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Background: The contemporary measures of hospital performance for heart failure hospitalization and 30-day risk-standardized readmission rate (RSRR) and risk-standardized mortality rate (RSMR) are estimated using the same risk adjustment model and overall event rate for all patients. Thus, these measures are mainly driven by the care quality and outcomes for the majority racial and ethnic group, and may not adequately represent the hospital performance for patients of Black and other races. Methods: Fee-for-service Medicare beneficiaries from January 2014 to December 2019 hospitalized with heart failure were identified. Hospital-level 30-day RSRR and RSMR were estimated using the traditional race-agnostic models and the race-specific approach. The composite race-specific performance metric was calculated as the average of the RSRR/RMSR measures derived separately for each race and ethnicity group. Correlation and concordance in hospital performance for all patients and patients of Black and other races were assessed using the composite race-specific and race-agnostic metrics. Results: The study included 1 903 232 patients (75.7% White [n=1 439 958]; 14.5% Black [n=276 684]; and 9.8% other races [n=186 590]) with heart failure from 1860 hospitals. There was a modest correlation between hospital-level 30-day performance metrics for patients of White versus Black race (Pearson correlation coefficient: RSRR=0.42; RSMR=0.26). Compared with the race-agnostic RSRR and RSMR, composite race-specific metrics for all patients demonstrated stronger correlation with RSRR (correlation coefficient: 0.60 versus 0.74) and RSMR (correlation coefficient: 0.44 versus 0.51) for Black patients. Concordance in hospital performance for all patients and patients of Black race was also higher with race-specific (versus race-agnostic) metrics (RSRR=64% versus 53% concordantly high-performing; 61% versus 51% concordantly low-performing). Race-specific RSRR and RSMR metrics (versus race-agnostic) led to reclassification in performance ranking of 35.8% and 39.2% of hospitals, respectively, with better 30-day and 1-year outcomes for patients of all race groups at hospitals reclassified as high-performing. Conclusions: Among patients hospitalized with heart failure, race-specific 30-day RSMR and RSRR are more equitable in representing hospital performance for patients of Black and other races.

Background: Assessing hospital performance for cardiac surgery necessitates consistent and valid care quality metrics. The association of hospital-level risk-standardized home time for cardiac surgeries with other performance metrics such as mortality rate, readmission rate, and annual surgical volume has not been evaluated previously. Methods: The study included Medicare beneficiaries who underwent isolated or concomitant coronary artery bypass graft, aortic valve, or mitral valve surgery from January 1, 2013, to October 1, 2019. Hospital-level performance metrics of annual surgical volume, 90-day risk-standardized mortality rate, 90-day risk-standardized readmission rate, and 90-day risk-standardized home time were estimated starting from the day of surgery using generalized linear mixed models with a random intercept for the hospital. Correlations between the performance metrics were assessed using the Pearson correlation coefficient. Patient-level clinical outcomes were also compared across hospital quartiles by 90-day risk-standardized home time. Last, the temporal stability of performance metrics for each hospital during the study years was also assessed. Results: Overall, 919 698 patients (age 74.2±5.8 years, 32% women) were included from 1179 hospitals. Median 90-day risk-standardized home time was 71.2 days (25th–75th percentile, 66.5–75.6), 90-day risk-standardized readmission rate was 26.0% (19.5%–35.7%), and 90-day risk-standardized mortality rate was 6.0% (4.0%–8.8%). Across 90-day home time quartiles, a graded decline was observed in the rates of in-hospital, 90-day, and 1-year mortality, and 90-day and 1-year readmission. Ninety-day home time had a significant positive correlation with annual surgical volume ( r =0.31; P r =–0.40; P r =–0.60; P Conclusions: Ninety-day risk-standardized home time is a feasible, comprehensive, patient-centered metric to assess hospital-level performance in cardiac surgery with greater temporal stability than mortality and readmission measures.

The purpose of this study was to determine physician assistants' (PAs') current level of confidence to engage in nutrition-related tasks and their satisfaction with the nutrition education they received in PA school.To achieve this goal, a mixed-methods approach that consisted of 3 data collection phases (qualitative online discussions, quantitative survey, and qualitative interviews) was used to explore and measure PAs' perceptions of the education they received in PA school and through other sources and how confident they felt addressing nutrition-related issues in clinical practice.While 80% of PAs endorse the idea that PAs should be more involved in providing nutritional care to patients, the majority reported basic or no knowledge of the nutritional implications of chronic conditions (69%), inflammatory bowel disease (69%), nutritional needs over the lifespan (67%), and food allergies and intolerances (64%). Barriers to patient care included knowledge-related challenges when selecting lab tests based on patient profile (46%) and identifying needs based on various gastrointestinal diseases (67%) and when using diagnostic data to identify deficiencies (74%). Overall, 59% of PAs reported being slightly or very dissatisfied with the nutrition-related content in the curricula used to formally train PAs.The primary goal of every PA program is to prepare its graduates to be competent to enter clinical practice. Regarding nutrition, these data indicate that programs are failing to do so. PAs lack the confidence and ability to provide optimal nutritional care, which is staggering considering that nutrition is the first line of treatment in the prevention and management of numerous chronic diseases.

Introduction: An increasing number of patients with acute ischemic stroke (AIS) have recently used non-vitamin K antagonist oral anticoagulants (NOACs). However, there are limited data on safety of endovascular therapy (EVT) in these patients. Methods: We performed a retrospective, observational, cohort study of patients treated with EVT within 6 hours of symptom onset in the American Heart Association’s “Get With The Guideline-Stroke Program” between October 2015 and March 2020 to compare safety and functional outcomes in patients who were or were not taking NOACs in the 7 days prior to stroke. Results: Of 33,355 patients (median age 72 years (60,81); 50.8% female), 3,727 (11.2%) were taking NOACs, and 29,628 (88.8%) were not taking any oral anticoagulants (OAC) prior to stroke. Compared with those not on OAC, patients taking NOACs were older (median age 75 vs. 71 years) and had a higher prevalence of comorbidities including cardiovascular risk factors, although stroke severity was similar between the groups (median NIHSS 18 vs. 17). After adjusting for baseline clinical factors including intravenous alteplase, patients taking NOACs were not at a significantly higher risk of sICH compared with patients not taking anticoagulants (4.9% vs 6.4%; aOR, 0.93 [95% CI, 0.75-1.14]) or in-hospital mortality (14.1% vs 13.1%; aOR, 0.90 [95% CI, 0.78-1.02]). Of the secondary discharge outcomes, 3 of 7 showed significant differences in favor of the NOAC group including ambulating independently (33.7% vs 38.7%; aOR, 1.15 [95% CI, 1.02-1.30]) and freedom from disability (modified Rankin Scale [mRS] 0-1, 13.0% vs 16.2%; aOR, 1.23 [95% CI, 1.04-1.46]) at discharge. In a subset of patients with documented time of last NOACs dose (n=213), sICH rate was 3.1% (6/196) with last dose ≤2 days and 0% (0/17) with >2 days. Conclusions: Among patients with acute ischemic stroke treated with EVT within 6 hours, use of NOACs within the preceding 7 days, compared with no use of anticoagulants, was not associated with a significantly increased risk of adverse events and was associated with better functional outcomes at discharge.

Introduction: Emergent endovascular thrombectomy (EVT) is effective in improving outcomes in patients with stroke caused by large vessel occlusion. However, there are limited data on the use of EVT in patients taking an oral vitamin K antagonist (VKA), constraining guideline development around EVT use in this vulnerable population. Methods: To address this knowledge gap, we performed a retrospective, observational, cohort study based on a population-based sample of stroke admissions in the US (the AHAs “Get With The Guidelines-Stroke" Program) between October 2015 and March 2020. We aimed to determine whether use of VKA was associated with the risk of symptomatic intracranial hemorrhage (sICH) and functional outcomes in patients undergoing EVT within 6 hours of time last known well after adjusting for pre-specified confounders. Results: Of 32,715 patients (median age 72 years; 50.7% female), 3,087 were taking a VKA and 29,628 were not on an OAC prior to stroke. Patients taking VKAs were older (median age 78 vs. 71 years) but stroke severity was similar between the groups (median NIHSS 18 vs. 17). Of patients taking a VKA, 211 (6.8%) suffered a sICH whereas 1,904 (6.4%) patients not on OAC developed a sICH. VKA was not associated with sICH (adjusted odds ratio 1.20, 95% CI: 0.96-1.49). VKA use was associated with a higher risk of life-threatening systemic hemorrhage (1.2% vs. 1.02%; aOR 1.93 (1.17-3.19)) but not with mortality/discharge to hospice (27.1% vs. 20.6%; aOR 1.02 (0.90-1.14)). Patients taking a VKA prior to EVT were more likely to be able to be ambulatory at discharge (aOR 1.24 [1.11-1.39]) and to have an mRS of 0-2 (aOR 1.23 [1.07-1.42]). Conclusions: Among patients with acute ischemic stroke on VKA, EVT appears to be well tolerated without prohibitive risks of sICH. Our results provide support for the deployment of this critical, disability-reducing therapy in this population of patients with a large vessel occlusion presenting within 6 hours of time last known well.

