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ImportanceRecent national guidelines recommend sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagonlike peptide-1 receptor agonists (GLP-1 RA) in patients with type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD); yet, there are limited data on the use of these agents in contemporary community practice.ObjectiveTo evaluate the use of SGLT2i and GLP-1 RA in adults with T2D and ASCVD across a diverse sample of health care systems in the US.Design, Setting, and ParticipantsThis multicenter, retrospective cohort study used electronic health record data from 88 US health care systems participating in Cerner Real World Data between January 2018 to March 2021. Adults with ASCVD and T2D taking at least 1 glucose-lowering medication, had end-stage kidney disease, or had stage 5 chronic kidney disease were excluded.Main Outcomes and MeasuresTreatment with SGLT2i or GLP-1 RA.ResultsA total of 321 304 patients were identified with T2D and ASCVD ASCVD (130 280 female [40.5%]; median [IQR] age, 70.9 [62.9-78.0] years) who were potentially eligible for SGLT2i and/or GLP-1 RA, including 37 754 Black individuals (11.8%), 51 522 Hispanic individuals (16.0%), and 256 008 White individuals (11.8%). From January 2018 to March 2021, the use of SGLT2i increased from 5.8% (11 285 of 194 264) to 12.9% (11 058 of 85 956), GLP-1 RA increased from 6.9% (13 402 of 194 264) to 13.8% (11 901 of 85 956), and use of either agent increased from 11.4% (22 069 of 194 264) to 23.2% (19 909 of 85 956). Those taking an SGLT2i or GLP-1 RA were younger, less frequently hospitalized in the year prior, and more likely to be taking additional secondary prevention medications. Treated and nontreated populations were similar in terms of race, ethnicity, and outpatient health care utilization. Sulfonylureas and dipeptidyl peptidase 4 inhibitors remained more commonly used than SGLT2i or GLP-1 RA through 2021.Conclusions and RelevanceIn this study, uptake of SGLT2i and GLP-1 RA in adults with T2D and ASCVD increased modestly after guideline recommendations, although less than a quarter of persons with ASCVD and T2D receiving medical therapy were taking either. Further efforts are necessary to maximize the potential population benefit of these therapies in this high-risk population.

Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) improve the risk for heart and kidney failure. However, their effects on major atherosclerotic cardiovascular events (MACE) are less clear. Although outcomes trials of drugs for diabetes were not powered to prove superiority, the totality of trial data yields an estimate of ∼11% relative reduction for MACE (HR 0.89, 95%CI 0.82-0.96) and neutral on stroke (HR 0.92, 95%CI 0.79-1.08). In animal models, SGLT-2i favorably affects plaque size, composition, and inflammatory pathways; human data in this regard are lacking. Ongoing trials are evaluating SGLT-2i efficacy in heart failure, kidney disease, and postmyocardial infarction populations, independent of diabetes status.

Background: The COVID-19 pandemic has evolved through multiple phases characterized by new viral variants, vaccine development, and changes in therapies. It is unknown whether rates of cardiovascular disease (CVD) risk factor profiles and complications have changed over time. Methods: We analyzed the American Heart Association COVID-19 CVD registry, a national multicenter registry of hospitalized adults with active COVID-19 infection. The time period from April 2020 to December 2021 was divided into 3-month epochs, with March 2020 analyzed separately as a potential outlier. Participating centers varied over the study period. Trends in all-cause in-hospital mortality, CVD risk factors, and in-hospital CVD outcomes, including a composite primary outcome of cardiovascular death, cardiogenic shock, new heart failure, stroke, and myocardial infarction, were evaluated across time epochs. Risk-adjusted analyses were performed using generalized linear mixed-effects models. Results: A total of 46 007 patient admissions from 134 hospitals were included (mean patient age 61.8 years, 53% male, 22% Black race). Patients admitted later in the pandemic were younger, more likely obese, and less likely to have existing CVD ( P trend ≤0.001 for each). The incidence of the primary outcome increased from 7.0% in March 2020 to 9.8% in October to December 2021 (risk-adjusted P trend =0.006). This was driven by an increase in the diagnosis of myocardial infarction and stroke ( P trend P trend P trend =0.63). Conclusions: Despite a shifting risk factor profile toward a younger population with lower rates of established CVD, the incidence of diagnosed cardiovascular complications of COVID increased from the onset of the pandemic through December 2021. All-cause mortality decreased during the initial months of the pandemic and thereafter remained consistently high through December 2021.

