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To verify whether transradial (TRA) compared to transfemoral (TFA) cardiac catheterization reduces the risk of periprocedural stroke (PS). We reviewed (CRD42021277918) published real-world cohorts reporting the incidence of PS within 3 days following diagnostic or interventional catheterization. Meta-analyses and meta-regressions of odds ratios (OR) performed using the DerSimonian and Laird method were checked for publication bias (Egger test) and adjusted for false-positive results (study sequential analysis SSA). The pooled incidence of PS from 2,188,047 catheterizations (14 cohorts), was 193 (105 to 355) per 100,000. Meta-analyses of adjusted estimates (OR = 0.66 (0.49 to 0.89); p = 0.007; I2 = 90%), unadjusted estimates (OR = 0.63 (0.51 to 0.77; I2 = 74%; p = 0.000)), and a sub-group of prospective cohorts (OR = 0.67 (0.48 to 0.94; p = 0.022; I2 = 16%)) had a lower risk of PS in TRA (without indication of publication bias). SSA confirmed the pooled sample size was sufficient to support these conclusions. Meta-regression decreased the unexplained heterogeneity but did not identify any independent predictor of PS nor any effect modifier. Periprocedural stroke remains a rare and hard-to-predict adverse event associated with cardiac catheterization. TRA is associated with a 20% to 30% lower risk of PS in real-world/common practice settings. Future studies are unlikely to change our conclusion.

Randomized controlled trials (RCTs) investigating the optimal screening strategy for atrial fibrillation (AF) have yielded conflicting results.To examine the comparative efficacy of different AF screening strategies in older adults.We searched MEDLINE, EMBASE and Cochrane without language restrictions through January 2022, for RCTs evaluating the outcomes of non-invasive AF screening approaches among adults ≥65 years. We conducted a pairwise meta-analysis comparing any AF screening approach versus no screening, and a network meta-analysis comparing systematic screening versus opportunistic screening versus no screening. The primary outcome was new AF detection.The final analysis included 9 RCTs with 85,209 patients. The weighted median follow-up was 12 months. The mean age was 73.4 years and men represented 45.6%. On pairwise meta-analysis, any AF screening (either systematic or opportunistic) was associated with higher AF detection (1.8% vs. 1.3%; risk ratio [RR] 2.10; 95% confidence interval [CI] 1.20-3.65) and initiation of oral anticoagulation (RR 3.26; 95%CI 1.15-9.23), compared with no screening. There was no significant difference between any AF screening versus no screening in all-cause mortality (RR 0.97; 95%CI 0.93-1.01) or acute cerebrovascular accident (CVA) (RR 0.92; 95%CI 0.84-1.01). On network meta-analysis, only systematic screening was associated with higher AF detection (RR 2.73; 95% CI 1.62-4.59) and initiation of oral anticoagulation (RR 5.67; 95% CI 2.68-11.99), but not with the opportunistic screening, compared with no screening.Systematic AF screening using non-invasive tools was associated with higher rate of new AF detection and initiation of OAC, but opportunistic screening was not associated with higher detection rates. There were no significant differences between the various AF screening approaches with respect to rates of all-cause mortality or CVA events. However, these analyses are likely underpowered and future RCTs are needed to examine the impact of systematic AF screening on mortality and CVA outcomes.None.

Inpatient management and outcomes of patients presenting with acute myocardial infarction (AMI) with a history of heart failure (HF) have not been well characterized.Hospitalizations for AMI from the Nationwide Inpatient Sample (2015-2018) were categorized according to a preexisting diagnosis of HF with preserved ejection fraction (HFpEF), reduced ejection fraction (HFrEF), or absence of HF. Utilization of invasive management and in-hospital outcomes were analyzed.Among 2,434,639 hospitalizations with an AMI, 19.8% had a history of HFrEF and 11.9% had a history of HFpEF. Coronary angiography and PCI respectively were performed significantly less among patients with HF (36.6% and 17.4% in HFpEF, 51.1% and 24.6% in HFrEF, and 64.4% and 42.3% among patients without HF, allHF is a common preexisting comorbidity among patients presenting with AMI and is associated with lower utilization of invasive procedures and higher complications including mortality, particularly among those with HFrEF.

BACKGROUND: National-level data of cancer patients’ readmissions after ST-segment elevation myocardial infarction (STEMI) are lacking. OBJECTIVES: The primary aim of this study was to compare the rates and causes of 30-day readmissions in patients with and without cancer. METHODS: Among patients admitted with STEMI in the United States National Readmission Database (NRD) from October 2015–December 2017, we identified patients with the diagnosis of active breast, colorectal, lung, or prostate cancer. The primary endpoint was the 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of patients with and without cancer. RESULTS: A total of 385,522 patients were included in the analysis: 5956 with cancer and 379,566 without cancer. After propensity score matching, 23,880 patients were compared (Cancer = 5949, No Cancer = 17,931). Patients with cancer had higher 30-day readmission rates (19% vs. 14%, p < 0.01). The most common causes for readmission among patients with cancer were cardiac (31%), infectious (21%), oncologic (17%), respiratory (4%), stroke (4%), and renal (3%). During the first readmission, patients with cancer had higher adjusted rates of in-hospital mortality (15% vs. 7%; p < 0.01) and bleeding complications (31% vs. 21%; p < 0.01), compared to the non-cancer group. In addition, cancer (OR 1.5, 95% CI 1.2–1.6, p < 0.01) was an independent predictor for 30-day readmission. CONCLUSIONS: About one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cardiac causes predominated the reason for 30-day readmissions in patients with cancer.

Background Transcatheter mitral edge-to-edge repair (TEER) is an increasingly common procedure performed on patients with severe mitral regurgitation. This study assessed the impact of race/ethnicity and socioeconomic status on in-hospital complications after TEER. Methods Cohort-based observational study using the National Inpatient Sample between October 2013 and December 2018. The population was stratified into 4 groups based on race/ethnicity and quartiles of neighborhood income levels. The primary outcome was in-hospital complications, defined as the composite of death, bleeding, cardiac and vascular complications, acute kidney injury, and ischemic stroke. Results 3795 hospitalizations for TEER were identified. Patients of Black and Hispanic race/ethnicity comprised 7.4% and 6.4%, respectively. We estimated that White patients received TEER with a frequency of 38.0/100,000, compared to 29.7/100,000 for Blacks and 30.5/100,000 for Hispanics. In-hospital complications occurred in 20.2% of patients and no differences were found between racial/ethnic groups (P = 0.06). After multilevel modelling, Black and Hispanic patients had similar rate of overall in-hospital complications (OR: 0.84, CI:0.67–1.05 and OR: 0.84, CI:0.66–1.07, respectively) as compared to White patients, however, higher rates of death were observed in Black patients. Individuals living in income quartile-1 had worse in-hospital outcomes as compared to quartile-4 (OR: 1.19, CI:0.99–1.42). Conclusion In this study assessing racial/ethnic disparities in TEER outcomes, aged-adjusted race/ethnicity minorities were less underrepresented as compared to other structural heart interventions. Black patients experienced a higher rate of in-hospital death, but similar overall rate of post-procedural adverse events as compared to White patients. Lower income levels appear to negatively impact on in-hospital outcomes. Brief summary This study appraises race/ethnic and socioeconomical disparities in access and outcomes following transcatheter mitral edge-to-edge repair. Racial minority groups were less underrepresented as compared to other structural heart interventions. While Black patients experienced a higher rate of in-hospital death, they experienced similar overall rate of post-procedural complications compared to White patients. Lower income levels also appeared to negatively impact on outcomes.

