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The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Pulmonary arterial hypertension (PAH) is a cardiopulmonary disease with high mortality. In recent years, it has been recognized that PAH is a multi-organ system disease, involving the systemic circulation, kidneys, skeletal muscles, and the central nervous system, among others. Right heart failure produces congestive hepatopathy, a disease state that has direct consequences on liver biochemistry, histology, and systemic glucose and lipid metabolism. This article aims to summarize the consequences of congestive hepatopathy with an emphasis on liver biochemistry, histology, and PAH-targeted therapy. Furthermore, PAH-specific changes in glucose and lipid metabolism will be discussed.

Chronic kidney disease (CKD) in patients with ST-elevation myocardial infarction (STEMI) is associated with worse outcomes. We assessed the impact of CKD on guideline directed coronary revascularization and outcomes among STEMI patients. The Nationwide Inpatient Sample dataset from 2012-2014 was used to identify patients with STEMI using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were categorized as non-CKD, CKD without dialysis, and CKD with dialysis (CKD-HD). Outcomes were revascularization, death and acute renal failure requiring dialysis (ARFD). A total of 534,845 were included (88.9% non-CKD; 9.6% CKD without dialysis, and 1.5% CKD-HD). PCI was performed in 77.4% non-CKD, 56.2% CKD without dialysis, and 48% CKD-HD patients (p < 0.0001). In-hospital mortality and ARFD were significantly higher in CKD patients (16.5% and 40.6%) compared with non-CKD patients (7.12% and 7.17%) (p < 0.0001). In-hospital mortality was significantly lower in patients treated revascularization compared with patients treated medically (non-CKD: adjusted odds ratio (aOR) 0.280, p < 0.0001; CKD without dialysis: aOR 0.39, p < 0.0001; CKD-HD: aOR 0.48, p < 0.0001). CKD was associated with higher length of hospital stay and cost (5.86 ± 13.97, 7.57 ± 26.06 and 3.99 ± 11.09 days; p < 0.0001; $25,696 ± $63,024, $35,666 ± $104,940 and $23,264 ± $49,712; p < 0.0001 in non-CKD, CKD without dialysis and CKD-HD patients respectively). In conclusion, CKD patients with STEMI receive significantly less PCI compared with patients without CKD. Coronary revascularization for STEMI in CKD patients was associated with lower mortality compared to medical management. The presence of CKD in patients with STEMI is associated with higher mortality and ARFD, prolonged hospital stay and higher hospital cost.

Several comorbidities have been shown to be associated with coronavirus disease 2019 (COVID-19) related severity and mortality. However, considerable variation in the prevalence estimates of comorbidities and their effects on COVID-19 morbidity and mortality have been observed in prior studies. This systematic review and meta-analysis aimed to determine geographical, age, and gender related differences in the prevalence of comorbidities and associated severity and mortality rates among COVID-19 patients. We conducted a search using PubMed, Scopus, and EMBASE to include all COVID-19 studies published between January 1st, 2020 to July 24th, 2020 reporting comorbidities with severity or mortality. We included studies reporting the confirmed diagnosis of COVID-19 on human patients that also provided information on comorbidities or disease outcomes. We used DerSimonian and Laird random effects method for calculating estimates. Of 120 studies with 125,446 patients, the most prevalent comorbidity was hypertension (32%), obesity (25%), diabetes (18%), and cardiovascular disease (16%) while chronic kidney or other renal diseases (51%, 44%), cerebrovascular accident (43%, 44%), and cardiovascular disease (44%, 40%) patients had more COVID-19 severity and mortality respectively. Considerable variation in the prevalence of comorbidities and associated disease severity and mortality in different geographic regions was observed. The highest mortality was observed in studies with Latin American and European patients with any medical condition, mostly older adults (≥ 65 years), and predominantly male patients. Although the US studies observed the highest prevalence of comorbidities in COVID-19 patients, the severity of COVID-19 among each comorbid condition was highest in Asian studies whereas the mortality was highest in the European and Latin American countries. Risk stratification and effective control strategies for the COVID-19 should be done according to comorbidities, age, and gender differences specific to geographical location.

Venous thromboembolism associated with COVID-19, particularly acute pulmonary embolism, may represent a challenging and complex clinical scenario. The benefits of having a multidisciplinary pulmonary embolism response team (PERT) can be important during such a pandemic. The aim of PERT in the care of such patients is to provide fast, appropriate, multidisciplinary, team-based approach, with the common goal to tailor the best therapeutic decision making, prioritizing always optimal patient care, especially given lack of evidence-based clinical practice guidelines in the setting of COVID-19, which potentially confers a significant prothrombotic state. Herein, we would like to briefly emphasize the importance and potential critical role of PERT in the care of patients in which these two devastating illnesses are present together.

The association between the presence of coronary artery calcium (CAC) and the risk of coronary artery disease (CAD) has been appreciated for decades. In this review, we critically appraise the role of CAC based on computerized tomography in contemporary risk stratification. Available evidence suggests that the measurement of CAC is a useful modality in many patients for more precise risk stratification and prognostic determination. Whether newer CAC score incorporating extra coronary calcification will add incremental value, especially for stroke and other non-coronary vascular outcomes, needs a prospective study.