To review the current evidence regarding the impact of the coronavirus disease 2019 (COVID-19) pandemic on cardiometabolic health, with a focus on strategies to help mitigate adverse effects on population health.Individuals with cardiometabolic disease are particularly vulnerable to worse outcomes with COVID-19 infection. In addition, the pandemic itself has had significant deleterious impact on the cardiometabolic health of the population, including declines in physical activity, increases in smoking and alcohol use, worsening blood pressure and glycemic control, and detrimental effects on mental health. Targeted interventions at the patient and community level will be needed to mitigate the long-term consequences of the COVID-19 pandemic on population cardiometabolic health. The COVID-19 pandemic has worsened cardiometabolic health, but there are several opportunities and enhanced tools available to counteract these changes.

INTRODUCTION: In the eValuation of ERTugliflozin effIcacy and Safety CardioVascular outcomes (VERTIS CV) trial (NCT01986881), patients with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (ASCVD) were randomized (1:1:1) to placebo, ertugliflozin 5 mg or 15 mg (doses pooled for analyses as prospectively planned). In this post hoc analysis, the effects of ertugliflozin on kidney outcomes were assessed in analyses stratified by baseline heart failure (HF). METHODS: Baseline HF was defined as a history of HF or prerandomization left ventricular ejection fraction ≤45%. Outcomes included estimated glomerular filtration rate (eGFR) over time, total 5-year eGFR slopes and time to first event of a prespecified exploratory kidney composite outcome of sustained ≥40% decrease from baseline eGFR, chronic kidney replacement therapy, or kidney death. All analyses were stratified by baseline HF status. RESULTS: Compared with no-HF at baseline (n = 5807; 70.4%), patients with HF (n = 2439; 29.6%) had a notably faster rate of eGFR decline, which is unlikely to be explained by the slightly lower baseline eGFR in that group. Ertugliflozin treatment resulted in a slower rate of eGFR decline in both subgroups; total placebo-adjusted 5-year eGFR slopes (ml/min per 1.73 m(2) per year [95% confidence intervals; CI]) were 0.96 (0.67–1.24) and 0.95 (0.76–1.14) for HF and no-HF subgroups, respectively. The placebo HF (vs. placebo no-HF) subgroup had a higher incidence of the composite kidney outcome (35/834 [4.20%] vs. 50/1913 [2.61%]). Hazard ratios (95% CI) for the effect of ertugliflozin on the composite kidney outcome did not differ significantly between HF and no-HF subgroups: 0.53 (0.33–0.84) and 0.76 (0.53–1.08), respectively (P(interaction) = 0.22). CONCLUSION: Although patients with HF at baseline had a faster rate of eGFR decline in VERTIS CV, the beneficial effects of ertugliflozin on kidney outcomes did not differ when stratified by baseline HF.

Introduction The “July effect” refers to the potential of adverse clinical outcomes related to the annual turnover of trainees. We investigated whether this impacts inpatient heart failure (HF) outcomes. Methods Data from all adults (≥18 years) admitted with a primary diagnosis of HF at US teaching hospitals from the 2012–2014 National Inpatient Sample were analyzed. Non-teaching hospital admissions were excluded. The primary outcome was in-hospital mortality. Secondary metrics included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic and linear regression models were used to adjust for confounders. Admissions were classified into 4 quarters (Q1–Q4), based on the academic calendar. Q1 and Q4 were designated to assess the effect of novice (July effect) versus experienced trainees, respectively. Results There were 699,675 HF admissions during Q1 and Q4 in the study period. Mean age was 71 ± 15 years and 48% were females. There were 20,270 in-hospital deaths, with no difference between Q1 and Q4; crude odds ratio (OR) 1.00, 95% confidence interval (CI) 0.94–1.07, p = 0.95. After risk adjustment, there was no in-hospital mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, 95% CI 0.89–1.03, p = 0.23. There was no difference in hospital LOS or total cost; 5.8 versus 5.8 days, p = 0.66 and $13,755 versus $13,586, p = 0.46, in Q1 and Q4, respectively. Conclusions In this nationally representative sample, there was no evidence of a “July effect” on inpatient HF outcomes. This suggests that HF patients should not delay seeking care during trainee transitions at teaching hospitals.

