk of any bleeding (odds ratio [OR], 0.53 [95% CI, 0.36-0.79], P &lt; .001 for trend) and access bleeding (OR, 0.23 [95% CI, 0.12-0.43], P &lt; .001) were decreased between 2001 and 2011. The medical records lacked documentation needed to calculate commonly used process metrics including door to balloon times for primary PCI and the prescription of evidence-based medications at discharge. CONCLUSIONS AND RELEVANCE: Although the use of catheterization and PCI in China has increased dramatically, we identified critical quality and documentation gaps that represent opportunities to improve care. Our findings can serve as a foundation to guide future quality improvement initiatives in China.

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It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI.

This study sought to describe the use of CRT-D and its association with survival for older patients.

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