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For at least a few centuries, if not millennia, psychological stress has been popularly believed to contribute to heart disease. Does psychological stress really contribute to heart disease? Are anecdotal, patient, and lay press reports that angina, heart attack, and even cardiac death are caused by stress based on fact, or are they just folklore? In this review, the study data supporting associations between stress and cardiovascular risk, as well as potential mechanisms by which psychological stress might contribute to heart disease and precipitate myocardial ischemia and infarction, are critically reviewed and summarized.

Gastrointestinal bleeding after percutaneous coronary intervention (PCI) is a not too uncommon clinical situation and is associated with high morbidity and mortality. After initial treatment, a number of clinical decisions must be made weighing the risks of ischemic events and future bleeding. In particular, healthcare providers must carefully balance the effectiveness of antiplatelet therapy in the secondary prevention of coronary events, primarily future spontaneous myocardial infarction and stent thrombosis, against the risk of major, most commonly gastrointestinal bleeding. The first question is whether a dual antiplatelet therapy strategy is required or if a single antiplatelet agent will suffice. Then, if a single antiplatelet agent is adequate, which agent should be continued. Although there is some guidance to answer some of these questions, there are inadequate evidence-based data for others. Below, we review the various considerations and summarize our approach and rationale to manage patients who had gastrointestinal bleeding after PCI.

Background In-hospital ST-elevation myocardial infarction (STEMI) is associated with a higher mortality rate than out-of-hospital STEMI. Quality measures and universal protocols for treatment of in-hospital STEMI do not exist, likely contributing to delays in recognition and treatment. Hypothesis To analyze differences in mortality among three subsets of patients who develop in-hospital STEMI. Methods This was a multicenter, retrospective observational study of patients who developed in-hospital STEMI at six United States medical centers between 2008 and 2017. Patients were stratified into three groups: (1) cardiac, (2) periprocedure, or (3) noncardiac/nonpostprocedure. Outcomes examined include time from electrocardiogram (ECG) acquisition to cardiac catheterization lab arrival (ECG-to-CCL) and survival to discharge. Results We identified 184 patients with in-hospital STEMI (mean age 68.7 years, 58.7% male). Group 1 (cardiac) patients had a shorter average ECG-to-CCL time (69 minutes) than group 2 (periprocedure, 215 minutes) and group 3 (noncardiac/nonpostprocedure, 199 minutes). Compared to group 1, survival to discharge was lower for group 2 (OR 0.33, P = .102) and group 3 (OR 0.20, P = .016). After adjusting for prespecified covariates, the relationship between group and survival showed a similar trend but did not reach statistical significance. Conclusions Patients who develop in-hospital STEMI in the context of a preceding procedure or noncardiac illness appear to have longer reperfusion times and higher in-hospital mortality than patients admitted with cardiac diagnoses. Larger studies are warranted to further investigate these observations. Health systems should place an increased emphasis on developing quality metrics and implementing quality improvement initiatives to improve outcomes for in-hospital STEMI.

The 2017 American Heart Association Scientific Statement on meditation and cardiovascular risk suggested that meditation may be considered as an adjunct to guideline-directed cardiovascular risk-reduction interventions. Meditation could potentially increase physical and mental relaxation, leading to improved outcomes after a major cardiovascular event. We hypothesized that meditation is associated with lower cardiovascular risk in the US general population. Using data from the 2012 and 2017 National Health Interview Survey, we identified all patients with hypercholesterolemia, systemic hypertension (SH), diabetes mellitus (DM), stroke, and coronary artery disease (CAD), as well as those who reported that they meditate. Multivariable logistic regression analyses were performed to evaluate the association between meditation and risk of hypercholesterolemia, SH, DM, stroke, and CAD, adjusting for potential confounders. Of 61,267 the National Health Interview Survey participants, 5,851 (9.6%) participated in some form of meditation. After adjusting for age, gender, body mass index, race, marital status, cigarette smoking, sleeping duration, and depression, meditation was independently associated with a lower prevalence of hypercholesterolemia (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.54 to 0.79; p = 0.001), SH (OR 0.86; 95% CI 0.75 to 0.99; p = 0.04), diabetes (OR 0.70; 95% CI 0.59 to 0.84; p = 0.0001), stroke (OR 0.76; 95% CI 0.58 to 0.99; p = 0.04), or CAD (OR 0.51; 95% CI 0.39 to 0.66; p0.001), compared with those who did not meditate. In conclusion, using a large national database, we found that meditation is associated with a lower prevalence of cardiovascular risks factors and disease.

