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Background: Diet intervention forms the cornerstone for cardiovascular disease (CVD) management., Objective: The objective was to measure the frequency of dietary counseling documentation for patients recently hospitalized with CVD., Design: This was an observational study., Participants and Setting: Patients were included from the Michigan Value Collaborative Multipayer Claims Registry from October 2015 to February 2020., Main Outcome Measure: The study measured the frequency of medical claims that document dietary counseling ≤90 days after hospitalization (ie, an episode of care) for CVD events (coronary artery bypass grafting, acute myocardial infarction, congestive heart failure, and percutaneous coronary intervention). Dietary counseling documentation was defined as having an encounter-level International Classification of Diseases 10th Revision code for dietary counseling or current procedural terminology code for medical nutrition therapy or cardiac rehabilitation., Statistical Analyses Performed: Multivariable logistic regression was used to measure variation in documentation across gender, age, comorbidities, hospital geography, CVD event, and insurer., Results: There were 175,631 episodes of care (congesitve heart failure 47.1%, acute myocardial infarction 28.7%, percutaneous coronary intervention 17.0%, and coronary artery bypass grafting 7.3%) among 146,185 individuals. Most episodes occurred among men (55.8%) and those older than age 65 years (71.9%). Dietary counseling was documented for 22.8% of episodes and was more common as cardiac rehabilitation (18.6%) than other encounter types (5.1%). In multivariable analysis, there was lower odds for dietary counseling documentation among those older than age 65 years (odds ratio [OR] 0.77; P < .001), women (OR 0.83; P < .001), with chronic kidney disease (OR 0.74; P < .001), or diabetes (OR 0.95; P < .001), but greater odds for those with obesity (OR 1.28; P < .001) and nonmetropolitan hospitals (OR 1.31; P < .001). Compared with coronary artery bypass grafting, acute myocardial infarction (OR 0.29; P < .001), confestive heart failure (OR 0.12; P < .001), and percutaneous coronary intervention (OR 0.36; P < .001) episodes had lower odds to have dietary counseling coded. Compared with Traditional Medicare, Medicaid and Medicare Advantage health maintenance organization plans had lower odds, whereas Commercial or Medicare Advantage preferred provider organization and Commercial health maintenance organization plans had higher odds to have dietary counseling documented. Results were mostly similar when evaluated by race., Conclusions: Dietary counseling was infrequently documented after hospitalization for CVD episodes in medical claims in a Michigan-based multipayer claims database with large variation by reason for hospitalization and patient factors., (Copyright © 2024 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Text messages may enhance physical activity levels in patients with cardiovascular disease, including those enrolled in cardiac rehabilitation. However, the independent and long-term effects of text messages remain uncertain., Methods: The VALENTINE study (Virtual Application-supported Environment to Increase Exercise) was a micro-randomized trial that delivered text messages through a smartwatch (Apple Watch or Fitbit Versa) to participants initiating cardiac rehabilitation. Participants were randomized 4× per day over 6-months to receive no text message or a message encouraging low-level physical activity. Text messages were tailored on contextual factors (eg, weather). Our primary outcome was step count 60 minutes following a text message, and we used a centered and weighted least squares mean method to estimate causal effects. Given potential measurement differences between devices determined a priori, data were assessed separately for Apple Watch and Fitbit Versa users over 3 time periods corresponding to the initiation (0-30 days), maintenance (31-120 days), and completion (121-182 days) of cardiac rehabilitation., Results: One hundred eight participants were included with 70 552 randomizations over 6 months; mean age was 59.5 (SD, 10.7) years with 36 (32.4%) female and 68 (63.0%) Apple Watch participants. For Apple Watch participants, text messages led to a trend in increased step count by 10% in the 60-minutes following a message during days 1 to 30 (95% CI, -1% to +20%), with no effect from days 31 to 120 (+1% [95% CI, -4% to +5%]), and a significant 6% increase during days 121 to 182 (95% CI, +0% to +11%). For Fitbit users, text messages significantly increased step count by 17% (95% CI, +7% to +28%) in the 60-minutes following a message in the first 30 days of the study with no effect subsequently., Conclusions: In patients undergoing cardiac rehabilitation, contextually tailored text messages may increase physical activity, but this effect varies over time and by device., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04587882., Competing Interests: Dr Golbus receives funding from the National Institutes of Health (NIH; L30HL143700, 1K23HL168220) and PCORI. Dr Nallamothu is a principal investigator or coinvestigator on research grants from the NIH, VA HSR&D and the American Heart Association. He also receives compensation as Editor-in-Chief of Circulation: Cardiovascular Quality and Outcomes, a journal of the American Heart Association. Finally, he is a coinventor on US Utility Patent Number US15/356 012 (US20170148158A1) entitled Automated Analysis of Vasculature in Coronary Angiograms that uses software technology with signal processing and machine learning to automate the reading of coronary angiograms, held by the University of Michigan. The patent is licensed to AngioInsight Inc, in which Dr Nallamothu holds ownership shares and receives consultancy fees. Dr SachinKheterpal is a principal investigator or coinvestigator on research grants from the US NIH, Blue Cross Blue Shield of Michigan, the American Heart Association, Apple, Merck & Co, and Becton Dickinson & Company; and is a coinventor on US patent number 62/791 257 entitled Automated System To Medical Procedures, which is held by the University of Michigan. Dr Klasnja is a principal investigator or a coinvestigator on research grants from NIH. Dr Murphy is a principal investigator or a coinvestigator on research grants from NIH. Dr Vik Kheterpal is a Principal and employee of CareEvolution. V. Taralunga is a Software Architect employed by CareEvolution. The other authors report no conflicts.