Background The WATCH‐DM (weight [body mass index], age, hypertension, creatinine, high‐density lipoprotein cholesterol, diabetes control [fasting plasma glucose], ECG QRS duration, myocardial infarction, and coronary artery bypass grafting) and TRS‐HF DM (Thrombolysis in Myocardial Infarction [TIMI] risk score for heart failure in diabetes) risk scores were developed to predict risk of heart failure (HF) among individuals with type 2 diabetes. WATCH‐DM was developed to predict incident HF, whereas TRS‐HF DM predicts HF hospitalization among patients with and without a prior HF history. We evaluated the model performance of both scores to predict incident HF events among patients with type 2 diabetes and no history of HF hospitalization across different cohorts and clinical settings with varying baseline risk. Methods and Results Incident HF risk was estimated by the integer‐based WATCH‐DM and TRS‐HF DM scores in participants with type 2 diabetes free of baseline HF from 2 randomized clinical trials (TECOS [Trial Evaluating Cardiovascular Outcomes With Sitagliptin], N=12 028; and Look AHEAD [Look Action for Health in Diabetes] trial, N=4867). The integer‐based WATCH‐DM score was also validated in electronic health record data from a single large health care system (N=7475). Model discrimination was assessed by the Harrell concordance index and calibration by the Greenwood‐Nam‐D’Agostino statistic. HF incidence rate was 7.5, 3.9, and 4.1 per 1000 person‐years in the TECOS, Look AHEAD trial, and electronic health record cohorts, respectively. Integer‐based WATCH‐DM and TRS‐HF DM scores had similar discrimination and calibration for predicting 5‐year HF risk in the Look AHEAD trial cohort (concordance indexes=0.70; Greenwood‐Nam‐D’Agostino P >0.30 for both). Both scores had lower discrimination and underpredicted HF risk in the TECOS cohort (concordance indexes=0.65 and 0.66, respectively; Greenwood‐Nam‐D’Agostino P P =0.96). TRS‐HF DM score could not be validated in the electronic health record because of unavailability of data on urine albumin/creatinine ratio in most patients in the contemporary clinical practice. Conclusions The WATCH‐DM and TRS‐HF DM risk scores can discriminate risk of HF among intermediate‐risk populations with type 2 diabetes.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to reduce the risk of hospitalization for heart failure (HHF) and composite kidney outcomes, but the mediators underlying these benefits are unknown.Among participants from VERTIS CV, a trial of patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease randomized to ertugliflozin versus placebo, Cox proportional hazards regression models were used to evaluate the percentage mediation of ertugliflozin efficacy on the first HHF and kidney composite outcome in 26 potential mediators. Time-dependent approaches were used to evaluate associations between early (change from baseline to the first post-baseline measurement) and average (weighted average of change from baseline using all post-baseline measurements) changes in covariates with clinical outcomes.For the HHF analyses, early changes in four biomarkers (haemoglobin, haematocrit, serum albumin and urate) and average changes in seven biomarkers (early biomarkers + weight, chloride and serum protein) were identified as fulfilling the criteria as mediators of ertugliflozin effects on the risk of HHF. Similar results were observed for the composite kidney outcome, with early changes in four biomarkers (glycated haemoglobin, haemoglobin, haematocrit and urate), and average changes in five biomarkers [early biomarkers (not glycated haemoglobin) + weight, serum albumin] mediating the effects of ertugliflozin on the kidney outcome.In these analyses from the VERTIS CV trial, markers of volume status and haemoconcentration and/or haematopoiesis were the strongest mediators of the effect of ertugliflozin on reducing risk of HHF and composite kidney outcomes in the early and average change periods.NCT01986881.