Introduction: The optimal approach to deal with severe coronary artery calcification (CAC) during percutaneous coronary intervention (PCI) remains ill-defined. Methods: We conducted an electronic database search of all published studies comparing Orbital versus Rotational Atherectomy in patients undergoing PCI. Results: Eight observational studies were included in the analysis. Overall, there were no significant differences in Major-adverse-cardiac-events/MACE (OR: 0.81, CI: 0.63–1.05, p =.11), myocardial-infarction/MI (OR: 0.75, CI: 0.56–1.00, p =.05), all-cause mortality (OR: 0.82, CI: 0.25–2.64, p =.73) or Target-vessel-revascularization/TVR (OR: 0.72, CI: 0.38–1.36, p =.31). However, OA was associated with lower long-term MACE (1-year), (OR: 0.66, CI: 0.44–0.99, p =.04), long-term TVR (OR: 0.40, CI: 0.18–0.89, p =.03), and short-term MI (in-hospital and 30-day) (OR: 0.64, CI: 0.44–0.94, p =.02). OA was associated with more coronary artery dissections (OR: 2.61, CI: 1.38–4.92, p =.003) and device-related coronary perforations (OR: 2.79, CI: 1.08–7.19, p =.03). There were no differences in cardiac tamponade (OR: 1.78, CI: 0.37–8.69, p =.47). OA was noted to have significantly lower fluoroscopy time (MD: −3.96 min, CI: −7.67, −0.25; p =.04) compared to RA. No significant difference was noted in terms of contrast volume between the two groups (OR: −4.35 ml, CI: −14.52, 23.22; p =.65). Conclusion: Although there was no difference in overall MACE, MI, all-cause mortality and TVR, OA was associated with lower long-term MACE and short-term MI. OA is associated with lower fluoroscopy time but higher rates of coronary artery dissection and coronary perforation.

Chronic total occlusion (CTO) of a coronary artery is typically defined as a completely occluded artery without any antegrade flow and a duration of at least 3 months. We reviewed the current literature describing the optimal management of CTO including the role of revascularization and choice of modality, i.e., percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery. Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL) were searched and relevant studies of patients with CTO were selected for review. The prevalence of coronary artery CTOs is approximately 25% among patients undergoing coronary angiography for angina. Available data suggests that PCI of CTO can be a technically complex procedure with relatively lower success rates compared with non-CTO PCI and typically associated with a higher complication rate especially at nonspecialized centers. Furthermore, successful CTO-PCI is associated with symptomatic improvement but does not appear to improve mortality, myocardial infarction, stroke, and repeat revascularization rates. Based on contemporary data, PCI of CTO lesions may be considered in patients with incapacitating angina despite treatment with optimal guideline-directed medical therapy and in whom based on coronary anatomy there is a reasonable chance of technical success with an acceptable risk.

Cryptogenic stroke and its relation to the Patent Foramen Ovale (PFO) is a long-debated topic. Recent clinical trials have unequivocally established the relationship between cryptogenic strokes and paradoxical embolism across the PFO. This slit-like communication exists in everyone before birth, but most often closes shortly after birth. PFO may persist as a narrow channel of communication between the right and left atria in approximately 25-27% of adults. : In this review, we examine the clinical relevance of the PFO with analysis of the latest trials evaluating catheter-based closure of PFO’s for cryptogenic stroke. We also review the current evidence examining the use of antiplatelet medications versus anticoagulants for stroke prevention in those patients with PFO who do not qualify for closure per current guidelines.

Aim:This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.Methods:A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.Structure:Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Introduction: Recent findings have shown that in Acute Ischemic Stroke (AIS) patients, elevated troponin is associated with increased mortality. However, due to concerns of cerebral hypoperfusion and hemorrhagic transformation, current practice has been slow to apply proven cardiac therapies to these patients. This study aims to determine this rate of utilization. Materials and Methods: A single-center review of 83 patients with AIS and measured troponin was conducted. Patients were stratified based on elevated and non-elevated troponin. Between groups, we measured the utilization of evidence-based cardiac therapies and used a univariate logistic regression to compare outcomes of mortality, re-hospitalization, recurrent acute ischemic stroke, recurrent acute myocardial infarction, and a composite of these outcomes. Results: Of 83 patients, 25 had elevated troponin and 58 had non-elevated troponin. There was no statistical difference in the use of cardiac therapies between the two groups. Adenosine diphosphate P2Y12 antagonists were infrequently used in both elevated and non-elevated troponin groups at 32% vs. 24% (p = 0.64), as were Angiotensin-Converting Enzyme Inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) at 56% vs. 69% (p = 0.38). Those in the elevated troponin group encountered a statistically significant increase in composite endpoint 64% vs. 33% (Odds Ratio [OR] 7.28, 95% Confidence interval [CI] 2.19-28.88, p Conclusion: Cardiac therapies are underutilized in patients with acute ischemic stroke and elevated troponin levels. In turn, this low usage may explain the increase in morbidity and mortality seen in these patients and the use of such therapies should be considered when treating this subset of patients as the cardio protective nature of these therapies may outweigh the risks associated with them in AIS patients.

Drug eluting stents (DES) are preferred over bare metal stents (BMS) for native coronary artery revascularization unless contraindicated. However, the preferred stent choice for saphenous venous graft (SVG) percutaneous coronary interventions (PCI) is unclear due to conflicting results.PubMed, Clinical trials registry and the Cochrane Center Register of Controlled Trials were searched through June 2018. Seven studies (n = 1639) comparing DES versus BMS in SVG-PCI were included. Endpoints were major adverse cardiac events (MACE), cardiovascular mortality, all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), in-stent thrombosis, binary in-stent restenosis, and late lumen loss (LLL).Overall, during a mean follow up of 32.1 months, there was no significant difference in the risk of MACE, cardiovascular mortality, all-cause mortality, MI, stent thrombosis, TVR and TLR between DES and BMS. However, short-term follow up (mean 11 months) showed lower rate of MACE (OR 0.66 [0.51, 0.85]; p = 0.002), TVR (OR 0.47 [0.23, 0.97]; p = 0.04) and binary in-stent restenosis (OR 0.14 [0.06, 0.37]; p 0.0001) in DES as compared with BMS. This benefit was lost on long-term follow up with a mean follow up 35.5 months.In this meta-analysis of SVG-PCI, DES use was associated with similar MACE, cardiovascular mortality, all-cause mortality, MI, in-stent thrombosis, TVR and TLR compared with BMS during long-term follow up. There was high incidence of MACE noted in both DES and BMS suggesting a need for exploring novel strategies to treat SVG disease to improve clinical outcomes.

