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Objective: Several lines of research in the last decade have indicated the potential utility of retina as a window to the brain. Emerging evidence suggests abnormalities in retinal vascular caliber in schizophrenia. However, the relationship between retinal vascular measures and brain structure has not been examined in schizophrenia to date. Hence, we examined the relationship between retinal vasculature measured using fundus photography and brain structure measured using magnetic resonance imaging., Method: We recruited 17 healthy volunteers and 20 patients with schizophrenia. Using a non-mydriatic camera, we captured the images for left and right eyes separately and retinal vascular calibers were calculated using a semi-automated software package. Whole-brain anatomical T1 MPRAGE images were acquired using a 3-Tesla MRI scanner. Whole-brain and regional volume and cortical thickness were calculated using the Freesurfer software package. We used FreeSurfer's QDEC interface to compute vertex-by-vertex for analysis of the volume and cortical thickness. The relation between brain volume, cortical thickness, and retinal vascular caliber was examined using partial correlation and regression analysis., Results: There was a significant negative correlation between average CRVE and global cortical mean thickness in schizophrenia but not in healthy. In schizophrenia patients, there was a significant negative correlation between average CRVE and cortical thickness in frontal regions - left rostral middle frontal, left superior frontal, and right caudal middle frontal gyri and posterior brain regions - left lateral occipital gyrus and left posterior cingulate cortex., Discussion: The findings of the study suggest potential utility of retinal venular diameter as a proxy marker to abnormal neurodevelopment in schizophrenia., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Importance: Randomized clinical trials (RCTs) are critical in advancing patient care, yet conducting such large-scale trials requires tremendous resources and coordination. Clinical site start-up performance metrics can provide insight into opportunities for improved trial efficiency but have not been well described., Objective: To measure the start-up time needed to reach prespecified milestones across sites in large cardiovascular RCTs in North America and to evaluate how these metrics vary by time and type of regulatory review process., Design, Setting, and Participants: This cohort study evaluated cardiovascular RCTs conducted from July 13, 2004, to February 1, 2017. The RCTs were coordinated by a single academic research organization, the Duke Clinical Research Institute. Nine consecutive trials with completed enrollment and publication of results in their target journal were studied. Data were analyzed from December 4, 2019, to January 11, 2021., Exposures: Year of trial enrollment initiation (2004-2007 vs 2008-2012) and use of a central vs local institutional review board (IRB)., Main Outcomes and Measures: The primary outcome was the median start-up time (from study protocol delivery to first participant enrollment) as compared by trial year and type of IRB used. The median start-up time for the top 10% of sites was also reported. Secondary outcomes included time to site regulatory approval, time to contract execution, and time to site activation., Results: For the 9 RCTs included, the median site start-up time shortened only slightly over time from 267 days (interquartile range [IQR], 185-358 days) for 2004-2007 trials to 237 days (IQR, 162-343 days) for 2008-2012 trials (overall median, 255 days [IQR, 177-350 days]; P < .001). For the top 10% of sites, median start-up time was 107 days (IQR, 95-121 days) for 2004-2007 trials vs 104 days (IQR, 84-118 days) for 2008-2012 trials (overall median, 106 days [IQR, 90-120 days]; P = .04). The median start-up time was shorter among sites using a central IRB (199 days [IQR, 140-292 days]) than those using a local IRB (287 days [IQR, 205-390 days]; P < .001)., Conclusions and Relevance: This cohort study of North American research sites in large cardiovascular RCTs found a duration of nearly 9 months from the time of study protocol delivery to the first participant enrollment; this metric was only slightly shortened during the study period but was reduced to less than 4 months for top-performing sites. These findings suggest that the use of central IRBs has the potential to improve RCT efficiency.

[Figure: see text].

Background: More effective and progressively safer generations of drug-elut-ing stents (DES) have replaced bare metal stents (BMS) in rou-tine clinical practice. However, patients considered to be at high bleeding risk (HBR) have traditionally been underrepresented in pivotal DES trials., Aims: The aim of this study was to model the safety and effectiveness of drug-coated stents (DCS) versus BMS in HBR patients according to the Academic Research Consortium (ARC) criteria., Methods: Participants from the LEADERS FREE (LF) and LEADERS FREE II (LFII) studies were pooled into one data set. Participants were treated with 30 days of DAPT. The primary safety (composite of cardiac death, myocardial infarction, or stent thrombosis) and effectiveness (target lesion revascularisation) endpoints were compared between DCS and BMS in the subgroup of patients satisfying the ARC-HBR definition using propensity-score modelling., Results: From the 3,635 participants included in the combined LF and LFII data set, 2,898 (79.7%) satisfied the ARC-HBR criteria (DCS: 1,923; BMS: 975). The primary safety endpoint occurred in 184 (9.8%) and in 132 (13.8%) participants in the DCS and BMS groups, respectively (adjusted HR 0.72, 95% CI: 0.57-0.91; p=0.006). The risk of the primary effectiveness endpoint was also significantly lower with DCS (6.2%) versus BMS (8.8%) (adjusted HR 0.70, 95% CI: 0.52-0.94; p=0.016). The safety and effectiveness of DCS versus BMS were consistent according to ARC-HBR status (p for interaction=0.206 and 0.260, respectively)., Conclusions: DCS are safer and more effective than BMS in an ARC-defined HBR population.

Optimal treatment of stable ischemic heart disease for those in the transportation industry is considered in the context of the individual's health, as well as with the perspective that sudden impairment could have catastrophic consequences for others. This article focuses on two high risk occupations that one may encounter in practice: commercial motor vehicle drivers and commercial pilots. This article discusses coronary heart disease in patients in high risk occupations and covers current guideline recommendations for screening, treatment, and secondary prevention. The importance of the complimentary perspectives of the regulatory agency, medical examiners, physicians, and pilot or driver are considered in this narrative review, as are considerations for future guideline updates.