There are limited data on the prognostic utility of regadenoson SPECT myocardial perfusion imaging (MPI) in patients with end-stage renal disease (ESRD). In a single-center, retrospective study, we analyzed consecutive ESRD patients who underwent regadenoson SPECT-MPI. The severity of MPI abnormalities and ischemic burden were determined quantitatively. The primary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiac death or myocardial infarction. Among 1,227 subjects (mean age 54 ± 13 years, 47% men), 60 (5%) MACE were observed during a mean follow-up of 2.5 ± 1.8 years. The presence and severity of MPI abnormalities and ischemic burden were associated with a stepwise increase in MACE risk. Abnormal MPI (SSS ≥ 4) was associated with increased MACE risk, independent and incremental to relevant clinical covariates; adjusted hazard ratio, 1.95; 95% confidence interval, 1.15-3.32; Δχ2 = 5.97; P = .013. Myocardial ischemia (SDS ≥ 2) was associated with a trend towards increased MACE risk; adjusted hazard ratio, 1.63; 95% confidence interval, 0.96-2.77; Δχ2 = 3.12; P = .072. In the largest cohort to date, we demonstrated the incremental prognostic value of abnormal MPI in predicting MACE risk in ESRD patients. Given its size, our study provides improved risk estimates in this population compared to previous reports.

Data on the prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) is limited and based on small cohorts. We conducted a single-center, retrospective cohort study of 10,275 consecutive patients who underwent regadenoson SPECT-MPI. Among the study subjects, 28.7% had abnormal MPI and 25.5% had myocardial ischemia. Patients were followed for a mean of 2.4 ± 2.2 years for major adverse cardiac events (MACE), defined as cardiac death or myocardial infarction. There was a significant stepwise increase in MACE with an increasing burden of perfusion abnormality (P

The aim of this study was to examine whether hospital surgical aortic valve replacement (SAVR) volume was associated with corresponding transcatheter aortic valve replacement (TAVR) outcomes.Recent studies have demonstrated a volume-outcome relationship for TAVR.In total, 208,400 fee-for-service Medicare beneficiaries were analyzed for all aortic valve replacement procedures from 2012 to 2015. Claims for patients 65 years of age, concomitant coronary artery bypass grafting surgery, other heart valve procedures, or other major open heart procedures were excluded, as were secondary admissions for aortic valve replacement. Hospital SAVR volumes were stratified on the basis of mean annual SAVR procedures during the study period. The primary outcomes were 30-day and 1-year post-operative TAVR survival. Adjusted survival following TAVR was assessed using multivariate Cox regression.A total of 65,757 SAVR and 42,967 TAVR admissions were evaluated. Among TAVR procedures, 21.7% (n = 9,324) were performed at hospitals with 100 (group 1), 35.6% (n = 15,298) at centers with 100 to 199 (group 2), 22.9% (n = 9,828) at centers with 200 to 299 (group 3), and 19.8% (n = 8,517) at hospitals with ≥300 SAVR cases/year (group 4). Compared with group 4, 30-day TAVR mortality risk-adjusted odds ratios were 1.32 (95% confidence interval: 1.18 to 1.47) for group 1, 1.25 (95% confidence interval: 1.12 to 1.39) for group 2, and 1.08 (95% confidence interval: 0.82 to 1.25) for group 3. These adjusted survival differences in TAVR outcomes persisted at 1 year post-procedure.Total hospital SAVR volume appears to be correlated with TAVR outcomes, with higher 30-day and 1-year mortality observed at low-volume centers. These data support the importance of a viable surgical program within the heart team, and the use of minimum SAVR hospital thresholds may be considered as an additional metric for TAVR performance.

The present study is a sub-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) that aimed to evaluate the role of intensive vs. standard hypertensive treatment on cardiovascular outcomes according to the body mass indices of trial participants. SPRINT participants were categorized according to their baseline BMI values into normal (BMI ≥ 18.5 to 0.05). In this sub-analysis of the SPRINT trial, intensive blood pressure control had a beneficial effect in reducing the primary endpoint and all-cause mortality irrespective of the participants’ BMI.