Heart failure with preserved ejection fraction (HFpEF) is the presence of clinical signs and/or symptoms of heart failure with a left ventricular ejection fraction (LVEF) ≥50%. Risk factors associated with this disease include hypertension, hyperlipidemia, atrial fibrillation (AF), obesity, diabetes and coronary artery disease (CAD). Despite the multiple risk factors identified for this condition, treatment and management remain challenging and a subject of ongoing research. Since a treatment approach that alters the natural course or lowers mortality for this disease has not been found, treating co-morbidities and symptom management is essential. From the comorbidities, hypertension is identified as the main risk factor for disease development. Thus, after congestive symptom control with diuretics, blood pressure (BP) management is considered one of the most important preventive measures and also a target for treatment. Amongst antihypertensives, angiotensin receptor blockers (ARBs) and aldosterone antagonists are the therapeutic agents used that have a role in reducing hospitalizations. Implantable monitoring devices have also been shown to reduce hospitalizations in comparison to standard heart failure therapies by allowing to tailor diuretic therapy based on ongoing hemodynamic data. In this manuscript we discuss pharmacologic strategies for HFpEF patients by risk factors, including those with and without a potential role.

COVID-19 has posed an extraordinary burden on health and the economy worldwide. Patients with cardiovascular diseases are more likely to have severe illness due to COVID-19 and are at increased risk for complications and mortality. We performed a narrative literature review to assess the burden of COVID-19 and cardiovascular morbidity and mortality. Myocardial injury has been reported in 20%–30% of patients hospitalized due to COVID-19 and is associated with a worse prognosis and high mortality (~50%–60%). Proposed mechanisms of myocardial injury include inflammation within the myocardium (due to direct viral infection or cytokine storm), endotheliitis, coronary vasculitis, myocarditis, demand ischemia, plaque destabilization and right ventricular failure. The right ventricle is particularly vulnerable to injury and failure in COVID-19-infected patients, given the hypoxic pulmonary vasoconstriction, pulmonary microthrombi or pulmonary embolism. Echocardiography is an effective and accessible tool to evaluate left and right ventricular functions and risk stratify patients with COVID-19 infection. Cardiac MRI has detected and characterized myocardial injury, with changes compatible with other inflammatory cardiomyopathies. The long-term consequences of these inflammatory changes are unknown, but accumulating data will provide insight regarding the longitudinal impact of COVID-19 infection on cardiovascular morbidity and mortality.

Background Transcatheter aortic valve replacement (TAVR)‐in‐TAVR is a possible treatment for transcatheter heart valve (THV) degeneration. However, the displaced leaflets of the first THV will create a risk plane (RP) under which the passage of a coronary catheter will be impossible. The aim of our study was to evaluate the potential risk of impaired coronary access (CA) after TAVR‐in‐TAVR. Methods and Results We prospectively performed coronary angiography after TAVR with different THVs in 137 consecutive patients, looking where the catheter crossed the valve frame. If coronary cannulation was achieved from below the RP, the distance between valve frame and aortic wall was measured by aortic angiography. CA after TAVR‐in‐TAVR was defined as feasible if the catheter passed above the RP, as theoretically feasible if passed under the RP with valve‐to‐aorta distance >2 mm, and as unfeasible if passed under the RP with valve‐to‐aorta distance ≤2 mm. Seventy‐two patients (53%) received a Sapien 3 THV, 26 (19%) received an Evolut Pro/R THV, and 39 (28%) received an Acurate Neo THV. CA after TAVR‐in‐TAVR was considered feasible in 40.9% (68.1%, 19.2%, and 5.1%, respectively; P30% of patients currently treated with TAVR. Patients with a small sinotubular junction and those who received a supra‐annular THV are at highest risk of potential CA impairment with TAVR‐in‐TAVR.

Limited data exist regarding patients with continuous-flow left ventricular assist device (LVAD) support who require long-term inotropes. Our primary objective was to evaluate the clinical characteristics and all-cause mortality of LVAD recipients with prolonged inotrope use (PIU). Secondary endpoints were to compare predictors of PIU, mortality, risk of late re-initiation of inotropes, time to gastrointestinal bleed (GIB), infection, and arrhythmias. Retrospective cohort study was conducted on adult patients with primary continuous-flow LVADs implanted from January 2008 to February 2017 and the patients were followed up through February 2018. We defined PIU as ≥14 days of inotrope support. Kaplan-Meier method, competing risk models and Cox proportional hazard models were used. Final analytic sample was 203 patients, 58% required PIU, and 10% were discharged on inotropes. There was no difference in preimplant characteristics. One-year survival rate was 87% if no PIU required, 74% if PIU required, and 72% if discharged on inotropes. PIU was associated with longer length of stay and higher incidence of GIB. We found no association between PIU and late re-initiation of inotropes, infection or arrhythmias. Adjusted hazard risk of death was increased in patients with PIU (HR = 1.66, P = .046), older age (HR = 1.28, P = .031), and higher creatinine levels (HR = 1.60, P = .007). Prolonged inotrope use is frequently encountered following LVAD implantation and is associated with adverse prognosis but remains a therapeutic option. Inability to wean inotropes prior to hospital discharge is a marker of patients at particularly higher risk of mortality following LVAD implantation.