BACKGROUND Optimal deployment of coronary stents in a bifurcation lesion remains a matter of debate. AIMS We sought to capture the daily practice of bifurcation stenting by means of a worldwide registry and to investigate how the post-implantation deployment techniques influence the clinical outcomes. METHODS Data from the e-ULTIMASTER registry were used to perform an analysis of 4395 patients undergoing percutaneous coronary intervention for bifurcation lesions. Inverse probability of treatment weights (IPTW) propensity score methodology was used to adjust for any baseline differences. The primary outcome of interest was target lesion failure (TLF) at 1-year (follow-up rate 96.2%). RESULTS Global one-year TLF rate was low: 5.1%. Proximal optimization technique was used in 33.9 % of cases and was associated with a reduction in adjusted TLF rate [4.0 (95% confidence interval:3.0-5.1)% versus 6.0(5.1-6.9)%, p

Background Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown. Methods Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. Results From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group. Conclusions BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher., Graphical abstract

Long lesions are known to have worse outcomes following percutaneous coronary intervention (PCI), but there are limited data assessing the association between lesion length and clinical outcomes in PCI procedures undertaken in chronic total occlusions (CTO).We formed a longitudinal cohort (2006-2018, n = 27,205) of stable angina patients who underwent PCI to CTO in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographical, procedural, and outcome data were analyzed in three groups by treated segment length,30 mm (n = 11,782), 30-59 mm (n = 10,415), ≥ 60 mm (n = 5008). Prevalence of previous myocardial infarction and PCI were higher in patients in 30-59 mm group or ≥ 60 mm group compared with30 mm group. Following multivariable analysis, no significant difference was observed in in-patient death (OR = 30-59 mm group = 1.10, CI:0.55-2.19, p = 0.78) (OR ≥ 60 mm group = 0.82, CI: 0.33-2.05, p = 0.67), and 1-year death (OR = 30-59 mm group = 1.06, CI: 0.81-1.37, p = 0.69) (OR ≥ 60 mm group =1.01, CI: 0.70-1.43, p = 0.99) (30 mm group = reference) but in-patient MACE was higher in = 60 mm group (OR: 1.52, CI: 1.15-2.01, p = 0.06) but similar in 30-59 mm group (OR: 1.16, CI: 0.91-1.48, p = 0.22) compared with30 mm group. The adjusted rates of procedural complications were higher in ≥ 60 mm group (OR: 1.61, CI: 1.40-1.85, p 0.001) but were similar in 30-59 mm group (OR: 1.06, CI: 0.94-1.20, p 0.31) compared with30 mm group. For every 10 mm increase, there was an increased adjusted risk of in-patient procedural complications and coronary perforation but not in-patient MACE or death.Patients with very long CTO lesions have higher risk of procedural complications and in-patient MACE but similar risk of short or long-term mortality compared with short CTO lesions.

This was an observational study of the 1-year outcomes of the 20,000 patients included in the original CHARIOT study. The aim of the study was to assess the association between high sensitivity troponin I (hs-cTnI) concentration and 1 year mortality in this cohort. The original CHARIOT study included a consecutive cohort of in- and out-patients undergoing blood tests for any reason. Hs-cTnI concentrations were measured regardless of whether the clinician requested them. These results were nested and not revealed to the team unless requested for clinical reasons. One year mortality data was obtained from NHS Digital as originally planned. Overall, 1782 (8.9%) patients had died at 1 year. Multivariable Cox regression analysis showed that a hs-cTnI concentration above the upper limit of normal was independently associated with the hazard of mortality (HR 2.23; 95% confidence intervals 1.97 to 2.52). Furthermore, the log (10) hs-cTnI concentration was independently associated with the hazard of 1 year mortality (HR 1.77; 95% confidence intervals 1.64 to 1.91). In conclusion, in a large, unselected hospital population of both in- and out-patients, in 18,282 (91.4%) of whom there was no clinical indication for testing, hs-cTnI concentration was associated with 1 year mortality.

Data comparing outcomes of transradial (TR) versus transfemoral (TF) access for percutaneous coronary intervention (PCI) in chronic kidney disease (CKD) including patients with eGFR30 ml/min/1.73m

Introduction: There are limited data on causes of cardiovascular (CV) admissions and associated outcomes among patients with different cancers. Methods: All CV admissions from the US National Inpatient Sample between October 2015 to December 2017 were stratified by cancer type as well as metastatic status. Multivariable logistic regression was performed to determine the adjusted odds ratios (aOR) of in-hospital mortality in different groups. Results: From 5, 936, 014 eligible CV admissions, cancer was present in 265, 221 (4.5%) hospitalizations. There was significant variation in the admission diagnoses among the different cancers, with hematological malignancies being principally associated with heart failure (HF), lung cancer with atrial fibrillation (AF), and colorectal and prostate cancer with acute myocardial infarction (AMI). Admission with haemorrhagic stroke has the highest associated mortality across cancers (20.0–38.4%). In-hospital mortality was higher in cancer than non-cancer patients across most CV admissions (P < 0.001) with AF having the worst prognosis. Compared to group without any cancer, the greatest aOR of mortality was associated with lung cancer in AMI (aOR 2.32, 95% CI 2.18–2.47), ischemic stroke (aOR 2.21, 95%CI 2.08–2.34), AF (aOR 4.69, 95%CI 4.32–5.10) and HF (aOR 2.07, 95%CI 1.89–2.27). Conclusions: The most common causes of CV admission to hospital vary in patients with different types of cancer, with AMI being most common in patients with colon cancer, HF in patients with hematological malignancies and AF in patients with lung cancer. Patients with cancer, particularly lung cancer, have greater mortality than non-cancer patients after admissions with a CV cause.

Aims Little is known about the association between the type of admission ward and quality of care and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI). Methods and results We analysed data from 337 155 NSTEMI admissions between 2010 and 2017 in the UK Myocardial Ischaemia National Audit Project (MINAP) database. The cohort was dichotomised according to receipt of care either on a medical (n = 142,876) or cardiac ward, inclusive of acute cardiac wards and cardiac care unit (n = 194,279) on admission to hospital. Patients admitted to a cardiac ward were younger (median age 70 y vs. 75 y, P Conclusion Patients with NSTEMI admitted to a cardiac ward on admission were more likely to receive guideline directed management and had better clinical outcomes.

OBJECTIVE Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sex-specific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ≥18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ≥35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79–0.84), 0.79 (0.77–0.80), and 0.78 (0.76–0.79) for the female-specific model; and 0.78 (0.75–0.80), 0.77 (0.76–0.79), and 0.77 (0.75–0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA1c, and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development.

We investigated the incidence, management, and outcomes of acute myocardial infarction (AMI) patients according to cardiac arrest location. Patients admitted with a diagnosis of AMI between January 1, 2010 to March 31, 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. We used logistic regression models to evaluate predictors of the clinical outcomes and treatment strategy. The study population consisted of 580,796 patients admitted with AMI stratified into three groups: out of hospital cardiac arrest (OOHCA) (16,278[2.8%]), in-hospital cardiac arrest (IHCA) (21,073[3.7%]), plus a reference group consisting of those without cardiac arrest (non-cardiac arrest (543,418[93.5%]). IHCA declined steadily (from 666 per 1000 in 2010 to 477 per 1000 AMI with cardiac arrest admissions in 2017) with a commensurate rise in OOHCA (from 344 per 1000 to 533 per 1000 AMI with cardiac arrest admissions). Coronary angiography utilization (OOHCA 81.1% vs IHCA 60.3% vs non-cardiac arrest 70.4%, p0.001) and PCI (OOHCA 40% vs IHCA 32.8% vs non-cardiac arrest 45.2%, p0.001) were higher in OOHCA. In-hospital mortality odds were greatest for IHCA (OR 35.3, 95% CI 33.4-37.2) compared to OOHCA (OR 12.7, 95% CI 11.9-13.6), with the worse outcomes seen in patients on medical wards (OR 97.37, 95% CI 87.02-108.95) and the best outcomes seen in the emergency department (OR 8.35, 95% CI 7.32-9.53). In conclusion, outcomes of AMI complicated by cardiac arrest depended on cardiac arrest location, especially the outcomes of the IHCA.

