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Out-of-hospital cardiac arrest (OHCA) affects over 300,000 individuals per year in the United States with poor survival rates overall. A remarkable 5-fold difference in survival-to-hospital discharge rates exist across United States communities. We conducted a study using qualitative research methods comparing the system of care across sites in Michigan communities with varying OHCA survival outcomes, as measured by return to spontaneous circulation with pulse upon emergency department arrival. Major themes distinguishing higher performing sites were (1) working as a team, (2) devoting resources to coordination across agencies, and (3) developing a continuous quality improvement culture. These themes spanned the chain of survival framework for OHCA. By examining the unique processes, procedures, and characteristics of higher- relative to lower-performing sites, we gleaned lessons learned that appear to distinguish higher performers. The higher performing sites reported being the most collaborative, due in part to facilitation of system integration by progressive leadership that is willing to build bridges among stakeholders. Based on the distinguishing features of higher performing sites, we provide recommendations for toolkit development to improve survival in prehospital systems of care for OHCA. [ABSTRACT FROM AUTHOR]

Balloon pulmonary angioplasty (BPA) was introduced as a treatment modality for patients with inoperable, medically refractory chronic thromboembolic pulmonary hypertension decades ago; however, reports of high rates of pulmonary vascular injury have led to considerable refinement in procedural technique. The authors sought to better understand the evolution of BPA procedure-related complications over time. The authors conducted a systematic review of original articles published by pulmonary hypertension centers globally and performed a pooled cohort analysis of procedure-related outcomes with BPA. This systematic review identified 26 published articles from 18 countries worldwide from 2013 to 2022. A total of 1,714 patients underwent 7,561 total BPA procedures with an average follow up of 7.3 months. From the first period (2013-2017) to the second period (2018-2022), the cumulative incidence of hemoptysis/vascular injury decreased from 14.1% (474/3,351) to 7.7% (233/3,029) (P < 0.01); lung injury/reperfusion edema decreased from 11.3% (377/3,351) to 1.4% (57/3,943) (P < 0.01); invasive mechanical ventilation decreased from 0.7% (23/3,195) to 0.1% (4/3,062) (P < 0.01); and mortality decreased from 2.0% (13/636) to 0.8% (8/1,071) (P < 0.01). Procedure-related complications with BPA, including hemoptysis/vascular injury, lung injury/reperfusion edema, mechanical ventilation, and death, were less common in the second period (2018-2022), compared with first period (2013-2017), likely from refinement in patient and lesion selection and procedural technique over time. [Display omitted] [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2010.06.029 Byline: Zachary D. Goldberger, Javier A. Valle, Vineet K. Dandekar, Paul S. Chan, Dennis T. Ko, Brahmajee K. Nallamothu Abstract: Carotid intima-media thickness (CIMT) is increasingly being used as a surrogate end point in randomized control trials (RCTs) of novel cardiovascular therapies. However, it remains unclear whether changes in CIMT that result from these therapies correlate with nonfatal myocardial infarction (MI). Article History: Received 17 May 2010; Accepted 17 June 2010 Article Note: (footnote) Zachary D. Goldberger, MD, is a Robert Wood Johnson Foundation Clinical Scholar.

Background: In-person, exercise-based cardiac rehabilitation improves physical activity and reduces morbidity and mortality for patients with cardiovascular disease. However, activity levels may not be optimized and decline over time after patients graduate from cardiac rehabilitation. Scalable interventions through mobile health (mHealth) technologies have the potential to augment activity levels and extend the benefits of cardiac rehabilitation.Methods: The VALENTINE Study is a prospective, randomized-controlled, remotely-administered trial designed to evaluate an mHealth intervention to supplement cardiac rehabilitation for low- and moderate-risk patients (ClinicalTrials.gov NCT04587882). Participants are randomized to the control or intervention arms of the study. Both groups receive a compatible smartwatch (Fitbit Versa 2 or Apple Watch 4) and usual care. Participants in the intervention arm of the study additionally receive a just-in-time adaptive intervention (JITAI) delivered as contextually tailored notifications promoting low-level physical activity and exercise throughout the day. In addition, they have access to activity tracking and goal setting through the mobile study application and receive weekly activity summaries via email. The primary outcome is change in 6-minute walk distance at 6-months and, secondarily, change in average daily step count. Exploratory analyses will examine the impact of notifications on immediate short-term smartwatch-measured step counts and exercise minutes.Conclusions: The VALENTINE study leverages innovative techniques in behavioral and cardiovascular disease research and will make a significant contribution to our understanding of how to support patients using mHealth technologies to promote and sustain physical activity. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2008.02.018 Byline: Ioana Popescu (a)(b), Brahmajee K. Nallamothu (c), Mary S. Vaughan-Sarrazin (a)(b), Peter Cram (a)(b) Abstract: Supporters of specialty hospitals claim these facilities provide better patient care; however, empirical data on quality of care in specialty hospitals are limited. Author Affiliation: (a) The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Medical Center, Iowa City, IA (b) The Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA (c) The Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, MI Article History: Received 27 February 2007; Accepted 14 February 2008 Article Note: (footnote) The study is supported by a grants from the National Center for Research Resources, Bethesda, MD (K23 RR01997201), National Heart, Lung, and Blood Institute, Bethesda, MD, and the Robert Wood Johnson Physician Faculty Scholars Program, Stanford, CA (Dr Cram); from the Health Services Research and Development Service, Veterans Health Administration, Department of Veterans Affairs (HFP 04-149) (Dr Vaughan-Sarrazin); and from the Agency for Health care Research and Quality (1R01HS015571-01A1) (Dr Nallamothu). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2007.10.051 Byline: Jeremy W. Buckley (a), Eric R. Bates (a), Brahmajee K. Nallamothu (a)(b) Abstract: In 2005, Michigan expanded primary percutaneous coronary intervention (P-PCI) capability to 12 hospitals without on-site cardiac surgery. We determined the potential impact of this expansion on geographic access to P-PCI for patients. Author Affiliation: (a) University of Michigan Medical School, Ann Arbor, MI (b) VA Health Services Research & Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, MI Article History: Received 28 June 2007; Accepted 1 October 2007