Mechanical circulatory support (MCS) devices maintain or improve hemodynamic profiles in patients at risk for hemodynamic deterioration during percutaneous coronary intervention (PCI) or those in cardiogenic shock. Clinical trials of MCS have been difficult to complete due to challenges with equipoise; however, there are several "real-world" comparative effectiveness analyses of outcomes of patients undergoing high-risk PCI or cardiogenic shock with different MCS. This review summarizes the real-world data on Impella and intra-aortic balloon pump, 2 of the most commonly used MCS, and provides insight into the limitations of such data and challenges to completing clinical trials., Competing Interests: The author has no financial conflicts of interest., (Copyright © 2021. The Korean Society of Cardiology.)

Background: Interventional cardiologists receive feedback on their clinical care from a variety of sources including registry-based quality measures, case conferences, and informal peer interactions. However, the impact of this feedback on clinical care is unclear., Methods: We interviewed interventional cardiologists regarding the use of feedback to improve their care of percutaneous coronary intervention (PCI) patients. Interviews were assessed with template analysis using deductive and inductive techniques., Results: Among 20 interventional cardiologists from private, academic, and Department of Veterans Affairs practice, 85% were male, 75% performed at least 100 PCIs annually, and 55% were in practice for 5 years or more. All reported receiving feedback on their practice, including formal quality measures and peer learning activities. Many respondents were critical of quality measure reporting, citing lack of trust in outcomes measures and poor applicability to clinical care. Some respondents reported the use of process measures such as contrast volume and fluoroscopy time for benchmarking their performance. Case conferences and informal peer feedback were perceived as timelier and more impactful on clinical care. Respondents identified facilitators of successful feedback interventions including transparent processes, respectful and reciprocal peer relationships, and integration of feedback into collective goals. Hierarchy and competitive environments inhibited useful feedback., Conclusions: Despite substantial resources dedicated to performance measurement and feedback for PCI, interventional cardiologists perceive existing quality measures to be of only modest value for improving clinical care. Catherization laboratories should seek to integrate quality measures into a holistic quality program that emphasizes peer learning, collective goals and mutual respect., (Published by Elsevier Inc.)

Background: Revascularization of ischemic cardiomyopathy by coronary artery bypass grafting has been shown to improve survival among patients with left ventricular ejection fraction (LVEF) ≤35%, but the role of percutaneous coronary intervention (PCI) in this context is incompletely described. This study sought to evaluate the effect of PCI on mortality and hospitalization among patients with stable coronary artery disease and reduced left ventricular ejection fraction., Methods: We performed a retrospective analysis comparing PCI with medical therapy among patients with ischemic cardiomyopathy in the Veterans Affairs Health Administration. Patients with angiographic evidence of 1 or more epicardial stenoses amenable to PCI and LVEF ≤35% were included in the analysis. Outcome data were determined by VA and non-VA data sources on mortality and hospital admission., Results: From 2008 through 2015, a study sample of 4,628 patients was identified, of which 1,322 patients underwent ad hoc PCI. Patients were followed to a maximum of 3 years. Propensity score weighted landmark analysis was used to evaluate the primary and secondary outcomes. The primary outcome of all-cause mortality was significantly lower in the PCI cohort compared with medical therapy (21.6% vs 30.0%, P <.001). The secondary outcome of all-cause rehospitalization or death was also lower in the PCI cohort (76.5% vs 83.8%, P <.001)., Conclusions: In this retrospective analysis of patients with ischemic cardiomyopathy with coronary artery disease amenable to PCI and LVEF ≤35%, revascularization by PCI was associated with decreased all-cause mortality and decreased all-cause death or rehospitalization., (Published by Elsevier Inc.)

Objectives: The aims of this study were to examine rates of radial artery access in post-coronary artery bypass grafting (CABG) patients undergoing diagnostic catherization and/or percutaneous coronary intervention (PCI), whether operators with higher procedural volumes and higher percentage radial use were more likely to perform diagnostic catherization and/or PCI via the radial approach in post-CABG patients, and clinical and procedural outcomes in post-CABG patients who undergo diagnostic catherization and/or PCI via the radial or femoral approach., Background: There are limited data comparing outcomes of patients with prior CABG undergoing transradial or transfemoral diagnostic catheterization and/or PCI., Methods: Using the National Cardiovascular Data Registry CathPCI Registry, all diagnostic catheterizations and PCIs performed in patients with prior CABG from July 1, 2009, to March 31, 2018 (n = 1,279,058, 1,173 sites) were evaluated. Temporal trends in transradial access were examined, and mortality, bleeding, vascular complications, and procedural metrics were compared between transradial and transfemoral access., Results: The rate of transradial access increased from 1.4% to 18.7% over the study period. Transradial access was associated with decreased mortality (adjusted odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.75 to 0.91), decreased bleeding (OR: 0.57; 95% CI: 0.51 to 0.63), decreased vascular complications (OR: 0.38; 95% CI: 0.30 to 0.47), increased PCI procedural success (OR: 1.11; 95% CI: 1.06 to 1.16; p < 0.0001), and significantly decreased contrast volume across all procedure types. Transradial access was associated with shorter fluoroscopy time for PCI-only procedures but longer fluoroscopy time for diagnostic procedures plus ad hoc PCI and diagnostic procedures only. Operators with a higher rate of transradial access in non-CABG patients were more likely to perform transradial access in patients with prior CABG., Conclusions: The rate of transradial artery access in patients with prior CABG undergoing diagnostic catheterization and/or PCI has increased over the past decade in the United States, and it was more often performed by operators using a transradial approach in non-CABG patients. Compared with transfemoral access, transradial access was associated with improved clinical outcomes in patients with prior CABG., Competing Interests: Funding Support and Author Disclosures The American College of Cardiology National Cardiovascular Data Registry is an initiative of the American College of Cardiology Foundation. This research was supported by the American College of Cardiology Foundation’s National Cardiovascular Data Registry. Dr. Rymer has received research grants from Boston Scientific and Abbott Pharmaceuticals. Dr. Swaminathan receives research support from ACIST Medical; and provides consulting services for Medtronic. Dr. Abbott has received grant support with no personal compensation from Sinomed, CSL Behring, AstraZeneca, Bristol Myers Squibb, and Abbott Vascular; and provides consulting services for Recor and Philips. Dr. Gilchrist provides consulting services for Cardinal Health and Terumo Medical Corporation. Dr. Panetta is the co-owner of the medical device company LP Medical. Dr. Brilakis provides consulting services for Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Ebix, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; receives research support from Regeneron and Siemens; and is a shareholder in MHI Ventures. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.