Background: Clinical guidelines recommend that older patients (65+) with mild cognitive impairment (MCI) and early-stage dementia receive similar guideline-concordant care after cardiovascular disease (CVD) events as those with normal cognition (NC). However, older patients with MCI and dementia receive less care for CVD and other conditions than those with NC. Whether physician recommendations for guideline-concordant treatments after two common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke (stroke), differ between older patients with NC, MCI, and early-stage dementia is unknown., Objective: To test the influence of patient cognitive status (NC, MCI, early-stage dementia) on physicians' recommendations for guideline-concordant treatments for AMI and stroke., Design: We conducted two parallel, randomized survey studies for AMI and stroke in the US using clinical vignettes where the hypothetical patient's cognitive status was randomized between physicians., Participants: The study included cardiologists, neurologists, and generalists who care for most patients hospitalized for AMI and stroke., Main Measures: The primary outcome was a composite quality score representing the number of five guideline-concordant treatments physicians recommended for a hypothetical patient after AMI or stroke., Key Results: 1,031 physicians completed the study (58.5% response rate). Of 1,031 respondents, 980 physicians had complete information. After adjusting for physician factors, physicians recommended similar treatments after AMI and stroke in hypothetical patients with pre-existing MCI (adjusted ratio of expected composite quality score, 0.98 [95% CI, 0.94, 1.02]; P = 0.36) as hypothetical patients with NC. Physicians recommended fewer treatments to hypothetical patients with pre-existing early-stage dementia than to hypothetical patients with NC (adjusted ratio of expected composite quality score, 0.90 [0.86, 0.94]; P < 0.001)., Conclusion: In these randomized survey studies, physicians recommended fewer guideline-concordant AMI and stroke treatments to hypothetical patients with early-stage dementia than those with NC. We did not find evidence that physicians recommend fewer treatments to hypothetical patients with MCI than those with NC., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Importance: Food insecurity is a risk factor for poor cardiovascular outcomes that occur disproportionately among individuals from racial and ethnic minority backgrounds who have cardiovascular disease (CVD) or cardiometabolic risk factors., Objective: To assess long-term prevalence of food insecurity among those with CVD or cardiometabolic risk factors in the United States., Design, Setting, and Participants: This serial cross-sectional study includes data for noninstitutionalized US adults from the National Health and Nutrition Examination Survey (1999-2018)., Main Outcomes and Measures: Food insecurity was assessed using the US Department of Agriculture Adult Food Security Survey Module. We estimated prevalence of food insecurity among adults with prior CVD (myocardial infarction, stroke, heart failure) and cardiometabolic risk factors (hypertension, diabetes, obesity, hyperlipidemia) across racial and ethnic groups and prevalence of Supplemental Nutrition Assistance Program (SNAP) participation among those reporting food insecurity., Results: In the analytic sample of 57 517 adults, 6770 individuals (11.8%) reported food insecurity, which was more prevalent among Hispanic (1938 [24.0%]) and non-Hispanic Black (1202 [18.2%]) than non-Hispanic Asian (100 [8.0%]) and non-Hispanic White adults (3221 [8.5%]). Among 57 517 adults, 4527 (7.9%) had any CVD, 2933 (5.1%) coronary artery disease, 1536 (2.7%) stroke, 1363 (2.4%) heart failure, 28 528 (49.6%) hypertension, 17 979 (33.2%) obesity, 6418 (11.2%) diabetes, and 19 178 (30.8%) dyslipidemia. All CVD and cardiometabolic diseases except coronary artery disease were more prevalent among those with food insecurity. Food insecurity increased over time and was more frequent for patients with CVD but not for cardiometabolic risk factors. From 2011 to 2018, non-Hispanic Black adults with CVD had a decrease in food insecurity prevalence (36.6%; 95% CI, 23.9%-49.4%, to 25.4%; 95% CI, 21.4%-29.3%; P = .04 for trend), whereas adults of other races and ethnicities or data based on cardiometabolic risk factors had no significant change. For individuals who had food insecurity, SNAP participation was higher among those with CVD vs without CVD (54.2%; 95% CI, 46.6%-61.8%, vs 44.3%; 95% CI, 40.5%-48.1%; P = .01)., Conclusions and Relevance: The prevalence of food insecurity among patients with CVD increased over time. Although members of non-Hispanic Black and Hispanic groups had the highest food insecurity, non-Hispanic Black individuals with CVD were the only group to have a significant decrease in food insecurity since 2011. Increased recognition of food insecurity and resources for treating it are needed to address the negative consequences of food insecurity on CVD outcomes.