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2007.06.031 Byline: Vivian Ho (a)(b), Joseph S. Ross (c)(d), Brahmajee K. Nallamothu (e), Harlan M. Krumholz (f)(g)(h) Abstract: Many states enforce Certificate of Need (CON) regulations for cardiac procedures, but little is known about how CON affects utilization. We assessed the association between cardiac CON regulations, availability of revascularization facilities, and revascularization rates. Author Affiliation: (a) Baker Institute for Public Policy, Rice University, Houston, TX (b) Department of Medicine, Baylor College of Medicine (c) Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY (d) Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (e) Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, MI (f) Department of Medicine, Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, New Haven, CT (g) Department of Epidemiology and Public Health, Section of Health Policy and Administration, Yale University School of Medicine, New Haven, CT (h) Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT Article History: Received 29 January 2007; Accepted 19 June 2007 Article Note: (footnote) Dr Ross was a scholar in the Robert Wood Johnson Clinical Scholars Program at Yale University sponsored by the Robert Wood Johnson Foundation at times during his involvement in the project., Support was given from a grant awarded to Dr Ho by the National Heart, Lung, and Blood Institute (R01 HL073825-01A1).

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2007.04.052 Byline: Catherine Kim (a)(b), Ana V. Diez Roux (c), Timothy P. Hofer (d)(e), Brahmajee K. Nallamothu (d)(f), Steven J. Bernstein (d)(f), Mary A.M. Rogers (g) Abstract: Individuals of low socioeconomic status (SES) have reduced access to coronary artery bypass graft surgery (CABG). It is unknown if low-SES CABG patients have reduced access to hospitals with better outcomes. Author Affiliation: (a) Division of General Internal Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI (b) Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI (c) Department of Epidemiology, Robert Wood Johnson Health and Society Scholars Program, University of Michigan School of Public Health, Ann Arbor, MI (d) Department of Veterans Affairs, VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (e) Department of Internal Medicine, Michigan Diabetes Research and Training Center, The Robert Wood Johnson Clinical Scholars Program, University of Michigan, School of Medicine, Ann Arbor, MI (f) Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI (g) Division of General Internal Medicine, Department of Medicine, Patient Safety Enhancement Program, University of Michigan School of Medicine, Ann Arbor, MI Article History: Received 29 January 2007; Accepted 1 April 2007 Article Note: (footnote) This study was supported by a grant from the Robert Wood Johnson Health and Society Scholars Program, the American Diabetes Association, and NIDDK K23-DK071552.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2007.01.006 Byline: Ali Mahajerin (a), Hitinder S. Gurm (a), Thomas T. Tsai (a), Paul S. Chan (a), Brahmajee K. Nallamothu (a)(b) Abstract: The use of vasodilators to improve long-term outcomes in asymptomatic patients with chronic aortic insufficiency (AI) is controversial. Author Affiliation: (a) Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI (b) Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, MI Article History: Received 18 November 2006; Accepted 10 January 2007