Background: The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. Methods: We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010–2013) and Target: Stroke Phase II (2014–2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. Results: Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60–98) preintervention, to 66 minutes (51–87) during Phase I, and 50 minutes (37–66) during Phase II ( P P P Conclusions: A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

Background Among patients with nonvalvular atrial fibrillation (AF) and an elevated stroke risk, guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention. Changes in DOAC use over the past decade have not been well described. Methods and Results We evaluated trends in use of DOACs and warfarin from 2011 to 2020 among adults with AF and a CHA 2 DS 2 ‐VASc score ≥2 based on electronic health record data from 88 health systems in the United States contributing to Cerner Real World Data. The use of DOACs and warfarin was described over time, by age, sex, race, and ethnicity, and at the health‐system level. We identified 436 864 patients with AF at risk for stroke (median age, 78 years; 52.1% men). From 2011 to 2020, overall anticoagulation rates increased from 56.3% to 64.7%, as DOAC use increased steadily (from 4.7% to 47.9%), while warfarin use declined (from 52.4% to 17.7%). DOAC uptake was similar across age, sex, and race and ethnicity groups but varied by health system. In 2020, the median health‐system‐level proportion of patients with AF on a DOAC was 49% (interquartile range, 40%–54%). Conclusions Over the past decade, anticoagulation rates for patients with AF have increased modestly as DOACs largely replaced warfarin, though significant gaps remain: One in 3 high‐risk patients with AF is not on any anticoagulant. While DOAC adoption was generally consistent across major demographic groups, use between health systems remained highly variable, suggesting that provider and system factors influence DOAC uptake use more than patient‐level factors.

Background The WATCH‐DM (weight [body mass index], age, hypertension, creatinine, high‐density lipoprotein cholesterol, diabetes control [fasting plasma glucose], ECG QRS duration, myocardial infarction, and coronary artery bypass grafting) and TRS‐HF DM (Thrombolysis in Myocardial Infarction [TIMI] risk score for heart failure in diabetes) risk scores were developed to predict risk of heart failure (HF) among individuals with type 2 diabetes. WATCH‐DM was developed to predict incident HF, whereas TRS‐HF DM predicts HF hospitalization among patients with and without a prior HF history. We evaluated the model performance of both scores to predict incident HF events among patients with type 2 diabetes and no history of HF hospitalization across different cohorts and clinical settings with varying baseline risk. Methods and Results Incident HF risk was estimated by the integer‐based WATCH‐DM and TRS‐HF DM scores in participants with type 2 diabetes free of baseline HF from 2 randomized clinical trials (TECOS [Trial Evaluating Cardiovascular Outcomes With Sitagliptin], N=12 028; and Look AHEAD [Look Action for Health in Diabetes] trial, N=4867). The integer‐based WATCH‐DM score was also validated in electronic health record data from a single large health care system (N=7475). Model discrimination was assessed by the Harrell concordance index and calibration by the Greenwood‐Nam‐D’Agostino statistic. HF incidence rate was 7.5, 3.9, and 4.1 per 1000 person‐years in the TECOS, Look AHEAD trial, and electronic health record cohorts, respectively. Integer‐based WATCH‐DM and TRS‐HF DM scores had similar discrimination and calibration for predicting 5‐year HF risk in the Look AHEAD trial cohort (concordance indexes=0.70; Greenwood‐Nam‐D’Agostino P >0.30 for both). Both scores had lower discrimination and underpredicted HF risk in the TECOS cohort (concordance indexes=0.65 and 0.66, respectively; Greenwood‐Nam‐D’Agostino P P =0.96). TRS‐HF DM score could not be validated in the electronic health record because of unavailability of data on urine albumin/creatinine ratio in most patients in the contemporary clinical practice. Conclusions The WATCH‐DM and TRS‐HF DM risk scores can discriminate risk of HF among intermediate‐risk populations with type 2 diabetes.

Background The COVID‐19 pandemic resulted in a rapid implementation of telemedicine into clinical practice. This study examined whether early outpatient follow‐up via telemedicine is as effective as in‐person visits for reducing 30‐day readmissions in patients with heart failure. Methods and Results Using electronic health records from a large health system, we included patients with heart failure living in North Carolina (N=6918) who were hospitalized between March 16, 2020 and March 14, 2021. All‐cause readmission within 30 days after discharge was examined using weighted logistic regression models. Overall, 7.6% (N=526) of patients received early telemedicine follow‐up, 38.8% (N=2681) received early in‐person follow‐up, and 53.6% (N=3711) did not receive follow‐up within 14 days of discharge. Compared with patients without early follow‐up, those who received early follow‐up were younger, were more likely to be Medicare beneficiaries, had more comorbidities, and were less likely to live in an disadvantaged neighborhood. Relative to in‐person visits, those with telemedicine follow‐up were of similar age, sex, and race but with generally fewer comorbidities. Overall, the 30‐day readmission rate (19.0%) varied among patients who received telemedicine visits (15.0%), in‐person visits (14.0%), or no follow‐up (23.1%). After covariate adjustment, patients who received either telemedicine (odds ratio [OR], 0.55; 95% CI, 0.44–0.72) or in‐person (OR, 0.52; 95% CI, 0.45–0.60) visits were similarly less likely to be readmitted within 30 days compared with patients with no follow‐up. Conclusions During the COVID‐19 pandemic, the use of telemedicine visits for early follow‐up increased rapidly. Patients with heart failure who received outpatient follow‐up either via telemedicine or in‐person had better outcomes than those who received no follow‐up.

BACKGROUND The best timing for early invasive therapy in non-ST-segment elevation myocardial infarction (NSTEMI) patients remains controversial. We sought to determine the optimal timing of early catheterization in order to improve long-term outcomes in elderly (>65 years old) patients with NSTEMI. METHODS Using data from the CRUSADE registry linked to Medicare claims, we evaluated the association of early catheterization within the first 24 h or earlier time cut-points of NSTEMI presentation with long-term mortality among older Medicare beneficiaries. RESULTS Of 15 575 NSTEMI patients from 398 CRUSADE hospitals (2003-2006), 3880 (24.9%) received early (≤12 h) catheterization. Compared with those undergoing later catheterization, patients treated early were younger and had less comorbid illness. Relative to those treated later, patients receiving early catheterization had similar 1-year all-cause mortality (11.8% vs 11.9%, P = 0.90). Using on- vs off-hour presentation as an instrumental variable, balancing potential measured and unmeasured confounders, early and later catheterization patients had nonsignificant differences in 1-year mortality (+5.6% [-11.5%, +22.7%]). Similar results were observed in clinically relevant subgroups, such as age (< or ≥75 years), gender, diabetes status, Global Registry of Acute Coronary Events score (< or ≥140), presence of heart failure, and sensitivity analyses of alternative definitions of early catheterization (≤6 and ≤24 h). CONCLUSIONS Among older NSTEMI patients, we found that

Background and objectives Patients on maintenance dialysis with in-hospital cardiac arrest have been reported to have worse outcomes relative to those not on dialysis; however, it is unknown if poor outcomes are related to the quality of resuscitation. Using the Get With The Guidelines-Resuscitation (GWTG-R) registry, we examined processes of care and outcomes of in-hospital cardiac arrest for patients on maintenance dialysis compared with nondialysis patients. Design, setting, participants, & measurements We used GWTG-R data linked to Centers for Medicare and Medicaid data to identify patients with ESKD receiving maintenance dialysis from 2000 to 2012. We then case-matched adult patients on maintenance dialysis to nondialysis patients in a 1:3 ratio on the basis of age, sex, race, hospital, and year of arrest. Logistic regression models with generalized estimating equations were used to assess the association of in-hospital cardiac arrest and outcomes by dialysis status. Results After matching, there were a total of 31,144 GWTG-R patients from 372 sites, of which 8498 (27%) were on maintenance dialysis. Patients on maintenance dialysis were less likely to have a shockable initial rhythm (20% versus 21%) and less likely to be within the intensive care unit at the time of arrest (46% versus 47%) compared with nondialysis patients; they also had lower composite scores for resuscitation quality (89% versus 90%) and were less likely to have defibrillation within 2 minutes (54% versus 58%). After adjustment, patients on maintenance dialysis had similar adjusted odds of survival to discharge (odds ratio [OR], 1.05; 95% confidence interval [95% CI], 0.97 to 1.13), better acute survival (OR, 1.33; 95% CI, 1.26 to 1.40), and were more likely to have favorable neurologic status (OR, 1.12; 95% CI, 1.04 to 1.22) compared with nondialysis patients. Conclusions Although there appears to be opportunities to improve the quality of in-hospital cardiac arrest care for among those on maintenance dialysis, survival to discharge was similar for these patients compared with nondialysis patients.

Introduction: The WATCH-DM score can predict risk of heart failure (HF) in patients with diabetes. Hypothesis: Addition of natriuretic peptide (NP) levels will improve WATCH-DM performance in individuals with dysglycemia. Methods: Adults with diabetes/pre-diabetes free of HF at baseline from 4 cohort studies (ARIC, CHS, FHS, and MESA) were included. The integer- [WATCH-DM(i)] and machine learning-based [WATCH-DM(ml)] scores were used to estimate the 5-year risk of incident HF. Discrimination was assessed by Harrell's concordance index (C-index) and calibration by the Greenwood-Nam-D'Agostino (GND) statistic. Improvement in model performance with the addition of NP-levels was assessed by C-index, Brier score, and continuous net reclassification improvement (NRI). Results: Of the 8,938 participants included, 3,554 (39.8%) had diabetes and 432 (4.8%) developed HF within 5-years. Among 5,384 (60.2%) participants with pre-diabetes, 647 (12.0%) developed incident HF. The WATCH-DM(ml) and (i) scores demonstrated high discrimination for predicting HF risk in diabetes (C-indices=0.76 and 0.69), pre-diabetes (0.83 and 0.72), and overall cohort (0.80 and 0.71), respectively, with no evidence of miscalibration (GND=P >0.10). A greater improvement in C-index was observed with the addition of NP-levels at lower WATCH-DM(i) scores with degradation of risk discrimination at higher scores (Fig. A). Calibration was also improved with addition of NP-levels at lower compared to higher WATCH-DM(i) scores (Fig. B). A greater improvement in reclassification was observed by combing WATCH-DM(i) score with selected NP-levels assessment in low (score Conclusions: The WATCH-DM risk score can accurately predict incident HF risk in community-based individuals with dysglycemia. The addition of NP-levels improves risk prediction among adults with low/intermediate but not high HF risk.