Background: In-person, exercise-based cardiac rehabilitation improves physical activity and reduces morbidity and mortality for patients with cardiovascular disease. However, activity levels may not be optimized and decline over time after patients graduate from cardiac rehabilitation. Scalable interventions through mobile health (mHealth) technologies have the potential to augment activity levels and extend the benefits of cardiac rehabilitation., Methods: The VALENTINE Study is a prospective, randomized-controlled, remotely-administered trial designed to evaluate an mHealth intervention to supplement cardiac rehabilitation for low- and moderate-risk patients (ClinicalTrials.gov NCT04587882). Participants are randomized to the control or intervention arms of the study. Both groups receive a compatible smartwatch (Fitbit Versa 2 or Apple Watch 4) and usual care. Participants in the intervention arm of the study additionally receive a just-in-time adaptive intervention (JITAI) delivered as contextually tailored notifications promoting low-level physical activity and exercise throughout the day. In addition, they have access to activity tracking and goal setting through the mobile study application and receive weekly activity summaries via email. The primary outcome is change in 6-minute walk distance at 6-months and, secondarily, change in average daily step count. Exploratory analyses will examine the impact of notifications on immediate short-term smartwatch-measured step counts and exercise minutes., Conclusions: The VALENTINE study leverages innovative techniques in behavioral and cardiovascular disease research and will make a significant contribution to our understanding of how to support patients using mHealth technologies to promote and sustain physical activity., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system-, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.

Smartphone and wearable device use is rising broadly and can be leveraged for chronic disease management. Just-in-time adaptive interventions promise to deliver personalized, dynamic interventions directly to patients through use of push notifications from mobile devices. Although just-in-time adaptive interventions are a powerful tool for shaping health behavior, their application to cardiovascular disease management has been limited as they can be challenging to design. Herein, we provide a general overview and conceptual framework for microrandomized trials, a novel experimental study design that can be used to optimize just-in-time adaptive interventions. Microrandomized trials leverage mobile devices to sequentially randomize participants to types or levels of an intervention to determine the effectiveness of an intervention and time-varying moderators of those effects. Microrandomized trials are an efficient study design that can be used to determine which intervention components to include in just-in-time adaptive interventions and to optimize their decision rules while maintaining the strength of causal inference associated with traditional randomized controlled trials.

Importance: Although cardiovascular disease is the leading cause of death in most developed countries, little is known about current physicians' cardiovascular health and outcomes., Objective: To compare cardiac risk factor burden, health services use, and major cardiovascular event incidence between physicians and the general population., Design, Setting, and Participants: This cohort study used data from practicing physicians and nonphysicians without cardiovascular disease aged 40 to 75 years in Ontario, Canada. Cohorts were assembled beginning January 1, 2008, and were followed up to December 31, 2015. Data analysis was performed between November 2017 and September 2019., Exposure: Being a practicing physician., Main Outcomes and Measures: The primary outcome was 8-year incidence of a major cardiovascular event (ie, cardiovascular death or hospitalization for myocardial infarction, stroke, heart failure, or coronary revascularization). Secondary outcomes included health services used, such as physician assessments and guideline-recommended tests., Results: The cohort comprised 17 071 physicians (mean [SD] age, 53.3 [8.8] years; 11 963 [70.1%] men) and 5 306 038 nonphysicians (mean [SD] age, 53.7 [9.5] years; 2 556 044 [48.2%] men). Physicians had significantly lower baseline rates of hypertension (16.9% vs 29.6%), diabetes (5.0% vs 11.3%), and smoking (13.1% vs 21.6%), while having better cholesterol profiles (total cholesterol levels >240 mg/dL, 13.3% vs 16.5%; low-density lipoprotein cholesterol >130 mg/dL, 33.2% vs 36.8%); age- and sex-adjusted differences were even larger. Physicians also had lower rates of periodic health examinations (58.9% [95% CI, 57.5%-60.4%] vs 67.9% [95% CI, 67.8%-67.9%]), hyperlipidemia screening (76.3% [95% CI, 74.7%-78.0%] vs 83.8% [95% CI, 83.7%-83.9%]), and diabetes screening (79.0% [95% CI, 77.3%-80.8%] vs 85.3% [95% CI, 85.2%-85.4%]), but higher rates of cardiologist consultations (25.2% [95% CI, 24.2%-26.3%] vs 19.5% [95% CI, 19.4%-19.5%]). The 8-year age- and sex-standardized primary outcome incidence was 4.4 major cardiovascular events per 1000 person-years for physicians and 7.1 major cardiovascular events per 1000 person-years for the general population. After adjusting for age, sex, socioeconomic status, and cardiac risks and comorbidities, physicians had a 22% lower hazard (hazard ratio, 0.78; 95% CI, 0.72-0.85) of experiencing the primary outcome compared with the general population., Conclusions and Relevance: Practicing physicians in Ontario had fewer cardiovascular risk factors, underwent less preventive testing, and were less likely to experience major adverse cardiovascular outcomes than the general population.

