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A study was conducted to evaluate the relationship between the use of bleeding avoidance strategies and risk of periprocedural bleeding among patients undergoing percutaneous coronary intervention. Results indicated that vascular closure devices and bivalirudin were associated with significantly lower bleeding rates; however, were less often used among high-risk patients.

The study attempts to evaluate the efficacy and safety of contraindicated medications like enoxaparin and eptifibatide among dialysis patients undergoing percutaneous coronary intervention (PCI). The results indicate that in many cases use of such drugs led to an increased risk of in-hospital major bleeding.

A study was conducted to evaluate the negative outcomes of patients using clopidogrel and proton pump inhibitors (PPI) after suffering from acute coronary syndrome. Results indicated that clopidogrel used without PPI resulted in better outcomes than in the case of patients using both.

A study aims to investigate the degree to which hospital process performance rankings and eligibility for financial incentives are altered after accounting for hospitals' patient demographics and treatment opportunities. The results indicate that accounting for hospital differences is associated with modest changes in hospital performance rankings and eligibility for financial incentives.

A study to examine whether the effect of stoppage of clopidogrel could lead to death and myocardial infarction in patients recovering from acute coronary syndrome (ACS) is conducted. Results show a clustering of adverse events after stopping clopidogrel that supports the possibility of clopidogrel rebound effect.

A study carried out to determine whether pay for performance improves the quality of care and outcomes for acute myocardial infarction at hospitals is presented.

Depression can adversely affect a cardiac patient's quality of life, according to a study of 1,024 patients with coronary heart disease. The 201 patients who were depressed were more likely than the others to say they had a poor quality of life and poor overall health. Depression had a greater impact on their self-perceived quality of life than their heart disease symptoms.

Heart attack patients treated with angioplasty are more likely to survive than those treated with thrombolytic drugs, but only if they are treated at hospitals with doctors who are experienced in angioplasty. This was the conclusion of a study of 62,299 patients who received either one of the treatments, both of which are used to open blocked coronary arteries.

Several surveys of the safety of different medical devices are being conducted to analyze the gaps present in the US postapproval device surveillance safety net. The deployment of automated surveillance tools, use of national data and leveraging national data platforms are shown to be some of the most important steps that can be taken for a better surveillance of these devices.

Importance: Little contemporary information is available about comparative performance between Veterans Affairs (VA) and non-VA hospitals, particularly related to mortality and readmission rates, 2 important outcomes of care.Objective: To assess and compare mortality and readmission rates among men in VA and non-VA hospitals.Design, Setting, and Participants: Cross-sectional analysis involving male Medicare fee-for-service beneficiaries aged 65 years or older hospitalized between 2010 and 2013 in VA and non-VA acute care hospitals for acute myocardial infarction (AMI), heart failure (HF), or pneumonia using the Medicare Standard Analytic Files and Enrollment Database together with VA administrative claims data. To avoid confounding geographic effects with health care system effects, we studied VA and non-VA hospitals within the same metropolitan statistical area (MSA).Exposures: Hospitalization in a VA or non-VA hospital in MSAs that contained at least 1 VA and non-VA hospital.Main Outcomes and Measures: For each condition, 30-day risk-standardized mortality rates and risk-standardized readmission rates for VA and non-VA hospitals. Mean aggregated within-MSA differences in mortality and readmission rates were also assessed.Results: We studied 104 VA and 1513 non-VA hospitals, with each condition-outcome analysis cohort for VA and non-VA hospitals containing at least 7900 patients (men; ≥65 years), in 92 MSAs. Mortality rates were lower in VA hospitals than non-VA hospitals for AMI (13.5% vs 13.7%, P = .02; -0.2 percentage-point difference) and HF (11.4% vs 11.9%, P = .008; -0.5 percentage-point difference), but higher for pneumonia (12.6% vs 12.2%, P = .045; 0.4 percentage-point difference). In contrast, readmission rates were higher in VA hospitals for all 3 conditions (AMI, 17.8% vs 17.2%, 0.6 percentage-point difference; HF, 24.7% vs 23.5%, 1.2 percentage-point difference; pneumonia, 19.4% vs 18.7%, 0.7 percentage-point difference, all P < .001). In within-MSA comparisons, VA hospitals had lower mortality rates for AMI (percentage-point difference, -0.22; 95% CI, -0.40 to -0.04) and HF (-0.63; 95% CI, -0.95 to -0.31), and mortality rates for pneumonia were not significantly different (-0.03; 95% CI, -0.46 to 0.40); however, VA hospitals had higher readmission rates for AMI (0.62; 95% CI, 0.48 to 0.75), HF (0.97; 95% CI, 0.59 to 1.34), or pneumonia (0.66; 95% CI, 0.41 to 0.91).Conclusions and Relevance: Among older men with AMI, HF, or pneumonia, hospitalization at VA hospitals, compared with hospitalization at non-VA hospitals, was associated with lower 30-day risk-standardized all-cause mortality rates for AMI and HF, and higher 30-day risk-standardized all-cause readmission rates for all 3 conditions, both nationally and within similar geographic areas, although absolute differences between these outcomes at VA and non-VA hospitals were small. [ABSTRACT FROM AUTHOR]