The complexity and costs associated with traditional randomized, controlled trials have increased exponentially over time, and now threaten to stifle the development of new drugs and devices. Nevertheless, the growing use of electronic health records, mobile applications, and wearable devices offers significant promise for transforming clinical trials, making them more pragmatic and efficient. However, many challenges must be overcome before these innovations can be implemented routinely in randomized, controlled trial operations. In October of 2018, a diverse stakeholder group convened in Washington, DC, to examine how electronic health record, mobile, and wearable technologies could be applied to clinical trials. The group specifically examined how these technologies might streamline the execution of clinical trial components, delineated innovative trial designs facilitated by technological developments, identified barriers to implementation, and determined the optimal frameworks needed for regulatory oversight. The group concluded that the application of novel technologies to clinical trials provided enormous potential, yet these changes needed to be iterative and facilitated by continuous learning and pilot studies.

Background and Purpose— Acute ischemic stroke patients with history of prior ischemic stroke plus concomitant diabetes mellitus (DM) were excluded from the ECASS III trial (European Cooperative Acute Stroke Study) because of safety concerns. However, there are few data on use of intravenous tissue-type plasminogen activator and symptomatic intracerebral hemorrhage or outcomes in this population. Methods— Using data from the Get With The Guidelines–Stroke Registry between February 2009 and September 2017 (n=1619 hospitals), we examined characteristics and outcomes among patients with acute ischemic stroke treated with tissue-type plasminogen activator within the 3- to 4.5-hour window who had a history of stroke plus diabetes mellitus (HxS+DM) (n=2129) versus those without either history (n=16 690). Results— Compared with patients without either history, those with both prior stroke and DM treated with tissue-type plasminogen activator after an acute ischemic stroke had a higher prevalence of cardiovascular risk factors in addition to history of stroke, DM, and more severe stroke (National Institutes of Health Stroke Scale: median, 8 [interquartile range, 5–15] versus 7 [4–13]). The unadjusted rates of symptomatic intracerebral hemorrhage and in-hospital mortality were 4.3% (HxS+DM) versus 3.8% (without either history; P =0.31) and 6.2% versus 5.5% ( P =0.20), respectively. These differences were not statistically significant after risk adjustment (symptomatic intracerebral hemorrhage: adjusted odds ratio, 0.79 [95% CI, 0.51–1.21]; P =0.28; in-hospital mortality: odds ratio, 0.77 [95% CI, 0.52–1.14]; P =0.19). Unadjusted rate of functional independence (modified Rankin Scale score, 0–2) at discharge was lower in those with HxS+DM (30.9% HxS+DM versus 44.8% without either history; P ≤0.0001), and this difference persisted after adjusting for baseline clinical factors (adjusted odds ratio, 0.76 [95% CI, 0.59–0.99]; P =0.04). Conclusions— Among patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator within the 3- to 4.5-hour window, HxS+DM was not associated with statistically significant increased symptomatic intracerebral hemorrhage or mortality risk.

ObjectiveTo determine whether young adults (≤40 years old) with acute ischemic stroke are less likely to receive IV tissue plasminogen activator (tPA) and more likely to have longer times to brain imaging and treatment.MethodsWe analyzed data from the Get With The Guidelines–Stroke registry for patients with acute ischemic stroke hospitalized between January 2009 and September 2015. We used multivariable models with generalized estimating equations to evaluate tPA treatment and outcomes between younger (age 18–40 years) and older (age >40 years) patients with acute ischemic stroke.ResultsOf 1,320,965 patients with acute ischemic stroke admitted to 1,983 hospitals, 2.3% (30,448) were 18 to 40 years of age. Among these patients, 12.5% received tPA vs 8.8% of those >40 years of age (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.56–1.71). However, younger patients were less likely to receive brain imaging within 25 minutes (62.5% vs 71.5%, aOR 0.78, 95% CI 0.73–0.84) and to be treated with tPA within 60 minutes of hospital arrival (37.0% vs 42.8%, aOR 0.74, 95% CI 0.68–0.79). Compared to older patients, younger patients treated with tPA had a lower symptomatic intracranial hemorrhage rate (1.7% vs 4.5%, aOR 0.55, 95% CI 0.42–0.72) and lower in-hospital mortality (2.0% vs 4.3%, aOR 0.65, 95% CI 0.52–0.81).ConclusionsIn contrast to our hypothesis, younger patients with acute ischemic stroke were more likely to be treated with tPA than older patients, but they were more likely to experience delay in evaluation and treatment. Compared with older patients, younger patients had better outcomes, including fewer intracranial hemorrhages.

Supplemental Digital Content is available in the text., Background: To optimize preventive strategies for coronary heart disease (CHD), it is essential to understand and appropriately quantify the contribution of its key risk factors. Our objective was to compare the associations of key modifiable CHD risk factors—specifically lipids, systolic blood pressure (SBP), diabetes mellitus, and smoking—with incident CHD events based on their prognostic performance, attributable risk fractions, and treatment benefits, overall and by age. Methods: Pooled participant-level data from 4 observational cohort studies sponsored by the National Heart, Lung, and Blood Institute were used to create a cohort of 22 626 individuals aged 45 to 84 years who were initially free of cardiovascular disease. Individuals were followed for 10 years from baseline evaluation for incident CHD. Proportional hazards regression was used to estimate metrics of prognostic model performance (likelihood ratio, C index, net reclassification, discrimination slope), hazard ratios, and population attributable fractions for SBP, non–high-density lipoprotein cholesterol (non–HDL-C), diabetes mellitus, and smoking. Expected absolute risk reductions for antihypertensive and lipid-lowering treatment were assessed. Results: Age, sex, and race capture 63% to 80% of the prognostic performance of cardiovascular risk models. In contrast, adding either SBP, non–HDL-C, diabetes mellitus, or smoking to a model with other risk factors increases the C index by only 0.004 to 0.013. However, primordial prevention could have a substantial effect as demonstrated by population attributable fractions of 28% for SBP≥130 mm Hg and 17% for non–HDL-C≥130 mg/dL. Similarly, lowering the SBP of all individuals to

The ability for PAs to easily move from one specialty to another without additional formal training is a unique feature of the profession that is valued by PAs and their employers. Specialty certification has been viewed as a threat to this flexibility, yet 73% of PAs are in specialty practice. How can the desire to preserve flexibility be balanced against the desire of specialized PAs to distinguish themselves in their chosen specialty? This article reviews the issue of specialty certification in the context of contemporary PA practice and concludes that although specialty certification remains a threat to the flexibility of the PA model, it may be appropriate in some situations. In particular, specialty certification may be appropriate as a means for promotion within healthcare systems so long as it is not used as a requirement for entry into specialty practice, credentialing, or third-party reimbursement. A portfolio model may give stakeholders an alternative way to assess the experience and competencies of PAs in specialty practice areas.

Background: Endovascular therapy (EVT) is standard of care in patients with acute disabling ischemic stroke attributable to large-vessel occlusion and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can be achieved in clinical practice. We describe interval times from patient arrival in the emergency department (door) to first pass (treatment initiation) in patients receiving EVT within Get With The Guidelines-Stroke hospitals and analyze patient- and hospital-level variables associated with these times. Methods: Data are from sites participating fully as Comprehensive Stroke Centers within Get With The Guidelines-Stroke hospitals from October 2014 to September 2016. Workflow times analyzed include door to imaging, imaging to arterial access, arterial access to first pass, and the composite door to first pass time. Data are described overall and by calendar-year quarters. Multivariable modeling was used to identify patient- and hospital-level variables associated with workflow times. Results: Among 2929 patients with EVT from 195 hospitals (median age, 71 years [interquartile range {IQR}, 60–81]; 50.7% female; median baseline National Institute of Health Stroke Score, 17 [IQR, 12–22]; median annual EVT administration number, 16 [IQR, 10–27]), median door to first pass time was 130 minutes (IQR, 101–170 minutes), door to imaging time was 12 minutes (IQR, 7–20 minutes), imaging to arterial puncture time was 93 minutes (IQR, 68–126 minutes), and arterial puncture to first pass time was 18 minutes (IQR, 4–31 minutes). Overall, 3% patients achieved a door to first pass time ≤60 minutes. A statistically significant linear time trend was noted for door to first pass time (quarter 4 year 2014 median time, 134.5 minutes to quarter 3 year 2016 median time, 128 minutes, P =0.002). In multivariable analysis, older age, arrival during nonregular hours, and history of diabetes mellitus were associated with longer door to first pass time. Hospitals achieving shorter door to intravenous alteplase administration (door to needle) times were more likely to achieve faster door to first pass time ( P P Conclusions: Although EVT treatment times are modestly improving, additional efforts are needed to streamline workflow so that the true potential of this treatment is realized. These data may inform benchmark goals for EVT workflow times.

Introduction: Aspirin is one of the most commonly used medications for cardiovascular disease and stroke prevention. Many older patients who present with a first or recurrent stroke are already on aspirin monotherapy, yet little evidence is available to guide antithrombotic strategies for these patients. Method: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we described discharge antithrombotic treatment pattern among Medicare beneficiaries without atrial fibrillation who were discharged alive for acute ischemic stroke from 1734 hospitals in the United States between October 2012 and December 2017. Results: Of 261,634 ischemic stroke survivors, 100,016 (38.2%) were on prior aspirin monotherapy (median age 78 years; 53% women; 79.4% initial stroke and 20.6% recurrent stroke). The most common discharge antithrombotics (Figure) were 81 mg aspirin monotherapy (20.9%), 325 mg aspirin monotherapy (18.2%), clopidogrel monotherapy (17.8%), and dual antiplatelet therapy (DAPT) of 81 mg aspirin and clopidogrel (17.1%). Combined, aspirin monotherapy, clopidogrel monotherapy, and DAPT accounted for 86.8% of discharge antithrombotics. The rest of 13.2% were discharged on either aspirin/dipyridamole, warfarin or non-vitamin K antagonist oral anticoagulants with or without antiplatelet, or no antithrombotics at all. Among patients with documented stroke etiology (TOAST criteria), 81 mg aspirin monotherapy (21.2-24.0%) was the most commonly prescribed antithrombotic for secondary stroke prevention. The only exception was those with large-artery atherosclerosis, in which, 25.3% received DAPT of 81 mg aspirin and clopidogrel at discharge. Conclusion: Substantial variations exist in discharge antithrombotic therapy for secondary stroke prevention in ischemic stroke with prior aspirin failure. Future research is needed to identify best management strategies to care for this complex but common clinical scenario.