Women with pregnancy-induced hypertension, defined as gestational hypertension and preeclampsia/eclampsia, are at increased risk of long-term cardiovascular disease, but less is known about the spectrum of acute cardiovascular outcomes, especially across racial/ethnic groups. We evaluated the risk of cardiovascular events at delivery associated with gestational hypertension and preeclampsia/eclampsia, compared with no pregnancy-induced hypertension, overall and by race/ethnicity. We used the 2016 to 2018 National Inpatient Sample data.International Classification of Diseases,Tenth Revision, Clinical Modification codes identified delivery hospitalizations and clinical diagnoses. Using survey weights, cardiovascular events were examined using logistic regression by pregnancy-induced hypertension status, with subsequent stratification by race/ethnicity. Among 11 304 996 deliveries in 2016 to 2018, gestational hypertension occurred in 614 995 (5.4%) and preeclampsia in 593 516 (5.2%). Black women had higher odds for preeclampsia independent of underlying comorbidities (adjusted odds ratio, 1.45 [95% CI, 1.42–1.49]) and had the highest rates for several complications (peripartum cardiomyopathy, 506; heart failure, 660; acute renal failure, 953; and arrhythmias, 418 per 100 000 deliveries). After adjustment for socioeconomic factors and comorbidities, preeclampsia/eclampsia was associated with increased risk of cardiovascular events in women of all races/ethnicities. However, risk was highest among Asian/Pacific Islander women and lowest among Black women. In sum, while Black women were the most likely to experience preeclampsia, Asian/Pacific women were the most at risk for acute cardiovascular complications during delivery hospitalization.

We aimed to determine whether chronic kidney disease (CKD) is associated with adverse in-hospital outcomes after acute ischaemic stroke (AIS) and whether this association is dependent on thrombolysis administration.885,537 records representative of 4,283,086 AIS admissions were extracted from the US National Inpatient Sample (2005-2015) and categorized into 3 mutually exclusive groups: no CKD, CKD without end-stage renal disease (ESRD) and ESRD. Outcomes (mortality, prolonged hospitalisation4 days and disability on discharge-derived using discharge destination as a proxy) were compared between groups using multivariable logistic regressions. Separate models containing interaction terms with thrombolysis were also computed.The median age (interquartile range) of the cohort was 73 (61-83) years and 47.32% were men. Compared with the no CKD group, both CKD/no ESRD group (odds ratio (99% confidence interval) = 1.04 (1.0003-1.09), p = 0.009) and the ESRD groups (2.06 (1.90-2.25), p 0.001) had significantly increased odds of in-hospital mortality. Patients with CKD/No ESRD (1.03 (1.02-1.06), p 0.001) and ESRD (1.44 (1.37-1.51), p 0.001) were at higher odds of prolonged hospitalisation. Patients with CKD/No ESRD (1.13 (1.10-1.15), p 0.001) and ESRD (1.34 (1.26-1.41), p 0.001) were also at higher odds of moderate-to-severe disability on discharge. Interaction terms between thrombolysis and the CKD/ESRD groups were not statistically significant (p 0.01) for any outcome.Renal dysfunction was independently associated with worse in-hospital outcomes in the acute phase of AIS. These associations were not influenced by the use of thrombolysis as an emergency treatment for AIS. CKD/ESRD should not represent sole contraindications to thrombolysis for AIS.

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.

Background: Higher anticholinergic burden from medications is associated with increased risk of cardiovascular disease and cognitive function decline. A mechanistic pathway has never been established. We aimed to determine whether chronic inflammation may mediate these associations. Methods: Participants were drawn from the European Prospective Investigation into Cancer, Norfolk cohort (40-79 years at baseline). The anticholinergic cognitive burden score (ACB) was calculated at baseline/first (1HC) (1993/97) and second (2HC) (1998/2000) health checks. Plasma fibrinogen and C-reactive protein (CRP) were measured during 1HC and Tumour Necrosis Factor alpha (TNF-α) and interleukin 6 (IL-6) during 2HC. Cross-sectional associations between ACB and inflammatory markers were examined for 1HC and 2HC, respectively. The prospective association was also examined between 1HC ACB and 2HC inflammatory markers. All models adjusted for age, sex, lifestyle factors, co-morbidities and medications. Results: 17,678 and 22,051 participants were included in cross-sectional analyses for CRP, and fibrinogen, respectively. A total of 5,101 participants with available data for TNF-α and IL-6 were included in the longitudinal analyses. Cross-sectionally, a point increase in the ACB was associated with a significant increase in all inflammatory markers (beta (standard error): fibrinogen – 0.035g/l (0.006), pConclusion: Higher anticholinergic burden was significantly associated with higher inflammatory markers. Inflammation may mediate the relationship between exposure to anticholinergic medications and adverse outcomes

Background\ud The LACE index—length of stay (L), acuity (A), Charlson co-morbidities (C), and emergent visits (E)—predicts 30-day outcomes following heart failure (HF) hospitalization but is complex to score. A simpler LE index (length of stay and emergent visits) could offer a practical advantage in point-of-care risk prediction.\ud \ud Methods and results\ud This was a sub-study of the patient-centred care transitions in HF (PACT-HF) multicentre trial. The derivation cohort comprised patients hospitalized for HF, enrolled in the trial, and followed prospectively. External validation was performed retrospectively in a cohort of patients hospitalized for HF. We used log-binomial regression models with LACE or LE as the predictor and either 30-day composite all-cause readmission or death or 30-day all-cause readmission as the outcomes, adjusting only for post-discharge services. There were 1985 patients (mean [SD] age 78.1 [12.1] years) in the derivation cohort and 378 (mean [SD] age 73.1 [13.2] years) in the validation cohort. Increments in the LACE and LE indices were associated with 17% (RR 1.17; 95% CI 1.12, 1.21; C-statistic 0.64) and 21% (RR 1.21; 95% CI 1.15, 1.26; C-statistic 0.63) increases, respectively, in 30-day composite all-cause readmission or death; and 16% (RR 1.16; 95% CI 1.11, 1.20; C-statistic 0.64) and 18% (RR 1.18; 95% CI 1.13, 1.24; C-statistic 0.62) increases, respectively, in 30-day all-cause readmission. The LE index provided better risk discrimination for the 30-day outcomes than did the LACE index in the external validation cohort.\ud \ud Conclusions\ud The LE index predicts 30-day outcomes following HF hospitalization with similar or better performance than the more complex LACE index.