IMPORTANCE. Introducing new medical devices into routine practice raises concerns because patients and outcomes may differ from those in randomized trials. OBJECTIVE. To update the previous report of 30-day outcomes and present 1-year outcomes following transcatheter aortic valve replacement (TAVR) in the United States. DESIGN, SETTING, AND PARTICIPANTS Data from the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve Therapies Registry were linked with patient-specific Centers for Medicare & Medicaid Services (CMS) administrative claims data. At 299 US hospitals, 12182 patients linked with CMS data underwent TAVR procedures performed from November 2011 through June 30,2013, and the end of the follow-up period was June 30,2014. EXPOSURE. Transcatheter aortic valve replacement. MAIN OUTCOMES AND MEASURES. One-year outcomes including mortality, stroke, and rehospitalization were evaluated using multivariate modeling. RESULTS. The median age of patients was 84 years and 52% were women, with a median STS Predicted Risk of Operative Mortality (STS PROM) score of 7.1%. Following the TAVR procedure, 59.8% were discharged to home and the 30-day mortality was 7.0% (95% Cl, 6.5%-7.4%) (n = 847 deaths). In the first year after TAVR, patients were alive and out of the hospital for a median of 353 days (interquartile range, 312-359 days); 24.4% (n = 2074) of survivors were rehospitalized once and 12.5% (n = 1525) were rehospitalized twice. By 1 year, the overall mortality rate was 23.7% (95% Cl, 22.8%-24.5%) (n = 2450 deaths), the stroke rate was 4.1% (95% Cl, 3.7%-4.5%) (n = 455 stroke events), and the rate of the composite outcome of mortality and stroke was 26.0% (25.1%-26.8%) (n = 2719 events). Characteristics significantly associated with 1-year mortality included advanced age (hazard ratio [HR] for a 95 vs <75 years, 1.61 [95% Cl, 1.24-2.09]; HR for 85-94 years vs <75 years, 1.35 [95% Cl, 1.18-1.55]; and HR for 75-84 years vs <75 years, 1.23 [95% Cl, 1.08-1.41]), male sex (HR, 1.21; 95% Cl, 1.12-1.31), end-stage renal disease (HR, 1.66; 95% Cl, 1.41-1.95), severe chronic obstructive pulmonary disease (HR, 1.39; 95% Cl, 1.25-1.55), nontransfemoral access (HR, 1.37; 95% Cl, 1.27-1.48), STS PROM score greater than 15% vs less than 8% (HR, 1.82; 95% Cl, 1.60-2.06), and preoperative atrial fibrillation/flutter (HR, 1.37; 95% Cl, 1.27-1.48). Compared with men, women had a higher risk of stroke (HR, 1.40; 95% Cl, 1.15-1.71). CONCLUSIONS. AND RELEVANCE Among patients undergoing TAVR in US clinical practice, at 1-year follow-up, overall mortality was 23.7%, the stroke rate was 4.1%, and the rate of the composite outcome of death and stroke was 26.0%. These findings should be helpful in discussions with patients undergoing TAVR. [ABSTRACT FROM AUTHOR]