The concept of a direct association between coronary graft patency and clinical status is generally accepted. However, the relationship is more complex and variable than usually thought. Key issues are the lack of a common definition of graft occlusion and of a standardized imaging protocol for patients undergoing coronary bypass surgery. Factors like the type of graft, the timing of the occlusion, and the amount of myocardium at risk, as well as baseline patients' characteristics, modulate the patency-to-clinical status association. Available evidence suggests that graft occlusion is more often associated with non-fatal events rather than death. Also, graft failure due to competitive flow is generally a benign event, while graft occlusion in a graft-dependent circulation is associated with clinical symptoms. In this systematic review, we summarize the evidence on the association between graft status and clinical outcomes., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

We compare coincident thermospheric neutral wind observations made by the Michelson Interferometer for Global High-Resolution Thermospheric Imaging (MIGHTI) on the Ionospheric Connection Explorer (ICON) spacecraft, and four ground-based specular meteor radars (SMRs). Using the green-line MIGHTI channel, we analyze 1158 coincidences between Dec 2019 and May 2020 in the altitude range from 94 to 104 km where the observations overlap. We find that the two datasets are strongly correlated ( r = 0.82) with a small mean difference (4.5 m/s). Although this agreement is good, an analysis of known error sources (e.g., shot noise, calibration errors, and analysis assumptions) can only account for about a quarter of the disagreement variance. The unexplained variance is 27.8% of the total signal variance and could be caused by unknown errors. However, based on an analysis of the spatial and caused by temporal variability of the wind on scales ≲70 min. The observed magnitudes agree well during temporal averaging of the two measurement modalities, we suggest that some of the disagreement is likely the night, but during the day, MIGHTI observes 16%-25% faster winds than the SMRs. This remains unresolved but is similar in certain ways to previous SMR-satellite comparisons.

Transradial intervention (TRI) was first introduced by Lucien Campeau in 1989 and since then has created a lasting impact in the field of interventional cardiology. Several studies have demonstrated that TRI is associated with fewer vascular site complications, offer earlier ambulation and greater post-procedural comfort. Patients presenting with ST Segment Elevation Myocardial Infarction (STEMI) have experienced survival benefit and higher quality-of-life metrics as well with TRI. While both the updated scientific statement by the American Heart Association and the 2017 European Society of Cardiology guidelines recommend a "radial first" approach there appears to be a lag in physicians adapting TRI as the preferred vascular access. We present a review focusing on identification and management of TRA related challenges and complications using a systematic algorithmic approach., Competing Interests: Conflicts of interest All authors have none to declare., (Copyright © 2020. Published by Elsevier B.V.)

A comprehensive review on backyard poultry farming (BYPF) was carried out with respect to history, status, production systems, management practices, role in socio-economic development, etc., considering the Indian scenario in particular. Backyard poultry is an age-old traditional practice where small numbers of native chickens are reared with or without inputs under the free-range scavenging conditions. Currently, BYPF contributes about 17.8% (18.41 billion) of the total egg production (103.32 billion) of India. The introduction of high yielding chicken varieties, which resemble the native chicken, transformed the BYPF into a highly remunerative farming activity. The BYPF has a proven potential to alleviate poverty, eradicate malnutrition, empower women, and provide subsidiary income, and gainful employment in rural and tribal areas. In India, four types of backyard poultry farming are practiced, i.e., traditional, small-scale rural, small-scale intensive, and native chicken farming. The aspects of breeding and nutritional strategies in the nursery, and free-range conditions, besides the housing and health care practices that are followed in India, are discussed in detail. Backyard poultry farming has huge potential for further expansion as the produce from this system is preferred across the country.

BACKGROUND The long-term safety of paclitaxel-coated devices (PCDs; drug-coated balloon or drug-eluting stent) for peripheral endovascular intervention is uncertain. We used data from the Veterans Health Administration to evaluate the association between PCDs, long-term mortality, and cause of death. METHODS AND RESULTS Using the Veterans Administration Corporate Data Warehouse in conjunction with International Classification of Diseases, Tenth Revision ( ICD-10 ) Procedure Coding System, Current Procedural Terminology, and Healthcare Common Procedure Coding System codes, we identified patients with peripheral artery disease treated within the Veterans Administration for femoropopliteal artery revascularization between October 1, 2015, and June 30, 2019. An adjusted Cox regression, using stabilized inverse probability-weighted estimates, was used to evaluate the association between PCDs and long-term survival. Cause of death data were obtained using the National Death Index. In total, 10 505 patients underwent femoropopliteal peripheral endovascular intervention; 2265 (21.6%) with a PCD and 8240 (78.4%) with a non-PCD (percutaneous angioplasty balloon and/or bare metal stent). Survival rates at 2 years (77.4% versus 79.7%) and 3 years (70.7% versus 71.8%) were similar between PCD and non-PCD groups, respectively. The adjusted hazard for all-cause mortality for patients treated with a PCD versus non-PCD was 1.06 (95% CI, 0.95-1.18, P =0.3013). Among patients who died between October 1, 2015, and December 31, 2017, the cause of death according to treatment group, PCD versus non-PCD, was similar. CONCLUSIONS Among patients undergoing femoropopliteal peripheral endovascular intervention within the Veterans Administration Health Administration, there was no increased risk of long-term, all-cause mortality associated with PCD use. Cause-specific mortality rates were similar between treatment groups.

