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Endothelial cell damage related to coronavirus disease 2019 (COVID‐19) has been described in multiple vascular beds, and many survivors of COVID‐19 report chest pain. This case series describes two previously healthy middle‐aged individuals who survived COVID‐19 and were subsequently found to have symptomatic coronary endothelial dysfunction months after initial infection. [ABSTRACT FROM AUTHOR]

Prognosis communication in heart failure is often narrowly defined as a discussion of life expectancy, but as clinical guidelines and research suggest, these discussions should provide a broader understanding of the disease, including information about disease trajectory, the experiences of living with heart failure, potential burden on patients and families, and mortality. Furthermore, despite clinical guidelines recommending early discussions, evidence suggests that these discussions occur infrequently or late in the disease trajectory. We review the literature concerning patient, caregiver, and clinician perspectives on discussions of this type, including the frequency, timing, desire for, effects of, and barriers to their occurrence. We propose an alternate view of prognosis communication, in which the patient and family/caregiver are educated about the nature of the disease at the time of diagnosis, and a process of engagement is undertaken so that the patient's full participation in their care is marshalled, and the care team engages the patient in the informed decision making that will guide care throughout the disease trajectory. We also identify and discuss evidence gaps concerning (i) patient preferences and readiness for prognosis information along the trajectory; (ii) best practices for communicating prognosis information; and (iii) effects of prognosis communication on patient's quality of life, mental health, engagement in critical self‐care, and clinical outcomes. Research is needed to determine best practices for engaging patients in prognosis communication and for evaluating the effects of this communication on patient engagement and clinical outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND Age is known to be associated with the prevalence and pathophysiology of hypertension. However, there is little information on whether age stands as a good proxy for the specific hemodynamic profile of an individual with elevated blood pressure (BP), which could be important in the selection of therapy. DESIGN This is a cross‐sectional study. SETTING People who underwent a noninvasive, hemodynamic assessment using impedance cardiography at 51 sites of iKang Health Checkup Centers throughout China between January 2012 and October 2018. PARTICIPANTS We included 116,851 individuals, aged 20 to 80 years. MAIN OUTCOMES AND MEASURES Relationship between age and hemodynamic parameters (cardiac index, systemic vascular resistance index [SVRI]), among individuals with elevated BP (systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg). RESULTS: Final study population included 45,082 individuals with elevated BP: 29,194 men and 15,888 women with a mean (±SD) age of 48 (±13) and 54 (±12) years, respectively. Cardiac index was negatively associated with age with an adjusted, per decade decrease of 0.17 (95% confidence interval [CI] = 0.17‐0.18) L/min/m2 in men and 0.24 (95% CI = 0.23‐0.25) L/min/m2 in women. SVRI was positively associated with age with an adjusted, per‐decade increase of 174.2 (95% CI = 168.8‐179.7) dynes·s·cm−5·m2 in men and 214.1 (95% CI = 204.3‐223.8) dynes·s·cm−5·m2 in women. However, there was substantial overlap in the distribution of these parameters across different age groups in both sexes. CONCLUSIONS: In this large study, we observed that cardiac index decreased and SVRI increased with age among individuals with elevated BP. Even though there was a general trend with age, we observed heterogeneity within age strata, suggesting that age alone is inadequate to indicate the hemodynamic profile for an individual. J Am Geriatr Soc 68:1520‐1528, 2020. [ABSTRACT FROM AUTHOR]

Summary: The incidence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection has been increasing with over 10 million people affected globally. The role biomarkers play as predictors of cardiovascular disease (CVD) risk among coinfected individuals is not well defined. We aimed to systematically review current evidence describing CVD biomarkers among individuals with HIV/HCV coinfection. We searched EMBASE, CINAHL, Google Scholar, PubMed, and Web of Science from inception to June 2017. MeSH terms and keywords were used to identify studies with information on HIV/HCV coinfection and CVD biomarkers (structural, functional, and serological) such as carotid intima‐media thickness (CIMT), endothelial markers, C‐reactive protein (CRP), homocysteine, and lipids. Among 332 articles screened, 28 were included (39,498 participants). Study designs varied: 18 cross‐sectional, 9 cohort, and 1 clinical trial. Compared with healthy controls and people with HIV or HCV monoinfection, individuals with HIV/HCV coinfection had statistically significant lower levels of lipids and CRP and higher levels of endothelial markers (sICAM‐1 and sVCAM‐1), CIMT, homocysteine, and IL‐6. One study found the odds of carotid plaque in coinfected individuals was 1.64 (0.91–2.94) compared with healthy controls, and another study showed the prevalence of vascular plaques (carotid and femoral) in coinfected individuals was higher compared with HIV monoinfected individuals (44% vs 14%, P = 0.04). Biomarkers of CVD have different patterns of association with HIV/HCV coinfection compared with monoinfection and healthy controls. Prospective studies are needed to confirm the predictive value of these biomarkers for clinical CVD risk among coinfected individuals. [ABSTRACT FROM AUTHOR]