Background: Cardiovascular prevention guidelines use estimated 10-year atherosclerotic cardiovascular disease (CVD) risk based on the pooled cohort equations to guide treatment decisions and engage patients in shared decision-making. We sought to determine patient perceived versus actual risk of atherosclerotic CVD and associations with willingness for preventive therapy. Methods: We evaluated calculated and perceived CVD risk among 4187 patients across 124 sites in the Patient and Provider Assessment of Lipid Management Registry. Ten-year risk was assessed using the pooled cohort equations; risk relative-to-peers was determined based on age-, sex-, and race-based percentiles; and patient estimates of risk were assessed using patient surveys. Poisson regression models evaluated associations between risk estimates, statin use, and willingness to take prevention therapy. Results: Overall, there was no correlation between patients’ estimates of their 10-year CVD risk and calculated 10-year risk (ρ=−0.01, P correlation =0.46), regardless of age, sex, race, or socioeconomic status. The majority (72.2%) overestimated their 10-year CVD risk relative to the pooled cohorts equation (mean perceived 33.3% versus mean calculated 17.1%, P difference P P =0.18) but was associated with willingness to consider future prevention therapy ( P Conclusions: When asked, most patients overestimate their 10-year risk but hold an optimistic bias of their risk relative to age-, race-, and sex-matched peers. Providing accurate absolute risk assessments to patients without proper context may paradoxically decrease many patients’ perceived risk of CVD, thereby disincentivizing initiation of CVD risk reduction therapy.

Background: Cardiovascular disease (CVD) is the leading cause of hospitalization in the United States, and patients with CVD are at a high risk of readmission after discharge. We examined whether patients’ perceived risk of readmission at discharge was associated with actual 30-day readmissions in patients hospitalized with CVD. Methods: We recruited 730 patients from the Duke Heart Center who were admitted for treatment of CVD between January 1, 2015, and August 31, 2017. A standardized survey was linked with electronic health records to ascertain patients’ perceived risk of readmission, and other sociodemographic, psychosocial, behavioral, and clinical data before discharge. All-cause readmission within 30 days after discharge was examined. Results: Nearly 1-in-3 patients perceived a high risk of readmission at index admission and those who perceived a high risk had significantly more readmissions within 30 days than patients who perceived low risks of readmission (23.6% versus 15.8%, P =0.016). Among those who perceived a high risk of readmission, non-White patients (odds ratio [OR], 2.07 [95% CI, 1.28–3.36]), those with poor self-rated health (OR, 2.30 [95% CI, 1.38–3.85]), difficulty accessing care (OR, 2.72 [95% CI, 1.24–6.00]), and prior hospitalizations in the past year (OR, 2.13 [95% CI, 1.21–3.74]) were more likely to be readmitted. Among those who perceived a low risk of readmission, patients who were widowed (OR, 2.69 [95% CI, 1.60–4.51]) and reported difficulty accessing care (OR, 1.89 [95% CI, 1.07–3.33]) were more likely to be readmitted. Conclusions: Patients who perceived a high risk of readmission had a higher rate of 30-day readmission than patients who perceived a low risk. These findings have important implications for identifying CVD patients at a high risk of 30-day readmission and targeting the factors associated with perceived and actual risks of readmission.

Background: The Shelter-in-place response to the COVID-19 pandemic has demonstrated the value of telemedicine and remote monitoring platforms like Livongo’s Home Blood Pressure Monitoring Program (HBMP) that utilizes a Bluetooth connected blood pressure cuff and access to coaches. The objective of this study was to understand the HBPM frequency and blood pressure trends during the pandemic for this high-risk group of people. Methods: Utilizing Livongo’s national repository of HBMP participants, we selected members with valid measurements between September 16, 2019 and June 15, 2020. The COVID-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University was used to identify the first date a COVID-19 case was identified in each state and county. The top 9 counties with the highest cumulative COVID-19 cases were selected for further evaluation. Weekly national, regional, state, and county number of BP checks, mean SBP and DBP readings, and percentage of people with BP >= 130/80, >=140/90, and >= 160/100 were evaluated. Results: There were 47,745 HBPM participants, age of 54 year, 47% female, mean baseline BP of 129/79. The national trend showed slight increases in SBP and DBP during March 2020 though BP monitoring frequencies seem unchanged. Figure 1 shows state SBP and DBP trends by region. Some of the variability in the states is due to top counties with cases. Cook County, IL had a mean (95% CI) SBP increase of 6.5 mmHg (7.8, 5.1) resulting in while New York City's mean SBP decresed to -1.4 mmHg (-0.1, -2.7). Conclusion: There is a lot of variation in regional trends on the impact of COVID-19 on BP, even for the 9 selected counties. Further study is required to understand the possible drivers of the trends, such as, medication adherence, exercise, and stress.

Introduction: People with type 2 diabetes mellitus (DM) have a large burden of cardiovascular (CV) morbidity and mortality, but the likelihood of these outcomes varies and existing risk calculators do not fully capture risk for individuals. Hypothesis: Circulating metabolites characterizing mitochondrial dysfunction may be novel predictors for CV outcomes. Methods: We performed targeted mass-spectrometry metabolite profiling (45 acylcarnitines, 15 amino acids) on baseline plasma samples from 568 cases (498 with major adverse cardiac events (MACE) and 131 with incident hospitalization for heart failure (hHF)) and 568 matched controls (without events) from the patients assigned to placebo in Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS). Matching was based on history of HF, coronary artery disease, BMI, hemoglobin A1C, creatinine, low-density lipoprotein cholesterol, fasting status and ejection fraction. Principal components analysis (PCA) was used for dimensionality reduction, and conditional logistic regression to determine association of PCA factors with MACE or hHF and for individual metabolites within significant factors (false discovery rate q Results: Of 12 PCA-derived metabolite factors, three were associated significantly with MACE or hHF; these factors were composed of: 1) short-chain dicarboxylacylcarnitines and long chain acylcarnitines (OR 1.50, q=0.03); 2) medium chain acylcarnitines (OR 1.28, q=0.001); 3) C5:1 and one medium-chain dicarboxylacylcarnitine (OR 1.17, q=0.03). Of these three factors, none were significantly associated with the individual components of MACE. Ten individual metabolites, including short- and medium-chain dicarboxylacylcarnitines and medium- and long-chain acylcarnitines, remained significantly associated with MACE (q Conclusions: Metabolites reporting on dysregulated mitochondrial fatty acid oxidation and endoplasmic reticulum stress are elevated in individuals with DM who progress to MACE and/or hHF. These biomarkers may improve CV risk prediction in DM patients and help highlight emerging risk mechanisms.

Introduction: To date, there are limited data on the potential role of proteomic biomarkers to predict future cardiovascular (CV) events among patients with type 2 diabetes mellitus (DM). Hypothesis: Specific protein biomarkers will be predictive of major adverse CV events (MACE) and incident heart failure hospitalization (HFH) among patients with DM. Methods: Using the Olink aptamer-based platform, we performed proteomic profiling (>700 proteins) on 440 paired cases and matched controls from placebo-assigned participants in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS). Cases were defined as having met the primary composite outcome of MACE or incident HFH and matched to controls on baseline prevalent heart failure, coronary artery disease, BMI, hemoglobin A1C, creatinine, low-density lipoprotein cholesterol, fasting status and ejection fraction. Conditional logistic regression was used to determine the association between log-transformed relative protein expression and incident MACE or HFH. False-discovery-rate (FDR) was used to adjust for multiple comparisons. Results: We identified three specific proteins that were significantly associated with prevalent MACE or HFH: METRNL, Notch 3, and ROR1 (OR 2.1, 1.6, 1.7 and q-value 0.01, 0.02, and 0.05 respectively) (Figure 1). METRNL, in particular, performed similarly to the established biomarker NT-proBNP (Figure 1). When MACE and HFH were analyzed separately, METRNL, in particular, remained strongly associated with both outcomes (OR 2.0, p Conclusions: Three novel protein biomarkers, in particular METRNL (a circulating adipokine that regulates insulin-sensitivity), may identify diabetic patients at high risk for subsequent HF and MACE. Additional studies are needed to replicate these findings and uncover the biologic mechanism linking adipokine signaling and heart failure.

Background: Nationwide, intensive care unit (ICU) utilization for initially stable patients with non-ST-segment elevation myocardial infarction (NSTEMI) is not associated with patient risk. Use of the ACTION ICU risk score, which predicts clinical deterioration requiring ICU care in initially stable NSTEMI patients, could guide admission of high-risk patients to the ICU and low-risk patients to a lower acuity unit. Methods: We created a modified best practice advisory (BPA) within the electronic health record (EHR) at a single institution. The BPA semi-automatically calculates the ACTION ICU score (5 elements automatically populate from the EHR and 4 are entered manually) and recommends a location for admission based on a 10% risk threshold for clinical deterioration over the course of admission. The BPA was triggered for all ED patients with serum 4 th generation troponin T above the local upper limit of normal. Physicians could temporarily hide the BPA, permanently cancel it if they felt the patient’s presentation was not primarily due to NSTEMI, or generate the ACTION ICU score. We measured how ED physicians used the BPA, and clinical and utilization outcomes for patients admitted through the ED with a discharge diagnosis of NSTEMI in the 12 months before and after BPA roll-out. Results: Between August 14, 2017 and August 13, 2018, the BPA triggered 972 times. It was hidden until the patient left the ED 230 times (23.7%) and canceled 561 times (57.7%). Providers opted to calculate a risk score 181 times (18.6%), and a score was successfully calculated 146 times. Among 135 patients for whom the BPA triggered that had a final hospital diagnosis of NSTEMI, the BPA was inappropriately canceled in 62 (45.9%) and hidden in 16 (11.9%). Overall, there were 190 NSTEMI admissions through the ED in the year after BPA integration into the EHR and 253 in the year prior. In the year after BPA integration 32.6% of the NSTEMI patients were admitted directly to the ICU compared with 37.5% admitted to ICU prior to BPA (p=0.32). No change was found in the distribution of ACTION ICU scores of NSTEMI patients admitted to the ICU prior to vs after BPA integration, as well as no differences in ICU length of stay (p=0.96), hospital length of stay (p=0.27), the proportion of patients transferred from the ward to the ICU (p=0.78), or in-hospital mortality (p=0.18). Conclusions: Embedding the ACTION ICU risk score into the EHR did not affect clinical or utilization outcomes for patients presenting to the ED with NSTEMI, but was limited by inappropriate cancellation of the risk score calculator. Better EHR mapping to enable risk calculation without the need for user input may be needed for successful deployment of predictive analytics in this patient population.

