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Background: Mechanical circulatory support (MCS) devices can be used in high-risk percutaneous coronary intervention (PCI). Our objective was to describe trends and outcomes of prophylactic MCS use in elective PCI for patients with stable coronary artery disease in the American College of Cardiology National Cardiovascular Data Registry's CathPCI registry., Methods: Among 2 108 715 consecutive patients with stable coronary artery disease undergoing elective PCI in the CathPCI registry between 2009 and 2018, we examined patterns of prophylactic use of MCS. Propensity score models with inverse probability of treatment weighting compared effectiveness (in-hospital death, cardiogenic shock, or new heart failure) and safety (stroke, tamponade, major bleeding, or vascular complication requiring treatment) between patients treated with intra-aortic balloon pump versus other MCS (Impella or extracorporeal membrane oxygenation)., Results: Overall, 6905 (0.3%) patients underwent elective PCI with prophylactic MCS. MCS use trended up from 0.2% of elective PCIs in 2009 to 0.6% in 2018 ( P <0.0001), driven by other MCS ( P <0.0001), whereas intra-aortic balloon pump use remained low and constant ( P =0.12). In-hospital major adverse cardiac events and cardiovascular complications occurred in 7.1% and 18.8% of elective PCI patients with prophylactic MCS use and 0.5% and 2.3% of patients without prophylactic MCS use. Intra-aortic balloon pump use was associated with a higher risk of major adverse cardiac events (9.6% versus 6.0%, adjusted odds ratio, 1.59 [95% CI, 1.32-1.91]) but lower risk of complications (18.2% versus 19.1%, adjusted odds ratio, 0.88 [95% CI, 0.77-0.99]) than use of other MCS., Conclusions: The use of prophylactic MCS has increased over time for elective PCI in patients with stable coronary artery disease. Intra-aortic balloon pump was associated with higher major adverse cardiac events but lower risk of procedural complications compared with other MCS.

To examine patterns of preadmission and discharge antithrombotic therapies in coronary artery disease (CAD) and atrial fibrillation (AF) patients admitted for acute myocardial infarction (AMI), we performed a retrospective analysis of the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG), which captures consecutive AMI patients treated at participating US hospitals. We included patients with CAD, AF, and CHA 2 DS 2 -VASc score ≥2 admitted for AMI (07/01/2013-09/30/2016). In the 15,034 AMI patients with previous AF and CAD, median age was 75; 32% were female. Preadmission, 32% of patients were on P2Y 12 inhibitors, 36% were anticoagulated, 72% were on aspirin, and 5% were on triple therapy. At discharge post-AMI, 73% were prescribed P2Y 12 inhibitors and 41% anticoagulation. Discharge anticoagulation use did not vary directly with CHA 2 DS 2 -VASc score; 16% of previously anticoagulated patients had discontinued anticoagulation at discharge. In patients receiving anticoagulants at discharge, 27% used nonvitamin K antagonist oral anticoagulants. Triple therapy was prescribed in 23% at discharge; 27% of these were with nonvitamin K antagonist oral anticoagulants and 14% with prasugrel or ticagrelor. P2Y 12 inhibitors and anticoagulants without aspirin were used in 2%. In conclusion, patients with previous CAD and AF are undertreated for both recurrent ischemic events and stroke prevention. After AMI hospitalization, P2Y 12 inhibition was preferentially selected over oral anticoagulation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Cardiac computed tomography angiography (CCTA) reduces emergency department length of stay compared with standard evaluation in patients with low- and intermediate-risk acute chest pain. Whether diabetic patients have similar benefits is unknown., Methods and Results: In this prespecified analysis of the Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT II) multicenter trial, we randomized 1000 patients (17% diabetic) with symptoms suggestive of acute coronary syndrome to CCTA or standard evaluation. The rate of acute coronary syndrome was 8% in both diabetic and nondiabetic patients (P=1.0). Length of stay was unaffected by the CCTA strategy for diabetic patients (23.9 versus 27.2 hours, P=0.86) but was reduced for nondiabetic patients compared with standard evaluation (8.4 versus 26.5 hours, P<0.0001; P interaction=0.004). CCTA resulted in 3-fold more direct emergency department discharge in both groups (each P≤0.0001, P interaction=0.27). No difference in hospital admissions was seen between the 2 strategies in diabetic and nondiabetic