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2006.03.025 Byline: Brahmajee K. Nallamothu (a)(b), Paul A. Taheri (c), William G. Barsan (d), Eric R. Bates (b) Abstract: Many cardiovascular experts have called for the creation of specialized myocardial infarction centers and networks in the United States analogous to the current model for major trauma. Patients suffering ST-elevation myocardial infarction (STEMI) and trauma share an essential feature that makes the argument for regionalization persuasive: rapid triage and treatment by highly trained personnel improve survival in both conditions. Despite this similarity, however, the trauma system may be limited as a model for regionalizing STEMI care. First, the development of trauma systems has been hindered by the struggle for sufficient and stable funding, competing interests among individual stakeholders, and the overall lack of desire for state-sponsored healthcare planning in the United States. These same obstacles would need to be overcome if STEMI care is regionalized. Second, unique characteristics related to STEMI care, such as its varied clinical presentation and more lucrative reimbursement, will create new challenges. In this article, we briefly review the current status of trauma systems in the United States and describe why the regionalization of STEMI care may require different methods of healthcare organization. Author Affiliation: (a) Health Services Research and Development Center of Excellence, VA Medical Center, Ann Arbor, MI (b) Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI (c) Section of Trauma Burn and Critical Care, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI (d) Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI Article History: Received 21 December 2005; Accepted 20 March 2006 Article Note: (footnote) Conflicts of Interest Disclosures: The authors have no potential conflicts of interests that affected the reporting of this work., Dr Nallamothu is being supported as a clinical scholar under a K12 grant from the National Institutes of Health (RR017607-01) and a grant by the Mardigian Foundation.

Symptoms in atrial fibrillation are generally assumed to correspond to heart rhythm; however, patient affect - the experience of feelings, emotion or mood - is known to frequently modulate how patients report symptoms but this has not been studied in atrial fibrillation. In this study, we investigated the relationship between affect, symptoms and heart rhythm in patients with paroxysmal or persistent atrial fibrillation. We found that presence of negative affect portended reporting of more severe symptoms to the same or greater extent than heart rhythm. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2008.04.024 Byline: Harindra C. Wijeysundera (a), John J. You (b)(c)(d), Brahmajee K. Nallamothu (e), Harlan M. Krumholz (f)(g), Warren J. Cantor (h), Dennis T. Ko (a)(d) Abstract: Although the use of an early invasive strategy among patients with ST-segment elevation myocardial infarctions (STEMI) who are treated initially with fibrinolytic therapy is common, the safety and efficacy of this approach remains uncertain. We performed a meta-analysis to best estimate the benefits and harms of an early invasive strategy in STEMI patients treated initially with full-dose intravenous fibrinolytic therapy, as compared to a traditional strategy of ischemia-guided management. Author Affiliation: (a) Division of Cardiology, Schulich Heart Center and Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada (b) Department of Medicine, McMaster University, Hamilton, Ontario, Canada (c) Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (d) Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (e) Health Services and Research Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, MI (f) Section of Health Policy and Administration, Department of Epidemiology and Public Health; Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, CT (g) Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, CT (h) Division of Cardiology, Southlake Regional Health Center, Newmarket, Ontario, Canada Article History: Received 12 February 2008; Accepted 28 April 2008 Article Note: (footnote) Dr. Wijeysundera is supported by a University of Toronto, Department of Medicine Clinician Scientist Training Program, and a research fellowship award from the Canadian Institute of Health Research (CIHR) (Ottawa, Ontario, Canada). Dr. You is supported by a McMaster University Department of Medicine Internal Career Research Award. Dr. Ko is supported by a Heart and Stroke Foundation of Ontario Clinician Scientist Award. This project is funded in part by a CIHR operating grant., Dr. Warren Cantor has received consulting fees, speaker's honoraria, and unrestricted research grants from Hoffman La Roche Canada (Montreal, Quebec, Canada).