IMPORTANCE Little is known about cardiac adverse events among patients with nonobstructive coronary artery disease (CAD). OBJECTIVE To compare myocardial infarction (Ml) and mortality rates between patients with nonobstructive CAD, obstructive CAD, and no apparent CAD in a national cohort. DESIGN. SETTING, AND PARTICIPANTS Retrospective cohort study of all US veterans undergoing elective coronary angiography for CAD between October 2007 and September 2012 in the Veterans Affairs health care system. Patients with prior CAD events were excluded. EXPOSURES Angiographic CAD extent, defined by degree (no apparent CAD: no stenosis >20%; nonobstructive CAD: ≥1 stenosis ≥ 20% but no stenosis ≥ 70%; obstructive CAD: any stenosis ≥ 70% or left main [LM] stenosis ≥ 50%) and distribution (1,2, or 3 vessel). MAIN OUTCOMES AND MEASURES The primary outcome was 1-year hospitalization for nonfatal Ml after the index angiography. Secondary outcomes included 1-year all-cause mortality and combined 1-year Ml and mortality. RESULTS Among 37 674 patients, 8384 patients (22.3%) had nonobstructive CAD and 20 899 patients (55.4%) had obstructive CAD. Within 1 year, 845 patients died and 385 were rehospitalized for Ml. Among patients with no apparent CAD, the 1-year Ml rate was 0.11% (n = 8,95% Cl, 0.10%-0.20%) and increased progressively by 1-vessel nonobstructive CAD, 0.24% (n = 10, 95% Cl, 0.10%-0.40%); 2-vessel nonobstructive CAD, 0.56% (n = 13, 95% Cl, 0.30%-1.00%); 3-vessel nonobstructive CAD, 0.59% (n = 6,95% Cl, 0.30%-1.30%); 1-vessel obstructive CAD, 1.18% (n = 101, 95% Cl, 1.00%-1.40%); 2-vessel obstructive CAD, 2.18% (n = 110, 95% Cl, 1.80%-2.60%); and 3-vessel or LM obstructive CAD, 2.47% (n = 137, 95% Cl, 2.10%-2.90%). After adjustment, 1-year Ml rates increased with increasing CAD extent. Relative to patients with no apparent CAD, patients with 1-vessel nonobstructive CAD had a hazard ratio (HR) for 1-year Ml of 2.0 (95% Cl, 0.8-5.1); 2-vessel nonobstructive HR, 4.6 (95% Cl, 2.0-10.5); 3-vessel nonobstructive HR, 4.5 (95% Cl, 1.6-12.5); 1-vessel obstructive HR, 9.0 (95% Cl, 4.2-19.0); 2-vessel obstructive HR, 16.5 (95% Cl, 8.1-33.7); and 3-vessel or LM obstructive HR, 19.5 (95% Cl, 9.9-38.2). One-year mortality rates were associated with increasing CAD extent, ranging from 1.38% among patients without apparent CAD to 4.30% with 3-vessel or LM obstructive CAD. After risk adjustment, there was no significant association between 1- or 2-vessel nonobstructive CAD and mortality, but there were significant associations with mortality for 3-vessel nonobstructive CAD (HR, 1.6; 95% Cl, 1.1-2.5), 1-vessel obstructive CAD (HR, 1.9; 95% Cl, 1.4-2.6), 2-vessel obstructive CAD (HR, 2.8; 95% Cl, 2.1-3.7), and 3-vessel or LM obstructive CAD (HR, 3.4; 95% Cl, 2.6-4.4). Similar associations were noted with the combined outcome. CONCLUSIONS AND RELEVANCE In this cohort of patients undergoing elective coronary angiography, nonobstructive CAD, compared with no apparent CAD, was associated with a significantly greater 1-year risk o f Ml and all-cause mortality. These findings suggest clinical importance of nonobstructive CAD and warrant further investigation of interventions to improve outcomes among these patients. [ABSTRACT FROM AUTHOR]