Antiplatelet therapy for patients with coronary artery disease has evolved dramatically over the last decade. P2Y12 inhibitors offering more potent and consistent platelet inhibition than clopidogrel are now widely available, dual antiplatelet therapy (DAPT) duration can be tailored to individual ischemic and bleeding risks, and strategies to personalize antiplatelet therapy have been developed when concomitant oral anticoagulation (OAC) is indicated. Scientific societies from Canada, the United States, and Europe have all published updated recommendations addressing antiplatelet therapy in the recent years. The purpose of this review is to put the Canadian guidelines into perspective vis-à-vis international recommendations by highlighting similarities and critically analyzing differences. We focus on 3 major topics relevant for clinical practice: DAPT duration following drug-eluting stent implantation, DAPT following percutaneous coronary intervention in patients with concomitant indications for OAC, and DAPT management for noncardiac surgery following drug-eluting stent implantation. Although guidelines broadly agree on the majority of recommendations, the justifications for major differences were contrasted in the manuscript. Unanswered questions remain, including the place of aspirin in secondary prevention of coronary artery disease in the contemporary era, aspirin-free strategies early after percutaneous coronary intervention, and the safe minimal duration of DAPT with newer generation stents.

The pivotal studies that led to the recommendations for emergent reperfusion therapy for ST-elevation myocardial infarction (STEMI) were conducted for the most part over 25 years ago. At that time, contemporary standard treatments including aspirin, statin, and even anticoagulation were not commonly used. The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines and the 2017 European Society of Cardiology guidelines give a class I recommendation (with the level of evidence A) for primary percutaneous coronary intervention (pPCI) in patients with STEMI and ischemic symptoms of less than 12 h. However, if the patient presents to a hospital without pPCI capacity, and it is anticipated that pPCI cannot be performed within 120 min of first medical contact, fibrinolytic therapy is indicated (if there are no contraindications) (class I indication, level of evidence A). Our review of the pertinent literature shows that the current recommendation for inferior STEMI is based on the level of evidence lower than A. We can consider level B even C, supporting the recommendation for fibrinolytic therapy if pPCI is not available for inferior STEMI.

To review the factors contributing to underutilization of guideline-directed therapies, identify strategies to alleviate these factors, and apply these strategies for effective and timely dissemination of novel cardioprotective glucose-lowering agents.Recent analyses demonstrate underutilization of cardioprotective glucose lowering agents despite guideline recommendations for their use. Major contributors to underutilization of guideline-directed therapies include therapeutic inertia, perceptions about side effects, and factors found at the level of the clinicians, patients, and the healthcare system. The recent emergence of several novel therapies, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, for use in cardiovascular disease provides a unique avenue to improve patient outcomes. To effectively utilize novel cardioprotective glucose lowering agents to improve cardiovascular outcomes, clinicians must recognize and learn from prior barriers to application of guideline-directed therapies. Further endeavors are prudent to ensure uptake of novel agents.

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health [(1)][1]. These guidelines, based on systematic methods to evaluate and classify

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

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

Objective: To assess the prevalence, temporal trends and sex- and racial/ethnic differences in the burden of mental health disorders (MHD) and outcomes among patients with myocardial infarction (MI) in the United States. Methods: Using the National Inpatient Sample Database, we evaluated a contemporary cohort of patients hospitalized for acute MI in the United States over 10 years period from 2008 to 2017. We used multivariable logistic regression analysis for in-hospital outcomes, yearly trends and estimated annual percent change (APC) in odds of MHD among MI patients. Results: We included a total sample of 6,117,804 hospitalizations for MI (ST elevation MI in 30.4%), with a mean age of 67.2 ​± ​0.04 years and 39% females. Major depression (6.2%) and anxiety disorders (6.0%) were the most common MHD, followed by bipolar disorder (0.9%), schizophrenia/psychotic disorders (0.8%) and post-traumatic stress disorder (PTSD) (0.3%). Between 2008 and 2017, the prevalences significantly increased for major depression (4.7%–7.4%, APC +6.2%, p ​