Background: Despite significant attention to resuscitation care by hospitals, national data on trends in the incidence and survival of patients with inhospital cardiac arrest (IHCA) are limited.Objective: To determine trends and hospital-level variation in the incidence and outcomes associated with IHCA. In exploratory analyses, we evaluated the relationship between hospital-level IHCA incidence and outcomes with general hospital-wide quality improvement activities.Design, Setting, and Participants: Retrospective cohort study of 2,205,123 hospitalizations at 101 Veterans Health Administration (VHA) hospitals between 2008 and 2012.Main Outcomes: Risk- and reliability-adjusted hospital-level IHCA incidence and survival to hospital discharge.Results: A total of 8821 (0.40%) IHCA occurred between 2008 and 2012, with no significant change in risk-adjusted incidence over this time (P = .77). Hospital-level IHCA incidence varied substantially across facilities, with a median hospital incidence of 4.0 per 1000 hospitalizations and a range from 1.4 to 11.8 per 1000 hospitalizations. Overall, survival to discharge after IHCA was 31.2%. Risk-adjusted odds of survival increased over the study period (2012 vs 2008, OR: 1.49, 95% CI: 1.27, 1.75) but survival varied substantially across facilities from 20.3% to 45.4%. General hospital quality improvement activities were inconsistently associated with IHCA incidence and survival.Conclusions: Within the VHA, the incidence and outcomes of IHCA showed important trends over time but varied substantially across hospitals with no consistent link to general hospital quality improvement activities. Identification of specific resuscitation practices at hospitals with low incidence and high survival of IHCA may guide further improvements for inhospital resuscitation. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to describe the contemporary incidence of chronic total occlusions (CTOs) and the success rates of CTO percutaneous coronary intervention (PCI), as well as the complications and long-term outcomes of these patients. Background The contemporary prevalence and management of coronary CTOs is understudied. Methods Consecutive veterans undergoing coronary angiography at 79 Veterans Affairs sites between 2007 and 2013 were examined. Detailed baseline clinical, angiographic, and follow-up outcomes were evaluated using national data from the Veterans Affairs Clinical Assessment Reporting and Tracking program. Results Among 111,273 patients with obstructive coronary artery disease, 29,399 (26.4%) had ≥1 CTO, most commonly in the right coronary artery distribution (n = 18,986 [64.6%]). Elective CTO PCI was attempted in 2,394 patients (8.1%), with a procedural success rate of 79.7%. The odds of CTO PCI success increased over the years of the study (odds ratio: 1.08; 95% confidence interval [CI]: 1.01 to 1.16; p = 0.03). Compared with failed CTO PCI, successful CTO PCI was associated with a decreased adjusted risk for mortality (hazard ratio: 0.67; 95% CI: 0.47 to 0.95; p = 0.02) and coronary artery bypass graft surgery (hazard ratio: 0.14; 95% CI: 0.08 to 0.24; p < 0.01) at 2 years but no significant change in the risk for hospitalization for myocardial infarction (hazard ratio: 0.89; 95% CI: 0.58 to 1.36; p = 0.58). Conclusions Approximately 1 in 4 patients with obstructive coronary artery disease on coronary angiography had CTOs. Among patients who went on to elective CTO PCI, the success rate was 79.7%. Compared with failed CTO PCI, successful CTO PCI was associated with a decreased risk for mortality as well as a decreased need for subsequent coronary artery bypass graft surgery. [ABSTRACT FROM AUTHOR]

Background: Transcatheter aortic valve replacement (TAVR) received US regulatory approval for treatment of severe symptomatic aortic stenosis (AS) in November 2011. After subsequent approvals for expanded indications, it is now performed throughout Michigan but the distribution of these providers and their impact on access is uncertain. As the number of providers and utilization for TAVR grows, how procedural volume is distributed among providers may significantly impact patient outcomes.Methods: We determined geographic access to TAVR in Michigan as of October 2014, and compared it to access of other invasive cardiac services; namely, percutaneous coronary intervention (PCI), non-transplant cardiac surgery, and cardiac transplant surgery. A geographic information systems analysis was performed using recent U.S. Census Survey data and statewide inpatient data to construct maps of service areas around hospitals providing TAVR, PCI, non-transplant cardiac surgery, and cardiac transplant surgery. Service areas ranging across multiple driving distances were included in the analysis. Geographic access was calculated as percentage of the population living within the hospital service areas providing invasive cardiac services.Results: In October 2014, 15 hospitals provide TAVR in Michigan. For TAVR sites, the mean number of beds, annual discharges, and annual patient days are 571, 28,946, and 140,859, respectively. Compared to hospitals not offering TAVR, TAVR facilities were more likely to be non-profit (86.7% vs 71.0%), a teaching hospital (93.3% vs 87.1%), and rural (12.1% vs 6.5%). Of the 9,883,640 persons in Michigan, 4,492,941 (45.5%) live within 10 miles, 7,856,455 (79.5%) live within 30 miles, and 9,004,943 (91.1%) live within 50 miles driving distance of TAVR sites. These proportions compare favorably with hospitals providing PCI (8,857,148 [89.6%] living within 30 miles) and non-transplant cardiac surgery (8,814,143 [89.2%] living within 30 miles) as opposed to cardiac transplant surgery (5,481,122 [55.5%] living within 30 miles). For Michigan patients who underwent surgical valve replacement (SAVR) in 2010-2011, the median driving distance to a TAVR site was under 15 miles and under 10 miles to a hospital providing non-transplant cardiac surgery.Conclusions: Nearly 4 of 5 Michigan residents lived within 30 miles of TAVR services early after its approval, suggesting its wide availability despite initial regulations on its use. These findings may encourage growth in TAVR utilization and limit the development of expertise as procedural volume is distributed among more providers. Given procedural volume tends to relate positively with outcomes, increased access to TAVR may have negative effects on patient outcomes. [ABSTRACT FROM AUTHOR]