IMPORTANCE Transcatheter aortic valve replacement (TAVR)was approved by the US Food and Drug Administration for the treatment of severe, symptomatic aortic stenosis and inoperable status (in 2011) and high-risk but operable status (starting in 2012). A national registry (the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy [STS/ACC TVT] Registry)was initiated to meet a condition for Medicare coverage and also facilitates outcome assessment and comparison with other trials and international registries. OBJECTIVE To report the initial US commercial experience with TAVR. DESIGN, SETTING, AND PARTICIPANTS We obtained results from all eligible US TAVR cases (n=7710) from 224 participating registry hospitals following the Edwards Sapien XT device commercialization (November 2011-May 2013). MAIN OUTCOMES AND MEASURES Primary outcomes included all-cause in-hospital mortality and stroke following TAVR. Secondary analyses included procedural complications and outcomes by clinical indication and access site. Device implantation success was defined as successful vascular access, deployment of a single device in the proper anatomic position, appropriate valve function without either moderate or severe AR, and successful retrieval of the delivery system. Thirty-day outcomes are presented for a representative 3133 cases (40.6%) at 114 centers with at least 80% complete follow-up reporting. RESULTS The 7710 patients who underwent TAVR included 1559 (20%) cases that were inoperable and 6151 (80%) cases that were high-risk but operable. The median agewas 84 years (interquartile range [IQR], 78-88 years); 3783 patients (49%) were women and the median STS predicted risk of mortalitywas 7%(IQR, 5%-11%). At baseline, 2176 patients (75%)were either not at all satisfied (1297 patients [45%]) or mostly dissatisfied (879 patients [30%]) with their symptom status; 2198 (72%) had a 5-mwalk time longer than 6 seconds (slow gait speed). The most common vascular access approachwas transfemoral (4972 patients [64%]), followed by transapical (2197 patients [29%]) and other alternative approaches (536 patients [7%]); successful device implantation occurred in 7069 patients (92%; 95%CI, 91%-92%). The observed incidence of in-hospital mortalitywas 5.5%(95%CI, 5.0%-6.1%). Other major complications included stroke (2.0%; 95%CI, 1.7%-2.4%), dialysis-dependent renal failure (1.9%; 95%CI, 1.6%-2.2%), and major vascular injury (6.4%; 95%CI, 5.8%-6.9%). Median hospital stay was 6 days (IQR, 4-10 days), with 4613 (63%) discharged home. Among patients with available follow-up at 30 days (n=3133), the incidence of mortalitywas 7.6%(95%CI, 6.7%-8.6%) (noncardiovascular cause, 52%); a stroke had occurred in 2.8%(95%CI, 2.3%-3.5%), new dialysis in 2.5%(95%CI, 2.0%-3.1%), and reintervention in 0.5%(95%CI, 0.3%-0.8%). CONCLUSIONS AND RELEVANCE Among patients undergoing TAVR at US centers in the STS/ACC TVT Registry, device implantation successwas achieved in 92%of cases, the overall in-hospital mortality rate was 5.5%, and the stroke ratewas 2.0%. Although these postmarket US approval findings are comparable with prior published trial data and international experience, long-term follow-up is essential to assess continued efficacy and safety. [ABSTRACT FROM AUTHOR]

IMPORTANCE Rates of testosterone therapy are increasing and the effects of testosterone therapy on cardiovascular outcomes and mortality are unknown. A recent randomized clinical trial of testosterone therapy in men with a high prevalence of cardiovascular diseases was stopped prematurely due to adverse cardiovascular events raising concerns about testosterone therapy safety. OBJECTIVES To assess the association between testosterone therapy and all-cause mortality, myocardial infarction (MI), or stroke among male veterans and to determine whether this association is modified by underlying coronary artery disease. DESIGN, SETTING, AND PATIENTS A retrospective national cohort study of men with low testosterone levels (<300 ng/dL) who underwent coronary angiography in the Veterans Affairs (VA) system between 2005 and 2011. MAIN OUTCOMES AND MEASURES Primary outcome was a composite of all-cause mortality, MI, and ischemic stroke. RESULTS Of the 8709 men with a total testosterone level lower than 300 ng/dL, 1223 patients started testosterone therapy after a median of 531 days following coronary angiography. Of the 1710 outcome events, 748 men died, 443 had MIs, and 519 had strokes. Of 7486 patients not receiving testosterone therapy, 681 died, 420 had MIs, and 486 had strokes. Among 1223 patients receiving testosterone therapy, 67 died, 23 had MIs, and 33 had strokes. The absolute rate of events were 19.9% in the no testosterone therapy group vs 25.7% in the testosterone therapy group, with an absolute risk difference of 5.8% (95% CI, -1.4% to 13.1%) at 3 years after coronary angiography. In Cox proportional hazards models adjusting for the presence of coronary artery disease, testosterone therapy use as a time-varying covariate was associated with increased risk of adverse outcomes (hazard ratio, 1.29; 95% CI, 1.04 to 1.58). There was no significant difference in the effect size of testosterone therapy among those with and without coronary artery disease (test for interaction, P = .41). CONCLUSIONS AND RELEVANCE Among a cohort of men in the VA health care system who underwent coronary angiography and had a low serum testosterone level, the use of testosterone therapy was associated with increased risk of adverse outcomes. These findings may inform the discussion about the potential risks of testosterone therapy. [ABSTRACT FROM AUTHOR]

The Physical Component Summary score of the Short-Form 36 (SF-36) questionnaire may predict which patients who have received coronary artery bypass graft (CABG) surgery might die. SF-36 is a questionnaire that assesses physical functioning, psychological functioning, social functioning, role functioning, and general health perceptions to determine a person's health-related quality of life. Researchers gave the SF-36 to 2,480 people who had CABG surgery. Five percent of the patients died within six months of surgery and a low Physical Component Summary score was associated with an increased risk of dying.