Cardiovascular disease syndromes comprising of coronary artery disease, ischemic stroke, and peripheral arterial disease (PAD) are extremely common in patients with chronic kidney disease (CKD). PAD is particularly common in those with severe CKD, and early detection and effective treatment of PAD is indicated in those with CKD and concomitant PAD. Measurement of the ankle-brachial index is a simple, reliable, and noninvasive test to diagnose PAD that can be used in the office. Lifestyle modification, including exercise and smoking cessation, combined with pharmacologic therapy to manage risk factors have been shown effective in reducing cardiovascular risks in patients with CKD and PAD with judicious use of revascularization strategies to reduce limb loss.

Pulmonary Hypertension (PH) related to Left Heart Disease (LHD) is the most common form of PH, accounting for more than two third of all PH cases. The hemodynamic abnormalities seen in PHLHD are complex, and there are currently minimal evidence-based recommendations for the management of PH-LHD. While it is accepted that PH in the context of left heart disease is a marker of worse prognosis, it remains unclear whether its primary treatment is beneficial or harmful. In this article, we discuss the prevalence and significance of PH in patients with Heart Failure (HF) with Reduced Ejection Fraction (HFrEF) as well as HF with Preserved Ejection Fraction (HFpEF), and those with valvular heart disease and provide insights into the complex pathophysiology of cardiopulmonary interrelationship in individuals with PH due to left heart disease. Furthermore, we provide a framework for diagnostic testing and an approach to optimal management of these complex patients based on current European Society of Cardiology (ESC) guidelines.

There is a strong relation between metabolic syndrome (MetS) and left ventricular (LV) mass in Hispanic patients. This population also tends to have a higher incidence of kidney disease, with progression to dialysis. We analyzed the change in LV mass in 982 Hispanic patients with MetS and used these data to anticipate the progression of renal dysfunction. Glomerular filtration rate (GFR) was calculated using the formula described by the Chronic Kidney Disease Epidemiology Collaboration. Echocardiographic data were collected using 2-dimensionally guided M-mode echocardiography measures. The data collected were then analyzed using linear regression analyses. Results showed a lower average GFR in individuals classified as having a severe change in LV mass in comparison to those with milder change in LV mass (P < 0.0001). This relation was also demonstrated when those with severe change in LV mass were compared with the control group (P < 0.0001). In those ≥54 years old, the presence of MetS and LV mass were negatively correlated with GFR (regression coefficient [RC] = 14.76, P < 0.063; RC = 0.11, P < 0.0001 respectively). In patients

Objectives This meta-analysis evaluated the effectiveness of hybrid coronary revascularization (HCR) compared to coronary artery bypass grafting (CABG) for the treatment of multivessel coronary artery disease (MVCAD). Background HCR involves a combination of surgical and percutaneous techniques, which in selected patients may present an alternative to conventional CABG. Methods Databases were searched through June 30, 2016, and studies comparing HCR with CABG for treatment of MVCAD were selected. We calculated summary odds ratios (ORs) and 95% CIs with the random-effects model. The primary outcome of interest was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of all cause mortality, myocardial infarction, and stroke. Results The analysis included 2,245 patients from 8 studies (1 randomized controlled trial and 7 observational studies). The risk of MACCE with HCR and CABG were 3.6% and 5.4%, respectively (OR, 0.53; 95% CI, 0.24–1.16). Compared to CABG group, patients in HCR group had similar risk of all cause mortality (OR, 0.85; 95% CI, 0.38–1.88), myocardial infarction (OR, 0.72; 95% CI, 0.31–1.64), stroke (OR, 0.53; 95% CI, 0.23–1.20), and repeat revascularization (OR, 1.28; 95% CI, 0.58–2.83). The need for postoperative blood transfusions (OR, 0.29; 95% CI, 0.14–0.59) and hospital stay (weighted mean difference −1.20 days; 95% CI −1.52 to −0.88 days) was significantly lower in the HCR group. Conclusion HCR appears to be safe, and has similar outcomes when compared with conventional CABG. HCR can be a suitable alternative to conventional CABG in select patients with MVCAD. © 2017 Wiley Periodicals, Inc.

Background: Left ventricular (LV) hypertrophy is considered to be a significant manifestation of increased blood pressure, which is associated with an increased risk of cardiovascular morbidity and mortality. Exercise training is recommended for reducing blood pressure in mild and moderate hypertensive patients. Methods: We conducted a search for interventional studies evaluating the effect of exercise on LV mass index (LVMI) in hypertensive patients. Studies were searched using different databases from 1990 to 2015. The primary end points were change in LVMI, systolic blood pressure (SBP), and diastolic blood pressure (DBP). Of 122 studies, eight studies were found to be eligible for this meta-analysis. Results: The produced effect size was found to be large for LVMI (3.6, 95% confidence interval [CI]: 1.7–5.5) and DBP (2.8, 95% CI: 1.6–3.9) with significant heterogeneity, while moderate (0.56, 95% CI: 0.35–0.77) for SBP without significant heterogeneity. The estimated predictive intervals for LVMI (95% CI: −3.2–10.3) and DBP (95% CI: −1.3–6.8) showed a positive but not significant difference in the intervention and control groups. Conclusion: The study demonstrated a significant reduction in LVMI and DBP in hypertensive patients after exercise training. A moderate reduction in the SBP of these patients was also depicted after exercise. Our study supports the American College of Cardiology/American Heart Association guidelines for regular exercise in hypertension.