The effects of patient-prosthesis mismatch (PPM) after surgical aortic valve replacement (SAVR) suggest worse outcomes with smaller valves. We assessed clinical outcomes of younger females undergoing SAVR, using small and large prostheses, and the incremental risk of PPM. Between January 2002 and June 2015, 451 younger (age ≤65 years) female patients underwent SAVR. Patients were stratified into small prostheses (SP) ≤21 mm (n = 256) and large prostheses (LP) ≥23 mm (n = 195) groups. PPM was classified as moderate if indexed effective orifice area (iEOA) 0.65–0.85 cm2/m2, or severe if iEOA

The cardiovascular benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) have increased the focus of type 2 diabetes mellitus (T2DM) care on comprehensive cardiovascular risk reduction. Herein, we review the results of the cardiovascular outcomes trials of SGLT2i and GLP-1 RA, discuss the concepts of relative vs. absolute risk reduction in the context of these trials, and highlight the importance of individualized risk assessment when applying trial results to clinical practice. To enable personalized treatment approaches, multiple clinical risk scores have been developed to assess risk of atherosclerotic cardiovascular disease (ASCVD) outcomes and hospitalization for heart failure (HHF) in patients with T2DM. In addition, circulating biomarkers of myocardial injury (cardiac troponin) and hemodynamic stress (natriuretic peptides) have been shown to further refine risk prediction of these clinically important cardiovascular complications. When making decisions about whether to initiate SGLT2i and GLP-1 RA, clinicians should consider the anticipated relative and absolute treatment benefits from these antihyperglycemic therapies. Clinicians can use available clinical and biomarker-based risk tools when counseling patients about their individual cardiovascular risk profiles and when estimating absolute treatment benefits from SGLT2i and GLP-1 RA.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and risks of standard‐ versus extended‐duration anticoagulation for primary VTE prophylaxis in acutely ill medical patients.

OBJECTIVESEdge-to-edge (E2E) mitral valve repair (MVP) is a versatile technique used in various situations for mitral regurgitation (MR). This technique has been regaining attention, given the increasing use of the MitraClip procedure. This real-world study evaluates the durability of the E2E technique in different settings.METHODSFrom January 2002 to May 2015, a total of 303 patients with at least moderate MR who underwent E2E MVP were identified. Patients undergoing isolated MVP (n = 133) and concomitant coronary artery bypass grafting or other valvular procedures (N = 170) were included. Cox proportional hazards modelling was used to evaluate the risk factors for cumulative survival, or MV event (i.e. MV reintervention or MR recurrence) while event-free survival—defined as time to composite outcome of either death or MV event—was determined using competing risk Kaplan–Meier analysis. Median follow-up duration was 6.9 (interquartile range 5.8) years.RESULTSThe most common MR aetiology was myxomatous (34%), followed by Barlow’s disease (27.7%), and ischaemic (21.5%). E2E MVP was performed for the following indications: persistent MR (51.5%), systolic anterior motion prophylaxis (22.1%), transaortic approach (17.5%) and systolic anterior motion treatment post-MVP (8.9%). Concomitant ring annuloplasty was performed in 224 patients (73.9%). Operative mortality was 3.6% and MV event rate was 18.5%. Significant predictors of decreased survival included age, renal insufficiency, peripheral vascular disease and ischaemic MR aetiology (all P CONCLUSIONSE2E repair is a versatile MVP technique, which can be used in prevention and treatment of systolic anterior motion, transaortic approach or with concomitant techniques, with reasonable outcomes. Ischaemic aetiology and absence of ring annuloplasty were associated with worse cumulative survival and MV event rates, respectively, which raises some concern in light of the expanding indication for MitraClip system.

Venous thromboembolism (VTE) and coronary artery disease are major health issues that cause substantial morbidity and mortality. New data have emerged suggesting that these two conditions could have a close relationship. Thus, we sought to determine the trends in annual rate of VTE occurrence in patients with ST-segment elevation myocardial infarction (STEMI) and measure its impact on in-hospital mortality, bleeding complications, and cost and length of hospitalization. We queried the 2003–2013 Nationwide Inpatient Sample databases to identify adults with primary diagnosis of STEMI. VTE events were then allocated. Inpatient outcomes of patients with VTE were compared to those without VTE. Out of 2,495,757 hospitalizations for STEMI, VTE was diagnosed in 25,149 (1%) hospitalizations. Patients who experienced VTE were older (mean age: 67.5 vs 64.8, p < 0.01) and had a higher proportion of black patients (10.1% vs 7.7%, p < 0.001) and females (40.1% vs 35%, p < 0.001) compared to patients without VTE. There was an increasing trend in the rate of VTE during the study period (2003: 0.8% vs 2013: 1.0%, p < 0.001). Patients with VTE had a prolonged hospitalization (median: 9 vs 3 days, p < 0.001), increased cost, higher risk of gastrointestinal bleeding (OR: 2.13, p < 0.001), intracranial hemorrhage (OR: 2.14, p < 0.001), blood transfusions (OR: 1.94, p < 0.001), and mortality (OR: 1.39, p < 0.001). The rate of VTE occurrence in patients with STEMI in our study was 10 per 1000 admissions. VTE was associated with more bleeding complications, longer hospital stays, higher costs, and mortality. These findings suggest that a more aggressive approach for VTE prophylaxis may be warranted in this population.

