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Background Medication adherence is generally low and challenging to address because patient actions control healthcare delivery outside of medical environments. Behavioral nudging changes clinician behavior, but nudging patient decision-making requires further testing. This trial evaluated whether behavioral nudges can increase statin adherence, measured as the proportion of days covered (PDC). Methods In a 12-month parallel-group, unblinded, randomized controlled trial, adult patients in Intermountain Healthcare cardiology clinics were enrolled. Inclusion required an indication for statins and membership in SelectHealth insurance. Subjects were randomized 1:1 to control or nudges. Nudge content, timing, frequency, and delivery route were personalized by CareCentra using machine learning of subject motivations and abilities from psychographic assessment, demographics, social determinants, and the Intermountain Mortality Risk Score. PDC calculation used SelectHealth claims data. Results Among 182 subjects, age averaged 63.2±8.5 years, 25.8% were female, baseline LDL-C was 82.5±32.7 mg/dL, and 93.4% had coronary disease. Characteristics were balanced between nudge (n=89) and control arms (n=93). The statin PDC was greater at 12 months in the nudge group (PDC: 0.742±0.318) compared to controls (PDC: 0.639±0.358, p=0.042). Adherent subjects (PDC ≥80%) were more concentrated in the nudge group (66.3% vs. controls: 50.5%, p=0.036) while a composite of death, myocardial infarction, stroke, and revascularization was non-significant (nudges: 6.7% vs. control: 10.8%, p=0.44). Conclusions Persuasive behavioral nudges driven by artificial intelligence resulted in a clinically important increase in statin adherence in general cardiology patients. This precision patient decision support utilized computerized nudge design and delivery with minimal on-going human input.

James A. Arrighi, MD, FACC, Chair Lisa A. Mendes, MD, FACC, Co-Chair Jesse E. Adams iii, MD, FACC[∗][1] John E. Brush, Jr, MD, FACC[∗][1] G. William Dec, Jr, MD, FACC Ali Denktas, MD, FACC Susan M. Fernandes, LPD, PA-C Sanjeev A. Francis, MD, FACC Rosario Freeman, MD, MS, FACC[∗][1

Background The rate-limiting step in STEMI diagnosis often is the availability of a 12-lead electrocardiogram (ECG) and its interpretation. The potential may exist to speed the availability of 12-lead ECG information by using commonly available mobile technologies. We sought to test whether combining serial smartphone single-lead ECGs to create a virtual 12-lead ECG can accurately diagnose STEMI. Methods Consenting patients presenting with symptoms consistent with a possible STEMI had contemporaneous standard 12-lead and smartphone ‘12-lead equivalent’ ECG (produced by electronically combining serial single-lead ECGs) recordings obtained. Matched ECGs were evaluated qualitatively and quantitatively by a panel of blinded readers and classified as STEMI/STEMI equivalent (LBBB), Not-STEMI, or uninterpretable. Interpretable ECG pairs were graded as showing good, fair, or poor correlation. Results Two hundred four subjects (age = 60 years, males = 57%, STEMI activation = 45%) were enrolled from 5 international sites. Smartphone ECG quality was graded as good in 151 (74.0%), fair in 32 (15.7%), poor in 8 (3.9%), and uninterpretable in 13 (6.4%). A STEMI/STEMI equivalent diagnosis was identified by standard 12-lead ECG in 57/204 (27.9%) recordings. For all interpretable pairs of smartphone ECGs compared with standard ECGs (n = 190), the sensitivity, specificity, and positive and negative predictive values for STEMI/STEMI equivalent by smartphone were 0.89, 0.84, 0.70 and 0.95, respectively. Conclusions A ‘12-lead equivalent’ ECG obtained from multiple serial single-lead ECGs from a smartphone can identify STEMI with good correlation to a standard 12-lead ECG. This technology holds promise to improve outcomes in STEMI by enhancing the reach and speed of diagnosis and thereby early treatment.

Background: As the COVID-19 pandemic evolves, stratifying risk is increasingly important. The Intermountain Risk Score (IMRS) uses the complete blood count (CBC) and basic metabolic profile (BMP) as a first-line predictor of mortality and is widely validated. We hypothesized that IMRS predicts COVID-19 outcomes. Methods: Intermountain Healthcare patients aged ≥18 years were evaluated if they had CBC and BMP measured in 2019 and tested positive for COVID-19 in 2020. Viral RNA testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was conducted March 3 through November 2, 2020. IMRS used published sex-specific weightings and associations were evaluated for the composite of COVID-19 hospitalization or mortality. Findings: Among 3,883 patients, 8.2% were hospitalized, 1.6% died. Subjects with low, mild, moderate, and high-risk IMRS had the composite endpoint in 3.5% (52/1,502), 8.6% (108/1,256), 15.5% (152/979), and 28.1% (41/146), respectively. Versus low-risk, subjects in mild, moderate, and high-risk groups had HR=2.33 (95% CI: 1.67, 3.24), HR=4.01 (CI: 2.93, 5.50), and HR=8.34 (CI: 5.54, 12.57), respectively. Subjects aged

The aim of this study was to assess the effect of testosterone replacement therapy (TRT) on cardiovascular outcomes. Men (January 1, 1996, to December 31, 2011) with a low initial total testosterone concentration, a subsequent testosterone level, and3 years of follow-up were studied. Levels were correlated with testosterone supplement use. The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of death, nonfatal myocardial infarction, and stroke at 3 years. Multivariate adjusted hazard ratios (HRs) comparing groups of persistent low (212 ng/dl, n = 801), normal (212 to 742 ng/dl, n = 2,241), and high (742 ng/dl, n = 1,694) achieved testosterone were calculated by Cox hazard regression. A total of 4,736 men were studied. Three-year rates of MACE and death were 6.6% and 4.3%, respectively. Subjects supplemented to normal testosterone had reduced 3-year MACE (HR 0.74; 95% confidence interval [CI] 0.56 to 0.98, p = 0.04) compared to persistently low testosterone, driven primarily by death (HR 0.65, 95% CI 0.47 to 0.90). HRs for MI and stroke were 0.73 (95% CI 0.40 to 1.34), p = 0.32, and 1.11 (95% CI 0.54 to 2.28), p = 0.78, respectively. MACE was noninferior but not superior for high achieved testosterone with no benefit on MI and a trend to greater stroke risk. In conclusion, in a large general health care population, TRT to normal levels was associated with reduced MACE and death over 3 years but a stroke signal with high achieved levels suggests a conservative approach to TRT.