It is unknown whether pretreatment with clopidogrel in acute coronary syndrome (ACS) managed invasively, is superior to a strategy of administering clopidogrel in the cardiac catheterization laboratory at the time of percutaneous coronary intervention (PCI). Current practice guidelines do not endorse one strategy over the other.A comprehensive literature search was done to identify all relevant studies comparing pretreatment with clopidogrel to administration in the cardiac catheterization laboratory at the time of PCI (no pretreatment). A meta-analysis using a random effects model was used to calculate outcomes of interest.Our search identified 16 studies including 61,517 ACS patients undergoing cardiac catheterization. At 30days, clopidogrel pretreatment was associated with lower MACE 7.67% vs 9.46% (odds ratio (OR) 0.77, 95% confidence interval (CI) [0.68, 0.86]; P0.0001) and all-cause mortality 2.8% vs 4.1% (OR 0.70, 95% CI [0.58, 0.85]; P=0.0003). Mortality according to the longest follow up available was also significantly lower with pretreatment. No difference in major bleeding events was observed. These results were not significantly different between randomized vs observational studies or STEMI vs NSTEACS patients. Sensitivity analysis showed significantly lower MACE 7.98% vs 9.6% (OR 0.83, 95% CI [0.71, 0.96]; P=0.01) without increased major bleeding in NSTEACS patients undergoing PCI within 48h from pretreatment.In ACS patients undergoing PCI, clopidogrel pretreatment was associated with significantly lower 30day all-cause mortality and major adverse cardiovascular events without increased major bleeding events.

Purpose Limited data exists regarding patients with continuous flow left ventricular assist device (LVAD) support who require long- term inotropes. The primary objective was to evaluate the clinical characteristics and all-cause mortality of LVAD recipients with prolonged inotrope use (PIU), particularly those requiring outpatient inotropic therapy. Secondary endpoints were to compare preimplant characteristics and predictors of PIU, mortality, time to gastrointestinal bleed, infection and arrhythmias. Methods Retrospective cohort study on all adult patients with primary continuous flow LVADs implanted during January 2008 to February 2017 and follow-up through February 2018. We defined PIU as ≥14 days of inotrope support and compared to those who required Results Analytic sample was 203 patients, 58% required PIU and 10% were discharged on inotropes. We found no statistical difference in pre-implant characteristics. One-year survival rate was 87% if no PIU required and 74% if PIU required. Those discharged on inotropes had 72% 1-year survival. PIU was associated with longer length of stay and higher cumulative incidence of gastrointestinal bleeding. We found no association between PIU and late re-initiation of inotropes, infection or arrhythmias. In multivariable analysis the hazard risk of death was increased in patients with PIU (HR=1.66, p=0.046), older age (HR=1.28, p=0.031) and higher creatinine levels (HR=1.60, p=0.007). Conclusion Prolonged inotrope use is frequently encountered following LVAD implantation and associated with adverse prognosis but remains a therapeutic option.

Myocardial bridging is a congenital coronary anomaly with normal epicardial coronary artery taking an intra-myocardial course also described as tunneled artery. The majority of patients with this coronary anomaly are asymptomatic and generally it is a benign condition. However, it is an important cause of myocardial ischemia, which may lead to anginal symptoms, acute coronary syndrome, cardiac arrhythmias and rarely sudden cardiac death. There are numerous studies published in the recent past on understanding the pathophysiology, diagnostic and management strategies of myocardial bridging. This review highlights some of the recent updates in the diagnosis and management of patients with myocardial bridging. We discuss the role of various non-invasive and invasive diagnostic methods to evaluate functional significance of bridging. In addition, role of medical therapy such as beta-blockers, percutaneous coronary intervention with stents/bioresorbable scaffolds and surgical unroofing in patients unresponsive to medical therapy is highlighted as well.

Background Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a heterogeneous disease entity. Its prognosis and predictor of mortality remain unclear. This study aimed to compare the prognosis between MINOCA and myocardial infarction with obstructive coronary artery disease and identify factors related to all‐cause death in MINOCA using a nation‐wide, multicenter, and prospective registry. Methods and Results Among 13 104 consecutive patients enrolled, patients without previous history of significant coronary artery disease who underwent coronary angiography were selected. The primary outcome was 2‐year all‐cause death. Secondary outcomes were cardiac death, noncardiac death, reinfarction, and repeat revascularization. Patients with MINOCA (n=396) and myocardial infarction with obstructive coronary artery disease (n=10 871) showed similar incidence of all‐cause death (9.1% versus 8.8%; hazard ratio [HR], 1.04; 95% CI, 0.74–1.45; P=0.83). Risks of cardiac death, noncardiac death, and reinfarction were not significantly different between the 2 groups (HR, 0.82; 95% CI, 0.53–1.28; P=0.38; HR, 1.55; 95% CI, 0.93–2.56; P=0.09; HR, 1.23; 95% CI, 0.65–2.31; P=0.38, respectively). MINOCA patients had lower incidence of repeat revascularization (1.3% versus 7.2%; HR, 0.17; 95% CI, 0.07–0.41; P, See Editorial Mukherjee

BACKGROUND Recent trials have shown benefits with percutaneous coronary intervention (PCI) on nonculprit coronary vessels in select ST-elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD). However, readmission rates and causes in this high-risk group are unknown. Objective of this study is to explore pattern, causes and factors associated with 30-day readmission after multivessel PCI in STEMI patients. METHODS AND RESULTS Nationwide Readmissions Data (NRD) between 2010 and 2014 was utilized to identify multivessel PCI cases in STEMI patients using appropriate ICD-9 codes. We evaluated 30-day readmission rate and factors associated with 30-day readmission. Hierarchical logistic regression model was used to identify factors associated with 30-day readmission. Among 22,257 STEMI patients who survived to discharge after multivessel PCI, 2,302 (10.3%) were readmitted within 30-days. Subsequent unresolved/aggravated cardiac issues most commonly triggered readmission (62.66%). Among cardiac causes, heart failure and ischemic heart disease were most frequent etiologies. Advancing age (OR: 1.073, 95%CI: 1.026 to 1.122, p = .002), female sex (OR: 1.36, 95%CI: 1.23 to 1.50, p