The article discusses a study to assess variations in drug-eluting stents (DES) use among U.S. physicians participating in the National Cardiovascular Data Registry (NCDR), the association between predicted target vessel revascularization (TVR) risk with bare-metal stents (BMS) with DES use and the estimated clinical and economic consequences of lower DES use in patients with low TVR risk. It concludes that DES use is common even on those predicted to be at the lowest restenosis risk.

The article discusses a study of the prevalence and outcomes of same-day discharge among older patients undergoing elective percutaneous coronary intervention (PCI) in the U.S. between November 2004 and December 2008. The Duke University Medical Center institutional review board in North Carolina has approved the study. Death and rehospitalization were included in the primary end points assessed for the analysis. Results stress the variability of same-day discharge among older patients undergoing elective PCI across PCI facilities. Also noted is the lack of association between a same-day discharge strategy and increased risk for death or readmission.

The article discusses a study which investigated the impact of a collaborative care model delivered by primary care providers for managing chronic stable angina. A prospective trial of patients with ischemic heart disease was conducted and changes in symptoms were monitored over a 12-month period. No significant improvements of angina symptoms or self-perceived health were noted.

The article discusses the relevance of percutaneous coronary intervention (PCI), which is performed in about 600,000 cases in the U.S. per year and costs a total of 12 billion U.S. dollars. In a study conducted by the authors to understand the need for the procedure, they use data from the National Cardiovascular Data Registry between July 1, 2009 and September 30, 2010 with an aim of finding the proportion of appropriate, uncertain or inappropriate PCI. They conclude that most PCIs done in the U.S. were appropriate with only 12% being tagged as inappropriate.

In this Viewpoint, Harlan Krumholz and colleagues discuss the promise that social media data hold for helping researchers better understand social determinants of health, and the challenges that must be overcome to reliably link social network data to clinical and health outcomes. [ABSTRACT FROM AUTHOR]

This Viewpoint discusses questions that should be addressed to successfully integrate artificial intelligence into clinical care. [ABSTRACT FROM AUTHOR]

The article discusses the importance of monitoring personal health outcomes to improve quality of healthcare in the U.S. with focus on the Veterans Affairs (VA) Patient Reported Health Status Assessment (PROST) system model. Topics discussed include the guidelines by the National Quality Forum on the measurement of outcomes, the thrust from volume-based to quality-based health care results and the VA clinical assessment reporting and tracking (CART) program.

Two letters to the editor are presented in response to the article "National Cardiovascular Data Registry: Association Between Use of Bleeding Avoidance Strategies and Risk of Periprocedural Bleeding Among Patients Undergoing Percutaneous Coronary Intervention," by S. P. Marso and colleagues, published in the 2010 issue, including a comment on the analysis of the efficacy of vascular closure device and the author's reply.

A letter to the editor is presented in response to the article "Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention," by Thomas T. Tsai et al, as well as a response by the authors.

A response is presented by P. Michael Ho and John S. Rumsfeld to a letter to the editor about their article about the adverse events associated with stopping the drug clopidogrel after acute coronary syndrome in a previous issue.

This article presents the authors' views on the obesity therapy drug rimonabant and the Strategy to Reduce Atherosclerosis Development Involving Administration of Rimonabant:The Intravascular Ultrasound Study (STRADIVARIUS) trial. The authors reflect on STRADIVARIUS and note that the study shows that rimonabant is effective in aiding weight loss, but not for halting the progression of heart disease. Other trials that examine rimonabant therapy are also discussed.

A response by P. Michael Ho and John S. Rumsfeld to a letter to the editor about their article "Risk of Adverse Outcomes Associated With Concomitant Use of Clopidogrel and Proton Pump Inhibitors Following Acute Coronary Syndrome" in the 2009 issue is presented.