Background: Despite widespread adoption of Medicare accountable care organizations (ACOs), healthcare spending reductions have been modest. This may relate to variable participation in ACOs by specialist physicians, who disproportionately drive spending. To examine whether specialist participation in Medicare ACOs was associated with changes in healthcare spending and clinical quality, we analyzed national Medicare data., Methods and Results: Working with a 20% random sample of Medicare beneficiaries (2008 to 2015), we identified those with cardiovascular disease. We estimated linear regression models at the beneficiary-quarter level to evaluate changes in healthcare spending and clinical quality after the start of the Shared Savings Program in 2012. We then examined whether changes in spending and quality across ACOs were conditional on cardiologist participation. Our study included ≈1.6 million beneficiaries per year. Although the number of ACOs increased over the study period (from 114 in 2012 to 392 in 2015), the proportion with any cardiologist participation remained stable (from 80% in 2012 to 83% in 2015). Compared with unaligned beneficiaries, those cared for by ACOs without cardiologist participation were associated with a spending reduction (per quarter) of -$75 (95% CI, -$105 to -$46; P <0.001). Care receipt in an ACO with cardiologist participation was associated with an additional difference in spending of -$56 (95% CI, -$87 to -$25; P <0.001), driven by lower spending for skilled nursing facilities, evaluation and management services, procedural care, and testing. While heart failure admission rates were similar among aligned and unaligned beneficiaries, ACO care was associated with fewer all-cause readmissions ( P <0.001) and emergency department visits ( P <0.001). Rates of these outcomes did not vary by cardiologist participation., Conclusions: Annual spending for beneficiaries with cardiovascular disease was ≈$200 lower when cared for by ACOs with cardiologist participation (compared with those without). These spending reductions did not come at the expense of clinical quality.