Aims Little is known about ethnic disparities in care and clinical outcomes of patients admitted with non-ST-segment elevation myocardial infarction (NSTEMI) in national cohorts from universal healthcare systems derived from Europe. Methods and results We identified 280 588 admissions with NSTEMI in the UK Myocardial Infarction National Audit Project (MINAP), 2010–2017, including White patients (n = 258 364) and Black, Asian, and Minority Ethnic (BAME) patients (n = 22 194). BAME patients were younger (66 years vs. 73 years, P Conclusion BAME patients with NSTEMI had higher cardiometabolic risk profiles and were more likely to undergo invasive angiography and revascularization, with similar clinical outcomes as those of their White counterparts. Among the quality indicators assessed, there is no evidence of care disparities among BAME patients presenting with NSTEMI.

Aims The post-discharge outcomes of patients with cancer who undergo PCI are not well understood. This study evaluates the rates of readmissions within 90 days for acute myocardial infarction (AMI) and bleeding among patients with cancer who undergo percutaneous coronary intervention (PCI). Methods and results Patients treated with PCI in the years from 2010 to 2014 in the US Nationwide Readmission Database were evaluated for the influence of cancer on 90-day readmissions for AMI and bleeding. A total of 1 933 324 patients were included in the analysis (2.7% active cancer, 6.8% previous history of cancer). The 90-day readmission for AMI after PCI was higher in patients with active cancer (12.1% in lung, 10.8% in colon, 7.5% in breast, 7.0% in prostate, and 9.1% for all cancers) compared to 5.6% among patients with no cancer. The 90-day readmission for bleeding after PCI was higher in patients with active cancer (4.2% in colon, 1.5% in lung, 1.4% in prostate, 0.6% in breast, and 1.6% in all cancer) compared to 0.6% among patients with no cancer. The average time to AMI readmission ranged from 26.7 days for lung cancer to 30.5 days in colon cancer, while the average time to bleeding readmission had a higher range from 38.2 days in colon cancer to 42.7 days in breast cancer. Conclusions Following PCI, patients with cancer have increased risk for readmissions for AMI or bleeding, with the magnitude of risk depending on both cancer type and the presence of metastasis.

Background Patients with pre-existing vascular disease are known to have worse outcomes after acute myocardial infarction (AMI). However, there is limited data for outcomes stratified by type and number of vascular territories involved. Methods Using the Nationwide Inpatient Sample (2015–2017), we examined outcomes of AMI in patients with pre-existent vascular disease stratified by number as well as types of diseased beds including all five major vascular sites: cardiac, cerebrovascular, renal, aortic and peripheral vascular disease (PVD). Multivariable logistic regression was used to determine the adjusted odds ratios (aOR) of adverse outcomes and invasive procedure utilization. Results Out of 2,184,614 AMI admissions, 49.7% had pre-existent vascular disease. The odds of major adverse cardiovascular and cerebrovascular events (MACCE), mortality, ischemic stroke and major bleeding incrementally increased and was highest in those with ≥3 vascular sites involved (aOR for MACCE 1.16, CI 1.13–1.19; mortality 1.3, CI 1.26–1.34; stroke 1.15, CI 1.1–1.2; major bleeding 1.21, CI 1.16–1.25). Amongst those with a single pre-existent diseased vascular bed, the adjusted odds of MACCE appeared to be higher in those with PVD (1.28, CI 1.26–1.31), aortic disease (1.24, CI 1.19–1.29), and cerebrovascular disease (1.22, CI 1.2–1.25). Patients with pre-existent vascular disease had a lower overall likelihood of undergoing invasive revascularization procedures. Conclusions Approximately half of the population presenting with AMI have pre-existent vascular disease. There is an incremental increase in adverse outcomes with increasing number of diseased vascular beds, with further differences in outcomes and utilization of invasive procedures based on sub-types of sites involved.

Aims The LE index (Length of hospitalization plus number of Emergent visits ≤6 months) predicts 30 day all‐cause readmission or death following hospitalization for heart failure (HF). We combined N‐terminal pro‐B type natriuretic peptide (NT‐proBNP) levels with the LE index to derive and validate the LENT index for risk prediction at the point of care on the day of hospital discharge. Methods and results In this prospective cohort sub‐study of the Patient‐centred Care Transitions in HF clinical trial, we used log‐binomial regression models with LE index and either admission or discharge NT‐proBNP as the predictors and 30 day composite all‐cause readmission or death as the primary outcome. No other variables were added to the model. We used regression coefficients to derive the LENT index and bootstrapping analysis for internal validation. There were 772 patients (mean [SD] age 77.0 [12.4] years, 49.9% female). Each increment in the LE index was associated with a 25% increased risk of the primary outcome (RR 1.25, 95% CI 1.16–1.35; C‐statistic 0.63). Adjusted for the LE index, every 10‐fold increase in admission and discharge NT‐proBNP was associated with a 48% (RR 1.48; 95% CI 1.10, 1.99; C‐statistic 0.64; net reclassification index [NRI] 0.19) and 56% (RR 1.56; 95% CI 1.08, 2.25; C‐statistic 0.64; NRI 0.21) increased risk of the primary outcome, respectively. The predicted probability of the primary outcome increased to a similar extent with incremental LENT, regardless of whether admission or discharge NT‐proBNP level was used. Conclusions The point‐of‐care LENT index predicts 30 day composite all‐cause readmission or death among patients hospitalized with HF, with improved risk reclassification compared with the LE index. The performance of this simple, 3‐variable index ‐ without adjustment for comorbidities ‐ is comparable to complex risk prediction models in HF. Trial Registration: ClinicalTrials.gov Identifier: NCT02112227

BACKGROUND Sex-based differences in transcatheter aortic valve replacement (TAVR) outcomes have been previously documented. However, whether these differences persist with contemporary third generation transcatheter heart valves (THVs) is unknown. METHODS We utilized Vizient's clinical database/resource manager (CDB/RM™) to identify patients who underwent TAVR between January 1, 2018 and March 31, 2020 to compare in-hospital outcomes between males and females. The primary endpoint was in-hospital mortality. Secondary endpoints included key in-hospital complications, length of stay, discharge disposition, and cost. Unadjusted, propensity-score matched and risk-adjusted analyses of outcomes were performed. RESULTS During the study period, 44,280 patients (24,842 males, 19,438 females) underwent TAVR. The primary endpoint of in-hospital mortality was higher in females than in males (1.6 vs. 1.1% p

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.

OBJECTIVE Octogenarians are a high-risk group presenting for percutaneous coronary intervention (PCI). We aimed to create a 30-day mortality risk model for octogenarians presenting with both acute coronary syndrome (ACS) and chronic stable angina (CSA), using comprehensive mandatory UK data submissions to the UK National database. BACKGROUND Octogenarians are a high-risk group presenting for percutaneous coronary intervention, and decisions on whether or not to undertake intervention in this cohort can be challenging. The increasing number of octogenarians in the general population means they represent an important high-risk subgroup of patients. METHODS The data group consisted of 425,897 PCI procedures undertaken in the UK between 2008 and 2012 during which time there was comprehensive data linkage to mortality via the Office of National Statistics. Of these procedures, 44,221 (10.4%) were in patients aged ≥80. These comprised the model group. Logistic regression was used to create a predictive score which ultimately consisted of the following weightings: age 80-89 (n = 1); age > 90 (n = 2); unstable angina/non-ST-elevation myocardial infraction (NSTEMI) (n = 1); STEMI (n = 2); creatinine >200 mmol/L (n = 1); preprocedural ventilation (n = 1); left ventricular ejection fraction