Gut microbiota plays an important role in the health and performance of the host. Characterizations of gut microbiota, core microbiomes, and microbial networks in different chicken breeds are expected to provide clues for pathogen exclusion, improving performance or feed efficiency. Here, we characterized the gut microbiota of "finishing" chickens (at the end of production life) of indigenous Indian Nicobari, Ghagus, and Aseel breeds, originating from the Nicobari island, coastal India, and the Indian mainland, respectively, as well as a global commercial broiler line, VenCobb 400, using 16S rDNA amplicon sequencing. We found that diversity, as well as richness of microbiota, was higher in indigenous breeds than in the broiler line. Beta diversity analysis indicated the highest overlap between Ghagus and Nicobari breeds and a very low overlap between the broiler line and all indigenous breeds. Linear discriminant analysis effect size (LEfSe) revealed 82 breed- or line-specific phylotype operational taxonomic unit (OTU) level biomarkers. We confirm the presence of breed specific and across-breed core microbiomes. Additionally, we show the existence of breed specific complex microbial networks in all groups. This study provides the first (and comprehensive) insight into the gut microbiota of three indigenous breeds and one commercial broiler line of chickens reared without antimicrobials, and underscores the need to study microbial diversity in other indigenous breeds.

Background: Effects of supplementation of dried alkaline (referred to as MVP1) and aqueous (referred to as PBD1) extracts of Kappaphycus alvarezii, were evaluated in broiler (Vencobb 400) chickens (1-35 days post-hatch). In experiment I, each of the seven diets (basal diet with three levels (0.5, 1.5 or 5.0 g kg -1 diet) of MVP1 or PBD1 and a negative control was fed to 12 pen replicates containing five birds in each. In experiment II, each of three diets [a negative control, and PBD1 at two levels (1.0 or 1.5 g kg -1 diet)] was fed to 16 pen replicates of five chicks in each., Results: Concentrations of total phenolics, phycobillins and free radical scavenging activity were higher (P < 0.01) whereas carrageenan was lower in PBD1 than in MVP1. In the experiment I, PBD1 at 1.5 g kg -1 diet improved (P < 0.05) body weight (BW) (7.11% higher). In the experiment II, both the treatments improved (P < 0.01) BW (9.18% and 8.47%, respectively) compared to the control. The group fed with PBD1@ 1.0 g kg -1 had higher (P < 0.05) haemagglutination inhibition titre, expression of intestinal claudin 2, TLR2A, NOD1, avian beta defensin 4, interleukin 2 and interleukin 6 genes than control. Treatments did not influence feed efficiency or levels of most of the antioxidant enzymes. Villus width and crypt depth were significantly higher in the group fed with 1.5 g kg -1 of PBD1., Conclusion: Supplementing dried aqueous extract of K. alvarezii at 1 g kg -1 diet may be an effective strategy to increase growth and immunity in broiler chickens. © 2020 Society of Chemical Industry., (© 2020 Society of Chemical Industry.)

Accurate evaluation of the quality of invasive cardiology procedures requires appraisal of case selection, technical performance, and procedural and clinical outcomes. Regrettably, the medical care delivery system poses a number of obstacles to developing and sustaining a high-quality environment. The purposes of this viewpoint are to summarize the most common impediments, followed to summarize the most common impediments, followed by the optimal ways to design and sustain a quality assurance program to overcome these barriers. A 7-step program to create and implement an effective quality assurance program is outlined., Competing Interests: Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest Alexander G. Truesdell is a consultant and member of the Speakers Bureau of Abiomed Inc. David A. Morrow reports no conflicts relevant to this work and reports grants from Anthos Therapeutics, grants and personal fees from AstraZeneca, personal fees from Bayer Pharma, grants from Daiichi Sankyo, grants from Eisai,grants from GlaxoSmithKline, personal fees from InCarda, grants from Medicines Company, grants and personal fees from Merck & Co, grants and personal fees from Novartis, grants from Pfizer, grants from Quark, grants from Regeneron, grants and personal fees from Roche Diagnostics, grants from Siemens, grants from Takeda, and grants from Zora Biosciences outside the submitted work; Dr. Morrow is also a member of the TIMI Study Group which has received institutional research grant support through Brigham and Women's Hospital from Abbott; Amgen; Aralez; AstraZeneca; Bayer HealthCare Pharmaceuticals, Inc.; BRAHMS, Daiichi-Sankyo; Eisai; GlaxoSmithKline; Intarcia; Janssen; MedImmune; Merck; Novartis; Pfizer; Poxel; Quark Pharmaceuticals; Regeneron; Roche; Siemens; Takeda; The Medicines Company; and Zora Biosciences. E. Magnus Ohman mentions Chiesi (USA), Jansen Pharmaceutical, Xylocor, Cardinal Health, Milestone Pharmaceutical, Abiomed, and Cara Therapeutics. Ian C. Gilchrist reports no conflicts relevant to this work and is a consultant for Terumo Medical, Inc. Judith S. Hochman reports no conflicts relevant to this work; Dr. Hochman is PI for the ISCHEMIA trial for which, in addition to support by National Heart, Lung, and Blood Institute grant, there were in-kind donations for participating sites from Abbott Vascular; Medtronic, Inc.; St. Jude Medical, Inc.; Volcano Corporation; Arbor Pharmaceuticals, LLC; AstraZeneca Pharmaceuticals, LP; Merck Sharp & Dohme Corp.; Omron Healthcare, Inc.; and Amgen Inc.; and financial donations from Arbor Pharmaceuticals LLC and AstraZeneca Pharmaceuticals LP. Navin K. Kapur is a consultant/receives speaker honoraria from Abbott, Abiomed, Boston Scientific, Medtronic, LivaNova, Getinge, MD Start, and Precardia as well as institutional research grants from Abiomed, Boston Scientific, and MD Start. Ron Waksman is an advisory board/board member and consultant for Abbott Vascular, Amgen, Pi-Cardia LTD, Cardioset, Medtronic, Philips (Volcano), and Boston Scientific Corp; consultant for Biosensors, Biotronik; received grant support from Abbott Vascular, AstraZeneca, Biosensors, Biotronik, Chiesi, and Boston Scientific Corp; is on the Speaker Bureau of AstraZeneca and Chiesi; and is an investor in MedAlliance. Eric Chen is an employee of Abbott. Adam DeVore reports research funding through his institution from the American Heart Association; Amgen; AstraZeneca; Bayer; Intra-Cellular Therapies; American Regent, Inc; the NHLBI; Novartis; and PCORI. He also provides consulting services for Amgen, AstraZeneca, Bayer, CareDx, InnaMed, LivaNova, Mardil Medical, Novartis, Procyrion, scPharmaceuticals, Story Health and Zoll and has also received non-financial support from Abbott for educational activities. William O’Neill is a consultant for Abiomed and Abbott and receives consulting fees for his services. Charles A. Simonton is an employee of Abiomed. Behram N. Tehrani is a consultant for Medtronic. Alastair G. Proudfoot, Andrew D. Althouse, Fernando Aguel, Fred Senatore, Holger Thiele , Ileana Pina, John Sapirstein, Marc Samsky, Mitchell Krucoff, Sunil Rao, Timothy D. Henry, Valarie Morrow, William T. Abraham, Joaquin E. Cigarroa, Jonathan Seltzer, and Meir Shinnar all report no conflicts relevant to this work.