Introduction: The accuracy of electronic health record (EHR) data to identify prevalent disease status and/or clinical events is a major concern for the use of ‘real world’ data for research. We assessed the accuracy of EHR data for specific CV conditions based on EHR data compared with manual chart review. Methods: Using a cloud-based infrastructure, Cerner’s HealtheIntent EHR data from two health systems were de-identified and aggregated. We created EHR-based computable phenotypes for patients with ASCVD, (based on prior diagnosis and procedure codes, to identify comorbidities and hospitalizations with acute limb ischemia (ALI), bleeding, acute coronary syndrome (ACS), and cerebrovascular events (stroke/transient ischemic attack/intracranial hemorrhage). Chart reviews were performed (n=1,869) to validate the hospitalization final diagnosis and prevalent comorbidities, with the first 100 charts undergoing review by two concurrent chart reviewers. When reviewers noted an absence of a comorbidity, but EHR data indicated it may be present, an automated cue was presented to the reviewer of “Are you Sure?”. Cohen’s kappas (κ) were calculated to indicate agreement inter-review of event types and comorbidities. The PPV of EHR data for hospitalization diagnosis and comorbidities compared with cue-augmented chart review as gold standard were assessed. Results: The inter-rater agreement for the hospitalization diagnosis was very good overall and highest for ACS (0.83), followed by ALI (0.75), , and cerebrovascular events (0.69). The PPV of EHR-based diagnoses for single chart reviewers was 0.93 for cerebrovascular events, 0.81 for bleeding, 0.78 for ACS, and 0.51 for ALI. Similarly, the predictive accuracy of the EHR-based computable phenotypes for comorbidities and events was variable: as high as 0.93 for hypertension, 0.87 for atrial fibrillation, and 0.86 for peripheral arterial disease, to as low as 0.13 for type 1 diabetes, 0.38 for prior transient ischemic attack, and 0.56 for heart failure with reduced ejection fraction. Providing the chart reviewer with automated cue for comorbidities improved PPV. Conclusions: Many, but not all, clinical outcomes and comorbidities can be identified using EHR-based algorithms, with variable performance depending on the condition. Human chart reviews, long considered a gold standard, may be improved using EHR data.

Background: Cost is frequently cited as a barrier to optimal medication use, but the extent to which copayment assistance interventions are used when available, and their impact on evidence-based medication persistence and major adverse cardiovascular events is unknown. Methods and Results: The ARTEMIS trial (Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study) randomized 301 hospitals to usual care versus the ability to provide patients with vouchers that offset copayment costs when filling P2Y 12 inhibitors in the 1 year post-myocardial infarction. In the intervention group, we used multivariable logistic regression to identify patient and medication cost characteristics associated with voucher use. We then used this model to stratify both intervention and usual care patients by likelihood of voucher use, and examined the impact of the voucher intervention on 1-year P2Y 12 inhibitor persistence (no gap in pharmacy supply >30 days) and major adverse cardiovascular events (all-cause death, myocardial infarction, or stroke). Among 10 102 enrolled patients, 6135 patients were treated at hospitals randomized to the copayment intervention. Of these, 1742 (28.4%) never used the voucher, although 1729 (99.2%) voucher never-users filled at least one P2Y 12 inhibitor prescription in the 1 year post-myocardial infarction. Characteristics most associated with voucher use included: discharge on ticagrelor, planned 1-year course of P2Y 12 inhibitor treatment, white race, commercial insurance, and higher out-of-pocket medication costs (c-statistic 0.74). Applying this propensity model to stratify all enrolled patients by likelihood of voucher use, the intervention improved medication persistence the most in patients with high likelihood of voucher use (adjusted interaction P =0.03, odds ratio, 1.86 [95% CI, 1.48–2.33]). The intervention did not significantly reduce major adverse cardiovascular events in any voucher use likelihood group, although the odds ratio was lowest (0.86 [95% CI, 0.56–1.16]) among patients with high likelihood of voucher use (adjusted interaction P =0.04). Conclusions: Among patients discharged after myocardial infarction, those with higher copayments and greater out-of-pocket medication costs were more likely to use a copayment assistance voucher, but some classes of patients were less likely to use a copayment assistance voucher. Patients at low likelihood of voucher use benefitted least from copayment assistance, and other interventions may be needed to improve medication-taking behaviors and clinical outcomes in these patients. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02406677.

Background: Bleeding is commonly cited as a reason for stopping oral anticoagulants (OACs). Whether minor bleeding events (nuisance bleeding, NB) in patients with atrial fibrillation on OACs are associated with OAC discontinuation, major bleeding, and stroke/systemic embolism (SSE) is unknown. Methods: Within the ORBIT-AF prospective, outpatient registry (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation), we identified 6771 patients ≥18 years of age at 172 sites with atrial fibrillation and eligible follow-up visits. NB was ascertained from the medical record and was defined as minor bleeding that did not require medical attention (eg, bruising, hemorrhoidal bleeding). We used multivariable pooled logistic regression modeling to evaluate the associations between NB and major bleeding and SSE in the 180 days after documentation of NB. Our unit of analysis was the patient visit, occurring at ≈6-month intervals for a median of 1.5 years following enrollment. Changes in anticoagulation treatment satisfaction after NB were examined descriptively in a subset of patients. Results: The median age of the overall population was 75.0 (interquartile range, 67.0–81.0); 90.0% were white and 42.5% were female. Among 6771 patients (18 560 visits), n=1357 (20.0%) had documented NB, for an incidence rate of 14.8 events per 100 person-years. Over 96.4% of patients remained on OAC therapy after the NB event. Overall, 287 (4.3%) patients experienced major bleeding and 64 (0.96%) had a SSE event during follow-up. NB was not associated with a significant increased risk of major bleeding over 6 months in models adjusting for the ATRIA bleeding score (Anticoagulation and Risk Factors in Atrial Fibrillation) (odds ratio, 1.04; 95% confidence interval, 0.68–1.60; P =0.86). NB was also not associated with increased SSE risk over 6 months in models adjusting for the CHA 2 DS 2 -VASc risk score (odds ratio, 1.24; 95% confidence interval, 0.53–2.91; P =0.62). Conclusions: NB is common among patients with atrial fibrillation on OACs. However, NB was not associated with a higher risk of major bleeding or SSE over the next 6 months, suggesting its occurrence should not lead to changes in anticoagulation treatment strategies in OAC-treated patients. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01165710.

Background: Medication adherence is important to improve the long-term outcomes after acute myocardial infarction (MI). We hypothesized that there is significant variation among US hospitals in terms of medication adherence after MI, and that patients treated at hospitals with higher medication adherence after MI will have better long-term cardiovascular outcomes. Methods: We identified 19 704 Medicare patients discharged after acute MI from 347 US hospitals participating in the ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines) from January 2, 2007, to October 1, 2010. Using linked Medicare Part D prescription filling data, medication adherence was defined as proportion of days covered >80% within 90 days after discharge. Cox proportional hazards modeling was used to compare 2-year major adverse cardiovascular events among hospitals with high, moderate, and low 90-day medication adherence. Results: By 90 days after MI, overall rates of adherence to medications prescribed at discharge were 68% for β-blockers, 63% for statins, 64% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 72% for thienopyridines. Adherence to these medications up to 90 days varied significantly among hospitals: β-blockers (proportion of days covered >80%; 59% to 75%), statins (55% to 69%), thienopyridines (64% to 77%), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (57% to 69%). Compared with hospitals in the lowest quartile of 90-day composite medication adherence, hospitals with the highest adherence had lower unadjusted and adjusted 2-year major adverse cardiovascular event risk (27.5% versus 35.3%; adjusted hazard ratio, 0.88; 95% confidence interval, 0.80–0.96). High-adherence hospitals also had lower adjusted rates of death or readmission (hazard ratio, 0.90; 95% confidence interval, 0.85–0.96), whereas there was no difference in mortality after adjustment. Conclusions: Use of secondary prevention medications after discharge varies significantly among US hospitals and is inversely associated with 2-year outcomes. Hospitals may improve medication adherence after discharge and patient outcomes through better coordination of care between inpatient and outpatient settings.