Background: Population-based studies of atrial fibrillation (AF) incidence are needed to inform health-service planning, but evidence is conflicting. We assessed trends of AF incidence in a large general population cohort from England. Methods: We used linked primary and secondary electronic health records of 3.4 million individuals. Eligible patients aged 16 years and older contributed data between Jan 2 1998 and Dec 31 2017. For patients with incident AF, we extracted baseline characteristics, comorbidities, socioeconomic status and geographic region. We calculated standardised rates by applying direct age and sex standardisation to the 2013 European Standard Population. We applied year-specific, age-specific and sex-specific incidence to UK census mid-year population estimates for yearly total incident AF. Findings: Comparing 2017 to 1998 standardised AF incidence increased by 30% (322 vs. 247 per 100 000 person-years; adjusted incidence ratio [IRR] 1·30, 95% CI 1·27-1·33). Absolute number of incident AF increased by 72% (202 333 vs. 117 880), due to an increasing number of older persons. Comorbidity burden at diagnosis of AF increased (3·74 [SD 2·29] vs 2·58 [1·83]; adjusted difference 1·26, 95% CI 1·14-1·39). The age of AF diagnosis declined in the most deprived individuals compared to the most affluent (adjusted difference 0·74 years, 0·62-0·88). Across the study period, age-standardised incidence was higher in men than women (IRR 1·49; 95% CI 1·46-1·52), and men were younger at diagnosis (adjusted difference 5·53 years; 95% CI 5·36 to 5·69). Socioeconomically deprived individuals had more comorbidities and a higher incidence of AF than the most affluent individuals (IRR 1·20; 95% CI 1·15-1·24). Interpretation: In England AF incidence has increased, and the socioeconomic gradient in age at diagnosis and comorbidity burden widened. This changing burden requires policy-based interventions to achieve health equity. Funding: British Heart Foundation and National Institute for Health Research.

Aims/hypothesis Our study aimed to examine the trends in diabetes-related mortality in urban and rural areas in the USA over the past two decades. Methods We examined the trends in diabetes-related mortality (as the underlying or a contributing cause of death) in urban and rural areas in the USA between 1999 and 2019, using the CDC WONDER Multiple Cause of Death database. We estimated the 20 year trends of the age-adjusted mortality rate (AAMR) per 100,000 population in urban vs rural counties. Results The AAMR of diabetes was higher in rural than urban areas across all subgroups. In urban areas, there was a significant decrease in the AAMR of diabetes as the underlying (−16.7%) and contributing (−13.5%) cause of death (ptrendptrendptrendptrend NS, NS, NS and Conclusions/interpretation The temporal decrease in diabetes-related mortality in the USA has been observed only in urban areas, and mainly among female and older patients. A synchronised effort is needed to improve cardiovascular health indices and healthcare access in rural areas and to decrease diabetes-related mortality. Graphical abstract

OBJECTIVE To assess associations between current use of sodium–glucose cotransporter 2 inhibitors (SGLT2is), glucagon-like peptide 1 receptor agonists (GLP-1RAs), and their combination and risk for major adverse cardiac and cerebrovascular events (MACCE) and heart failure (HF) in people with type 2 diabetes. RESEARCH DESIGN AND METHODS In three nested case-control studies involving patients with type 2 diabetes in England and Wales (primary care data from the Clinical Practice Research Datalink and Secure Anonymised Information Linkage Databank with linkage to hospital and mortality records), we matched each patient experiencing an event with up to 20 control subjects. Adjusted odds ratios (ORs) for MACCE and HF among patients receiving SGLT2i or GLP-1RA regimens versus other combinations were estimated using conditional logistic regression and pooled using random-effects meta-analysis. RESULTS Among 336,334 people with type 2 diabetes and without cardiovascular disease, 18,531 (5.5%) experienced a MACCE. In a cohort of 411,206 with type 2 diabetes and without HF, 17,451 (4.2%) experienced an HF event. Compared with other combination regimens, the adjusted pooled OR and 95% CI for MACCE associated with SGLT2i regimens was 0.82 (0.73, 0.92), with GLP-1RA regimens 0.93 (0.81, 1.06), and with the SGLT2i/GLP-1RA combination 0.70 (0.50, 0.98). Corresponding data for HF were SGLT2i 0.49 (0.42, 0.58), GLP-1RA 0.82 (0.71, 0.95), and SGLT2i/GLP-1RA combination 0.43 (0.28, 0.64). CONCLUSIONS SGLT2i and SGLT2i/GLP-1RA combination regimens may be beneficial in primary prevention of MACCE and HF and GLP-1RA for HF. These data call for primary prevention trials using these agents and their combination.

AIMS To evaluate temporal trends in the enrolment of females in randomized controlled trials (RCTs) of heart failure with reduced ejection fraction (HFrEF) published in high-impact journals, and assess RCT characteristics associated with under-enrolment. METHODS AND RESULTS We searched MEDLINE, EMBASE and CINAHL for studies published from January 2000 to May 2019 in journals with impact factor ≥10. We included RCTs that recruited adults with HFrEF. We used a 20% threshold below the sex distribution of HFrEF to define under-enrolment. We used multivariable logistic regression to assess trial characteristics independently associated with under-enrolment. We included 317 RCTs. Among the 183 097 participants, mean (standard deviation) age was 63.0 (7.0) years and 25.5% were female. Females were under-enrolled in 71.6% [95% confidence interval (CI) 66.6-76.6%] of the RCTs; enrolment did not increase significantly between 2000-2019. Sex-related eligibility criteria [odds ratio (OR) 2.05, 95% CI 1.01-4.16; P = 0.046]; recruitment in ambulatory settings (OR 2.56, 95% CI 1.37-4.81; P = 0.003); trial coordination in North America (OR 4.44, 95% CI 1.09-18.07; P = 0.037), Europe (OR 6.79, 95% CI 1.63-27.39; P = 0.018) and Asia (OR 9.33, 95% CI 1.40-12.40; P = 0.033); drug (OR 1.76, 95% CI 1.96-7.36; P

Background Inflammatory bowel disease (IBD) is associated with an increased acute coronary syndrome (ACS) risk. Data are limited regarding the epidemiology and outcomes of ACS in patients with IBD. Methods A retrospective cohort analysis of patients with IBD admitted for ACS in the U.S. Healthcare Cost and Utilization Project National Inpatient Sample for 2005 to 2015 was conducted. We analyzed trends in IBD-ACS admissions and mortality, differences in risk profiles, management strategies, and in-hospital mortality between IBD-ACS and non-IBD ACS and between ulcerative colitis (UC) and Crohn disease (CD). Results We studied 6,872,415 non-IBD ACS and 24,220 IBD-ACS hospitalizations (53% with CD). During the study period, the number of hospitalizations for IBD-ACS increased, particularly those related to CD. Compared with non-IBD ACS, patients with IBD-ACS had a lower prevalence of cardiovascular risk factors and similar rates of coronary angiography and revascularization. The in-hospital mortality rate was lower with IBD-ACS (3.9%) compared with non-IBD ACS (5.3%; odds ratio, 0.81; 95% confidence interval, 0.69-0.96; P = 0.011) and was stable between 2005 and 2015. Risk factors, ACS management strategies, and mortality were similar between CD and UC. Coagulopathy, weight loss, and gastrointestinal bleeding were more frequent in IBD-ACS and were strong independent predictors of mortality. Conclusions Hospitalizations for ACS in patients with IBD increased in recent years but death rates were stable. The ACS-related risk profiles and mortality were modestly favorable with IBD-ACS than with non-IBD ACS and were similar between CD and UC. Complications more frequently associated with IBD were strongly associated with mortality. These findings indicate that aggressive management of IBD and ACS comorbidities is required to improve outcomes.