Objectives To evaluate home health agency quality performance. Design Observational study. Setting Home health agencies. Participants All Medicare-certified agencies with at least 6 months of data from 2011 to 2015. Measurements Twenty-two quality indicators, five patient survey indicators, and their composite scores. Results The study included 11,462 Medicare-certified home health agencies that served 92.4% of all ZIP codes nationwide, accounting for 315.2 million people. The mean composite scores were 409.1 ± 22.7 out of 500 with the patient survey indicators and 492.3 ± 21.7 out of 600 without the patient survey indicators. Home health agency performance on 27 quality indicators varied, with the coefficients of dispersion ranging from 4.9 to 62.8. Categorization of agencies into performance quartiles revealed that 3,179 (27.7%) were in the low-performing group (below 25th percentile) at least one time during the period from 2011-12 to 2014-15 and that 493 were in the low-performing group throughout the study period. Geographic variation in agency performance was observed. Agencies with longer Medicare-certified years were more likely to have high-performing scores; agencies providing partial services, with proprietary ownership, and those with long travel distances to reach patients had lower performance. Agencies serving low-income counties and counties with lower proportions of women and senior residences and greater proportions of Hispanic residents were more likely to attain lower performance scores. Conclusion Home health agency performance on several quality indicators varied, and many agencies were persistently in the lowest quartile of performance. Still, there is a need to improve the quality of care of all agencies. Many parts of the United States, particularly lower-income areas and areas with more Hispanic residents, are more likely to receive lower quality home health care. [ABSTRACT FROM AUTHOR]

Objectives Administrative claims data sets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department ( ED) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital-based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare data set and to compare this definition to existing operational definitions used by researchers and policymakers. Methods We examined four operational definitions of an ED visit commonly used by researchers and policymakers using a 20% sample of the 2012 Medicare Chronic Condition Warehouse ( CCW) data set. The CCW data set included all Part A (hospital) and Part B (hospital outpatient, physician) claims for a nationally representative sample of continuously enrolled Medicare fee-for-services beneficiaries. Three definitions were based on published research or existing quality metrics including: 1) provider claims-based definition, 2) facility claims-based definition, and 3) CMS Research Data Assistance Center (Res DAC) definition. In addition, we developed a fourth operational definition (Yale definition) that sought to incorporate additional coding rules for identifying ED visits. We report levels of agreement and disagreement among the four definitions. Results Of 10,717,786 beneficiaries included in the sample data set, 22% had evidence of ED use during the study year under any of the ED visit definitions. The definition using provider claims identified a total of 4,199,148 ED visits, the facility definition 4,795,057 visits, the Res DAC definition 5,278,980 ED visits, and the Yale definition 5,192,235 ED visits. The Yale definition identified a statistically different (p < 0.05) collection of ED visits than all other definitions including 17% more ED visits than the provider definition and 2% fewer visits than the Res DAC definition. Differences in ED visitation counts between each definition occurred for several reasons including the inclusion of critical care or observation services in the ED, discrepancies between facility and provider billing regulations, and operational decisions of each definition. Conclusion Current operational definitions of ED visitation using administrative claims produce different estimates of ED visitation based on the underlying assumptions applied to billing data and data set availability. Future analyses using administrative claims data should seek to validate specific definitions and inform the development of a consistent, consensus ED visitation definitions to standardize research reporting and the interpretation of policy interventions. [ABSTRACT FROM AUTHOR]