Introduction: The emphasis on clinical trials to inform evidence-based medicine remains paramount within the cardiovascular community. Although such high-quality evidence is often translated into national and international guidelines, there exists a large gap between guideline development and guideline implementation into daily clinical practice.Areas covered: This article outlines barriers that impede guideline adherence and possible strategies to overcome such barriers. Barriers intrinsic and extrinsic to clinicians are discussed. The structured process of guideline implementation including guideline adoption, diffusion, and dissemination is discussed. Lastly, the authors review in detail the current and potential future elements of guideline diffusion and dissemination.Expert opinion: Improving guideline adherence remains challenging as it requires understanding of and navigation through various barriers. However, further research specific to cardiovascular medicine guidelines is necessary to better understand the objective effectiveness of various strategies employed by guideline writers and medical societies to improve adherence. The cost-effectiveness of nationwide dissemination strategies in improving guideline adherence and patient outcomes is also necessary but is largely unknown.

Acute myocardial infarction (MI) is still a large source of morbidity and mortality worldwide. Although early reperfusion therapy has been prioritized in the modern era of percutaneous coronary intervention and thrombolysis, attempts at incremental improvements in clinical outcomes by reducing MI size have not been successful so far. Herein, we review the studies that have evaluated immediate-onset antiplatelet therapy as attempts to improve meaningful clinical outcomes in ST-segment elevation MI (STEMI). Unfortunately, many of the adjunctive pharmacotherapies have proven to be disappointing. Recent studies performed in the background of routine oral administration of P2Y12 adenosine receptor inhibitors, which may take several hours to take full effect, and aspirin have largely shown no improvement in outcomes, despite an earlier onset of antiplatelet activity of the investigative agents. Further progress in improving outcomes during STEMI may depend on exploring therapeutics that modulate the pathophysiology of microvascular damage during ischemia–reperfusion injury, a phenomenon whose effects evolve over hours to days. We speculate that the dynamic nature of the no-reflow phenomenon may be an explanation for these disappointing results with the intravenous antiplatelet agents. We hope that appreciation for what has not worked in this domain may direct future research efforts to focus on novel pathways. Myocardial ischemia and reperfusion injury are very much still a lingering issue. Despite significant improvements in door-to-balloon times, rates of in-hospital mortality for STEMI remain unchanged. Outcomes following successfully reperfused STEMI are likely determined by the initial size of myocardial necrosis (ie, cardiomyocyte death during the period of ongoing ischemia), patency of the infarct-related epicardial coronary artery, possible reperfusion injury, the microvascular no-reflow phenomenon, and adverse remodeling after infarction.

Dual antiplatelet therapy (DAPT) is the cornerstone of pharmacological treatment aimed at preventing the atherothrombotic complications in patients with a variety of coronary artery disease...

The CHA2DS2-VASc score has been widely adopted as a risk stratification tool for strokes in patients with atrial fibrillation and to help in deciding when anticoagulation therapy for stroke prophylaxis may be beneficial. The score as a whole has been well validated and has been included in the current major practice guidelines. An advantage of the CHA2DS2-VASc score is its ease of use, allowing clinicians to quickly estimate risk based on a short set of criteria. However, the benefit of simplicity may also be a weakness. Studies on individual components of the score suggest that only a subset of patients deemed to be at risk based on the current definition are actually at risk for stroke. Thus, users of the score should be aware of the nuances based on available evidence and avoid over-generalization. Accurate assessment of stroke risk has important clinical implications as it influences decision-making on initiation of anticoagulation.

Developed in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation, Inter-Society Consensus for the Management of Peripheral Arterial Disease, Society for Cardiovascular Angiography and Interventions, Society for Clinical Vascular Surgery, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular Nursing, Society for Vascular Surgery, and Vascular and Endovascular Surgery Society

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

The 2013 American Heart Association Scientific Statement on pet ownership and cardiovascular risk suggested that dog ownership is probably associated with decreased cardiovascular risk. Several studies have been shown that pet ownership, particularly of dogs, is associated with increased physical activity levels, social support, and improved outcomes after a major cardiovascular event. We hypothesized that pet ownership is associated with a lower risk of cardiovascular disease in the US general population. Using the National Health and Nutrition Examination Survey, we identified all patients with heart failure, coronary artery disease, systemic hypertension (SH), diabetes mellitus, and stroke between 1999 and 2016. Multivariable analyses were performed to adjust for demographic factors such as age, gender, marital status, education, co-morbidities, cigarette smoking, family income, working hours, sleeping duration, depression, and lipid profiles. Of 42,038 National Health and Nutrition Examination Survey participants, 10,905 (31%) were inquired about pet ownership. Pet owners were older, less likely to be women or widowed, and more likely to be white, more educated, tobacco users, and work more than 35 hours per week than non-owners (all p values0.05). Pet owners had higher hemoglobin, lower low-density lipoprotein cholesterol, and a lower prevalence of DM, SH, and stroke (all p values0.05). After adjusting for potential confounders, pet ownership (either cat or dog ownership) was independently associated with a lower prevalence of SH (odds ratio 0.67; 95% confidence interval 0.49 to 0.89; p = 0.01), but not heart failure, coronary artery disease, DM, or stroke, compared with non-owners. In conclusions, using a large national database, we found that pet ownership is associated with a decreased prevalence of SH. Further longitudinal studies are needed to draw a conclusion on the protective effect of pet ownership in patients with cardiovascular disease.