Background The management of patients with severe but asymptomatic aortic stenosis is challenging. Evidence on early aortic valve replacement (AVR) versus symptom-driven intervention in these patients is unknown. Methods Electronic databases were searched, articles comparing early-AVR with conservative management for severe aortic stenosis were identified. Pooled adjusted odds ratio (OR) was computed using a random-effect model to determine all-cause and cardiovascular mortality. Results A total of eight studies consisting of 2201 patients were identified. Early-AVR was associated with lower all-cause mortality [OR 0.24, 95% confidence interval (CI) 0.13-0.45, P ≤ 0.00001] and cardiovascular mortality (OR 0.21, 95% CI 0.06-0.70, P = 0.01) compared with conservative management. The number needed to treat to prevent 1 all-cause and cardiovascular mortality was 4 and 9, respectively. The odds of all-cause mortality in a selected patient population undergoing surgical AVR (SAVR) (OR 0.16, 95% CI 0.09-0.29, P ≤ 0.00001) and SAVR or transcatheter AVR (TAVR) (OR 0.53, 95% CI 0.35-0.81, P = 0.003) were significantly lower compared with patients who are managed conservatively. A subgroup sensitivity analysis based on severe aortic stenosis (OR 0.24, 95% CI 0.11-0.52, P = 0.0004) versus very severe aortic stenosis (OR 0.20, 95% CI 0.08-0.51, P = 0.0008) also mirrored the findings of overall results. Conclusion Patients with asymptomatic aortic valve stenosis have lower odds of all-cause and cardiovascular mortality when managed with early-AVR compared with conservative management. However, because of significant heterogeneity in the classification of asymptomatic patients, large scale studies are required.

Background Coronary artery vasospasm (CAV) is a reversible, transient form of vasoconstriction with clinical manifestations ranging from stable angina to acute coronary syndromes (ACS). Vasospasm of epicardial coronary arteries or associated micro-vasculature can lead to total or subtotal occlusion and has been demonstrated in nearly 50% of patients undergoing angiography for suspected ACS. The mechanism for CAV has been described in literature, but in a subgroup of patients presenting with intracranial hemorrhage, it appears to be multifactorial. These patients tend to have electrocardiographic changes, elevation of cardiac biomarkers of injury and neurogenic stress cardiomyopathy. Case summary A 44-year-old woman presented with severe headaches and tonic-clonic seizures. She was found to have diffuse subarachnoid hemorrhage (SAH) requiring ventricular drain placement, coil embolization and induced hypertension. She subsequently developed chest pain with ST elevations in anterior precordial leads, elevated cardiac enzymes and apical ballooning with left ventricular ejection fraction of 35% on transthoracic echocardiogram. Coronary angiogram revealed severe diffuse triple vessel stenoses secondary to CAV seen distally. Subsequent cardiac MRI notable for apical non-viability and scar formation. Conclusion This case highlights a unique etiology of acute myocardial infarction in a patient with SAH leading to ST elevations, diffuse triple vessel CAV and apical scar.

Objectives The goal of this systematic review and meta-analysis was to provide a comprehensive evaluation of contemporary randomized trials addressing the efficacy and safety of multivessel versus culprit vessel–only percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction and multivessel coronary artery disease. Background Multivessel coronary artery disease is present in about one-half of patients with ST-segment elevation myocardial infarction. Randomized controlled trials comparing multivessel and culprit vessel–only PCI produced conflicting results regarding the benefits of a multivessel PCI strategy. Methods A comprehensive search for published randomized controlled trials comparing multivessel PCI with culprit vessel–only PCI was conducted on ClinicalTrials.gov, PubMed, Web of Science, EBSCO Services, the Cochrane Central Register of Controlled Trials, Google Scholar, and scientific conference sessions from inception to September 15, 2019. A meta-analysis was performed using a random-effects model to calculate the risk ratio (RR) and 95% confidence interval (CI). Primary efficacy outcomes were all-cause mortality and reinfarction. Results Ten randomized controlled trials were included, representing 7,030 patients: 3,426 underwent multivessel PCI and 3,604 received culprit vessel–only PCI. Compared with culprit vessel–only PCI, multivessel PCI was associated with no significant difference in all-cause mortality (RR: 0.85; 95% CI: 0.68 to 1.05) and lower risk for reinfarction (RR: 0.69; 95% CI: 0.50 to 0.95), cardiovascular mortality (RR: 0.71; 95% CI: 0.50 to 1.00), and repeat revascularization (RR: 0.34; 95% CI: 0.25 to 0.44). Major bleeding (RR: 0.92; 95% CI: 0.50 to 1.67), stroke (RR: 1.15; 95% CI: 0.65 to 2.01), and contrast-induced nephropathy (RR: 1.25; 95% CI: 0.80 to 1.95) were not significantly different between the 2 groups. Conclusions Multivessel PCI was associated with a lower risk for reinfarction, without any difference in all-cause mortality, compared with culprit vessel–only PCI in patients with ST-segment elevation myocardial infarction.

Despite current evidence, little is known about the impact of comorbidity burden on invasive management strategies and clinical outcomes in the context of acute coronary syndrome (ACS). All ACS hospitalizations between 2004 and 2014 from the National Inpatient Sample were included, stratified by Elixhauser Comorbidity Score (ECS) and number of Elixhauser Comorbidities (NEC) to compare the receipt of invasive management and clinical outcomes between different ECS and NEC classes to the lowest class of either measure. A total of 6,613,623 records with ACS were included in the analysis. Overall comorbidity burden increased over the 11-year period, with higher comorbidity classes (ECS ≥ 14 and NEC ≥ 5) increasing from 2.1% to 4.6% and 4% to 16%, respectively. Higher ECS and NEC classes negatively correlated with the rates of utilization of coronary angiography (CA) and percutaneous coronary intervention (PCI) (ECS ≥14 vs

There is limited information about readmissions to index compared with nonindex hospitals after percutaneous coronary intervention (PCI). This study aims to evaluate the rates, causes, and outcomes for unplanned readmissions following PCI depending on whether the patients were admitted to the index or nonindex hospital. Patients who underwent PCI between 2010 and 2014 in the United States. Nationwide Readmission Database were evaluated for unplanned readmissions at 30 days to index and nonindex hospitals. A total of 2,183,851 procedures were analyzed, with a 9.2% 30-day unplanned readmission rate documented, and 7.1 % and 2.1 % of these readmissions were admitted to the index and nonindex hospitals, respectively. There was also a higher prevalence of co-morbidities among patients readmitted to nonindex hospitals, and more patients who were discharged against medical advice at index PCI. Noncardiac readmissions were lower among patients who were readmitted to the index compared with nonindex hospital (53.4% vs 61.1 %, p < 0.001). There were greater adjusted odds of acute myocardial infarction (AMI) (odds ratio [OR] 1.14 95 % CI 1.06 to 1.22), PCI (OR 2.25 95% CI 2.06 to 2.46), and composite outcome (AMI, readmission PCI, and all-cause death) (OR 1.64 95% CI 1.53 to 1.75) for patients readmitted to the index hospital but their odds of all-cause death were lower (OR 0.77 95% CI 0.68 to 0.88). The majority of readmissions after PCI are to the index hospital that the PCI was undertaken, and these patients are more likely to have a readmission diagnosis of AMI and undergo a repeat PCI but less likely to die compared with patients admitted to a nonindex hospital.