Importance: Cardiovascular disease (CVD) is a leading cause of death among patients with end-stage renal disease (ESRD). Young adult (ages 22-29 years) have risks for ESRD-associated CVD that may vary from other ages., Objective: To test the hypothesis that young adult-onset ESRD is associated with higher cardiovascular (CV) hospitalizations and mortality with different characteristics than childhood-onset disease., Design, Setting, and Participants: This population-based cohort study used the US Renal Data System to categorize patients who initiated ESRD care between 2003 and 2013 by age at ESRD onset (1-11, 12-21, and 22-29 years). Cardiovascular hospitalizations were identified via International Classification of Diseases, Ninth Revision discharge codes and CV mortality from the Centers for Medicare & Medicaid ESRD Death Notification Form. Patients were censored at death from non-CVD events, loss to follow-up, recovery, or survival to December 31, 2014. Adjusted proportional hazard models (95% CI) were fit to determine risk of CV hospitalization and mortality by age group. Data analysis occurred from May 2016 and December 2017., Exposures: Onset of ESRD., Main Outcomes and Measures: Cardiovascular mortality and hospitalization., Results: A total of 33 156 patients aged 1 to 29 years were included in the study population. Young adults (aged 22-29 years) had a 1-year CV hospitalization rate of 138 (95% CI, 121-159) per 1000 patient-years. Young adults had a higher risk for CV hospitalization than children (aged 1-11 years; hazard ratio [HR], 0.41 [95% CI, 0.26-0.64]) and adolescents (aged 12-21 years; HR, 0.86 [95% CI, 0.77-0.97]). Of 4038 deaths in young adults, 1577 (39.1%) were owing to CVD. Five-year cumulative incidence of mortality in this group (7.3%) was higher than in younger patients (adolescents, 4.0%; children, 1.7%). Adjusted HRs for CV mortality were higher for young adults with all causes of ESRD than children (cystic, hereditary, and congenital conditions: HR, 0.22 [95% CI, 0.11-0.46]; P < .001; glomerulonephritis: HR, 0.21 [95% CI, 0.10-0.44]; P < .001; other conditions: HR, 0.33 [95% CI, 0.23-0.49]; P < .001). Adolescents had a lower risk for CV mortality than young adults for all causes of ESRD except glomerulonephritis (cystic, hereditary, and congenital conditions: HR, 0.45 [95% CI, 0.27-0.74]; glomerulonephritis: HR, 0.99 [95% CI, 0.76-1.11]; other: HR, 0.47 [95% CI, 0.40-0.57]). Higher risks for CV hospitalization and mortality were associated with lack of preemptive transplant compared with hemodialysis (hospital: HR, 14.24 [95% CI, 5.92-34.28]; mortality: HR, 13.64 [95% CI, 8.79-21.14]) and peritoneal dialysis [hospital: HR, 8.47 [95% CI, 3.50-20.53]; mortality: HR, 7.86 [95% CI, 4.96-12.45]). Nephrology care before ESRD was associated with lower risk for CV mortality (HR, 0.77 [95% CI, 0.70-0.85])., Conclusions and Relevance: Cardiovascular disease accounted for nearly 40% of deaths in young adults with incident ESRD in this cohort. Identified risk factors may inform development of age-appropriate ESRD strategies to improve the CV health of this population.

Background: Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures., Methods and Results: The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures among patients of PGPD practices compared with patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% confidence interval, -0.51% to 0.85%; P=0.595) or discretionary coronary imaging (-0.19%; 95% confidence interval, -0.73% to 0.35%; P=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% confidence interval, -0.008% to 0.002%; P=0.705) and coronary revascularization (-0.02%; 95% confidence interval, -0.11% to 0.07%; P=0.06). The difference-in-difference associated with PGPD implementation was also essentially 0 for nondiscretionary cardiovascular imaging or procedures., Conclusion: Implementation of a pilot accountable care organization did not limit the use of discretionary or nondiscretionary cardiovascular care in 10 large health systems., (© 2014 American Heart Association, Inc.)

Education, justification, and optimization are the cornerstones to enhancing the radiation safety of medical imaging. Education regarding the benefits and risks of imaging and the principles of radiation safety is required for all clinicians in order for them to be able to use imaging optimally. Empowering patients with knowledge of the benefits and risks of imaging will facilitate their meaningful participation in decisions related to their health care, which is necessary to achieve patient-centered care. Limiting the use of imaging to appropriate clinical indications can ensure that the benefits of imaging outweigh any potential risks. Finally, the continually expanding repertoire of techniques that allow high-quality imaging with lower radiation exposure should be used when available to achieve safer imaging. The implementation of these strategies in practice is necessary to achieve high-quality, patient-centered imaging and will require a shared effort and investment by all stakeholders, including physicians, patients, national scientific and educational organizations, politicians, and industry.

IMPORTANCE Current guidelines allow substantial discretion in use of noninvasive cardiac imaging for patients without acute myocardial infarction (AMI) who are being evaluated for ischemia. Imaging use may affect downstream testing and outcomes. OBJECTIVE To characterize hospital variation in use of noninvasive cardiac imaging and the association of imaging use with downstream testing, interventions, and outcomes. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of hospitals using 2010 administrative data from Premier, Inc, including patients with suspected ischemia on initial evaluation who were seen in the emergency department, observation unit, or inpatient ward; received at least 1 cardiac biomarker test on day 0 or 1; and had a principal discharge diagnosis for a common cause of chest discomfort, a sign or symptom of cardiac ischemia, and/or a comorbidity associated with coronary disease. We excluded patients with AMI. MAIN OUTCOMES AND MEASURES At each hospital, the proportion of patients who received noninvasive imaging to identify cardiac ischemia and the subsequent rates of admission, coronary angiography, and revascularization procedures. RESULTS We identified 549,078 patients at 224 hospitals. The median (interquartile range) hospital noninvasive imaging rate was 19.8% (10.9%-27.7%); range, 0.2% to 55.7%. Median hospital imaging rates by quartile were Q1, 6.0%; Q2, 15.9%; Q3, 23.5%; Q4, 34.8%. Compared with Q1, Q4 hospitals had higher rates of admission (Q1, 32.1% vs Q4, 40.0%), downstream coronary angiogram (Q1, 1.2% vs Q4, 4.9%), and revascularization procedures (Q1, 0.5% vs Q4, 1.9%). Hospitals in Q4 had a lower yield of revascularization for noninvasive imaging (Q1, 7.6% vs Q4, 5.4%) and for angiograms (Q1, 41.2% vs Q4, 38.8%). P <.001 for all comparisons. Readmission rates to the same hospital for AMI within 2 months were not different by quartiles (P = .51). Approximately 23% of variation in imaging use was attributable to the behavior of individual hospitals. CONCLUSIONS AND RELEVANCE Hospitals vary in their use of noninvasive cardiac imaging in patients with suspected ischemia who do not have AMI. Hospitals with higher imaging rates did not have substantially different rates of therapeutic interventions or lower readmission rates for AMI but were more likely to admit patients and perform angiography.