Severe hyperlipidemia (LDL-C >=190mg/dL) is an indication for statin therapy, with LDL-C >=160mg/dL a treatment enhancing factor (2018 AHA/ACC Cholesterol Treatment Guideline). The CorCal Vanguard Trial randomly invited 3770 Intermountain patients of age >=50yo without ASCVD or statin use to

Heart failure (HF), which is often subdivided according to baseline left ventricular ejection fraction (LVEF), remains a major cause of morbidity and mortality throughout the world. Although HF with reduced LVEF (HFrEF), when compared with preserved LVEF (HFpEF), is often considered to be more fatal

Statin therapy is standard for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, patients are not always adherent. It is proposed that patients may respond better to a recommendation for statin therapy if it is based on the results of a coronary artery calcium score

Hyperkalemia (HK) is a serious medical condition that can lead to life-threatening cardiac arrhythmias and sudden cardiac death. HK can result from various acute and chronic conditions that affect potassium (K) homeostasis. However, HK incidence and subsequent clinical and economic outcomes within a

Atrial fibrillation (AF) is associated with coronary artery disease (CAD) and major cardiovascular adverse events (MACE); cardiac PET imaging may be used to determine the risk of these outcomes. However, it is unclear whether having AF at the time of the PET will impact the results and subsequent

Coronary artery calcium (CAC) represents the presence of coronary artery disease (CAD) and is associated with major adverse cardiovascular events (MACE). It is unclear whether CAC predicts risk for MACE beyond assessment of ischemic burden (IB). Symptomatic patients without a history of CAD

High triglyceride (TG) levels have been associated with coronary heart disease (CHD), myocardial infarction (MI), and stroke, particularly among individuals with diabetes mellitus (DM). The purpose of this project was to examine the plasma-based proteomics associated with TG in a DM population

Acute myocardial infarction (AMI) pts have significantly lower blood levels of vitamin D (VitD) than controls. Whether low VitD levels contribute to causing or exacerbating AMI or are simply a result of the acute AMI response, and how effective preemptive VitD supplementation (VitD-S) is on

Cardiac stress testing is used to risk stratify patients for obstructive coronary artery disease (CAD). However, its effect on subsequent patient management has been challenged, specifically its underutilization in guiding the decision to perform coronary angiography. Here, we analyzed rates of

Absence of coronary artery calcium (CAC) is known to predict low risk of subsequent major adverse coronary artery events (MACE). However, little is known about its ability in symptomatic patients (pts) undergoing stress testing to predict using CAC subsequent coronary revascularization (Revasc) and

Despite advantages of cardiac positron emission testing (PET) over single photon emission computed tomography (SPECT) for diagnosing obstructive coronary artery disease (CAD), the adoption of cardiac PET has not been widespread. One of the arguments for cardiac PET is its superior diagnostic

Myocardial Perfusion Imaging (MPI) with PET technology has been shown to improve ischemia detection compared to SPECT, however limited data are available comparing the modalities in clinical practice. We report the impact of transitioning from SPECT testing to PET on the ability to assess myocardial

Coronary artery calcification (CAC) is pathognomonic for atherosclerosis and has been demonstrated to be associated with elevated risk of cardiovascular (CV) events. Diabetes (DM) is considered a “coronary equivalent” suggesting a risk of a first CV event comparable to that in those who have had

Background: Depression is a risk factor for CV disease incidence, recurrent events, and death. However, the impact between length of time following a CV event to depression on recurrent outcomes is unknown. Methods: Patients (N=24,137) who had angiographically determined CAD (stenosis ≥70%) were

Low serum testosterone (T) is an independent risk factor for CV and total mortality. The impact of T therapy on CV outcomes, especially among older men with pre-existing severe CAD, is unknown. All men >50 yrs of age, with severe CAD (≥70% stenosis), a low (

Existing literature is scarce regarding normal and abnormal measurements for coronary flow reserve (CFR) non-ischemic rubidium PET/CT cardiac stress perfusion scans using regadenoson as the stress agent. Here we analyze and compare global and vessel-specific CFR between diabetics (DM) and non

The Intermountain risk score (IMRS) is an exceptional predictor of mortality. Troponin-I (TropI) is a marker of acute myocardial injury used to diagnose MI and has been shown to have general prognostic utility. This study evaluated whether the addition of TropI to the IMRS improves risk

Acute coronary syndrome (ACS) patients benefit from dual antiplatelet therapy (DAPT), and most patients with atrial fibrillation (AF) merit anticoagulation stroke prophylaxis (AcP). Real world reporting of overall antithrombotic therapy among patients with ACS + AF is limited. We describe

It is unclear what factors determine the use of anticoagulants among patients presenting with acute coronary syndrome (ACS), in which the use of single (SAPT) or dual (DAPT) antiplatelet therapy is required. We retrospectively evaluated clinical factors associated with in-hospital and post