Objective: To describe from a noninterventional registry (Utilization of Ticagrelor in the Upstream Setting for Non-ST-Segment Elevation Acute Coronary Syndrome), the short-term ischemic and hemorrhagic outcomes in patients with non-ST elevation myocardial infarction (MI) are managed with a loading dose (LD) of a P2Y12 inhibitor (P2Y12i) given at least 4 hours before diagnostic angiography and delineation of coronary anatomy. Prior data on the effects of such "upstream loading" have been inconsistent., Methods: In 53 US hospitals, we evaluated the in-hospital care and outcomes of patients with confirmed non-ST elevation MI managed with an interventional strategy and loaded upstream (at least 4 h before diagnostic angiography) with oral P2Y12i therapy. Patients entered into the database were grouped into 1 of 4 cohorts for analysis: (1) overall cohort, (2) thienopyridine (clopidogrel or prasugrel) load, (3) ticagrelor load, and (4) ticagrelor-consistent. The fourth cohort is a subset of cohort 3 that received ticagrelor throughout the index hospital stay and at discharge. We evaluated in-hospital clinical course and ischemic and bleeding outcomes in all patients and also 30-day outcomes in the ticagrelor-consistent cohort., Results: A total of 3355 patients were enrolled, of whom 1087 had 30-day follow-up. The mean (±SD) age was 63.3 ± 12.5 years, and 62.6% were male. Thrombolysis in MI and Global Registry of Acute Coronary Events scores placed these patients in the intermediate risk range, and CRUSADE scores were in the moderate risk range. The LD in Utilization of Ticagrelor in the Upstream Setting for Non-ST-Segment Elevation Acute Coronary Syndrome was clopidogrel in 45.6%, ticagrelor in 53.6%, and prasugrel in 0.8%. The median upstream interval (LD to angiography) was 17:27 hours and did not change appreciably over the course of the data collection period (2/15-10/19). Access was radial in 48.6% and femoral in 51.4%. Postangiography management was medical only in 32.3%, percutaneous coronary intervention in 59.4%, and coronary artery bypass grafting in 8.3%. Median length of stay was 2.7 days, and median time from angiography to coronary artery bypass grafting was 3.6 days. In-hospital mortality was 0.51%, and major bleeding (thrombolysis in MI) was 0.24%; the in-hospital major adverse cardiovascular events rate was 0.7%, and stent thrombosis occurred in 0.18%. No significant differences were seen between the ticagrelor and clopidogrel cohorts in hospital, but 16% received more than 1 P2Y12i in-hospital. On follow-up (93.2% response), 86.7% of patients reported taking ticagrelor as directed., Conclusions: Upstream loading of P2Y12i was associated with very low rates of bleeding and short length of stay in a large cohort of non-ST elevation MI (NSTEMI) patients managed invasively.

Scheduling of resources and patients are crucial in outpatient clinics, particularly when the patient demand is high and patient arrivals are random. Generally, outpatient clinic systems are push systems where scheduling is based on average demand prediction and is considered for long term (monthly or bimonthly). Often, planning and actual scenario vary due to uncertainty and variability in demand and this mismatch results in prolonged waiting times and under-utilization of resources. In this article, we model an outpatient clinics as a multi-agent system and propose an intelligent real-time scheduler that schedules patients and resources based on the actual status of departments. Two algorithms are implemented: one for resource scheduling that is based on predictive demand and the other is patient scheduling which performs path optimization depending on the actual status of departments. In order to match resources with stochastic demand, a coordination mechanism is developed that reschedules the resources in the outpatient clinics in real time through auction-bidding procedures. First, a simulation study of intelligent real-time scheduler is carried out followed by implementation of the same in an outpatient clinic of Aravind Eye Hospital, Madurai, India. This hospital has huge patient demand and the patient arrivals are random. The results show that the intelligent real-time scheduler improved the performance measures like waiting time, cycle time, and utilization significantly compared to scheduling of resources and patients in isolation. By scheduling resources and patients, based on system status and demand, the outpatient clinic system becomes a pull system. This scheduler transforms outpatient clinics from open loop system to closed-loop system.

1. A study was conducted to evaluate the effects of including graded levels of an alternate protein mixture (APM) containing cottonseed meal, distillery dried grain with solubles and mustard seed meal in a fixed ratio as a substitute for soybean meal in layer diets (hens aged 27 to 46 weeks). The trial studied the possibility of higher inclusion levels of APM with increased dietary concentrations of crude protein (CP) or critical amino acids (CAA). 2. Maize-soybean meal diet was used as the control diet. In experiment 1, APM was included at 0, 120, 160 and 200 g/kg diet (145 g/kg CP). In experiment 2, the control and three test diets (200 g/kg APM) with three levels of CP (145, 155 and 165 g/kg) were used. In experiment 3, a control and four test diets (200 g/kg APM) with four concentrations of CAA (100%, 105%, 110% and 115% relative to the control) were used. In all experiments, each diet was fed ad libitum to nine replicates of 88 birds each, housed in colony cages. 3. In experiment 1, egg production (EP) and feed intake (FI) were not affected by feeding up to 160 g/kg APM, but, at 200 g/kg, EP was significantly reduced. Feed conversion ratio (FCR) for the hens fed the highest level of APM was similar to the control. Egg weight (EW) and egg mass (EM) in the 160 and 200 g/kg AMS groups were lower than the control group. 4. Increase in dietary CP from 145 to 155 g/kg improved EP and reduced FCR to levels similar to the control group. EM in hens fed 165 g/kg APM was similar to the control in experiment 2. 5. Increasing concentrations of CAA progressively improved EP and reduced FCR in experiment 3. The EP at CAA 110% and FCR at CAA 105% were similar to the control group. 6. Based on the results, it was concluded that the APM can be included up to 160 g/kg diet without affecting layer performance, as long as the diet supplied the recommended levels of protein and amino acids. By increasing either protein from 145 to 155 g/kg or CAA concentrations by 10%, the dietary levels of the APM could be increased to 200 g/kg without affecting the layer performance.