Background: This study aimed at understanding whether investigators from less wealthy countries were at a disadvantage in disseminating their research, after accounting for potential differences in research quality and infrastructure., Methods and Results: In this bibliometric analysis a representative random selection of 10% (n=1002 studies) of all abstracts submitted to the European Society of Cardiology (ESC) congress 2006 was followed for publication and citation from September 2006 to December 2011. The main variable of interest was the per-capita gross domestic product (GDP) of the country of the principal investigator. Using multivariable models that adjusted for socioeconomic indicators and previously identified markers of research quality, we examined the relationship between per-capita GDP and three study endpoints: Acceptance at the ESC congress, full-text publication, and number of two-year citations. Among 1002 abstracts from 63 countries, per-capita GDP was positively correlated with all three study endpoints. After adjusting for markers of research quality and infrastructure, per-capita GDP remained a strong predictor for acceptance at the ESC congress (adjusted OR for every 10,000 USD increase in per-capita GDP, 1.44; 95% CI, 1.15 to 1.80), full-text publication within 5years (adjusted OR, 1.49; 95% CI, 1.17 to 1.90), and high citation frequency (adjusted OR, 2.30; 95% CI, 1.31 to 4.04). These findings were largely consistent in a subgroup of abstracts of high-quality, prospective clinical trials., Conclusion: Investigators in less wealthy countries face challenges to disseminate their research, even after accounting for potential differences in the quality of their work and research infrastructure., (© 2013. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: Clinical guidelines recommend that older patients (65+) with mild cognitive impairment (MCI) and early-stage dementia receive similar guideline-concordant care after cardiovascular disease (CVD) events as those with normal cognition (NC). However, older patients with MCI and dementia receive less care for CVD and other conditions than those with NC. Whether physician recommendations for guideline-concordant treatments after two common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke (stroke), differ between older patients with NC, MCI, and early-stage dementia is unknown. Objective: To test the influence of patient cognitive status (NC, MCI, early-stage dementia) on physicians' recommendations for guideline-concordant treatments for AMI and stroke. Design: We conducted two parallel, randomized survey studies for AMI and stroke in the US using clinical vignettes where the hypothetical patient's cognitive status was randomized between physicians. Participants: The study included cardiologists, neurologists, and generalists who care for most patients hospitalized for AMI and stroke. Main Measures: The primary outcome was a composite quality score representing the number of five guideline-concordant treatments physicians recommended for a hypothetical patient after AMI or stroke. Key Results: 1,031 physicians completed the study (58.5% response rate). Of 1,031 respondents, 980 physicians had complete information. After adjusting for physician factors, physicians recommended similar treatments after AMI and stroke in hypothetical patients with pre-existing MCI (adjusted ratio of expected composite quality score, 0.98 [95% CI, 0.94, 1.02]; P = 0.36) as hypothetical patients with NC. Physicians recommended fewer treatments to hypothetical patients with pre-existing early-stage dementia than to hypothetical patients with NC (adjusted ratio of expected composite quality score, 0.90 [0.86, 0.94]; P < 0.001). Conclusion: In these randomized survey studies, physicians recommended fewer guideline-concordant AMI and stroke treatments to hypothetical patients with early-stage dementia than those with NC. We did not find evidence that physicians recommend fewer treatments to hypothetical patients with MCI than those with NC. [ABSTRACT FROM AUTHOR]

