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ObjectivesCHARISMA was a landmark randomized clinical trial that failed to demonstrate a benefit of dual antiplatelet therapy (DAPT) over aspirin alone for preventing cardiovascular events. However, subgroup analyses of the trial found fewer major adverse cardiovascular events (MACEs) for patients with established cardiovascular disease but more MACEs for patients with multiple risk factors without established cardiovascular disease. Our objective was to examine DAPT use in contemporary clinical practice after publication of CHARISMA results.Study designRetrospective analysis of a large clinical registry of outpatient cardiovascular visits to over 1000 physicians that collected data on patient clinical history, symptoms, vital signs, and medications.MethodsClinical characteristics and prescription rates of aspirin and clopidogrel were compared for patients with established cardiovascular disease and for patients with only multiple cardiovascular risk factors. Prescription of DAPT by calendar quarter was evaluated from 2008 to 2011 using multivariable Poisson regression models.ResultsOf 167,839 patients with established cardiovascular disease, 20.5% were prescribed both aspirin and clopidogrel. Of 20,478 patients with multiple risk factors but no known cardiovascular disease, 3.5% were prescribed both aspirin and clopidogrel. Across 14 calendar quarters, prescription rates of DAPT did not change significantly for patients with established CVD but decreased for patients with multiple risk factors with an incidence rate ratio of 0.77.ConclusionsUse of DAPT is modest in patients with established cardiovascular disease, for whom the CHARISMA trial suggested decreased MACEs, and prescription rates have remained stable over time. Use of DAPT in patients with multiple risk factors only, for whom CHARISMA suggested that DAPT may lead to increased MACE, was low and decreased over time.

Key Points: Question: Is the antisense oligonucleotide eplontersen associated with changes in serum transthyretin concentration and improvement in neuropathy symptoms among adults with hereditary transthyretin (ATTRv) amyloidosis with polyneuropathy? Findings: In this open-label study that enrolled 168 patients (144 assigned to subcutaneous eplontersen) and included 60 historical placebo patients, the eplontersen treatment group demonstrated changes from baseline to week 65/66 consistent with significantly lower serum transthyretin concentration (−81.7% vs −11.2%), less neuropathy impairment, and better quality of life compared with the historical placebo group. Meaning: Among adults with ATTRv polyneuropathy, the eplontersen treatment group had lower serum transthyretin concentration, less neuropathy impairment, and better quality of life compared with a historical placebo. Importance: Transthyretin gene silencing is an emerging treatment strategy for hereditary transthyretin (ATTRv) amyloidosis. Objective: To evaluate eplontersen, an investigational ligand-conjugated antisense oligonucleotide, in ATTRv polyneuropathy. Design, Setting, and Participants: NEURO-TTRansform was an open-label, single-group, phase 3 trial conducted at 40 sites across 15 countries (December 2019-April 2023) in 168 adults with Coutinho stage 1 or 2 ATTRv polyneuropathy, Neuropathy Impairment Score 10-130, and a documented TTR variant. Patients treated with placebo from NEURO-TTR (NCT01737398; March 2013–November 2017), an inotersen trial with similar eligibility criteria and end points, served as a historical placebo ("placebo") group. Interventions: Subcutaneous eplontersen (45 mg every 4 weeks; n = 144); a small reference group received subcutaneous inotersen (300 mg weekly; n = 24); subcutaneous placebo weekly (in NEURO-TTR; n = 60). Main Outcomes and Measures: Primary efficacy end points at week 65/66 were changes from baseline in serum transthyretin concentration, modified Neuropathy Impairment Score +7 (mNIS+7) composite score (scoring range, –22.3 to 346.3; higher scores indicate poorer function), and Norfolk Quality of Life Questionnaire–Diabetic Neuropathy (Norfolk QoL-DN) total score (scoring range, –4 to 136; higher scores indicate poorer quality of life). Analyses of efficacy end points were based on a mixed-effects model with repeated measures adjusted by propensity score weights. Results: Among 144 eplontersen-treated patients (mean age, 53.0 years; 69% male), 136 (94.4%) completed week-66 follow-up; among 60 placebo patients (mean age, 59.5 years; 68% male), 52 (86.7%) completed week-66 follow-up. At week 65, adjusted mean percentage reduction in serum transthyretin was −81.7% with eplontersen and −11.2% with placebo (difference, −70.4% [95% CI, −75.2% to −65.7%]; P <.001). Adjusted mean change from baseline to week 66 was lower (better) with eplontersen vs placebo for mNIS+7 composite score (0.3 vs 25.1; difference, −24.8 [95% CI, −31.0 to −18.6; P <.001) and for Norfolk QoL-DN (−5.5 vs 14.2; difference, −19.7 [95% CI, −25.6 to −13.8]; P <.001). Adverse events by week 66 that led to study drug discontinuation occurred in 6 patients (4%) in the eplontersen group vs 2 (3%) in the placebo group. Through week 66, there were 2 deaths in the eplontersen group consistent with known disease-related sequelae (cardiac arrhythmia; intracerebral hemorrhage); there were no deaths in the placebo group. Conclusions and Relevance: In patients with ATTRv polyneuropathy, the eplontersen treatment group demonstrated changes consistent with significantly lowered serum transthyretin concentration, less neuropathy impairment, and better quality of life compared with a historical placebo. Trial Registration: ClinicalTrials.gov Identifier: NCT04136184; EU Clinical Trials Register: EudraCT 2019-001698-10 This open-label, single-group, phase 3 trial evaluates eplontersen, an investigational ligand-conjugated antisense oligonucleotide, in adults with hereditary amyloid transthyretin (ATTRv) polyneuropathy at 40 sites in 15 countries, compared with historical controls. [ABSTRACT FROM AUTHOR]