Systolic blood pressure (SBP) treatment targets for adults with diabetes mellitus remain unclear. SBP levels among 12 275 adults with diabetes mellitus, prior cardiovascular disease, and treated hypertension were evaluated in the TECOS (Trial Evaluating Cardiovascular Outcomes With Sitagliptin) randomized trial of sitagliptin versus placebo. The association between baseline SBP and recurrent cardiovascular disease was evaluated using multivariable Cox proportional hazards modeling with restricted cubic splines, adjusting for clinical characteristics. Kaplan–Meier curves by baseline SBP were created to assess time to cardiovascular disease and 2 potential hypotension-related adverse events: worsening kidney function and fractures. The association between time-updated SBP and outcomes was examined using multivariable Cox proportional hazards models. Overall, 42.2% of adults with diabetes mellitus, cardiovascular disease, and hypertension had an SBP ≥140 mm Hg. The association between SBP and cardiovascular disease risk was U shaped, with a nadir ≈130 mm Hg. When the analysis was restricted to those with baseline SBP of 110 to 150 mm Hg, the adjusted association between SBP and cardiovascular disease risk was flat (hazard ratio per 10-mm Hg increase, 0.96; 95% confidence interval, 0.91–1.02). There was no association between SBP and risk of fracture. Above 150 mm Hg, higher SBP was associated with increasing risk of worsening kidney function (hazard ratio per 10-mm Hg increase, 1.10; 95% confidence interval, 1.02–1.18). Many patients with diabetes mellitus have uncontrolled hypertension. The U-shaped association between SBP and cardiovascular disease events was largely driven by those with very high or low SBP, with no difference in cardiovascular disease risk between 110 and 150 mm Hg. Lower SBP was not associated with higher risks of fractures or worsening kidney function.

Background: Intravenous rt-PA (recombinant tissue-type plasminogen activator) is effective in improving outcomes in ischemic stroke; however, there are few data on the use of rt-PA in patients who are receiving a non–vitamin K antagonist oral anticoagulant (NOAC). Methods: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we examined the outcomes of use of thrombolytic therapy in patients with ischemic stroke who received anticoagulation with NOACs versus those on warfarin (international normalized ratio Results: Of 42 887 patients with ischemic stroke treated with intravenous rt-PA within 4.5 hours, 251 were taking NOACs (dabigatran 87, rivaroxaban 129, and apixaban 35) before their stroke, 1500 were taking warfarin, and 41 136 were on neither. Patients on NOACs or warfarin were older, had more comorbid conditions, and experienced more severe strokes than did those who were not on anticoagulation (median National Institutes of Health Stroke Scale 12, 13, and 9, respectively). Unadjusted rates of symptomatic intracranial hemorrhage in the NOAC, warfarin, and none groups were 4.8%, 4.9%, and 3.9%, respectively ( P =0.11). In comparison with those not on anticoagulation, the adjusted odds ratio for symptomatic intracranial hemorrhage for those on NOACs was 0.92 (95% confidence interval, 0.51–1.65) and for those on warfarin the adjusted odds ratio was 0.85 (95% confidence interval, 0.66–1.10). There were also no significant differences in the risk for life-threatening/serious systemic hemorrhage, any rt-PA complication, in-hospital mortality, and modified Rankin Scale at discharge across 3 groups. Similar results were also found after propensity score matching. Conclusions: Although experience of using rt-PA in patients with ischemic stroke on a NOAC is limited, these preliminary observations suggest that rt-PA appears to be reasonably well tolerated without prohibitive risks for adverse events among selected NOAC-treated patients. Future studies should evaluate the safety and efficacy of intravenous rt-PA in patients with ischemic stroke who are taking NOACs.

Background: Race and sex disparities in in-hospital treatment and outcomes of patients with acute myocardial infarction (MI) have been described, but little is known about race and sex differences in post-MI angina and long-term risk of unplanned rehospitalization. We examined race and sex differences in post-MI angina frequency and 1-year unplanned rehospitalization to identify factors associated with unplanned rehospitalization, testing for whether race and sex modify these relationships. Methods: Using TRANSLATE-ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome) data, we examined 6-week and 1-year angina frequency and 1-year unplanned rehospitalization stratified by race and sex among MI patients treated with percutaneous coronary intervention. We used multivariable logistic regression to assess factors associated with unplanned rehospitalization and tested for interactions among angina frequency, race, and sex. Results: A total of 11 595 MI patients survived to 1 year postdischarge; there were 66.6% white male patients, 24.3% white female patients, 5.3% black male patients, and 3.8% black female patients. Overall, 29.7% had angina at 6 weeks, and 20.6% had angina at 1 year postdischarge. Relative to white patients, black patients were more likely to have angina at 6 weeks (female: 44.2% versus 31.8%; male: 33.5% versus 27.1%; both P P P P P interaction =0.41). Conclusions: One-fifth of MI patients treated with percutaneous coronary intervention report 1-year postdischarge angina, with black and female patients more likely to have angina and to be rehospitalized. Better treatment of post-MI angina may improve patient quality of life and quality of care and help to lower rates of rehospitalization overall and particularly among black and female patients, given their high prevalence of post-MI angina. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01088503.

Supplemental Digital Content is available in the text., Background: Patients with atrial fibrillation who undergo intracoronary stenting traditionally are treated with a vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT), yet this treatment leads to high risks of bleeding. We hypothesized that a regimen of rivaroxaban plus a P2Y12 inhibitor monotherapy or rivaroxaban plus DAPT could reduce bleeding and thereby have a favorable impact on all-cause mortality and the need for rehospitalization. Methods: Stented subjects with nonvalvular atrial fibrillation (n=2124) were randomized 1:1:1 to administration of reduced-dose rivaroxaban 15 mg daily plus a P2Y12 inhibitor for 12 months (group 1); rivaroxaban 2.5 mg twice daily with stratification to a prespecified duration of DAPT of 1, 6, or 12 months (group 2); or the reference arm of dose-adjusted VKA daily with a similar DAPT stratification (group 3). The present post hoc analysis assessed the end point of all-cause mortality or recurrent hospitalization for an adverse event, which was further classified as the result of bleeding, a cardiovascular cause, or another cause blinded to treatment assignment. Results: The risk of all-cause mortality or recurrent hospitalization was 34.9% in group 1 (hazard ratio=0.79; 95% confidence interval, 0.66–0.94; P=0.008 versus group 3; number needed to treat=15), 31.9% in group 2 (hazard ratio=0.75; 95% confidence interval, 0.62–0.90; P=0.002 versus group 3; number needed to treat=10), and 41.9% in group 3 (VKA+DAPT). Both all-cause death plus hospitalization potentially resulting from bleeding (group 1=8.6% [P=0.032 versus group 3], group 2=8.0% [P=0.012 versus group 3], and group 3=12.4%) and all-cause death plus rehospitalization potentially resulting from a cardiovascular cause (group 1=21.4% [P=0.001 versus group 3], group 2=21.7% [P=0.011 versus group 3], and group 3=29.3%) were reduced in the rivaroxaban arms compared with the VKA arm, but other forms of rehospitalization were not. Conclusions: Among patients with atrial fibrillation undergoing intracoronary stenting, administration of either rivaroxaban 15 mg daily plus P2Y12 inhibitor monotherapy or 2.5 mg rivaroxaban twice daily plus DAPT was associated with a reduced risk of all-cause mortality or recurrent hospitalization for adverse events compared with standard-of-care VKA plus DAPT. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01830543.

Background Patient satisfaction with therapy is an important metric of care quality and has been associated with greater medication persistence. We evaluated the association of patient satisfaction with warfarin therapy to other metrics of anticoagulation care quality and clinical outcomes among patients with atrial fibrillation ( AF ). Methods and Results Using data from the ORBIT ‐ AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) registry, patients were identified with AF who were taking warfarin and had completed an Anti‐Clot Treatment Scale ( ACTS ) questionnaire, a validated metric of patient‐reported burden and benefit of oral anticoagulation. Multivariate regressions were used to determine association of ACTS burden and benefit scores with time in therapeutic international normalized ratio range ( TTR ; both ≥75% and ≥60%), warfarin discontinuation, and clinical outcomes (death, stroke, major bleed, and all‐cause hospitalization). Among 1514 patients with AF on warfarin therapy (75±10 years; 42% women; CHA 2 DS 2 ‐ VAS c 3.9±1.7), those most burdened with warfarin therapy were younger and more likely to be women, have paroxysmal AF , and to be treated with antiarrhythmic drugs. After adjustment for covariates, ACTS burden scores were independent of TTR ( TTR ≥75%: odds ratio, 1.01 [95% CI , 0.99–1.03]; TTR ≥60%: odds ratio, 1.01 [95% CI , 0.98–1.05]), warfarin discontinuation (odds ratio, 0.99; 95% CI , 0.97–1.01), or clinical outcomes. ACTS benefit scores were also not associated with TTR , warfarin discontinuation, or clinical outcomes. Conclusions In a large registry of patients with AF taking warfarin, ACTS scores provided independent information beyond other traditional metrics of oral anticoagulation care quality and identified patient groups at high risk for dissatisfaction with warfarin therapy.

Background: The Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire has recently been validated to measure the impact of atrial fibrillation on quality of life, but a clinically important difference in AFEQT score has not been well defined. Methods and Results: To determine the clinically important difference in overall AFEQT (score range= 0 [worst] to 100 [best]) and selected subscales, we analyzed data in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry, a United States-based outpatient atrial fibrillation registry. AFEQT was assessed at baseline and 1 year in a subset of 1347 ORBIT-AF patients from 80 US sites participating in ORBIT-AF from June 2010 to August 2011. The mean change method was used to relate changes in 1-year AFEQT scores to clinically important changes in the physician assessment of European Heart Rhythm Association functional status (1 class improvement and separately 1 class deterioration). Clinically important differences and 95% CI corresponding to either a 1 European Heart Rhythm Association class improvement or deterioration were 5.4 (3.6–7.2) and −4.2 (−6.9 to −1.5) AFEQT points, respectively. Similarly, clinically important difference values were seen for a 1 European Heart Rhythm Association class improvement for the AFEQT subscales Activities of Daily Living and Symptoms: 5.1 (2.5–7.6) and 7.1 (5.3–9.0) AFEQT points, respectively. Conclusions: Based on the anchor of 1 European Heart Rhythm Association class change, changes in AFEQT score of + or −5 points are clinically important changes in patients’ health. Clinical Trial Registration: URL: https://clinicaltrials.gov . Unique identifier: NCT01165710.