Objective: To evaluate the association of plasma long pentraxin 3 (PTX3) concentration with angiographic and clinical outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by primary angioplasty., Background: Whether concentration of PTX3, a sensitive marker of inflammation, associates with angiographic and clinical outcomes in STEMI patients treated by primary angioplasty is unknown., Methods: We prospectively enrolled 335 consecutive patients with acute STEMI undergoing primary angioplasty. Blood samples for plasma PTX3 measurement were drawn in all patients at the emergency department before primary angioplasty, and were measured by ELISA method., Results: The median PTX3 concentrations were higher in patients with thrombus burden grade 4 and 5 versus grade <4 on initial coronary angiogram (0.29 ng/ml vs. 0.24 ng/ml, p = .02), thrombolysis in myocardial infarction (TIMI) grade <3 vs. TIMI grade-3 flow after primary angioplasty (0.31 ng/ml vs. 0.24 ng/ml, p < .001), incomplete versus complete ST-segment resolution within 12 hr after angioplasty (0.29 ng/ml vs. 0.22 ng/ml, p = .001) and in patients who did not survive versus those who survived at 30 days (0.44 ng/ml vs. 0.26 ng/ml, p = .001). A linear correlation was observed between PTX3 concentration and baseline leukocyte count (Spearman correlation = 0.21, p < .001). After adjustment for laboratory and selected clinical variables, patients in the highest quartile of PTX3 concentration (≥0.4 ng/ml) were associated with increased risk of 30-day mortality (hazard ratio = 11.83; 95% confidence interval = 1.52-92.27, p = .01)., Conclusion: This study suggests that higher plasma PTX3 concentration associates with worse angiographic and clinical outcomes in STEMI patients treated by primary angioplasty., (© 2019 Wiley Periodicals, Inc.)

Objectives: We sought to evaluate the efficacy and safety of bivalirudin versus heparin in patients with coronary artery disease undergoing transradial artery coronary intervention (TRI)., Background: Bivalirudin and radial artery access are independently associated with improved cardiovascular outcomes. However, data supporting a strategy of combining both to achieve additive improvements in cardiovascular outcomes provide conflicting results., Methods: A systematic search was performed to identify randomized controlled trials (RCTs) of bivalirudin, in which vascular access sites were reported. The primary outcome was net adverse clinical events (NACE) at 30 days. Secondary outcomes were long-term NACE, short-, and long-term major adverse cardiovascular events, all-cause mortality, myocardial infarction, unplanned revascularization, stent thrombosis, and major bleeding., Results: We identified 10 RCTs, including 16,328 patients who underwent TRI (mean age 64.6 ± 15.7 years, 72.5% male). Bivalirudin use was associated with decreased 30-day NACE compared with heparin (6.3 vs. 7.4%; risk ratio [RR] = 0.87; 95% confidence interval [CI] = 0.76-0.99; p = .04; number needed to treat = 91). No significant interactions were observed based on clinical presentation, administration of P2Y 12 inhibitors, or glycoprotein IIb/IIIa-receptor inhibitors (GPI) use. There were no significant differences between groups in any prespecified secondary outcomes. There was, however, a significant reduction of major bleeding in the bivalirudin group compared with heparin when used in combination with routine GPI (RR = 0.41; 95% CI = 0.19-0.90; p = .03)., Conclusions: Among patients undergoing TRI, use of bivalirudin was associated with significantly reduced 30-day NACE compared with heparin. There was no significant difference in long term NACE, ischemic, or bleeding events compared with heparin., (© 2020 Wiley Periodicals, Inc.)