Background: The treatment for patients with acute myocardial infarction (AMI) was transformed by the introduction of intensive care units (ICUs), yet we know little about how contemporary hospitals use this resource-intensive setting and whether higher use is associated with better outcomes.Methods: We identified 114,136 adult hospitalizations for AMI from 307 hospitals in the 2009 to 2010 Premier database using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. Hospitals were stratified into quartiles by rates of ICU admission for AMI patients. Across quartiles, we examined in-hospital risk-standardized mortality rates and usage rates of critical care therapies for these patients.Results: Rates of ICU admission for AMI patients varied markedly among hospitals (median 48%, Q1-Q4 20%-71%, range 0%-98%), and there was no association with in-hospital risk-standardized mortality rates (6% all quartiles, P = .7). However, hospitals admitting more AMI patients to the ICU were more likely to use critical care therapies overall (mechanical ventilation [from Q1 with lowest rate of ICU use to Q4 with highest rate 13%-16%], vasopressors/inotropes [17%-21%], intra-aortic balloon pumps [4%-7%], and pulmonary artery catheters [4%-5%]; P for trend < .05 in all comparisons).Conclusions: Rates of ICU admission for patients with AMI vary substantially across hospitals and were not associated with differences in mortality, but were associated with greater use of critical care therapies. These findings suggest uncertainty about the appropriate use of this resource-intensive setting and a need to optimize ICU triage for patients who will truly benefit. [ABSTRACT FROM AUTHOR]

Background Atrial fibrillation (AF) is associated with a significant increase in the risk of stroke and mortality. It is unclear whether maintaining sinus rhythm (SR) after radiofrequency ablation (RFA) is associated with an improvement in stroke risk and survival. Objective The purpose of this study was to determine whether SR after RFA of AF is associated with an improvement in the risk of cerebrovascular events (CVEs) and mortality during an extended 10-year follow-up. Methods RFA was performed in 3058 patients (age 58 ± 10 years) with paroxysmal (n = 1888) or persistent AF (n = 1170). The effects of time-dependent rhythm status on CVEs and cardiac and all-cause mortality were assessed using multivariable Cox models adjusted for baseline and time-dependent variables during 11,347 patient-years of follow-up. Results Independent predictors of a higher arrhythmia burden after RFA were age (estimated beta coefficient [β] = 0.017 per 10 years, 95% confidence interval [CI] 0.006-0.029, P = .003), left atrial (LA) diameter (β = 0.044 per 5-mm increase in LA diameter, 95% CI 0.034-0.055, P <.0001), and persistent AF (β = 0.174, 95% CI 0.147-0.201, P <.0001). CVEs and cardiac and all-cause mortality occurred in 71 (2.3%), 33 (1.1%), and 111 (3.6%), respectively. SR after RFA was associated with a significantly lower risk of cardiac mortality (hazard ratio [HR] 0.41, 95% CI 0.20-0.84, P = .015). There was not a significant reduction in all-cause mortality (HR 0.86, 95% CI 0.58-1.29, P = .48) or CVEs (HR 0.79, 95% CI 0.48-1.29, P = .34) in patients who remained in SR after RFA. Conclusion Maintenance of SR after RFA is associated with a reduction in cardiovascular mortality in patients with AF. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to examine the use of and outcomes associated with use of N-acetylcysteine (NAC) in real-world practice. Background: The role of NAC in the prevention of contrast-induced nephropathy (CIN) is controversial, leading to widely varying recommendations for its use. Methods: Use of NAC was assessed in consecutive patients undergoing nonemergent percutaneous coronary intervention from 2006 to 2009 in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium, a large multicenter quality improvement collaborative. We examined the overall prevalence of NAC use in these patients and then used propensity matching to link its use with clinical outcomes, including CIN, nephropathy-requiring dialysis, and death. Results: Of the 90,578 percutaneous coronary interventions performed during the study period, NAC was used in 10,574 (11.6%) procedures, with its use steadily increasing over the study period. Patients treated with NAC were slightly older and more likely to have baseline renal insufficiency and other comorbidities. In propensity-matched, risk-adjusted models, we found no differences in outcomes between patients treated with NAC and those not receiving NAC for CIN (5.5% vs. 5.5%, p = 0.99), nephropathy-requiring dialysis (0.6% vs. 0.6%, p = 0.69), or death (0.6% vs. 0.8%, p = 0.15). These findings were consistent across many prespecified subgroups. Conclusions: Use of NAC is common and has steadily increased over the study period but does not seem to be associated with improved clinical outcomes in real-world practice. [ABSTRACT FROM AUTHOR]