Guidelines have been heavily influenced by publication of Institute of Medicine’s Clinical Practice Guidelines We Can Trust [(1)][1]. The American Heart Association (AHA) and American College of Cardiology (ACC), through their Task Force on Clinical Practice Guidelines, updated already rigorous

Successful reperfusion of an infarct-related coronary artery by primary percutaneous intervention or fibrinolysis during acute ST-elevation myocardial infarction (STEMI) does not always restore myocardial tissue perfusion, a phenomenon termed “no-reflow.” Herein we discuss the pathophysiology of this highly prevalent phenomenon and highlight the most salient aspects of its clinical diagnosis and management as well as the limitations of presently used methods. There is a great need for understanding the dynamic nature of no-reflow, as its occurrence is associated with poor cardiovascular outcomes. The no-reflow phenomenon may lend an explanation to the lack of further improvements in in-hospital mortality in STEMI patients despite decreases in door-to-balloon time. Hence, no-reflow potentially presents an important target for investigators interested in improving outcomes in STEMI. In the era of reperfusion, much effort has been made to decrease myocardial infarct (MI) size by implementing early reperfusion with primary percutaneous coronary intervention (P-PCI) or thrombolytic agents. Door-to-balloon times have improved substantially while concomitant in-hospital mortality improvements lag behind [1]. It is plausible that outcomes after successfully reperfused MI are determined by the initial size of myocardial ischemia, time from onset of ischemia to reperfusion, potential reperfusion injury, patency of the epicardial infarct-related artery, distal thromboembolization, adverse remodeling after infarction, and the microvascular no-reflow phenomenon (NRP). Herein we describe the dynamic pathophysiology of the NRP. Additionally, we present a comparison of clinical diagnostic and therapeutic strategies.

A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association

Atrial fibrillation is a well-known risk factor for cardioembolic stroke; a number of risk stratification scoring systems have been developed to help differentiate which patients would stand to benefit from anticoagulation. However, these scoring systems cannot be utilized in patients whose atrial fibrillation has not been diagnosed. As implantable cardiac monitors become more prevalent, it becomes possible to identify occult, subclinical atrial fibrillation. With this data, it is also possible to examine the relationship between episodes of paroxysmal atrial fibrillation and thromboembolism and the total burden of paroxysmal atrial fibrillation and thromboembolic risk. The data gleaned from these devices provides insight and raises questions regarding the underlying mechanism of thromboembolism in atrial fibrillation, and in doing so, exposes shortcomings in the present clinical use of current risk scoring systems, specifically, the inability to account for atrial fibrillation burden and to apply scores at all in subclinical atrial fibrillation.

[Extract] Top 10 Take-Home Messages for the Primary Prevention of Cardiovascular Disease 1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life. 2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions. 3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. In addition, assessing for other risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning. 4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. 5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity. 6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations, are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist. 7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit. 8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit. 9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion. 10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be