Objective: This study details 6- and 12-month cardio-metabolic outcomes of an intense 12-week workplace lifestyle intervention program, the My Unlimited Potential (MyUP), conducted in a large healthcare organization.Methods: This study was conducted among 230 employees of Baptist Health South Florida with high cardiovascular disease (CVD) risk. Employees were considered at high risk and eligible for the study if they had two or more of the following cardio-metabolic risk factors: total cholesterol ≥ 200 mg/dl, systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg, hemoglobin A1C (HbA1c) ≥ 6.5%, body mass index (BMI) ≥ 30 kg/m(2) .Results: At the end of 12 weeks, there was significant reduction in the mean BMI, SBP and DBP, serum lipids, and HbA1c among persons with diabetes. At 1 year, there was significant decline in the mean BMI, SBP and DBP, HbA1c, and high-sensitivity C-reactive protein, and in the prevalence of poor BP control, BMI ≥ 35 kg/m(2) , and abnormal HbA1c among all persons and those with diabetes.Conclusions: This intensive 12-week lifestyle change program was successful at improving cardio-metabolic risk factors at 1 year. This study provides a template for other workplace programs aimed at improving CVD risk in high-risk employees. [ABSTRACT FROM AUTHOR]

Objective To describe core principles and processes in the implementation of a navigated care program to improve specialty care access for the uninsured. Study Setting Academic researchers, safety-net providers, and specialty physicians, partnered with hospitals and advocates for the underserved to establish Project Access- New Haven ( PA- NH). PA- NH expands access to specialty care for the uninsured and coordinates care through patient navigation. Study Design Case study to describe elements of implementation that may be relevant for other communities seeking to improve access for vulnerable populations. Principal Findings Implementation relied on the application of core principles from community-based participatory research ( CBPR). Effective partnerships were achieved by involving all stakeholders and by addressing barriers in each phase of development, including (1) assessment of the problem; (2) development of goals; (3) engagement of key stakeholders; (4) establishment of the research agenda; and (5) dissemination of research findings. Conclusions Including safety-net providers, specialty physicians, hospitals, and community stakeholders in all steps of development allowed us to respond to potential barriers and implement a navigated care model for the uninsured. This process, whereby we integrated principles from CBPR, may be relevant for future capacity-building efforts to accommodate the specialty care needs of other vulnerable populations. [ABSTRACT FROM AUTHOR]

Background: Atrioventricular (AV) node ablation with implantation of a permanent pacemaker is an established mode of therapy in the treatment of atrial fibrillation. However, concern exists regarding subsequent dependency on an entirely paced rhythm and the possible sequela of unheralded pacemaker failure. Data regarding escape rhythm lability, an important feature of pacemaker dependency, are limited. Aims and Methods: The purpose of this study was twofold: (1) to determine the characteristics of escape rhythms at predefined serial time intervals following AV node ablation and pacemaker implantation, and (2) to identify risk factors predictive of unstable escape rhythms. Patients undergoing AV node ablation and pacemaker implantation were assessed for the presence or absence of an escape rhythm during pacemaker interrogation at five predetermined serial time points. Baseline demographics and comorbid conditions were evaluated as potential predictors of those with labile escape rhythms. Results: Seventy-nine percent of the 96 patients studied had an underlying escape rhythm (≥30 beats per minute) immediately postablation. Although the percentage of patients with an escape rhythm increased at each follow-up interval, the number of patients who consistently demonstrated an escape rhythm declined with each follow-up, with 28% of patients lacking an escape rhythm at some time point, i.e., labile escape rhythm. There were no significant predictors of a labile escape rhythm. Conclusion: Among patients who have undergone AV node ablation and pacemaker implantation, 72% have a stable escape rhythm over time, but others are at risk for pacemaker dependency, as predicted by an underlying absent or labile escape rhythm. (PACE 2010; 939–944) [ABSTRACT FROM AUTHOR]

Background: Approximately 50% of women referred for invasive coronary angiography have angina and nonobstructive coronary arteries, which includes coronary microvascular dysfunction, vasospastic angina, and other vasomotor disorders. We sought to determine the real-world diagnostic yield of invasive coronary angiography and coronary function testing in women with angina and nonobstructive coronary arteries., Methods and Results: From 2018 to 2023, we enrolled 198 women who underwent either coronary angiography (CA) alone (n=99) or coronary function testing (CFT; n=99). Mean±SD age was 62±10 years (CA alone) compared with 57±10 years (CFT). Coronary angiography was interpreted as nonobstructive coronary artery disease more frequently after CA alone (79% versus 52%). Of the women who underwent CFT, 82% (N=81) were found to have vasomotor disorders, including coronary microvascular dysfunction (27%), vasospastic angina (32%), mixed coronary microvascular dysfunction/vasospastic angina (16%), endothelial dysfunction (10%; without spasm), elevated resting flow (2%), or symptomatic myocardial bridging (4%). Compared with women undergoing CA alone, medications were changed more frequently after CFT at 24 hours (41% versus 65%; P =0.001) and between 24 hours and 30 days (30% versus 44%; P =0.04) with intensification of antianginal therapy (79% versus 92%; P< 0.0001) and increased use of calcium channel blockers (36% versus 63%; P< 0.0001)., Conclusions: Our findings demonstrate that women presenting with suspected ischemic heart disease undergoing CA alone only received an anatomic diagnosis, whereas >80% of women undergoing CFT received a specific diagnosis of a coronary vasomotor disorder and greater intensification of antianginal therapy.