Background Hospitalization for acute myocardial infarction (MI) in the United States is both common and expensive, but those features alone provide little insight into cost‐saving opportunities. Methods and Results To understand the cost drivers during hospitalization for acute MI and in the following year, we prospectively studied 11 969 patients with acute MI undergoing percutaneous coronary intervention at 233 US hospitals (2010–2013) from the TRANSLATE‐ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) registry. Baseline costs were collected in a random subset (n=4619 patients, 54% ST‐segment–elevation MI [STEMI]), while follow‐up costs out to 1 year were collected for all patients. The mean index length of stay was 3.1 days (for both STEMI and non‐STEMI) and mean intensive care unit length of stay was 1.2 days (1.4 days for STEMI and 1.0 days for non‐STEMI). Index hospital costs averaged $18 931 ($19 327 for STEMI, $18 465 for non‐STEMI), with 45% catheterization laboratory–related and 20% attributable to postprocedure hospital stay. Patient factors, including severity of illness and extent of coronary disease, and hospital characteristics, including for profit status and geographic region, identified significant variations in cost. Intensive care was used for 53% of non‐STEMI and increased costs by $3282. Postdischarge 1‐year costs averaged $8037, and 48% of patients were rehospitalized (half within 2 months and 57% with a cardiovascular diagnosis). Conclusions While much of the cost of patients with acute MI treated with percutaneous coronary intervention is probably not modifiable by the care team, cost reductions are still possible through quality‐preserving practice efficiencies, such as need‐based use rather than routine use of intensive care unit for patients with stable non‐STEMI. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00097591.

Background: The ACC/AHA Pooled Cohort Equations (PCE), derived using data from adults ages 40-79, have not been evaluated for accuracy among older adults. Methods: We evaluated 2,667 adults aged ≥75 years without known ASCVD in the NIH pooled cohorts (Framingham, Framingham offspring, MESA, & CHS), stratified by number of major risk factors [smoking, diabetes, lipids (LDL≥130 mg/dL or on lipid-lowering therapy), and BP (≥140/90 mmHg or on BP medication)]. Observed vs. predicted 5-year ASCVD event rates were compared across strata. We also evaluated 5-year PCE model performance overall. Results: At the group level, the PCE somewhat overestimated risk across all strata in Kaplan Meier analysis: observed versus expected was 7.0% vs. 11.0%, (p=0.005) for those with no risk factors (N=429), 12.5% vs. 15.4%, (p Conclusion: The PCE can be used to risk-stratify older adults. However, it may over-predict risk, especially in those at the top quartile of risk.

Objectives: In young adults, which blood pressure (BP) patterns, determined over multiple clinic visits, are most associated with future risk for cardiovascular disease (CVD) and all-cause mortality remains unclear. We determined BP patterns during young adulthood most associated with CVD events and all-cause mortality by middle age. BP patterns included average systolic BP (SBP)/diastolic BP (DBP) levels, cumulative exposure to SBP/DBP, visit-to-visit SBP/DBP variability, and average annual change in SBP/DBP. Methods: We analyzed data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study, which enrolled 5115 adults aged 18-30 years from 1985-1986, with up to 30 years of follow-up (through 2015). BP patterns were evaluated with measurements at Year 0 [baseline], and 2, 5, 7, and 10 years following baseline. We estimated visit-to-visit BP variability as variability independent of the mean (VIM). Average annual change of BP from the Year 0 to Year 10 exams was calculated using linear regression. Cox proportional hazards models were used to assess the associations between BP patterns and adjudicated CVD events (coronary heart disease, stroke, heart failure, and other vascular disease) and all-cause mortality. Results: At Year 10, the mean±standard deviation (SD) age of the 3,394 participants was 35.1±3.6 years, 46% were African American, 56% were female, and only 3% were taking antihypertensive medication. Cumulative exposure to SBP and average SBP levels were highly correlated (Pearson’s correlation = 0.94). Over a median follow-up of 19.2 years, 162 CVD events and 181 deaths occurred. Average SBP and DBP levels and VIM of SBP were associated with increased CVD risk (see table), with no interaction by race or sex (each p>0.4). Only VIM of SBP was associated with all-cause mortality. Conclusions: Among young adults, the assessment of visit-to-visit SBP variability in addition to average SBP and DBP levels can help identify young adults who have an increased CVD risk and all-cause mortality by middle age.

Background: Patients with history of diabetes mellitus (DM) plus prior ischemic stroke were excluded from ECASS III trial due to safety concerns. However, there are few data on use of intravenous tissue plasminogen activator (IV tPA) and risk of symptomatic intracranial hemorrhage (sICH) or outcomes in this population. Methods: Using data from the Get With The Guidelines-Stroke Registry (GWTG-Stroke) between February 2009 and September 2017 (n=1619 hospitals), we examined characteristics and outcomes among AIS patients treated with tPA within the 3-4.5 hour window who had a history of prior stroke and DM (n=2129) versus those without either history (n=16,690). Results: Compared with patients without either history, those with prior stroke and DM had a higher prevalence of cardiovascular risk factors and more severe stroke (Table). The unadjusted rates of sICH and in-hospital mortality were 4.3% vs 3.8% and 6.2% vs 5.5%, respectively. These differences were not statistically significant after risk adjustment (sICH, adjusted odds ratio [OR] 0.79[95% CI, 0.51-1.21], p=0.28; in-hospital mortality OR 0.77 [95% CI, 0.52-1.14], p=0.19). Unadjusted rate of functional independence (Modified Rankin Scale score [mRS] 0-2) at discharge was lower in those with history of prior stroke and diabetes (30.9% vs 44.8%, p= Conclusion: Among AIS patients treated with intravenous tPA within the 3-4.5 hour window, history of prior stroke plus DM was not associated with statistically significant increased sICH or mortality risk.

Introduction: Guidelines recommend against use of Intravenous tissue Plasminogen Activator (IV tPA) in acute ischemic stroke (IS) patients with prior IS within past 3 months. However, there are limited data on the safety of IV tPA in this population. Methods: Using American Heart Association Get With the Guideline-Stroke between February 2009 and December 2015 we identified 1399 acute IS patients otherwise eligible for IV tPA but with IS within prior 3 months. Of these, 293 were treated with IV tPA. We compared them with 30,655 acute IS patients treated with IV tPA but with no prior IS history. Multivariable logistic regression models were used to evaluate association between recent prior IS (within 90 days, 1-14 days, 15-30 days, 31-90 days) with symptomatic intracranial hemorrhage (sICH) and discharge outcomes after IV tPA. Results: Age (median 80, IQR 74-87) and stroke severity as measured by NIHSS (median 11, IQR 6-18) were similar for acute IS patients treated with IV tPA with or without recent IS. However, patients with recent IS were more likely to have higher prevalence of cardiovascular risk factors. In unadjusted analysis, patients with recent IS within prior 90 days were more likely to experience sICH and in-hospital mortality and less likely to have good functional outcomes (modified Rankin Scale score, 0-1) than those with no history of IS (Table 1). On multivariate analysis, risk for sICH and in-hospital mortality was not significantly different but good functional outcomes at discharge occurred less often among patients with history of IS within prior 90 days. In a prespecified subgroup analysis, the increased risk for sICH appeared to concentrate in those with recent IS within 14 days of the acute index IS but not in later time window. Conclusions: Recent IS within 90 days is associated with increased risk of worse outcomes in acute IS patients treated with tPA. In our study, the risk of sICH after tPA was highest among those with a history of prior IS within the past 14 days.

Introduction: Direct oral anticoagulants (DOACs) are increasingly used as alternatives to warfarin for secondary prevention in ischemic stroke patients with atrial fibrillation. Despite demonstrated efficacy in clinical trials, there are few real-world experiences of DOACs vs. warfarin in community practice. Methods: We analyzed ischemic stroke survivors with atrial fibrillation discharged from the Get With The Guidelines Stroke hospitals between 2011-2014 and linked to Medicare claims for longitudinal outcomes through 2015. A propensity score overlap weighting method was used to compare DOACs vs. warfarin. The primary outcomes were major adverse cardiovascular events (MACE) and home time, a patient-centered outcome reflecting desire of “being alive at home, without recurrent stroke, or being hospitalized for complications.” Results: Among 11,662 stroke survivors (median age 80), 4,041 (34.7%) were discharged on DOACs (dabigatran, rivaroxaban, or apixaban) and 7,621 on warfarin. Except for NIHSS (median 4 [IQR 1-9] vs. 5 [2-11]), baseline demographics, medical history, and clinical characteristics were similar between two cohorts. Compared with warfarin, patients discharged on DOACs were less likely to experience MACE (33.95% vs. 40.36% per year, adjusted hazard ratio 0.89, 99% CI 0.83-0.96) and had more days at home (mean 287 vs. 263 days during the first year post discharge, adjusted difference 15.6 days, 99% CI 9.0-22.1) ( Table ). Additionally, there were fewer deaths, all-cause readmissions, cardiovascular readmissions, hemorrhagic strokes, and bleeding hospitalizations in DOAC-treated patients, although no significant differences in fatal bleeding, ischemic stroke readmission, systemic embolism, pneumonia, or sepsis (two negative outcome controls) between the two cohorts. Conclusions: In ischemic stroke survivors with atrial fibrillation, DOACs were associated with improved long-term clinical outcomes compared with warfarin.