Acute coronary syndrome (ACS) is a major cause of morbidity and mortality in the United States with an annual incidence of approximately 1 million. Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces cardiovascular event rates after ACS.In 2016, the updated guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommended aspirin plus a P2Y12 inhibitor for at least 12 months for patients with ACS. Since these recommendations were published, new randomized clinical trials have studied different regimens and durations of antiplatelet therapy. Recommendations vary according to the risk of bleeding. If bleeding risk is low, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established. If bleeding risk is high, shorter duration (ie, 3-6 months) of DAPT may be reasonable. A high risk of bleeding traditionally is defined as a 1-year risk of serious bleeding (either fatal or associated with a ≥3-g/dL drop in hemoglobin) of at least 4% or a risk of an intracranial hemorrhage of at least 1%. Patients at higher risk are 65 years old or older; have low body weight (BMI18.5), diabetes, or prior bleeding; or take oral anticoagulants. The newest P2Y12 inhibitors, prasugrel and ticagrelor, are more potent, with high on-treatment residual platelet reactivity of about 3% vs 30% to 40% with clopidogrel and act within 30 minutes compared with 2 hours for clopidogrel. Clinicians should avoid prescribing prasugrel to patients with a history of stroke or transient ischemic attack because of an increased risk of cerebrovascular events (6.5% vs 1.2% with clopidogrel, P = .002) and should avoid prescribing it to patients older than 75 years or who weigh less than 60 kg. The ISAR-REACT-5 trial found that prasugrel reduced rates of death, myocardial infarction, or stroke at 1 year compared with ticagrelor among patients with ACS undergoing percutaneous coronary intervention (9.3% vs 6.9%, P = .006) with no significant difference in bleeding. Recent trials suggested that discontinuing aspirin rather than the P2Y12 inhibitor may be associated with better outcomes.Dual antiplatelet therapy reduces rates of cardiovascular events in patients with acute coronary syndrome. Specific combinations and duration of dual antiplatelet therapy should be based on patient characteristics-risk of bleeding myocardial ischemia.

An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC, FAHA Joaquin E. Cigarroa, MD, FACC Lesley H. Curtis, PhD

Regular physical activity is associated with numerous health benefits, including the prevention of many chronic diseases and conditions or a reduction in their adverse effects. Intervention studies suggest that promoting dog walking among dog owners who do not routinely walk their dogs may be an effective strategy for increasing and maintaining regular physical activity. Strategies that emphasize the value of dog walking for both dogs and people, promote the context-dependent repetition of dog walking, enhance the social-interaction benefits, encourage family dog walking, and ensure availability of public space for dog walking may encourage increased dog walking. Research also supports organizing buddy systems via “loaner” dogs to facilitate informal walking by dog owners and non–dog owners. Given the number of homes that have dogs, strategies that promote dog walking could be effective at increasing physical activity levels among a significant proportion of the population. Maximizing the potential for dog walking to positively influence the health of individual people (and dogs) will only occur through implementing programs with broad population-level reach. Policies that facilitate dog walking at the community and population levels, such as “dogs allowed” places, off-leash zones, and dog-friendly built environments and parks, may contribute to greater physical activity through dog walking.

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

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair [∗∗][1] Nancy M. Albert, PhD, RN, FAHA[∗∗][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD

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

Importance In-hospital ST-segment elevation myocardial infarction (STEMI) is a unique clinical entity with epidemiology, incidence, and outcomes distinct from that of out-of-hospital STEMI and has only within the past 10 years begun to receive increased attention and research. Patients with in-hospital STEMI are older, have more comorbidities, and more frequently have coagulopathies and contraindications for anticoagulation and fibrinolytic therapy. A standardized clinical definition of in-hospital STEMI is lacking. The objectives of this special communication are to (1) summarize the knowledge base regarding in-hospital STEMI; (2) review the challenges of diagnosis and treatment of patients with in-hospital STEMI; (3) present a standardized clinical definition for in-hospital STEMI; and (4) provide a quality improvement protocol to improve diagnosis, triage, and treatment of patients with in-hospital STEMI. Observations Patients with in-hospital STEMI less frequently present with typical angina symptoms, and an electrocardiogram is often obtained owing to changes in clinical status, changes on telemetry, or a finding of elevated cardiac biomarker. The frequent nontypical presentations often lead to substantial delays in the diagnosis of STEMI. Only 34% to 71% of patients with in-hospital STEMI undergo diagnostic catheterization, and only 22% to 56% undergo percutaneous coronary intervention. Even in contemporary reports, some studies report in-hospital mortality in the range of 31% to 42%. Three areas of delay in the treatment of patients with in-hospital STEMI that merit particular attention are (1) delays in electrocardiogram acquisition, (2) delays in electrocardiogram interpretation, and (3) delays in activation of existing STEMI systems of care. Conclusions and Relevance Treatment of patients with in-hospital STEMI is more complex and challenging than treatment of patients who develop out-of-hospital STEMI, leading to delays in diagnosis and triage and less frequent use of reperfusion therapy. Quality improvement programs targeted at decreasing delays and streamlining treatment of such patients may improve treatment and outcome.