Background Readmissions after PCI are a burden to patients and health services that are not well understood. Methods A systematic review was performed to identify studies of readmission after PCI. Readmission rates and causes of readmission were examined and factors associated with 30-day readmissions were combined using meta-analyses. Results A total of 39 studies evaluated readmissions after PCI (6,569,690 patients, 31 studies). The 30-day readmission rate varied from 3.3%–15.8%. Beyond 30-days, the readmission rate was 6% at 2 months, 31.5% at 6 months, 18.6–50.4% at 12 months and 26.3–71% beyond 48 months. The pooled proportion of patients with cardiac cause for readmissions ranged from 4.6%–75.3%. The range of rates of 30-day readmissions for reinfarction/stent thrombosis, heart failure, chest pain and bleeding were 2.5%–9.5%, 5.9%–12%, 6.7–38.1% and 0.7–7.5%, respectively. Meta-analysis suggests that female gender (RR 1.25(1.20–1.30), I2 = 65.2%), diabetes (RR 1.22(1.20–1.25), I2 = 0%), heart failure (RR 1.43(CI 1.28–1.60), I2 = 92.8%), renal failure (RR 1.50(1.45–1.55), I2 = 0%), chronic lung disease (RR 1.34(1.26–1.44), I2 = 87.5%), peripheral artery disease (RR 1.20(1.15–1.25), I2 = 46.5%) and cancer (RR 1.35(1.15–1.58), I2 = 72.8%) were associated with 30-day readmissions. The average cost of unplanned and all 30-day readmissions has been reported to be $12,636 and $17,576, respectively. Conclusions We estimate that 1 in 7 patients who undergo PCI are readmitted within 30-days and the rate can rise to up to 3 in 4 patients beyond 3 years. Interventions should be considered to reduce readmissions such as discharge checklists, evaluation of medication compliance at follow-up and prompt management when patients re-present to emergency department.

ObjectivesDespite many shared risk factors and pathophysiological pathways, the risk of ischaemic heart disease (IHD) and myocardial infarction (MI) in interstitial lung disease (ILD) remains poorly understood. This lack of data could be preventing patients who may benefit from screening for these cardiovascular diseases from receiving it.MethodsA population-based cohort study used electronic patient records from the Clinical Practice Research Datalink and linked Hospital Episode Statistics to identify 68 572 patients (11 688 ILD exposed (mean follow-up: 3.8 years); 56 884 unexposed controls (mean follow-up: 4.0 years), with 349 067 person-years of follow-up. ILD-exposed patients (pulmonary sarcoidosis (PS) or idiopathic pulmonary fibrosis (PF)) were matched (by age, sex, registered general practice and available follow-up time) to patients without ILD or IHD/MI. Rates of incident MI and IHD were estimated. HRs were modelled using multivariable Cox proportional hazards regression accounting for potential confounders.ResultsILD was independently associated with IHD (HR 1.85, 95% CI 1.56 to 2.18) and MI (HR 1.74, 95% CI 1.44 to 2.11). In all disease categories, risk of both IHD and MI peaked between ages 60 and 69 years, except for the risk of MI in PS which was greatest ConclusionsILD, particularly PF, is independently associated with MI and IHD after adjustment for established cardiovascular risk factors. Our results suggest clinicians should prioritise targeted assessment of cardiovascular risk in patients with ILD, particularly those aged 60–69 years. Further research is needed to understand the impact of such an approach to risk management.

Transcatheter aortic valve implantation (TAVI) has emerged as a safe and effective alternative to surgical replacement for tricuspid aortic valve (TAV) stenosis. However, utilization of TAVI for aortic stenosis in bicuspid aortic valve (BAV) compared to TAV remains controversial. We queried online databases with various keywords to identify relevant articles. We compared major cardiovascular events and procedural outcomes using a random effect model to calculate odds ratios (OR). We included a total of 22 studies comprising 189,693 patients (BAV 12,669 vs. TAV 177,024). In the pooled analysis, there were no difference in TAVI for BAV vs. TAV for all-cause mortality, cardiovascular mortality, myocardial infarction (MI), vascular complications, acute kidney injury (AKI), coronary occlusion, annulus rupture, and reintervention/reoperation between the groups. The incidence of stroke (OR 1.24; 95% CI 1.1–1.39), paravalvular leak (PVLR) (OR 1.42; 95% CI 1.26–1.61), and the need for pacemaker (OR 1.15; 95% CI 1.06–1.26) was less in the TAV group compared to the BAV group, while incidence of life-threatening bleeding was higher in the TAV group. Subgroup analysis mirrored pooled outcomes except for all-cause mortality. The use of TAVI for the treatment of aortic stenosis in selective BAV appears to be safe and effective.

Aims The aim of this study is to evaluate temporal trends, treatment, and clinical outcomes of patients who present with an acute myocardial infarction (AMI) and have a current or historical diagnosis of cancer, according to cancer type and presence of metastases. Methods and results Data from 6 563 255 patients presenting with an AMI between 2004 and 2014 from the US National Inpatient Sample (NIS) database were analysed. A total of 5 966 955 had no cancer, 186 604 had current cancer, and 409 697 had a historical diagnosis of cancer. Prostate, breast, colon, and lung cancer were the four most common types of cancer. Patients with cancer were older with more comorbidities. Differences in invasive treatment were noted, 43.9% received percutaneous coronary intervention (PCI) in patients without cancer, whilst only 21.0% of patients with lung cancer received PCI. Lung cancer was associated with the highest in-hospital mortality [odds ratio (OR) 2.71, 95% confidence interval (CI) 2.62–2.80], major adverse cardiovascular and cerebrovascular complications (OR 2.38, 95% CI 2.31–2.45), and stroke (OR 1.91, 95% CI 1.80–2.02), while colon cancer was associated with highest risk of bleeding (OR 2.82, 95% CI 2.68–2.98). Irrespective of the type of cancer, presence of metastasis was associated with worse in-hospital outcomes, and historical cancer did not adversely impact on survival (OR 0.90, 95% CI 0.89–0.91). Conclusion A concomitant cancer diagnosis is associated with a conservative medical management strategy for AMI, and worse clinical outcomes, compared to patients without cancer. Survival and clinical outcomes in the context of AMI vary significantly according to the type of cancer and metastasis status. The management of this high-risk group is challenging and requires a multidisciplinary and patient-centred approach to improve their outcomes.

Background New messenger RNA (mRNA) and adenovirus-based vaccines (AdV) against Coronavirus disease 2019 (COVID-19) have entered large scale clinical trials. Since healthcare professionals (HCPs) and armed forces personnel (AFP) represent a high-risk category, they act as a suitable target population to investigate vaccine-related side effects, including headache, which has emerged as a common complaint. Methods We investigated the side-effects of COVID-19 vaccines among HCPs and AFP through a 38 closed-question international survey. The electronic link was distributed via e-mail or via Whatsapp to more than 500 contacts. Responses to the survey questions were analyzed with bivariate tests. Results A total of 375 complete surveys have been analyzed. More than 88% received an mRNA vaccine and 11% received AdV first dose. A second dose of mRNA vaccine was administered in 76% of individuals. No severe adverse effects were reported, whereas moderate reactions and those lasting more than 1 day were more common with AdV (P=0.002 and P=0.024 respectively). Headache was commonly reported regardless of the vaccine type, but less frequently, with shorter duration and lower severity that usually experienced by participants, without significant difference irrespective of vaccine type. Conclusions Both mRNA and AdV COVID-19 vaccines were safe and well tolerated in a real-life subset of HCPs and AFP subjects.