Objectives: The goal of this study was to compare patterns of downstream testing and procedures after stress testing with imaging performed at physician offices versus at hospital-outpatient facilities Background: Stress testing with imaging has grown dramatically in recent years, but whether the location of where the test is performed correlates with different patterns for subsequent cardiac testing and procedures is unknown Methods: We identified 82,178 adults with private health insurance from 2005 to 2007 who underwent ambulatory myocardial perfusion imaging (MPI) or stress echocardiography (SE). Subsequent MPI, SE, cardiac catheterization or revascularization within 6 months was compared between physician office and hospital outpatient settings. Results: Overall, 85.1% of MPI and 84.9% of SE were performed in physician offices. The proportion of patients who underwent subsequent MPI, SE, or cardiac catheterization was not statistically different between physician office and hospital outpatient settings for MPI (14.2% vs. 13.9%, p = 0.44) or SE (7.9% vs. 8.6%, p = 0.21). However, patients with physician office imaging had slightly higher rates of repeat MPI within 6 months compared with hospital-outpatient imaging for both index MPI (3.5% vs. 2.0%, p < 0.001) and SE (3.4% vs. 2.1%, p < 0.001), and slightly lower rates of cardiac catheterization after index MPI (11.4% vs. 12.2%, p = 0.04) and SE (4.5% vs. 7.0%, p < 0.001). Differences in 6-month utilization were observed across the 5 healthcare markets after index MPI but not after index SE Conclusions: Physician office imaging is associated with slightly higher repeat MPI and fewer cardiac catheterizations than hospital outpatient imaging, but no overall difference in the proportion of patients undergoing additional further testing or procedures. Although regional variation exists, especially for MPI, the relationship between physician office location of stress testing with imaging and greater downstream resource utilization appears modest. [Copyright &y& Elsevier]

Objectives: This study sought to assess the prognostic utility of echocardiographic dyssynchrony for health status improvement after cardiac resynchronization therapy (CRT). Background: Echocardiographic measures of dyssynchrony have been proposed for patient selection for CRT, but prospective validation studies are lacking. Methods: A prospective cohort of 324 patients from 53 centers with moderate to severe heart failure, left ventricular dysfunction, QRS ≥130 ms, and available echocardiographic and health status information were identified from the PROSPECT (Predictors of Response to Cardiac Re-Synchronization Therapy) trial, which evaluated the prognostic utility of dyssynchrony measures in CRT recipients. The association of 12 echocardiographic dyssynchrony parameters with 6-month improvement in health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), was assessed both as a continuous variable and by responder status (ΔKCCQ ≥+10 points reflecting moderate to large improvement). Results: Of 12 pre-defined dyssynchrony parameters, only 3 were consistently reported: interventricular mechanical delay (IVMD), left ventricular filling time relative to the cardiac cycle (LVFT), and left ventricular pre-ejection interval. After multivariable adjustment, IVMD (+5.18, 95% confidence interval [CI]: +0.76 to +9.60; p = 0.02) and LVFT (+5.19, 95% CI: +0.45 to +0.94; p = 0.03) were independently associated with 6-month improvements in KCCQ. Patients with 6-month improvements in KCCQ had lower subsequent mortality (adjusted hazard ratio [HR] for each 5-point improvement: 0.83; 95% CI: 0.72 to 0.93; p = 0.03). Additionally, IVMD was associated with CRT responder status (for ΔKCCQ ≥+10 points: odds ratio [OR]: 1.85; 95% CI: 1.12 to 3.05; p = 0.03), whereas LVFT was not (OR: 1.63; 95% CI: 0.85 to 3.11; p = 0.14). Patients classified as health status responders had a 76% lower subsequent risk of all-cause mortality (adjusted HR: 0.24; 95% CI: 0.07 to 0.84; p = 0.03). Conclusions: The presence of pre-implantation IVMD and LVFT was associated with 6-month health status improvement, and IVMD was associated with a significant CRT response. These echocardiographic factors may help clinicians counsel patients regarding their likelihood of symptomatic improvement with CRT. (PROSPECT: Predictors of Response to Cardiac Re-Synchronization Therapy; NCT00253357) [Copyright &y& Elsevier]

Objectives: The purpose of this study was to determine if enrollment in the Door-to-Balloon (D2B) Alliance, a national quality campaign sponsored by the American College of Cardiology and 38 partner organizations, was associated with increased likelihood of patients who received primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) being treated within 90 min of hospital presentation. Background: The D2B Alliance, launched in November 2006, sought to achieve the goal of having 75% of patients with STEMI treated within 90 min of hospital presentation. Methods: We conducted a longitudinal study of D2B times in 831 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, April 1, 2005, to March 31, 2008. Results: By March 2008, >75% of patients had D2B times of ≤90 min, compared with only about one-half of patients with D2B times within 90 min in April 2005. Trends since the launch of the D2B Alliance showed that patients treated in hospitals enrolled in the D2B Alliance for at least 3 months were significantly more likely than patients treated in nonenrolled hospitals to have D2B times within 90 min, although the magnitude of the difference was modest (odds ratio: 1.16; 95% confidence interval: 1.07 to 1.27). Conclusions: The D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by 2008. [Copyright &y& Elsevier]