A study was conducted to evaluated the association between length of stay and short-term outcomes among Medicare older patients hospitalized for heart failure. Results indicated that with a reduced length of hospital stay 30-day mortality decreased; however, posthospital readmission and mortality risk increased.

Cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries hospitalized between 2004 and 2006 in acute care hospitals in US was conducted to determine the association between hospital volume threshold and the death rate for patients hospitalized for acute myocardial infarction, heart failure, or pneumonia. Admission to higher-volume hospitals was found to be associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, but volume threshold above which an increased condition-specific hospital was not significantly associated with reduced mortality.

A study was conducted to evaluate the low-dose ionizing radiation exposure that occurs after medical imaging procedures. Results indicate that such procedures lead to high cumulative effective doses of radiation.

The study attempts to evaluate the hospital 30-day risk-standardized mortality rates (RSMRs) for those patients that have been discharged with acute myocardial infarction (AMI). The results indicate that there was a significant decrease in hospital mortality rate for patients with AMI.

A study was conducted to evaluate whether patients receiving an implantable cardioverter-defibrillator (ICD) from nonelectrophysiologists had more negative outcomes as compared to implants done by electrophysiologists who were certified for the procedure. Results indicated that implants done by nonelectrophysiologists had a higher risk of procedural complications.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2005.03.009 Byline: Tobias T. Lee, Jersey Chen, David J. Cohen, Lana Tsao Abstract: The association between low blood pressure and prognosis in the general population has been controversial, with some reports suggesting an increased mortality for patients with the lowest blood pressures. Whereas many standard heart failure therapies decrease blood pressure, the relationship between mortality and blood pressure in patients with heart failure has not been previously evaluated. Author Affiliation: Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA Article History: Received 6 October 2004; Accepted 1 March 2005

Internet-based report cards may not be the best way to rate hospitals. In a study of 141,914 Medicare patients admitted to 3,363 hospitals for treatment of a heart attack, report cards on HealthGrades.com did not accurately discriminate between hospitals that provided the best care and hospitals that provided the worst care., Context: Health care "report cards" have attracted significant consumer interest, particularly publicly available internet health care quality rating systems. However, the ability of these ratings to discriminate between hospitals is not known. Objective: To determine whether hospital rating for acute myocardial infarction (AMI) mortality from a prominent Internet hospital ratir g system accurately discriminate between hospitals&apos; performance based on process of care and outcomes. Design, Setting, and Patients: Data from the Cooperative Cardiovascular Project, a retrospective systematic medical record review of 141914 Medicare fee-for-service beneficiaries 65 years or older hospitalized with AMI at 3363 US acute care hospitals during a 4- to 8-month period between January 1994 and February 1996 were compared with ratings obtained from HealthGrades.com (1-star: worse outcomes than predicted, 5-star: better outcomes than predicted) based on 1994-1997 Medicare data. Main Outcome Measures: Quality indicators of AMI care, including use of acute reperfusion therapy, aspirin, [beta]-blockers, angiotensin-converting enzyme inhibitors; 30-day mortality. Results: Patients treated at higher-rated hospitals were significantly more likely to receive aspirin (admission: 75.4% 5-star vs 66.4% 1-star, P for trend = .001; discharge: 79.7% 5-star vs 68.0% 1-star, P = .001 and [beta]-blockers (admission: 54.8% 5-star vs 35.7% 1-star, P = .001; discharge: 63.3% 5-star vs 52.1% 1-star, P = .001), but not angiotensin-converting enzyme inhibitors (59.6% 5-star vs 57.4% 1-star, P = .40). Acute reperfusion therapy rates were highest for patients treated at 2-star hospitals (60.6%) and lowest for 5-star hospitals (53.6% 5-star, P =.008). Risk-standardized 30-day mortality rates were lower for patients treated at higher-rated than lower-rated hospitals (21.9% 1-star vs 15.9% 5-star, P = .001). However, there was marked heterogeneity within rating groups and substantial overlap of individual hospitals across rating strata for mortality and process of care; only 3.1% of comparisons between 1-star and 5-star hospitals had statistically lower risk-standardized 30-day mortality rat es in 5-star hospitals. Similar findings were observed in comparisons of 30-day mortality rates between individual hospitals in all other rating groups and when comparisons were restricted to hospitals with a minimum of 30 cases during the study period. Conclusion Hospital ratings published by a prominent Internet health care quality rating system identified groups of hospitals that, in the aggregate, differed in their quality of care and outcomes. However, the ratings poorly discriminated between any 2 individual hospitals&apos; process of care or mortality rates during the study period. Limitations in discrimination may undermine the value of health care quality ratings for patients or payers and may lead to misperceptions of hospitals&apos; performance.