This article is intended for any physician, administrator, or cardiovascular catheterization laboratory (CCL) staff member who desires a fundamental understanding of finances and economics of CCLs in the United States. The authors' goal is to illuminate general economic principles of CCL operations and provide details that can be used immediately by CCL leaders. Any article on economics in medicine should start by acknowledging the primacy of the principles of medical ethics. While physicians have been trained to act in the best interests of their patients and avoid actions that would harm patients it is vitally important that all professionals in the CCL focus on patients' needs. Caregivers both at the bedside and in the office must consider how their actions will affect not only the patient they are treating at the time, but others as well. If the best interests of a patient were to conflict with any recommendation in this article, the former should prevail. KEY POINTS: To be successful and financially viable under current payment systems, CCL physicians, and managers must optimize the outcomes and efficiency of care by aligning CCL leadership, strategy, organization, processes, personnel, and culture. Optimizing a CCL's operating margin (profitability) requires maximizing revenues and minimizing expenses. CCL managers often focus on expense reduction; they should also pay attention to revenue generation. Expense reduction depends on efficiency (on-time starts, short turn-over time, smooth day-to-day schedules), identifying cost-effective materials, and negotiating their price downward. Revenue optimization requires accurate documentation and coding of procedures, comorbidities, and complications. In fee-for-service and bundled payment reimbursement systems, higher volumes of procedures yield higher revenues. New procedures that improve patient care but are expensive can usually be justified by negotiating with vendors for lower prices and including the "halo effect" of collateral services that accompany the new procedure. Fiscal considerations should never eclipse quality concerns. High quality CCL care that prevents complications, increases efficiency, reduces waste, and eliminates unnecessary procedures represents a win for patients, physicians, and CCL administrators.

Background: The objective of this study was to evaluate the evidence-base supporting the American Heart Association and American College of Cardiology guidelines on peripheral vascular interventions. Methods and Results: American Heart Association/American College of Cardiology guideline documents available as of May 2018 were abstracted for both endovascular and surgical peripheral vascular intervention. The number of recommendations, class of recommendations (I, II, and III) and the distribution of their respective level of evidence (LOE; A, B, and C) were determined for each procedure. Guidelines were also evaluated for changes in recommendations over time. Of 5 current guidelines reporting 134 recommendations, only 13% were supported by LOE A and 39% were supported by LOE C. Overall, most recommendations were class II (54%), while 35% were class I. Lower LOEs were observed for interventions for pulmonary embolism/deep vein thrombosis (A 0%, B 24%, C 76%), inferior vena cava filter (A 0%, B 31%, C 69%), and renal artery stenosis (A 0%, B 67%, C 33%). Comparatively higher LOE A was observed for endovascular stroke therapy (24%). Compared with previous versions, total number of recommendations for lower extremity peripheral artery disease in the current guideline, decreased from 49 to 26, without an improvement in high-quality evidence. Conclusions: There is significant variation in the LOE supporting various peripheral vascular intervention in the current American Heart Association/American College of Cardiology guidelines. Overall, the availability of high-quality evidence remains low and the LOE appears insufficient to support many guideline recommendations for peripheral vascular intervention. These findings highlight the need for more objective and comparative evidence to support the use of endovascular and surgical therapy and in some areas, for updated guidelines.

Coronary artery disease (CAD) is prevalent throughout the world, with a significant impact on global health. There is a vast collection of data in the medical literature relating to the topic of dual antiplatelet therapy (DAPT) in patients considered to be at high cardiovascular (CV) risk. In order to perform a narrative review of literature regarding the use of DAPT in patients with high CV risk, PubMed, Google Scholar and Embase were searched for English-language articles from 1985 to December 2020 by using the medical subject heading terms and keywords 'antiplatelet therapy' and 'high-risk cardiovascular disease', alone or in combination. Both authors critically reviewed the design, population characteristics and results of the selected studies. The topic of DAPT in patients with high CV risk is fluid and constantly evolving. The landmark trials of CURE, TRITON-TIMI 38 and PLATO provided evidence for the optimal use of DAPT in patients after acute coronary syndrome, while the CHARISMA and MATCH trials provided guidance for clinicians for their use in patients with stable coronary artery disease. The American College of Cardiology/American Heart Association focused update, published in 2016, and the European Society of Cardiology guidelines, published in 2017, were developed to provide guidance to clinicians based on the available data at the time to be able to choose the appropriate DAPT strategy that would provide patients with the maximum clinical benefit. The management of DAPT in patients with high CV risk is a challenging task, with new data on the subject constantly being reported. Balancing ischaemic benefit with potential bleeding complications adds to the complexity of managing DAPT in these patients. With all the available data and current clinical guidelines, patients deemed at high CV risk should be considered for DAPT, taking into account individual risk:benefit ratio. In most individuals with high CV risk, the net clinical benefit favours the use of DAPT.

An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC, FAHA Joaquin E. Cigarroa, MD, FACC Lesley H. Curtis, PhD

Studies have shown that iodinated radiocontrast use is associated with acute renal failure especially in the presence of chronic kidney disease and multiple factors modulate this risk. The purpose of this meta-analysis is to compare the incidence of renal failure requiring hemodialysis between transfemoral (TF) and transapical (TA) transcatheter aortic valve replacement using the Edwards valve.The PubMed database was searched from January 2000 through December 2014. A total of 10 studies (n = 2,459) comparing TF (n = 1,268) and TA (n = 1,191) TAVR procedures using the Edwards valve were included. Variables of interest were baseline logistic EuroSCORE, prevalence of diabetes mellitus, hypertension, peripheral arterial disease, chronic kidney disease and amount of contrast used. The primary endpoint was incidence of renal failure requiring hemodialysis. The odds ratio and 95% CI were computed and P0.05 was considered as the level of significance.The logistic EuroSCORE was significantly higher in TA compared to TF (P = 0.001) TAVR. The amount of contrast (mL) used was significantly higher in the TF group compared to the TA group (mean difference: 36.9, CI: 25.7-48.1, P0.001). The incidence of hemodialysis following the procedure was significantly higher in the TA group compared to TF group (odds ratio = 4.3, CI: 2.4-7.8, P0.00001).This meta-analysis suggests that despite the lower amount of contrast used in TA-TAVR, the incidence of renal failure requiring hemodialysis was higher with the Edwards valve. This suggests that the incidence of renal failure requiring hemodialysis after TAVR is associated with baseline comorbidities in the TA-TAVR group rather than the volume of contrast used.