Background and objective: Previous reports indicated that patients on thrice-weekly hemodialysis (HD) had higher mortality rates after the 3-day interdialytic interval. However, day-of-the-week patterns of emergency department (ED) visits and hospitalizations remain under-investigated. Methods: We conducted a retrospective cohort study of HD patients on thrice-weekly dialysis, using 2013 data from the United States Renal Data System (USRDS). We estimated crude incidence rates of ED visits and hospitalizations by day of the week and dialysis schedule (Monday, Wednesday, Friday or Tuesday, Thursday, Saturday). Using Poisson regression, we estimated case-mix adjusted rate ratios of all-cause ED visits and hospitalizations, and adjusted rates of cause-specific ED visits and hospitalizations. Results: We identified 241,093 eligible HD patients in 2013, who had 514,773 ED visits and 301,674 hospitalizations that year. Three distinct but related patterns of outcome events were observed. Crude and adjusted incidence rates of all-cause, cardiovascular, and infection-related ED visits and hospitalizations, but not vascular-access-related events, were higher on all three HD treatment days (“dialysis-day effect”). Rates for ED visits and hospitalizations were lower on weekends than weekdays, rising appreciably from Sunday to Monday for both dialysis schedules (“post-weekend effect”); and rates were highest after the long 3-day interval between dialysis sessions for both dialysis schedules (“interdialytic-gap effect”). In contrast, rates of hospitalizations not preceded by an ED visit were nearly the same Monday through Friday and lower on weekends for both dialysis schedules. Conclusions: Higher rates of ED visits and hospitalizations on the days of HD sessions and early in the week are a public-health concern that should stimulate research to explain these patterns and reduce the excessive morbidity and associated costs among patients on thrice-weekly HD, while improving quality of care and patient experience with dialysis. [ABSTRACT FROM AUTHOR]

Objective: This study aims to determine the relationship between door-to-balloon delay in primary percutaneous coronary intervention and ST-elevation myocardial infarction (MI) outcomes and examine for potential effect modifiers.Methods: We conducted a systematic review and meta-analysis of prospective observational studies that have investigated the relationship of door-to-balloon delay and clinical outcomes. The main outcomes include mortality and heart failure.Results: 32 studies involving 299 320 patients contained adequate data for quantitative reporting. Patients with ST-elevation MI who experienced longer (>90 min) door-to-balloon delay had a higher risk of short-term mortality (pooled OR 1.52, 95% CI 1.40 to 1.65) and medium-term to long-term mortality (pooled OR 1.53, 95% CI 1.13 to 2.06). A non-linear time-risk relation was observed (P=0.004 for non-linearity). The association between longer door-to-balloon delay and short-term mortality differed between those presented early and late after symptom onset (Cochran's Q 3.88, P value 0.049) with a stronger relationship among those with shorter prehospital delays.Conclusion: Longer door-to-balloon delay in primary percutaneous coronary intervention for ST-elevation MI is related to higher risk of adverse outcomes. Prehospital delays modified this effect. The non-linearity of the time-risk relation might explain the lack of population effect despite an improved door-to-balloon time in the USA.Clinical Trial Registration: PROSPERO (CRD42015026069). [ABSTRACT FROM AUTHOR]

Background: Revascularization decisions can profoundly impact patient survival, quality of life, and procedural risk. Although use of Heart Teams to make revascularization decisions is growing, data on their implementation in the real-world are limited. Our objective was to assess the prevalence of Heart Teams and their association with collaboration in routine practice. Methods: A survey of cardiologists and cardiac surgeons at 31 hospitals in Michigan was performed in May, 2011 – prior to the recommendation for using Heart Teams in national guidelines. This survey included all percutaneous coronary intervention-performing hospitals in Michigan participating in the Blue Cross/Blue Shield of Michigan Cardiovascular Consortium and Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. It targeted both the use of Heart Teams and multidisciplinary Case Conferences. Results: There were 53 physician survey respondents from 27 hospitals with 4 hospitals not responding. Among respondents, 11 (40.7%) hospitals reported no Heart Teams or Case Conferences while 7 (25.9%) hospitals reported either a Heart Team or Case Conference. However, there was disagreement about the presence of a Heart Team at seven hospitals, and about Case Conferences at nine hospitals. Hospitals with definite Heart Teams reported significantly greater levels of collaboration between cardiologists and cardiac surgeons. Conclusion: The overall presence of Heart Teams prior to their recommendation in national guidelines was limited. Even among hospitals with a potential Heart Team, there was substantial disagreement between respondents about their presence. Further refinement of the definition of a Heart Team and measures of successful implementation are needed. [ABSTRACT FROM AUTHOR]

The article presents the case of a 44-year-old male who was rushed to the emergency department with chest pain that has awakened him from sleep and is accompanied by nausea and nonbilious, nonbloody vomiting. He has no family history of premature coronary artery disease. He was diagnosed to be suffering from primary myelofibrosis.