BACKGROUND Women are underrepresented in chronic total occlusion (CTO) trials and little is known about sex differences in the outcomes of CTO percutaneous coronary intervention (PCI). This meta-analysis aims to compare the outcomes of CTO PCI in males and females. METHODS A comprehensive search of PubMed, EMBASE, Cochrane, Web of Science, and Google Scholar was performed for studies comparing outcomes of CTO PCI in females versus males from inception to January 26, 2021. The current statistical analysis was performed using STATA version 15.1 software (Stata Corporation, TX); P

Background Elderly patients have a higher burden of comorbidities that influence clinical outcomes. We aimed to compare in‐hospital outcomes in patients ≥80 years old to younger patients, and to determine the factors associated with increased risk of major adverse events (MAE) after left atrial appendage closure. Methods and Results The National Inpatient Sample was used to identify discharges after left atrial appendage closure between October 2015 and December 2018. The primary outcome was in‐hospital MAE defined as the composite of postprocedural bleeding, vascular and cardiac complications, acute kidney injury, stroke, and death. A total of 6779 hospitalizations were identified, of which, 2371 (35%) were ≥80 years old and 4408 (65%) were P =0.01), and this difference was driven by a numerically higher rate of cardiac complications (2.4% versus 1.8%, P =0.09) and death (0.3% versus 0.1%, P =0.05) among individuals ≥80 years old. In patients ≥80 years old, higher odds of in‐hospital MAE were observed in women (1.61‐fold), and those with preprocedural congestive heart failure (≈2‐fold), diabetes (≈1.5‐fold), renal disease (≈2.6‐fold), anemia (≈2.7‐fold), and dementia (≈5‐fold). In patients Conclusions Patients ≥80 years old had higher rates of in‐hospital MAE compared with patients aged

Introduction The diagnosis and clinical implication of periprocedural myocardial infarction (PPMI) following coronary artery bypass grafting (CABG) is contentious, especially given its importance in the interpretation of trial data. Two accepted definitions of PPMI yield discrepant results. Little is known about the association between the diagnosis of PPMI, using high sensitivity troponin (hs-cTn), and medium term mortality in patients who undergo CABG, either alone or in conjunction with another procedure. In addition, there are currently no criteria for the diagnosis of PPMI following non-CABG surgery. Method Consecutive patients admitted to a cardiothoracic critical care unit (CCCU) over a six month period following open cardiac surgery had hs-cTnI assay performed on admission and every day for forty-eight hours, regardless of whether there was a clinical indication. Patients were categorised as PPMI using both the Universal Definition of MI (UDMI) and Society of Cardiovascular Angiography and Interventions (SCAI) criteria. Comorbidity data, surgical details and clinical progress in CCCU were recorded. One year mortality data were obtained from NHS Digital. Results There were 245 CABG patients, of whom 20.4% met criteria for UDMI PPMI and 87.6% for SCAI UDMI (figure 1). The diagnosis of UDMI PPMI was independently associated with one year mortality (hazard ratio 4.175 (95% confidence interval 1.281 – 13.608)), whereas there was no association between SCAI PPMI and one year mortality (figure 2). Of the 243 patients who had non CABG cardiac surgery, 11.4% met criteria for UDMI PPMI and 85.2% for SCAI PPMI (figure1) but neither was associated with one year mortality. Conclusions The incidence of SCAI PPMI in a real world cohort of cardiac surgery patients is so high as to be of limited clinical value. By contrast, a diagnosis of UDMI PPMI post CABG is independently associated with one year mortality, so may have clinical utility. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Beckman Coulter - supplied the assays used in the study but had no role in the study Figure 1. Frequency of PPMIFigure 2. Kaplan Meier curves

Background There are limited data on the management strategies, temporal trends and clinical outcomes of patients who present with non–ST‐segment–elevation myocardial infarction and have a prior history of CABG. Methods and Results We identified 287 658 patients with non–ST‐segment–elevation myocardial infarction between 2010 and 2017 in the United Kingdom Myocardial Infarction National Audit Project database. Clinical and outcome data were analyzed by dividing into 2 groups by prior history of coronary artery bypass grafting (CABG): group 1, no prior CABG (n=262 362); and group 2, prior CABG (n=25 296). Patients in group 2 were older, had higher GRACE (Global Registry of Acute Coronary Events) risk scores and burden of comorbid illnesses. More patients underwent coronary angiography (69% versus 63%) and revascularization (53% versus 40%) in group 1 compared with group 2. Adjusted odds of receiving inpatient coronary angiogram (odds ratio [OR], 0.91; 95% CI, 0.88–0.95; P P P =0.44), all‐cause mortality (OR, 0.96; 95% CI, 0.88–1.04; P =0.31), reinfarction (OR, 1.02; 95% CI, 0.89–1.17; P =0.78), and major bleeding (OR, 1.01; 95% CI, 0.90–1.11; P =0.98) were similar across groups. Lower adjusted risk of inpatient mortality (OR, 0.67; 95% CI, 0.46–0.98; P =0.04) but similar risk of bleeding (OR,1.07; CI, 0.79–1.44; P =0.68) and reinfarction (OR, 1.13; 95% CI, 0.81–1.57; P =0.47) were observed in group 2 patients who underwent percutaneous coronary intervention compared with those managed medically. Conclusions In this national cohort, patients with non–ST‐segment–elevation myocardial infarction with prior CABG had a higher risk profile, but similar risk‐adjusted in‐hospital adverse outcomes compared with patients without prior CABG. Patients with prior CABG who received percutaneous coronary intervention had lower in‐hospital mortality compared with those who received medical management.

BackgroundPeople with osteoarthritis are at a high risk of cardiovascular disease (CVD). Detecting CVD risk factors in this high-risk population will help to improve CVD outcomes. Primary care electronic health records (EHRs) provide opportunities for the surveillance of CVD risk factors in the osteoarthritis population. This paper aimed to systematically review evidence of prevalence estimates of CVD risk factors in people with osteoarthritis derived from primary care EHRs.MethodsEight databases including MEDLINE were systematically searched to January 2019. Observational studies using primary care EHRs data to estimate the prevalence of six CVD risk factors in people with osteoarthritis were included. A narrative review was conducted to summarise study results.ResultsSix studies were identified. High heterogeneity between studies prevented the calculation of pooled estimates. One study reported the prevalence of smoking (12.5%); five reported hypertension (range: 19.7%-55.5%); four reported obesity (range: 34.4%-51.6%); two reported dyslipidaemia (6.0%, 13.3%); five reported diabetes (range: 5.2%-18.6%); and one reported chronic kidney disease (1.8%) in people with osteoarthritis. One study reported a higher prevalence of hypertension (Odds Ratio (OR) 1.25, 95% confidence interval (CI) 1.19-1.32), obesity (OR 2.44, 95%CI 2.33-2.55), dyslipidaemia (OR 1.24, 95%CI 1.14-1.35) and diabetes (1.11, 95%CI 1.02-1.22) in the osteoarthritis population compared with the matched non-osteoarthritis population.ConclusionsFrom studies identified in this review that had used primary care EHRs, prevalence estimates of CVD risk factors were higher in people with osteoarthritis compared with those without. These estimates may provide baseline frequency of CVD risk factors in osteoarthritis patients in primary care, although this is limited by the small number of studies and high heterogeneity. Further studies of frequency, using primary care EHRs, will help to answer whether this data source can be used for evaluating approaches to manage CVD risk factors in osteoarthritis patients.Subject AreaPrimary care research