patients (P interaction=0.09). Both groups had more downstream testing and higher radiation doses with CCTA, but these were highest in diabetic patients (all P interaction≤0.04). Diabetic patients had fewer normal CCTAs than nondiabetic patients (32% versus 50%, P=0.003) and similar normalcy rates with standard evaluation (P=0.70). Notably, 66% of diabetic patients had no or mild stenosis by CCTA with short length of stay comparable to that of nondiabetic patients (P=0.34), whereas those with >50% stenosis had a high prevalence of acute coronary syndrome, invasive coronary angiography, and revascularization., Conclusions: Knowledge of coronary anatomy with CCTA is beneficial for diabetic patients and can discriminate between lower risk patients with no or little coronary artery disease who can be discharged immediately and higher risk patients with moderate to severe disease who warrant further workup., Clinical Trial Registration: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01084239., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Coronary CT angiography (CCTA) is used in the emergency department to rule out acute coronary syndrome in low-intermediate risk patients., Objectives: We evaluated the potential of CCTA to tailor aspirin (ASA) and statin therapy in acute chest pain patients., Methods: We included all patients in the ROMICAT I trial who underwent CCTA before admission. Results of CCTA were blinded to caretakers. We documented ASA and statin therapy at admission and discharge and determined change in medications during hospitalization, agreement of discharge medications with contemporaneous guidelines, and agreement with the presence and severity of coronary artery disease (CAD) as determined by CCTA., Results: We included 368 patients (53 ± 12 years; 61% male). Baseline medical therapy at presentation included 27% on ASA and 24% on statin. Most patients who qualified for secondary prevention were on ASA and statin therapy at discharge (95% and 80%, respectively), whereas among those qualifying for primary prevention therapy, only 59% of patients were on aspirin and 33% were on statin at discharge. Excluding secondary prevention patients, among those with CCTA-detected CAD, only 66/131 (50%) were on ASA at discharge and only 53/131 (40%) were on statin. Conversely, in those without CCTA-detected CAD, 54/156 (35%) were on ASA and 20/151 (13%) were on statin at discharge., Conclusion: There are significant discrepancies between discharge prescription of statin and ASA with the presence and extent of CAD. CCTA presents an efficient opportunity to tailor medical therapy to CAD in patients undergoing CCTA as part of their acute chest pain evaluation., (Copyright © 2015 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Whether a coronary artery calcium (CAC) scan provides added value to coronary computed tomographic angiography (CCTA) in emergency department patients with acute chest pain remains unsettled. We sought to determine the value of CAC scan in patients with acute chest pain undergoing CCTA., Methods and Results: In the multicenter Rule Out Myocardial Infarction using Computer-Assisted Tomography (ROMICAT) II trial, we enrolled low-intermediate risk emergency department patients with symptoms suggesting acute coronary syndrome (ACS). In this prespecified subanalysis of 473 patients (54±8 years, 53% men) who underwent both CAC scanning and CCTA, the ACS rate was 8%. Overall, 53% of patients had CAC=0 of whom 2 (0.8%) developed ACS, whereas 7% had CAC>400 with 49% whom developed ACS. C-statistic of CAC>0 was 0.76, whereas that using the optimal cut point of CAC≥22 was 0.81. Continuous CAC score had lower discriminatory capacity than CCTA (c-statistic, 0.86 versus 0.92; P=0.03). Compared with CCTA alone, there was no benefit combining CAC score with CCTA (c-statistic, 0.93; P=0.88) or with selective CCTA strategies after initial CAC>0 or optimal cut point CAC≥22 (P≥0.09). Mean radiation dose from CAC acquisition was 1.4±0.7 mSv. Higher CAC scores resulted in more nondiagnostic CCTA studies although the majority remained interpretable., Conclusions: In emergency department patients with acute chest pain, CAC score does not provide incremental value beyond CCTA for ACS diagnosis. CAC=0 does not exclude ACS, nor a high CAC score preclude interpretation of CCTA in most patients. Thus, CAC results should not influence the decision to proceed with CCTA, and the decision to perform a CAC scan should be balanced with the additional radiation exposure required., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT01084239., (© 2015 American Heart Association, Inc.)