Objectives This study sought to examine predictors, trends, and outcomes associated with β-blocker prescriptions at discharge in patients with stable angina without prior history of myocardial infarction (MI) or systolic heart failure (HF) undergoing elective percutaneous coronary intervention (PCI). Background The benefits of β-blockers in patients with MI and/or systolic HF are well established. However, whether β-blockers affect outcomes in patients with stable angina, especially after PCI, remains uncertain. Methods We included patients with stable angina without prior history of MI, left ventricular systolic dysfunction (left ventricular ejection fraction Results A total of 755,215 patients from 1,443 sites were studied, and 71.4% population of our cohort was discharged on β-blockers. At 3-year follow-up among patients ≥65 years of age with CMS data linkage (16.3% of the studied population), there was no difference in adjusted mortality rate (14.0% vs. 13.3%; adjusted hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.96 to 1.03; p = 0.84), MI (4.2% vs. 3.9%; adjusted HR: 1.00; 95% CI: 0.93 to 1.07; p = 0.92), stroke (2.3% vs. 2.0%; adjusted HR: 1.08; 95% CI: 0.98 to 1.18; p = 0.14) or revascularization (18.2% vs. 17.8%; adjusted HR: 0.97; 95% CI: 0.94 to 1.01; p = 0.10) with β-blocker prescription. However, discharge on β-blockers was associated with more HF readmissions at 3-year follow-up (8.0% vs. 6.1%; adjusted HR: 1.18; 95% CI: 1.12 to 1.25; p Conclusions Among patients ≥65 years of age with history of stable angina without prior MI, systolic HF or left ventricular ejection fraction

Objective To evaluate efficacy and safety of long duration dual anti-platelet therapy i.e., >12months (L-DAPT) and short duration DAPT i.e., ≤12months (S-DAPT) after various drug-eluting stent (DES) implantation. Methods We searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials (RCTs) assessing the effect of L-DAPT versus S-DAPT after sirolimus-eluting (Cypher®); paclitaxel-eluting stents (Taxus®); zotarolimus-eluting (Endeavor®) and everolimus-eluting stents (Xience V®) implantation. Odds ratio (OR) and 95% confidence intervals (CI) were calculated using random-effects models. Subgroup analyses were performed comparing two second generation DES and for RCTs comparing S-DAPT and L-DAPT. Results We included six RCTs that randomized 19,012 patients to S-DAPT versus L-DAPT (4638 in first generation DES; 14,374 in second generation DES; 8099 EES; 4876 in ZES). Compared with L-DAPT, S-DAPT was associated with a higher rate of myocardial infarction (MI) and stent thrombosis (ST) after first [2.65 (1.88, 3.73) and 3.85 (2.14–6.93) respectively] and a higher rate of MI after second generation DES [1.33 (1.06, 1.67)]. There were no significant differences in the rates of all cause mortality, cardiovascular (CV) mortality and stroke with L-DAPT and S-DAPT after implantation of first [0.97 (0.52, 1.81); 1.19 (0.52–2.70); and 1.12 (0.36–3.52) respectively] and second generation DES [0.93 (0.69, 1.25); 0.93 (0.63, 1.36); and 0.58 (0.19, 1.75), respectively]. On further analysis of type of second generation DES, S-DAPT continues to show a higher rate of MI and ST after EES implantation [1.54 (1.11, 2.13) and 2.68 (1.20–5.94) respectively]; however there was no significant difference in the rate of MI and ST with S-DAPT and L-DAPT after ZES implantation [1.07 (0.44, 2.61) and 1.11(0.39, 3.13), respectively]. Conclusion 1) Compared with L-DAPT, S-DAPT was associated with a higher rate of MI without any significant difference in the rate of all cause mortality, CV mortality and stroke after first and second generation DES. 2) Rate of ST was also higher with S-DAPT compared to L-DAPT after first generation DES implantation; however, it was not significantly different after second generation DES. 3) On further subgroup analysis of second-generation stent there was no significant difference in the rate of all cause mortality, CV mortality, MI, ST and stroke with S-DAPT and L-DAPT after ZES implantation. S-DAPT may be optimal for newer generation stents particularly ZES.

Background Use of uninterrupted vitamin K antagonists (VKAs) during ablation of atrial fibrillation is superior to bridging with heparin. Few studies evaluated the use of uninterrupted new oral anticoagulants (NOACs) during ablation of atrial fibrillation. These studies are relatively small in size and mostly underpowered to show differences in the infrequent thromboembolic complications between comparators. Methods We performed the first meta-analysis of uninterrupted NOAC compared with uninterrupted VKA in ablation of atrial fibrillation. We searched the online databases until May 2015 and report outcomes of interest as odds ratios (ORs) using a random effects model. A total of 3544 atrial fibrillation patients in 8 studies who underwent catheter ablation were included in this analysis. Results Overall, stroke and/or transient ischemic attack events were of very low incidence with uninterrupted anticoagulation strategy in 6 of 3544. There were no differences in rates of stroke and/or transient ischemic attack between uninterrupted NOAC and uninterrupted VKA, 0.11% vs 0.22% (OR, 0.65; 95% confidence interval [CI], 0.14-2.96; P = 0.58), nor in major bleeding 0.9% vs 1% (OR, 0.94; 95% CI, 0.48-1.87; P = 0.87). All bleeding 6.5% vs 7.3% (OR, 0.93; 95% CI, 0.67-1.29; P = 0.65), minor bleeding 6.3% vs 7.1% (OR, 0.93; 95% CI, 0.67-1.28), and cardiac tamponade 0.6% vs 0.6% (OR, 1.0; 95% CI, 0.43-2.31; P = 1.0) were all equal with uninterrupted NOACs compared with uninterrupted VKAs. Among 3544 patients, only one death occurred in the VKA group. Conclusions Use of uninterrupted NOACs in ablation appears to be as safe and efficacious as use of uninterrupted VKAs.

