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We describe variables and outcomes associated with peri-operative mechanical circulatory support (MCS) utilization among patients enrolled in the Levosimendan in patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial.In the LEVO-CTS trial, MCS utilization (defined as intra-aortic balloon pump, extracorporeal membrane oxygenation, or surgical ventricular assist device) within 5 days of surgery was examined. The association between MCS use and outcomes including 90-day mortality, 30-day renal-replacement therapy, and hospital and critical stay length of stay were determined.Among the 849 patients from 70 centers randomized to levosimendan or placebo, 85 (10.0%) patients were treated with MCS (71 intra-aortic balloon pump, 7 extracorporeal membrane oxygenation, 7 ventricular assist device); with 89.4% started on post-operative day 0. Inter-institutional use ranged from 0% to 100%. Variables independently associated with MCS utilization included combined coronary artery bypass grafting and valve surgery (adjusted odds ratio [OR] 2.73, 95% confidence interval [CI] 1.70-4.37, P.001), history of lung disease (OR 1.70, 95% CI 1.06-2.70, P = .029), and history of heart failure (OR 2.44, 95% CI 1.10-5.45, P = .027). Adjusted 90-day mortality (22.4% vs 4.1%, hazard ratio 6.11, 95% CI 3.95-9.44, P.001) was higher, and median critical care length of stay (8.0 vs 4.0 days, P.001) was longer in patients managed with MCS.In a randomized controlled trial of high-risk cardiac surgical patients in North America, we observed patient, and surgical variables associated with MCS utilization. MCS use was associated with a higher risk of post-operative mortality.

Background Obesity is a risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). Whether obesity affects outcomes among those with T2D and atherosclerotic CVD (ASCVD) remains uncertain. Our objective was to investigate the relationship between body mass index (BMI) and ASCVD outcomes among TECOS participants with T2D and ASCVD. Methods BMI categories were defined as underweight/normal weight (BMI 2 ), overweight (25-29.9 kg/m 2 ), obese class I (30-34.9 kg/m 2 ), obese class II (35-39.9 kg/m 2 ), and obese class III (≥ 40 kg/m 2 ). Asian-specific BMI categories were applied to Asian participants. Kaplan-Meier survival analysis and Cox proportional hazards models were used to examine associations between baseline BMI and a composite CV outcome (CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina). Results For 14,534 TECOS patients with available BMI, mean age was 65.5 years; 29.3% were female, 32.0% non-White, and 23.1% insulin-treated, with median 3 years' follow-up. At baseline, 11.6% (n = 1686) were underweight/normal weight, 38.1% (n = 5532) overweight, 32.2% (n = 4683) obese class I, 12.4% (n = 1806) obese class II, and 5.7% (n = 827) obese class III. The composite CV outcome occurred in 11.4% (n = 1663) of participants; the outcome risk was lower, compared with under/normal weight, in overweight (HR 0.83, 95% CI 0.71-0.98) and obese class I (HR 0.79, 95% CI 0.67-0.93) individuals. Obesity was not associated with worse glycemic control. Conclusions The majority of TECOS participants with ASCVD and T2D were overweight or obese, yet overweight or obese class I individuals had lower CV risk than those who were under/normal weight. These results suggest the presence of an obesity paradox, but this paradox may reflect an epidemiological artifact rather than a true negative association between normal weight and clinical outcomes.

Background: Although appropriate noninvasive cardiac tests (NICTs) after an acute coronary syndrome (ACS) provide useful prognostic information, inappropriate use leads to inefficient expenditure of existing healthcare resources. By using the Alberta Contemporary Acute Coronary Syndrome Patient Invasive Treatment Strategies (COAPT) Registry, we evaluated the use and costs of NICTs among patients discharged within 1 year after ACS. Methods: All patients discharged from the hospital with a primary diagnosis of ACS in Alberta between 2004/2005 and 2015/2016 were included. Frequency of NICTs (stress tests [± imaging] and nonstress imaging tests) was determined from linked provincial databases. Costs were obtained from the Alberta Health Care Insurance Plan Medical Procedure List. Results: Of 55,516 patients with ACS, 30,760 had at least 1 NICT (55.4%), with 13,505 (24.3%) having > 1 NICT performed within 1 year. Temporal trends of NICT increased over time (stress tests: P trend < 0.001; nonstress imaging tests: P trend < 0.001). NICT most commonly occurred within the first 4 months after hospital discharge (stress tests at 2 months; nonstress imaging tests at 3-4 months). In 2015/2016, the total estimated costs of NICT were $1.35M, a 22.4% increase from 2004/2005 (1.10M) (P < 0.001), whereas a decrease in incidence of ACS over the same time period was noted (P = 0.008). Conclusions: Rates of NICT 1 year after ACS are high and increasing over time. Estimated costs of NICT appear to be escalating out of proportion to the ACS growth. Further investigation is warranted because it is speculative whether the increase in NICT and costs results in clinical benefit after ACS. Résumé: Contexte: Bien que les différents examens cardiaques non effractifs (ECNE) effectués après un syndrome coronarien aigu (SCA) fournissent des renseignements utiles au pronostic, leur emploi dans des situations inappropriées entraîne un gaspillage des ressources en santé. À l’aide du registre COAPT (Contemporary Acute Coronary Syndrome Patient Invasive Treatment Strategies) de l’Alberta, nous avons évalué l’emploi des ECNE et les coûts qui y sont associés chez les patients qui ont reçu leur congé de l’hôpital dans l’année suivant un SCA. Méthodologie: Tous les patients qui ont reçu leur congé de l’hôpital après un diagnostic primaire de SCA en Alberta entre 2004-2005 et 2015-2016 ont été inclus. La fréquence des ECNE (épreuves d’effort [avec ou sans examen d’imagerie] et examens d’imagerie au repos) a été déterminée à partir des bases de données provinciales couplées. Les coûts ont été établis à partir de la liste des actes médicaux du régime d’assurance-maladie de l’Alberta. Résultats: Des 55 516 patients ayant présenté un SCA, 30 760 ont subi au moins un ECNE (55,4 %) dans l’année qui a suivi l’événement; 13 505 (24,3 %) d’entre eux ont subi plus d’un ECNE. Les tendances temporelles en matière d’ECNE affichent une hausse (épreuves d’effort : p tendance < 0,001; examens d’imagerie au repos : p tendance < 0,001). Les ECNE ont généralement été effectués au cours des 4 premiers mois après la sortie de l’hôpital (épreuves d’effort, dans les 2 mois; examens d’imagerie au repos, dans les 3 à 4 mois). Le coût total des ECNE effectués en 2015-2016 a été évalué à 1,35 M$, soit une hausse de 22,4 % par rapport à 2004-2005 (1,10 M$) (p < 0,001), tandis que l’incidence des SCA a diminué au cours de la même période (p = 0,008). Conclusions: Les taux d’ECNE effectués dans l’année suivant un SCA sont élevés et augmentent au fil du temps. Le coût estimatif de ces ECNE semble s’accroître de façon disproportionnée par rapport à la croissance des SCA. Une enquête plus approfondie s’impose; à l’heure actuelle, on ne peut que spéculer quant aux bienfaits cliniques qui découlent de l’augmentation des ECNE effectués après un SCA et des coûts qu’ils engendrent.