Background: Treatment with intravenous recombinant tissue plasminogen activator (rtPA) for acute ischemic stroke (AIS) in patients with a recent history of myocardial infarction (MI) within 3 months prior to AIS is controversial. Methods: We used probabilistic linkage of Medicare claim files with the Get With The Guidelines-Stroke registry to identify patients who were treated with rtPA for AIS between 2/2009 and 12/2015. Recent MI was determined from Medicare claims. Multivariable logistic regression models were used to evaluate the association of a recent history of MI with in-hospital clinical outcomes. Results: Among 40,396 patients age 65 years or older treated with rtPA for AIS from 1522 sites (mean age [SD] 81.0 [8.1] years; 58.0% women), 241 (0.6%) had recent MI within 3 months prior to AIS, of which 19.5% were STEMI. Patients with recent MI had more severe stroke than those without (median NIHSS [IQR]: 13.0 [7.0-20.0] vs. 11.0 [6.0-18.0]) and were more likely to be on antiplatelets prior to AIS (87.8% vs. 53.6%). The unadjusted rates of in-hospital mortality and any serious rtPA-related complications were 17.4% and 13.5% for those with recent MI, and 9.0% and 9.4% for those without, respectively. Hemopericardium was observed in 1 (0.4%) patient with recent MI. After risk adjustment, recent MI within 3 months was associated with a significant increased risk of mortality (adjusted odds ratio [OR] 1.61, 95%CI [1.11-2.34], P=0.012), whereas there were no statistically significant differences in any serious rtPA-related complications ( Table ). When stratified by the type of MI, recent ST-elevation MI was associated with higher risk of death and tPA complications, but the difference was not statistically significant in those with recent non ST-elevation MI. Conclusions: Among older ischemic stroke patients treated with rtPA, recent MI within 3 months was associated with an increased risk of mortality, and recent STEMI with mortality and serious tPA complications.

Background: Randomized trials have shown the benefit of endovascular reperfusion therapy (ERT) in acute ischemic stroke (AIS) is time dependent. However, generalizability to routine practice is uncertain; and modest sample sizes have limited characterization of the degree to which onset to treatment time influences outcome from ERT. Methods: We analyzed data of 6756 AIS patients treated with ERT at 231 hospitals between January 2015 to December 2016. Multivariable logistic regression modeling was conducted to evaluate the independent impact of onset to puncture (OTP) and door to puncture (DTP) time on efficacy and safety outcomes. Results: Among the 6756 patients, median age was 71, 51.2% were female, and NIHSS was 17 (IQR 12-22). Median OTP was 230m (IQR 170-305) and DTP 87m (IQR 62-116). Substantial reperfusion (TICI 2b-3) was in 85.9%. At discharge, 36.9% had independent ambulation, 27.8% were discharged to home, and 23.0% were functionally independent (mRS 0-2). Symptomatic intracranial hemorrhage (sICH) occurred in 6.7% and in-hospital mortality/hospice in 19.6%. For OTP, time-outcome relationships were nonlinear, with steeper slope in 0-270m than 271-480m (see Table and Figure). DTP showed a similar nonlinear time-outcome relationship, with steeper benefit decline in the 30-120m than 121-180m period. Conclusions: In this national registry, faster endovascular therapy start, after onset and after arrival, was associated with better ambulation and functional independence at discharge, and reduced sICH and mortality/hospice. These findings support intensive efforts to accelerate hospital presentation and endovascular treatment in patients with stroke.

Background and Purpose: Adherence to evidence-based guidelines is an important indicator of hospital stroke care quality; yet, there is lack of assessment of patient characteristics and performance measures in acute ischemic stroke for most world regions. Methods: We analyzed data of 19,604 acute ischemic stroke patients in China National Stroke Registry and 194,876 patients in GWTG-Stroke registry in US between 2012 to 2013 and compare their baseline characteristics and hospital performance measures. Results: Compared with US, Chinese patients were younger and had lower prevalence of comorbidities except for history of stroke/TIA or smoking. NIHSS was similar (China vs. US: median 4 [IQR 2-7] vs. 4 [1-10]). Chinese patients were more likely to have delays from last-known-well to hospital arrival (median 1,318 minutes [330-3,209] vs. 644 [142-2,055]), less likely to receive thrombolytic therapy (2.5% vs. 8.1%), and were more likely to experience treatment delays (door-to-needle time 95 minutes [72-112] vs. 62 [49-85]). Adherence to early and discharge antithrombotics, smoking cessation counseling, and dysphagia screening were relatively high (e.g.>80%) in both countries. However, large gaps existed in administration of intravenous thrombolytics within 3 hours (18.3% vs. 83.6%), door-to-needle time ≤60 minutes (14.6% vs. 48.0%), deep vein thrombosis prophylaxis (65.0% vs. 97.8%), anticoagulation for atrial fibrillation (21.0% vs. 94.4%), lipid treatment for low-density lipoprotein > 100 mg/dL (66.3% vs. 95.8%), and rehabilitation assessment (58.8% vs. 97.4%). Door-to-CT ≤25 minutes was relatively low in both countries (26.4% vs. 27.9%). Conclusions: We found significant differences in clinical characteristics and gaps in adherence for certain performance measures between China and US. Additional efforts are needed for continued improvements in acute stroke care and secondary prevention in both nations, especially China.

Background: Stroke is the leading cause of death in China. Despite the wide dissemination of evidence-based guidelines, data about adherence to these in routine clinical practice are scarce. We conducted a study using a nationwide registry to evaluate the implementation of evidence-based stroke performance indicators and associated guidelines, for patients with an ischemic stroke in China. Methods and Results: The China National Stroke Registry is a prospective cohort study, including 12 416 patients diagnosed with acute ischemic stroke from 132 hospitals across China, for 1 year beginning September 2007. Twelve performance indicators were selected to evaluate the quality of stroke care. Multivariable Cox models were used to determine the association between optimal compliance and clinical outcomes. Conformity with performance measures ranged from a median of 6.5% for the use of intravenous tPA (tissue-type plasminogen activator) to 81.8% for early use of antithrombotics. The optimal compliance with all in-hospital measures was associated with 1-year death after admission (hazard ratio, 0.66; 95% CI, 0.55–0.79). The optimal compliance with all discharge measures was associated with the 1-year death after discharge (hazard ratio, 0.55; 95% CI, 0.44–0.69), 1-year stroke recurrence (hazard ratio, 0.81; 95% CI, 0.70–0.93), and favorable functional outcomes (defined as modified Rankin Scale score of ≤2) (hazard ratio, 1.10; 95% CI, 1.04–1.16). Conclusions: Adherence to evidence-based ischemic stroke care measures in China revealed substantial gaps, and select measures were associated with improved outcomes. These findings support the need for ongoing quality measurement and improvement in stroke care in China.

Background— The use of transcatheter aortic valve replacement (TAVR) to treat aortic stenosis in the United States is growing, yet little is known about the variation in procedural outcomes in community practice. We developed a TAVR in-hospital mortality risk model and used it to quantify variation in mortality rates across United States (US) TAVR centers. Methods and Results— We analyzed data from 22 248 TAVR procedures performed at 318 sites participating in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry (November 2011 to October 2014). A Bayesian hierarchical model was developed to estimate hospital-specific risk-adjusted mortality rates adjusting for 40 patient baseline factors. A total of 1130 in-hospital deaths (5.1%) were observed. Reliability-adjusted risk-adjusted mortality rate estimates ranged from 3.4% to 7.7% with an interquartile range of 4.8% to 5.4%. A patient’s predicted odds of dying was 80% higher if treated by a hospital 1 standard deviation above the mean compared with a hospital 1 standard deviation below the mean (odds ratio =1.8; 95% credible interval, 1.4%–2.2%). Conclusions— Risk modeling of TAVR in-hospital mortality revealed variation in risk-adjusted mortality rates during the US early commercial experience. Transcatheter Valve Therapy Registry analyses using this model will support research, feedback reporting, and the identification of factors associated with quality.

Background and Purpose— Antithrombotics are the mainstay of treatment in primary and secondary prevention of stroke, and their use before an acute event may be associated with better outcomes. Methods— Using data from Get With The Guidelines-Stroke with over half a million acute ischemic strokes recorded between October 2011 and March 2014 (n=540 993) from 1661 hospitals across the United States, we examined the unadjusted and adjusted associations between previous antithrombotic use and clinical outcomes. Results— There were 250 104 (46%) stroke patients not receiving any antithrombotic before stroke; of whom approximately one third had a documented previous vascular indication. After controlling for clinical and hospital factors, patients who were receiving antithrombotics before stroke had better outcomes than those who did not, regardless of whether a previous vascular indication was present or not: adjusted odds ratio (95% confidence intervals) were 0.82 (0.80–0.84) for in-hospital mortality, 1.18 (1.16–1.19) for home as the discharge destination, 1.15 (1.13–1.16) for independent ambulatory status at discharge, and 1.15 (1.12–1.17) for discharge modified Rankin Scale score of 0 or 1. Conclusions— Previous antithrombotic therapy was independently associated with improved clinical outcomes after acute ischemic stroke. Ensuring the use of antithrombotics in appropriate patient populations may be associated with benefits beyond stroke prevention.

Background— Previous studies examining early readmission after acute myocardial infarction have focused exclusively on inpatient readmissions. However, from a patient’s perspective, any unplanned inpatient or observation rehospitalization after acute myocardial infarction represents a significant event; these unplanned rehospitalizations have not been well characterized. Methods and Results— We examined all patients with acute myocardial infarction treated with percutaneous coronary intervention and discharged alive from 233 hospitals in the Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome (TRANSLATE-ACS) study from 2010 to 2012. Our primary outcome was unplanned rehospitalizations (inpatient or observation status) within 30 days after discharge. We identified factors associated with unplanned rehospitalizations using multivariable logistic regression. Among 12 312 patients, 1326 (10.8%) had 1483 unplanned rehospitalizations within 30 days of the index event: 1028 (69.3%) were inpatient readmissions, and 455 (30.7%) were observation stays. The majority of unplanned rehospitalizations (72%) were for cardiovascular reasons. Variation in hospital rates of 30-day unplanned rehospitalization ranged from 5.4% to 20.0%, with a median of 10.7%. After multivariable modeling, the factors most strongly associated with unplanned rehospitalization were baseline quality of life and depression, followed by index hospital length of stay. Conclusions— Early unplanned rehospitalizations are common after acute myocardial infarction, and close to one third were classified as an observation stay. Predischarge and postdischarge assessments of overall, not just cardiovascular, health and strategies to optimize patient functional status may help to reduce unplanned rehospitalizations. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01088503.