Background: The benefits and risks of blood transfusion in patients with acute myocardial infarction who are anemic or who experience bleeding are debated. We sought to study the association between blood transfusion and ischemic outcomes according to haemoglobin nadir and bleeding status in patients with NST-elevation myocardial infarction (NSTEMI)., Methods: The TAO trial randomized patients with NSTEMI and coronary angiogram scheduled within 72h to heparin plus eptifibatide versus otamixaban. After exclusion of patients who underwent coronary artery bypass surgery, patients were categorized according to transfusion status considering transfusion as a time-varying covariate. The primary ischemic outcome was the composite of all-cause death or MI within 180 days of randomization. Subgroup analyses were performed according to pre-transfusion hemoglobin nadir and bleeding status., Results: 12,547 patients were enrolled. Among these, blood transfusion was used in 489 (3.9%) patients. Patients who received transfusion had a higher rate of death or MI (29.9% vs. 8.1%, p<0.01). This excess risk persisted after adjustment on GRACE score and nadir of hemoglobin (HR 3.36 95%CI 2.63-4.29 p<0.01). Subgroup analyses showed that blood transfusion was associated with a higher risk in patients without overt bleeding (adjusted HR 6.25 vs. 2.85; p-interaction 0.001) as well as in those with hemoglobin nadir > 9.0 g/dl (HR 4.01; p-interaction<0.0001)., Conclusion: In patients with NSTEMI, blood transfusion was associated with an overall increased risk of ischaemic events. However, this was mainly driven by patients without overt bleeding and those hemoglobin nadir > 9.0g/dl. This suggests possible harm of transfusion in those groups., Competing Interests: Disclosures PG Steg Research grants: Amarin, Bayer, Sanofi, and Servier Clinical trials (Steering committee or CEC or DMC), speaker or consultant : Amarin, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Idorsia, Mylan, Novo-Nordisk, Novartis, Pfizer, Sanofi, Servier. CV Pollack Consultant for Sanofi. J W Jukema : JW Jukema/his department has received research grants from and/or was speaker (with or without lecture fees) on a.o.(CME accredited) meetings sponsored by Amgen, Athera, Astra-Zeneca, Biotronik, Boston Scientific, Dalcor, Daiichi Sankyo, Lilly, Medtronic, Merck-Schering-Plough, Pfizer, Roche, Sanofi Aventis, The Medicine Company, the Netherlands Heart Foundation, CardioVascular Research the Netherlands (CVON), the Netherlands Heart Institute and the European Community Framework KP7 Programme. M Cohen : speaker Sanofi, Consultant to and research support from AstraZeneca. SD Wiviott: Sanofi Aventis, AstraZeneca, Merck, Eli Lilly/Daiichi Sankyo, Boehringer Ingelheim. SR Mehta: Research grants AstraZeneca and Boston scientific; M Sabatine : to be suppressed Sunil V Rao A.Erglis , C Bode, T Cuisset, T Moccetti, G Ducrocq Y Elbez None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: For low-risk patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) the recommended optimal discharge timing is inconsistent in guidelines. The European Society of Cardiology guidelines recommend early discharge within 48-72 h, while the American College of Cardiology guidelines do not recommend a specific discharge strategy. In this systematic review and meta-analysis we compared outcomes with early discharge (≤3 days) versus late discharge (>3 days)., Methods: Randomized controlled trials (RCTs) and observational studies were selected after searching MEDLINE and EMBASE database. Meta-analysis was stratified according to study design. Outcomes were reported as random effects risk ratios (RR) with 95% confidence intervals., Results: Seven RCTs comprising 1780 patients and 4 observational studies comprising 39,288 patients were selected. The RCT-restricted analysis did not demonstrate significant differences in terms of all-cause mortality (RR, 0.97 [0.23-4.05]) and major adverse cardiac events (MACE) (RR, 0.84 [0.56-1.26]). Conversely, observational study restricted analysis showed that early vs late discharge strategy was associated with a reduction in all-cause mortality (RR, 0.40 [0.23-0.71]) and MACE (RR, 0.45 [0.26-0.78]). There were no significant differences in hospital readmissions between early vs late discharge in both RCT or observational study analyses., Conclusions: Early discharge strategy in appropriately selected low-risk patients with STEMI undergoing PCI is safe and it has the potential to improve cost of care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Cardiogenic shock (CS) is a complex condition with a high risk for morbidity and mortality. Mechanical circulatory support (MCS) devices were developed to support patients with CS in cases refractory to treatment with vasoactive medications. Current devices include intra-aortic balloon pumps, intravascular microaxial pumps, percutaneous LVAD, percutaneous RVAD, and VA ECMO. Data from limited observational studies and clinical trials show a clear difference in the level of hemodynamic support offered by each device. However, at this point, there are insufficient clinical trial data to guide MCS selection and, until ongoing clinical trials are completed, use of the right device for the right patient depends largely on clinical judgment., Competing Interests: Disclosure Z.K. Wegermann and S.V. Rao report no relevant disclosures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The Centers for Medicare & Medicaid Services (CMS) began reimbursement for percutaneous coronary intervention (PCI) performed in ambulatory surgical centers (ASC) in January 2020. The ability to perform PCI in an ASC has been made possible due to the outcomes data from observational studies and randomized controlled trials supporting same day discharge (SDD) after PCI. In appropriately selected patients for outpatient PCI, clinical outcomes for SDD or routine overnight observation are comparable without any difference in short-term or long-term adverse events. Furthermore, a potential for lower cost of care without a compromise in clinical outcomes exists. These studies provide the framework and justification for performing PCI in an ASC. The Society for Cardiovascular Angiography and Interventions (SCAI) supported this coverage decision provided the quality and safety standards for PCI in an ASC were equivalent to the hospital setting. The current position paper is written to provide guidance for starting a PCI program in an ASC with an emphasis on maintaining quality standards. Regulatory requirements and appropriate standards for the facility, staff and physicians are delineated. The consensus document identified appropriate patients for consideration of PCI in an ASC. The key components of an ongoing quality assurance program are defined and the ethical issues relevant to PCI in an ASC are reviewed., (© 2020 Wiley Periodicals LLC.)

The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 has resulted in a new and lethal disease termed coronavirus disease-2019 (COVID-19). Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with this novel coronavirus. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating an ST-elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury, and the prevalence of COVID-19 disease in the U.S. population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on 1) the varied clinical presentations; 2) appropriate personal protection equipment (PPE) for health care workers; 3) role of the Emergency Department, Emergency Medical System and the Cardiac Catheterization Laboratory; and 4) Regional STEMI systems of care. During the COVID-19 pandemic, primary PCI remains the standard of care for STEMI patients at PCI capable hospitals when it can be provided in a timely fashion, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option., (Copyright © 2020 American College of Cardiology Foundation and Wiley Periodicals, Inc. Published by Elsevier Inc. All rights reserved.)