Background: Patients with acute myocardial infarction (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability, yet we know little about the basis for how such revascularization hospitals are selected.Methods and Results: We examined interhospital transfer patterns in 71 336 AMI patients admitted to hospitals without revascularization capabilities in the 2006 Medicare claims using network analysis and regression models. A total of 31 607 (44.3%) AMI patients were transferred from 1684 nonrevascularization hospitals to 1104 revascularization hospitals. Median time to transfer was 2 days. Median transfer distance was 26.7 miles, with 96.1% within 100 miles. In 45.8% of cases, patients bypassed a closer hospital to go to a farther hospital that had a better 30-day risk standardized mortality rates. However, in 36.8% of cases, another revascularization hospital with lower 30-day risk-standardized mortality was actually closer to the original admitting nonrevascularization hospital than the observed transfer destination. Adjusted regression models demonstrated that shorter transfer distances were more common than transfers to the hospitals with lowest 30-day mortality rates. Simulations suggest that an optimized system that prioritized the transfer of AMI patients to a nearby hospital with the lowest 30-day mortality rate might produce clinically meaningful reductions in mortality.Conclusions: More than 40% of AMI patients admitted to nonrevascularization hospitals are transferred to revascularization hospitals. Many patients are not directed to nearby hospitals with the lowest 30-day risk-standardized mortality, and this may represent an opportunity for improvement. [ABSTRACT FROM AUTHOR]

Acute kidney injury, cardiovascular diseases, computed tomography angiography, contrast media, practice guideline, renal insufficiency, chronic Keywords: acute kidney injury; cardiovascular diseases; computed tomography angiography; contrast media; practice guideline; renal insufficiency, chronic EN acute kidney injury cardiovascular diseases computed tomography angiography contrast media practice guideline renal insufficiency, chronic 847 849 3 03/14/23 20230314 NES 230314 In 2020, the American College of Radiology and the National Kidney Foundation released consensus statements declaring the prevalence of contrast-induced acute kidney injury (CI-AKI) to be much lower than historically reported.[1] This guideline concluded that most CI-AKI from intravenous contrast medium administration is not caused by contrast medium, but instead by coincident nephrotoxic exposures.[1],[2] It was a dramatic shift in thinking. These differences may relate to the contrast medium (eg, contrast medium dose, contrast medium concentration received by the kidneys, such as with ventriculography) or to other factors unrelated to contrast medium administration (eg, atheroemboli). [Extracted from the article]

The author discusses the rising worldwide epidemic in cardiovascular diseases in low and middle income countries (LMICs) that resulted in death and disability in these region. He references an article by D. Solla et al. on the establishment of an integrated regional network for poor patients with ST-segment-elevation myocardial infarction (STEMI) in the Salvador-Bahia region. He cites a growing number of STEMI patients in LMICs who die at high rates and at ages when they were most productive.

Abstract: Objective: Cardiac troponin levels help risk-stratify patients presenting with an acute coronary syndrome. Although cardiac troponin levels may be elevated in patients presenting with non-acute coronary syndrome conditions, specific diagnoses and long-term outcomes within that cohort are unclear. Methods: By using the Veterans Affairs centralized databases, we identified all hospitalized patients in 2006 who had a troponin assay obtained during their initial reference hospitalization. On the basis of the diagnostic codes of the International Classification of Diseases, 9th Revision, primary diagnoses were categorized as acute coronary syndrome or non-acute coronary syndrome conditions. Results: Of a total of 21,668 patients with an elevated troponin level who were discharged from the hospital, 12,400 (57.2%) had a non-acute coronary syndrome condition. Among that cohort, the most common diagnostic category involved the cardiovascular system, and congestive heart failure (N=1661) and chronic coronary artery disease (N=1648) accounted for the major classifications. At 1 year after hospital discharge, mortality in patients with a non-acute coronary syndrome condition was 22.8% and was higher than in the acute coronary syndrome cohort (odds ratio 1.39; 95% confidence interval, 1.30-1.49). Despite the high prevalence of cardiovascular diseases in patients with a non-acute coronary syndrome diagnosis, use of cardiac imaging within 90 days of hospitalization was low compared with that in patients with acute coronary syndrome (odds ratio 0.25; 95% confidence interval, 0.23-0.27). Conclusions: Hospitalized patients with an elevated troponin level more often have a primary diagnosis that is not an acute coronary syndrome. Their long-term survival is poor and justifies novel diagnostic or therapeutic strategy-based studies to target the highest risk subsets before hospital discharge. [Copyright &y& Elsevier]

A response from the author of the article "Poorly Cited Articles in Peer-Reviewed Cardiovascular Journals from 1997 to 2007: Analysis of 5-Year Citation Rates" in the previous is presented.