Background Stress experienced in a marriage or committed relationship may be associated with worse patient-reported outcomes after acute myocardial infarction (AMI), but little is known about this association in young adults (≤55 years) with AMI. Methods and Results We used data from VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients), an observational cohort study that enrolled individuals aged 18 to 55 years with AMI (2008-2012). Marital stress was self-reported 1 month after AMI using the Stockholm Marital Stress Scale (categorized as absent/mild, moderate, and severe). Outcomes were physical/mental health (Short Form-12 ) , generic health status (EuroQol-5 Dimensions), cardiac-specific quality of life and angina (Seattle Angina Questionnaire), depressive symptoms (Patient Health Questionnaire-9), and all-cause readmission 1 year after AMI. Regression models were sequentially adjusted for baseline health, demographics (sex, age, race or ethnicity), and socioeconomic factors (education, income, employment, and insurance). Sex and marital stress interaction was also tested. Among 1593 married/partnered participants, 576 (36.2%) reported severe marital stress, which was more common in female than male participants (39.4% versus 30.4%, P =0.001). Severe marital stress was significantly associated with worse mental health (beta=-2.13, SE=0.75, P =0.004), generic health status (beta=-3.87, SE=1.46, P =0.008), cardiac-specific quality of life (beta=-6.41, SE=1.65, P <0.001), and greater odds of angina (odds ratio [OR], 1.49 [95% CI, 1.06-2.10], P =0.023) and all-cause readmissions (OR, 1.45 [95% CI, 1.04-2.00], P =0.006), after adjusting for baseline health, demographics, and socioeconomic factors. These associations were similar across sexes ( P -interaction all >0.05). Conclusions The association between marital stress and worse 1-year health outcomes was statistically significant in young patients with AMI, suggesting a need for routine screening and the creation of interventions to support patients with stress recovering from an AMI.

Background It is unknown if initiation of a sodium-glucose cotransporter-2 inhibitor (SGLT-2i) is associated with changes in patient-reported health status outside of clinical trials. Methods and Results Using a prospective observational study design, adults with type 2 diabetes and cardiovascular disease were recruited from 14 US hospitals between November 2019 and December 2021 if they were new users of noninsulin antidiabetic medications. The primary outcome was change in 6-month diabetes treatment satisfaction. Secondary outcomes included diabetes-related symptom distress, diabetes-specific quality of life, and general health status for all patients and based on cardiovascular disease type. Inverse probability of treatment weight using propensity score was performed to compare outcome changes based on medication use. Of 887 patients (SGLT-2i: n=242) included in the inverse probability of treatment weight analyses, there was no difference in changes in treatment satisfaction in SGLT-2i users compared with other diabetes medication users (0.99 [95% CI, -0.14 to 2.13] versus 1.54 [1.08 to 2.00], P =0.38). Initiating an SGLT-2i versus other diabetes medications was associated with a greater reduction in ophthalmological symptoms (-3.09 [95% CI, -4.99 to -1.18] versus -0.38 [-1.54 to 0.77], P =0.018) but less improvement in hyperglycemia (1.08 [-2.63 to 4.79] versus -3.60 [-5.34 to -1.86], P =0.026). In subgroup analyses by cardiovascular disease type, SGLT-2i use was associated with a greater reduction in total diabetes symptom burden and neurological sensory symptoms in patients with heart failure. Conclusions Among patients with type 2 diabetes and cardiovascular disease, initiating an SGLT-2i was not associated with changes in diabetes treatment satisfaction, total diabetes symptoms, diabetes-specific quality of life, or general health status.