Women who have had a heart attack are less likely than men to have cardiac catheterization even when the woman's doctor is also a woman. This means that bias on the part of male doctors is not responsible for the lower rate of cardiac catheterization in female cardiac patients., Context Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction (AMI), raising concerns of sexual bias in clinical care. However, no data exist regarding the relationship between patient sex, physician sex, and use of cardiac procedures. Objective To determine whether sex differences in cardiac catheterization after AMI were greater when patients were treated by male attending physicians compared with female attending physicians. Design, Setting, and Patients Analysis of data from the Cooperative Cardiovascular Project, a retrospective medical record review. A total of 104231 Medicare fee-for-service beneficiaries who were hospitalized in US acute care hospitals for an AMI between January 1994 and February 1995. Main Outcome Measure Use of cardiac catheterization within 60 days of admission, compared between the 4 groups of patient sex-physician sex combinations. Results Women underwent fewer cardiac catheterizations than men when treated by either male physicians (38.6% vs 50.8%; P=.001) or female physicians (34.8% vs 45.8%; P=.001). Sex differences in procedure use were not greater when a patient and physician were of different sexes (P for interaction=.85). After potential confounders in multivariable analysis were accounted for, women were less likely to undergo cardiac catheterization (risk ratio, 0.90 [95% confidence interval {CI}, 0.880.92]), regardless of the treating physician&apos;s sex. Patients treated by male physicians were more likely to undergo cardiac catheterization (risk ratio, 1.06 [95% CI, 1.02-1.10]) than those treated by female physicians, regardless of patient sex. Conclusions Women who have had an AMI undergo a cardiac catheterization less often than men, whether treated by a male or female physician. These results suggest that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.

Black heart attack patients who are treated by a black doctor are no more likely to have cardiac catheterization then black patients treated by a white doctor. Black heart attack patients as a group are less likely to have cardiac catheterization than whites, but a study of 35,676 white patients and 4,039 black patients found this was not caused by the race of the doctor.

Heart attack patients admitted to hospitals ranked high on a U.S. News & World Report annual list have lower mortality rates because these hospitals are more likely to use aspirin and beta blockers. Researchers compared mortality rates among elderly heart attack patients at three different types of hospitals: those whose cardiology services ranked high on the America's Best Hospitals list, similarly-equipped hospitals not ranked as high, and all other hospitals. Although 30-day mortality rates were lowest at the high-ranking hospitals, these hospitals were also more likely to use aspirin and beta blockers. After adjusting for this factor, mortality rates were approximately the same.

Many elderly heart attack patients are not receiving thrombolytic therapy even though they might benefit from it. Thrombolytic drugs break up the blood clots that cause most heart attacks. Researchers analyzed Medicare data on 3,093 patients treated for a heart attack. Of the 753 patients who had no contraindications for thrombolytic therapy, over half did not receive it. Those who were older, had no chest pain and who were hospitalized more than 6 hours after their symptoms began were most likely not to receive thrombolytic therapy., Objective. -- To determine the correlates of thrombolytic therapy use in a population-based sample of elderly patients hospitalized with acute myocardial infarction who were eligible for the therapy on presentation. Design. -- Retrospective cohort study using data from medical charts and administrative files. Setting. -- All acute care, nongovernmental hospitals in Connecticut. Patients. -- A cohort of 3093 patients aged 65 years and older with a discharge diagnosis of acute myocardial infarction covered by Medicare from May 1992 to May 1993. Results. -- Among the 753 patients with ST-segment elevation of 1 mm or more in at least 2 contiguous leads, left bundle branch block not known to be old, and no absolute contraindications to thrombolytic therapy who were not referred for direct angioplasty or bypass surgery, 419 patients (56%) did not receive thrombolytic therapy. The strongest predictors of not receiving thrombolytic therapy included advanced age, absence of chest pain, presentation more than 6 hours after the onset of symptoms, left bundle branch block, total ST-segment elevation of 6 mm or less, presence of Q waves, ST-segment elevation in only 2 leads, and altered mental status. Physicians documented why they did not administer thrombolytic therapy in 19% of the charts. Delay in presentation and increased age were the most common reasons cited. Among the subset of 261 patients who presented with chest pain and within 6 hours of symptoms, 197 (75%) received thrombolytic therapy. Conclusions. -- Many eligible and ideal patients for thrombolytic therapy are not treated. Physicians are less likely to use thrombolytic therapy in eligible patients with characteristics associated with an increased risk of bleeding, lower-risk infarction, less certain diagnosis, less certain efficacy, or altered mental status. These findings suggest that the lack of treatment represents a clinical judgment rather than an inadvertent omission. In some cases, such as the lower use of thrombolytic therapy with older age, these judgments are not consistent with the published literature and may represent opportunities to improve care.