To improve hospital performance in door-to-balloon (DTB) times nationally, the American College of Cardiology D2B Alliance recently enrolled approximately 1,000 hospitals that perform percutaneous coronary intervention (PCI) across the United States in a large national quality improvement effort. We evaluated recent changes in DTB times in hospitals within the Get-With-The-Guidelines (GWTG) Coronary Artery Disease (CAD) program, a partner in the D2B Alliance. Within GWTG-CAD participating hospitals, we studied DTB in nontransferred patients with ST-elevation myocardial infarction treated with primary PCI from July 2006 to March 2008. We evaluated the percentage of patients treated within 90 minutes and used multivariable models with generalized estimating equations to examine trends over time after accounting for changes in patients'' characteristics. A total of 5,801 patients at 167 hospitals were included in our analysis, with 3,567 patients at 98 hospitals that joined the D2B Alliance. From July to September 2006, 54.1% of patients received primary PCI within 90 minutes. This number increased significantly during the study period: 335 (74.1%) of 452 patients at GWTG-CAD participating hospitals were treated within 90 minutes from January to March 2008, including 229 of 304 patients (75.3%) treated at hospitals that joined the D2B Alliance and 106 of 148 patients (71.6%) treated at other GWTG-CAD participating hospitals (p <0.001 for all comparisons over time). No statistically significant differences were noted in the rate of change between hospitals that joined the D2B Alliance and other GWTG-CAD participating hospitals. In conclusion, the percentage of patients treated with 90 minutes has dramatically increased at hospitals participating within the GWTG-CAD program, coinciding with the launch of the D2B Alliance. These improvements were broad and not limited to hospitals that joined the D2B Alliance. [Copyright &y& Elsevier]

Background: The optimal hydration strategy for prevention of contrast-induced acute kidney injury (AKI) remains unknown. The purpose of this meta-analysis is to compare the effectiveness of normal saline (NS) versus sodium bicarbonate hydration (NaHCO3) for prevention of contrast-induced AKI. Methods: We performed a meta-analysis of randomized controlled trials that compared saline-based hydration with sodium bicarbonate–based hydration regimen for prophylaxis of contrast-induced AKI. The literature search included MEDLINE, EMBASE, and Cochrane databases (2000 to October 2007); conference proceedings; and bibliographies of retrieved articles. Information was extracted on study design, sample characteristics, and interventions. Random-effects models were used to calculate summary risk ratios for contrast-induced AKI, need for hemodialysis, and death. Results: Seven trials with 1,307 subjects were included. Preprocedural hydration with sodium bicarbonate was associated with a significant decrease in the rate of contrast-induced AKI (5.96% in the NaHCO3 arm versus 17.23% in the NS arm, summary risk ratio 0.37, 95% CI 0.18-0.714, P = .005). There was no difference in the rates of postprocedure hemodialysis or death. Formal testing revealed moderate heterogeneity and a strong likelihood of publication bias. Conclusions: Although sodium bicarbonate hydration was found to be superior to NS in prevention of contrast-induced AKI, these results are in the context of study heterogeneity and, likely, publication bias. An adequately powered randomized controlled trial is warranted to define the optimal hydration strategy in patients at high risk of contrast-induced AKI who are scheduled to undergo contrast administration. [Copyright &y& Elsevier]

Objectives: We sought to describe the rationale and methods for Door-to-Balloon (D2B): An Alliance for Quality, an international effort organized by the American College of Cardiology in partnership with the American Heart Association and 37 other organizations to rapidly translate research about how best to achieve outstanding D2B times for patients with ST-segment elevation myocardial infarction (STEMI) into practice. Background: The D2B time, the time between hospital arrival and primary percutaneous coronary intervention for patients with STEMI, is strongly associated with the likelihood of survival, yet the majority of patients are not treated within the guideline-recommended time of ≤90 min. Recent research has revealed key and underused strategies that are associated with achieving faster D2B times. Methods: The D2B Alliance has enrolled approximately 1,000 hospitals. Its goal is to achieve a D2B time of ≤90 min for at least 75% of non-transferred patients. The key strategies chosen by the D2B Alliance include having the emergency medicine physician activate the catheterization laboratory with a single call, having the team prepared within 20 to 30 min of the call; rapid data feedback; a team-based approach; and administrative support. The use of a pre-hospital electrocardiogram by emergency medical services personnel to activate the catheterization laboratory was also noted as an additional optional strategy. The project has many approaches to promote participation and adoption of effective strategies. An evaluation component is also described. Conclusions: The design of the D2B: An Alliance for Quality, a novel campaign to improve D2B time, is described. [Copyright &y& Elsevier]