Background The digital transformation of medical data provides opportunities to perform digital population health surveillance and identify people inadequately managed in usual care. We leveraged the electronic health records of a large health system to identify patients with markedly elevated blood pressure and characterize their follow-up care pattern. Methods and Results We included 373 861 patients aged 18 to 85 years, who had at least 1 outpatient encounter in the Yale New Haven Health System between January 2013 and December 2017. We described the prevalence and follow-up pattern of patients with at least 1 systolic blood pressure (SBP) ≥160 mm Hg or diastolic blood pressure (DBP) ≥100 mm Hg and patients with at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Of 373 861 patients included, 56 909 (15.2%) had at least 1 SBP ≥160 mm Hg or DBP ≥100 mm Hg, and 10 476 (2.8%) had at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Among patients with SBP ≥160 mm Hg or DBP ≥100 mm Hg, only 28.3% had a follow visit within 1 month (time window of follow-up recommended by the guideline) and 19.9% subsequently achieved control targets (SBP <130 mm Hg and DBP <80 mm Hg) within 6 months. Follow-up rate at 1 month and control rate at 6 months for patients with SBP ≥180 mm Hg or DBP ≥120 mm Hg was 31.9% and 17.2%. Conclusions Digital population health surveillance with an electronic health record identified a large number of patients with markedly elevated blood pressure and inadequate follow-up. Many of these patients subsequently failed to achieve control targets.

Background Diabetes mellitus increases the risk of mortality after acute myocardial infarction (AMI). However, little is known about the association of diabetes mellitus with post-AMI health status outcomes (symptoms, functioning, and quality of life) in younger adults. Methods and Results We investigated the association between diabetes mellitus and health status during the first 12 months after AMI, using data from 3501 adults with AMI (42.6% with diabetes mellitus) aged 18 to 55 years enrolled in the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study. Health status was measured with Seattle Angina Questionnaire (SAQ), 12-item Short-Form Health Survey, and EuroQol-Visual Analogue Scale at baseline hospitalization, 1-month, and 12-months post-AMI. At baseline, patients with diabetes mellitus had significantly worse SAQ-angina frequency (81±22 versus 86±19), SAQ-physical limitations (77±28 versus 85±23), SAQ-quality of life (55±25 versus 57±23), 12-item Short-Form Health Survey mental (44±13 versus 46±12)/physical functioning (41±12 versus 46±12), and EuroQol-Visual Analogue Scale (61±22 versus 66±21) than those without diabetes mellitus. Over time, both groups (with and without diabetes mellitus) improved considerably and the differences in health status scores progressively narrowed (except for 12-item Short-Form Health Survey physical functioning). In the linear-mixed effects models, adjusted for sociodemographics, cardiovascular risk factors, comorbidities, clinical characteristics, psychosocial factors, healthcare use, and AMI treatment, diabetes mellitus was associated with worse health status at baseline but not after discharge, and the association did not vary by sex. Conclusions At baseline, young adults with diabetes mellitus had poorer health status than those without diabetes mellitus. After AMI, however, they experienced significant improvements and diabetes mellitus was not associated with worse angina, SAQ-physical limitations, mental functioning, and quality of life, after adjustment for baseline covariates. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00597922.

Background Traditional Chinese medicine (TCM) is used in the treatment of many conditions, including heart failure (HF), although it is not well characterized. Methods and Results We conducted a retrospective analysis of TCM use in a random sample of hospitalizations for HF within a random sample of Western medicine hospitals in China in 2015 using data from the China PEACE 5r-HF (China Patient-Centered Evaluative Assessment of Cardiac Events 5 Retrospective Heart Failure Study). We describe the frequency of TCM use and its association with patient characteristics, in-hospital use of evidence-based therapies, and hospital characteristics using hierarchical logistic regression models. Finally, we assessed risk-adjusted in-hospital bleeding and mortality. Among 10 004 patients hospitalized with HF (median age, 73 years; 48.9% women) from 189 hospitals, 74.7% received TCM (83.3% administered intravenously). The most commonly used agent was Salvia miltiorrhiza (51.2%). Patients with coronary artery disease (odds ratio [OR], 1.73; 95% CI, 1.53-1.95) or stroke (OR, 1.32; 95% CI, 1.15-1.51) were more likely to receive TCM; there was no correlation with evidence-based therapy use. Nearly all hospitals (99.4%) used TCM, with substantial variation across hospitals (median OR, 3.29; 95% CI, 2.82-3.76). In-patient bleeding (OR, 1.39; 95% CI, 1.03-1.88) and mortality (OR, 1.36; 95% CI, 1.04-1.79) were higher with Salvia miltiorrhiza, although not with other TCMs. Conclusions In a nationally representative sample of patients hospitalized with acute HF in China, three fourths received TCM. Nearly all hospitals used TCM, although use varied substantially by hospital. Although TCM was not used in lieu of evidence-based therapies for HF, we found a signal for harm with the most commonly used TCM. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02877914.