Standard evaluation and management of the patient with suspected or proven cardiovascular complications of coronavirus disease-2019 (COVID-19), the disease caused by severe acute respiratory syndrome related-coronavirus-2 (SARS-CoV-2), is challenging. Routine history, physical examination, laboratory testing, electrocardiography, and plain x-ray imaging may often suffice for such patients, but given overlap between COVID-19 and typical cardiovascular diagnoses such as heart failure and acute myocardial infarction, need frequently arises for advanced imaging techniques to assist in differential diagnosis and management. This document provides guidance in several common scenarios among patients with confirmed or suspected COVID-19 infection and possible cardiovascular involvement, including chest discomfort with electrocardiographic changes, acute hemodynamic instability, newly recognized left ventricular dysfunction, as well as imaging during the subacute/chronic phase of COVID-19. For each, the authors consider the role of biomarker testing to guide imaging decision-making, provide differential diagnostic considerations, and offer general suggestions regarding application of various advanced imaging techniques., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The experiment was conducted to study the effect of feeding diets with quality protein maize (QPM) along with cottonseed meal (CSM) and guar meal (GM) on nutrient utilization, body weight (BW) gain (BWG), feed efficiency, and antioxidant status in broiler chickens. The biological trial was conducted on day-old broiler chicks (n = 240), which were randomly distributed into 6 dietary groups having 8 replicates with 5 chicks. Six experimental diets were formulated to contain maize (diet I), QPM (diet II), maize+CSM80 g/kg + GM40 g/kg (diet III), maize + CSM120 g/kg + GM60 g/kg (diet IV), QPM+CSM80 g/kg + GM40 g/kg (diet V), and QPM+CSM120 g/kg + GM60g/kg (diet VI). The BWG and feed intake were recorded at weekly intervals. Supplementation of CSM and GM along with QPM or maize depressed (P < 0.05) BWG, feed conversion ratio, and slaughter variables in commercial broilers. Improvement of BWG and breast weight was recorded among the groups supplemented 80 g/kg CSM and 40 g/kg GM with a QPM-based diet compared with those groups fed 120 g/kg CSM and 60 g/kg GM with maize or QPM. The energy and protein utilization decreased among the groups supplemented CSM and GM. However, protein and energy utilization was increased (P < 0.05) among the groups fed QPM-based diets compared with those groups fed CSM and GM with maize or QPM. Therefore, it has been concluded that the performance and other parameters did not differ between the groups fed maize- and QPM-based diets in the present experiment. However, QPM with CSM and GM improved the performance, slaughter parameters, and nutrient utilization over CSM and GM with maize.

Objectives: We hypothesized that splanchnic nerve blockade (SNB) would attenuate increased exercise-induced cardiac filling pressures in patients with chronic HF., Background: Chronic heart failure (HF) is characterized by limited exercise capacity driven in part by an excessive elevation of cardiac filling pressures., Methods: This is a prospective, open-label, single-arm interventional study in chronic HF patients. Eligible patients had a wedge pressure ≥15 mm Hg at rest or ≥25 mm Hg with exercise on baseline right heart catheterization. Patients underwent cardiopulmonary exercise testing with invasive hemodynamic assessment, followed by percutaneous SNB with ropivacaine., Results: Nineteen patients were enrolled, 15 of whom underwent SNB. The average age was 58 ± 13 years, 7 (47%) patients were women and 6 (40%) were black. Left ventricular ejection fraction was ≤35% in 14 (93%) patients. No procedural complications were encountered. SNB reduced mean pulmonary arterial pressure at peak exercise from 54.1 ± 14.4 (pre-SNB) to 45.8 ± 17.7 mm Hg (p < 0.001) (post-SNB). Similarly, SNB reduced exercise-induced wedge pressure from 34.8 ± 10.0 (pre-SNB) to 25.1 ± 10.7 mm Hg (p < 0.001) (post-SNB). The cardiac index changed with peak exercise from 3.4 ± 1.2 (pre-SNB) to 3.8 ± 1.1 l/min/m 2 (p = 0.011) (post-SNB). After SNB, patients exercised for approximately the same duration at a greater workload (33 ± 24 W vs. 50 ± 30 W; p = 0.019) and peak oxygen consumption VO 2 (9.1 ± 2.5 vs. 9.8 ± 2.7 ml/kg/min; p = 0.053)., Conclusions: SNB reduced resting and exercise-induced pulmonary arterial and wedge pressure with favorable effects on cardiac output and exercise capacity. Continued efforts to investigate short- and long-term effects of SNB in chronic HF are warranted. Clinical Trials Registration (Abdominal Nerve Blockade in Chronic Heart Failure; NCT03453151)., (Copyright © 2020. Published by Elsevier Inc.)

Background: Prior randomized controlled trials (RCT) evaluating the optimal antithrombotic therapies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not been powered to evaluate ischemic outcomes. We compared double therapy with oral anticoagulation (OAC) and a P2Y12 inhibitor to triple therapy with an OAC + dual antiplatelet therapy in patients with AF requiring PCI., Methods: Using PRISMA guidelines, we searched for RCTs including patients with AF as an indication for OAC and undergoing PCI or medical management of acute coronary syndrome. The results were pooled using fixed-effects and random-effects models to estimate the overall effect of double therapy versus triple therapy on ischemic and bleeding outcomes., Results: We identified four RCTs, comprising 10,238 patients (5,498 double therapy, 4,740 triple therapy). Trial-reported major adverse cardiovascular events were similar between double therapy and triple therapy (fixed effect model OR 1.09, 95% CI 0.94-1.26). However, stent thrombosis (61/5,496 double therapy vs. 33/4738 triple therapy; fixed effect model OR 1.57, 95% CI 1.02-2.40; number needed to treat with triple therapy = 242) favored triple therapy. Bleeding outcomes were less frequent with double therapy (746/5470 vs. 950/4710; fixed effect model OR 0.59, 95% CI 0.53-0.65; number needed to harm with triple therapy = 16), but with significant heterogeneity (Q = 8.33, p = .04; I 2 = 64%), as were intracranial hemorrhages (19/5470 vs. 30/4710; fixed effect model OR 0.54, 95% CI 0.31-0.96)., Conclusions: Double therapy in patients with AF requiring OAC following PCI or Acute coronary syndrome has a significantly better safety profile than triple therapy but may be associated with a modest increased risk of stent thrombosis., (© 2019 Wiley Periodicals, Inc.)

The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 has resulted in a new and lethal disease termed coronavirus disease 2019 (COVID-19). Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with this novel coronavirus. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating an ST-elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury, and the prevalence of COVID-19 disease in the US population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on (a) varied clinical presentations; (b) appropriate personal protection equipment (PPE) for health care workers; (c) the roles of the emergency department, emergency medical system, and the cardiac catheterization laboratory (CCL); and (4) regional STEMI systems of care. During the COVID-19 pandemic, primary percutaneous coronary intervention (PCI) remains the standard of care for STEMI patients at PCI-capable hospitals when it can be provided in a timely manner, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI-capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option., (© 2020 Wiley Periodicals, Inc.)