To ensure that guidelines reflect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modified and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines (“Task Force”) has issued this focused update to revise guideline recommendations on the basis of recently published data. This update is not based on a complete literature review from the date of previous guideline publications, but it has been subject to rigorous, multilevel review and approval, similar to the full guidelines. For specific focused update criteria and additional methodological details, please see the ACC/AHA guideline methodology manual.1 ### Modernization In response to published reports from the Institute of Medicine2,3 and ACC/AHA mandates,4–7 processes have changed leading to adoption of a “knowledge byte” format. This entails delineation of recommendations addressing specific clinical questions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommodates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving technology (eg, smart phone apps), and supports the evolution of guidelines as “living documents” that can be …

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair [∗∗][1] Nancy M. Albert, PhD, RN, FAHA[∗∗][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD

Data regarding the effects of intraprocedural thrombotic events (IPTE) are scarce. Hence we aim to perform a meta-analysis to examine the outcomes of IPTE compared to non-IPTE during PCI.We performed a literature search of all published full-length articles of studies that reported data on patients with IPTE compared with non-IPTE during PCI. We calculated odd ratios via random effects model.A total of 26,697 patients, of which 1572 patients had IPTE, were included in this analysis. In-hospital, IPTE was associated with higher mortality (odds ratio (OR) 5.36, 95% confidence interval (CI) [2.31, 12.41]; p0.0001), myocardial infarction (MI) and major bleeding compared to non-IPTE. At 30 days, IPTE was also associated with higher mortality (OR 4.57, 95% CI [2.43, 8.60]; p0.0001), MI, repeat revascularization, stent thrombosis and major bleeding compared to non-IPTE group. IPTE was also associated with higher long-term mortality (OR 2.19, 95% CI [1.35, 3.53]; p=0.001). Among IPTE patients, intraprocedural stent thrombosis was associated with greater odds of MI compared to both no reflow and distal embolization events.IPTE during PCI is associated with more adverse ischemic events, including mortality, during the index hospitalization, at 30 days and long-term.

SOURCE CITATION Bonaca MP, Bauersachs RM, Anand SS, et al. Rivaroxaban in peripheral artery disease after revascularization. N Engl J Med. 2020;382:1994-2004. 32222135.

Aims In the CHAMPION PHOENIX trial, the potent, rapidly acting, intravenous platelet adenosine diphosphate receptor antagonist cangrelor reduced the 48-h incidence of major adverse cardiac events (MACE; death, myocardial infarction, stent thrombosis, or ischaemia-driven revascularization) compared with a loading dose of clopidogrel in patients undergoing percutaneous coronary intervention (PCI). We sought to determine whether the efficacy of cangrelor during PCI varies in patients with simple vs. complex target lesion coronary anatomy. Methods and results Blinded angiographic core laboratory analysis was completed in 10 854 of 10 942 (99.2%) randomized patients in CHAMPION PHOENIX (13 418 target lesions). Outcomes were analysed according to the number of angiographic PCI target lesion high-risk features (HRF) present (bifurcation, left main, thrombus, angulated, tortuous, eccentric, calcified, long, or multi-lesion treatment). The number of patients with 0, 1, 2, and ≥3 HRFs was 1817 (16.7%), 3442 (31.7%), 2901 (26.7%), and 2694 (24.8%), respectively. The 48-h MACE rate in clopidogrel-treated patients increased progressively with lesion complexity (from 3.3% to 4.4% to 6.9% to 8.7%, respectively, P

Background Previous studies comparing outcomes between culprit vessel only percutaneous coronary intervention (CV-PCI) versus multivessel percutaneous coronary intervention (MV-PCI) in patients with cardiogenic shock in the setting of acute myocardial infarction have shown conflicting results. This meta-analysis investigates the optimal approach for management of these patients considering recently published data. Methods Electronic databases including MEDLINE, ClinicalTrials.gov and the Cochrane Library were searched for all clinical studies published until May 1, 2018, which compared outcomes in patients presenting with acute myocardial infarction and cardiogenic shock. Studies comparing CV-PCI versus MV-PCI in patients with multivessel coronary artery disease were screened for inclusion in final analysis. The primary end point was in-hospital/30 day mortality. Secondary endpoints included long term (>6 months) mortality, renal failure requiring renal replacement therapy, stroke, bleeding, and recurrent myocardial infarction. Odds ratio (OR) with 95% of confidence interval (CI) were computed and p values Results Patient who underwent CV-PCI had significantly lower short-term mortality (in-hospital or 30-day mortality) (OR: 0.73, CI: 0.61–0.87, p = 0.0005), and lower odds of severe renal failure requiring renal replacement therapy (OR: 0.76, CI: 0.59‐0.98, p = 0.03). There was no statistically significant difference in long-term mortality, stroke, bleeding, and recurrent myocardial infarction between two groups. Conclusion This meta-analysis showed lower short-term mortality and decreased odds of renal failure requiring renal replacement therapy with CV-PCI compared to MV-PCI. However, subgroup analysis including studies exclusively assessing STEMI patients revealed no statistically significant difference in outcomes. Further randomized trials are needed to confirm these findings and evaluate long term results.