Objectives We evaluated inter-reader agreement of the ST-segment between two electrocardiogram (ECG) core laboratories. Background Accurate measurement of the ST-segment is key to diagnosis and management of acute coronary syndromes (ACS). Clinical trials also rely on adherence to the pre-specified ECG eligibility criteria. Methods 150 patients (100 ST-segment elevation (STE)-ACS, 50 non-STE-ACS) were selected. An experienced ECG reader from each laboratory measured ST-segment deviation on the baseline ECGs (nearest 0.1 mm). Results ∑ ST-segment deviation showed excellent inter-reader agreement (R = 0.965, intraclass correlation coefficient (ICC) 0.949, 95% CI (0.930–0.963)). Similar agreement was observed when ∑ ST-segment elevation (∑ STE) and ∑ ST-segment depression (∑ STD) were assessed separately. Better agreement was evident in STE-ACS cohort (ICC (95% CI): 0.968 (0.953–0.978, 0.969 (0.954–0.979), 0.931 (0.899–0.953)) compared to NSTE-ACS patients (ICC (95% CI): 0.860 (0.768–0.917), 0.816 (0.699–0.890), 0.753 (0.605–0.851) across measurement of ∑ ST-segment deviation, ∑ STE, and ∑ STD. Conclusions We demonstrated excellent agreement on ST-segment measurements between two experienced readers from two ECG core laboratories.

The secondary prevention effects of beta-blocker therapy (BBT) in type 2 diabetes (T2D) and established atherosclerotic cardiovascular disease (ASCVD) are unclear. Using an inverse probability of treatment-weighted Cox proportional hazards model, we examined the association between baseline BBT and

Ticagrelor (TIC) based dual antiplatelet therapy (DAPT) is standard of care for acute coronary syndromes (ACS) with the exception of fibrinolysis treated ST-segment elevation myocardial infarction (STEMI) patients where clopidogrel (CLOP) is recommended. Although comparable 30-day safety was shown

Background: Baseline Q waves on the initial 12-lead ECG in clinical trials has been shown to be a simple predictor of clinical outcomes in STEMI patients. Whether this relationship applies in real world STEMI care is unknown. Using a large comprehensive STEMI registry, we evaluated the relationships

Background Elderly patients with ST-segment elevation myocardial infarction (STEMI) have worse outcomes and a greater risk of intracranial bleeding than nonelderly patients. Baseline characteristics, clinical outcomes, and the relationship of the tenecteplase (TNK) dose reduction to the efficacy, safety, and electrocardiographic indicators of reperfusion efficacy were evaluated in STEMI patients ≥75 years. Methods The STREAM trial evaluated early presenting STEMI patients who could not undergo primary percutaneous coronary intervention within 1 hour of first medical contact. Because of excess intracranial hemorrhage (ICH) in patients ≥75 years, the dose of TNK was reduced by 50%. Results Before dose amendment, there were 3 (7.1%) of 42 elderly patients with ICH; 2 of these were fatal, whereas no ICH occurred in the 93 elderly patients who received half-dose TNK postamendment. The median extent of ST-segment elevation resolution (≥50%) and proportion of patients with ≥2 mm in the electrocardiogram lead with greatest ST-segment elevation was comparable in elderly patients preamendment and postamendment (63.2% vs 56.0% and 43.6% vs 40.0%, respectively). Patients requiring rescue coronary intervention after TNK was also similar (42.9% vs 44.1%). The primary composite end point (30-day all-cause death, cardiogenic shock, congestive heart failure, and reinfarction) was 31.0% before versus 24.7% postamendment. Conclusions Our data, from a modest-sized population of elderly STEMI patients, indicate that half-dose TNK reduces the likelihood of ICH without compromising reperfusion efficacy. These observations are hypothesis generating and warrant further confirmation in randomized clinical trials in the elderly.

ECGs and accurate STEMI diagnosis (r1⁄4 0.482, p 20 ECGs read per week showed statistically significant improvement in accuracy (P 20 ECGs per week was shown to significantly improve STEMI diagnosis, regardless of underlying training. Increased training and paramedic exposure to ECG interpretation may improve STEMI diagnosis and decrease false positive CCL activation.