Diabetes mellitus is a major risk factor for restenosis in patients undergoing percutaneous coronary intervention. Randomized controlled trials comparing drug-eluting stents (DESs) with bare metal stents (BMSs) showed a marked decrease in in-stent restenosis and target lesion revascularization with DESs in the total patient population enrolled in the studies, including patients with diabetes. However, it remains unclear whether the antirestenotic benefit of DESs is preserved in the high-risk diabetic subgroup. MEDLINE, EMBASE, ISI Web of Knowledge, Current Contents, International Pharmaceutical Abstracts, and recent Scientific Sessions databases were searched to identify relevant clinical trials comparing DESs with BMSs. A randomized controlled trial was included if it provided outcome data for patients with diabetes for ≥1 of the following: late lumen loss, in-stent restenosis, or target lesion revascularization. Data were combined using fixed-effects models, and standard tests for heterogeneity were performed. Eight studies with 1,520 patients with diabetes were identified that reported ≥1 outcome of interest. Mean late lumen losses (7 studies) were 0.93 mm (95% confidence interval [CI] 0.510 to 1.348) with BMSs and 0.18 mm (95% CI −0.088 to +0.446) with DESs. For patients receiving a DES, this translated into a marked decrease in in-stent restenosis (7 studies, RR 0.14, 95% CI 0.10 to 0.22, p <0.001) and target lesion revascularization (8 studies, RR 0.34, 95% CI 0.26 to 0.45, p <0.001). DES use is associated with a marked decrease in in-stent restenosis and target lesion revascularization in patients with diabetes. In conclusion, the analysis supports the current widespread use of DESs in these high-risk patients. [Copyright &y& Elsevier]

Medical advances may be shifting patients with coronary artery disease away from the hospital setting despite an aging United States population. We explored this possibility using national inpatient data to estimate the number and population-based rates of hospitalization for acute myocardial infarction (AMI) and coronary revascularization from 2002 to 2005. Our primary data source was the Acute Care Tracker database, a proprietary administrative database that contains data on approximately 6 million discharges per year from 458 hospitals across the United States. Using the Acute Care Tracker database, we estimated the annual number and population-based rates of hospitalization for AMI (transmural, subendocardial) and coronary revascularization (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]). Hospitalizations for AMI steadily decreased from 661,000 to 591,000 per year between 2002 and 2005, primarily due to decreases in transmural AMI. Hospitalizations for coronary revascularizations during this period varied between 794,000 and 815,000 per year, with the number of PCIs increasing and the number of CABGs decreasing. In addition, rates of hospitalization for AMI decreased from 309 to 266 per 100,000 persons between 2002 and 2005, with rates of transmural AMI decreasing substantially from 118 to 87 per 100,000 persons. Rates of hospitalization for coronary revascularization also decreased from 382 to 358 per 100,000 during this period, primarily due to decreases in CABG. In conclusion, the number and rates of hospitalization for AMI and coronary revascularization in the United States are decreasing. [Copyright &y& Elsevier]

Background: The number of peripheral vascular intervention (PVI) procedures performed is steadily increasing in the United States. PVD-QI2 is a prospective, multicenter observational study designed to improve the quality of care for patients undergoing PVI and to better understand the effectiveness and appropriateness of PVI in improving outcomes of peripheral arterial disease. The registry aims to elucidate which comorbid conditions and procedure-related variables are associated with beneficial or adverse outcomes after vascular interventions. Methods: Five centers are currently prospectively collecting data on consecutive PVIs performed at their institutions and will include patients with both claudication and critical limb ischemia. A common data collection form and a standard set of definitions were developed during several planning meetings. Information on patient demographics, clinical history, comorbid conditions, treatment approaches, and inhospital outcomes are being collected. Patients will be followed up at 30 days, 6 months, and 1 year after each procedure to identify recurrent vascular events, medication use, lifestyle modifications (regular exercise, dietary modification), self-reported walking scores, and mortality. Data validity will be assured through review of data form accuracy by a trained nurse, by automatic database diagnostic routines, and by site visits that include review of angiography suite logs and randomly selected charts. Conclusions: The development of a quality-controlled PVI registry requires the commitment and collaboration of clinician-investigators and hospital systems devoted to understanding factors that contribute to quality outcomes. Central to achievement of this goal is the creation of a careful diagnostic and data quality assessment system. This registry will provide important clinical insights into patient demographic and clinical characteristics, procedural characteristics, and current practice patterns that foster or impede achievement of long-term quality-based clinical outcomes for patients with peripheral arterial disease. [Copyright &y& Elsevier]