Background: The “July effect” is a well-described phenomenon in academic medicine, relating to the annual influx of new trainees. We examined whether the “July effect” impacts inpatient outcomes of admissions for heart failure (HF). Methods: Between 2012 and 2014, we included adult patients (≥18 years) with a primary diagnosis of HF, defined using ICD-9 codes, from the National Inpatient Sample. We excluded non-teaching hospitals. Primary endpoint was in-hospital mortality. Secondary endpoints included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic regression and adjusted odds ratio (OR) were used to adjust for confounders. Based on academic calendar, we classified admissions into 4 quarters (Q1-4). Q1 and Q4 were designated to assess the effect of novice (July effect) vs. seasoned trainees, respectively. Results: We identified 699,675 HF admissions during Q1 and Q4 over the study period. Mean age was 71 years and 48% were females. There were 20,270 in-hospital deaths (Q1 9,695 vs. Q4 10,575). After adjusting for confounders, there was no mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, p = 0.23 (Figure). Similarly, there was no difference in hospital LOS or total cost; 5.8 vs. 5.8 days, p = 0.66 and $13,755 vs. $13,586, p = 0.46, in Q1 and Q4, respectively. Conclusion: In the largest study to date, there was no evidence of a “July effect” on inpatient HF outcomes. This may be credited to the well-defined guidelines which facilitate safe patient care in these patients.

Aortic valve stenosis (AS) is a growing health problem worldwide, especially in elderly populations.1 Its severity is classified by a number of clinical and echocardiographic parameters into mild, moderate and severe AS. The latter, if left untreated, can be deleterious to the affected individuals’ quality of life and may ultimately be fatal.1 Clinical manifestations of severe AS include exertional dyspnoea, chest pain and syncope.1 Surgical aortic valve replacement (SAVR) has long been the classical treatment modality for severe, symptomatic AS. SAVR has been proven to alleviate symptoms and prolong survival, rendering it the standard of care.2 In the current era, with the rapidly evolving technology and growing momentum towards minimally invasive procedures, transcatheter aortic valve implantation (TAVI) has emerged as a viable, alternative treatment option.3 TAVI has demonstrated outcomes comparable to SAVR in patients who are deemed inoperable or at a high to intermediate surgical risk.2 Nonetheless, whether TAVI improves outcomes in patients who are deemed to have a low surgical risk remains a matter of debate. Accordingly, in our Cochrane review,4 we sought to assess the comparative outcomes of TAVI and SAVR for severe AS in people with low surgical risk. We conducted an exhaustive literature search for randomised controlled trials (RCTs) comparing TAVI and SAVR for severe AS in patients with low surgical risk. We included adults (≥18 years old) of both sexes. The low surgical risk was defined as a Society of Thoracic Surgery (STS) risk score or European System for Cardiac Operative Risk Evaluation (EuroSCORE) II of

There are limited data on the prognostic utility of regadenoson SPECT myocardial perfusion imaging (MPI) in patients with end-stage renal disease (ESRD).In a single-center, retrospective study, we analyzed consecutive ESRD patients who underwent regadenoson SPECT-MPI. The severity of MPI abnormalities and ischemic burden were determined quantitatively. The primary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiac death or myocardial infarction. Among 1,227 subjects (mean age 54 ± 13 years, 47% men), 60 (5%) MACE were observed during a mean follow-up of 2.5 ± 1.8 years. The presence and severity of MPI abnormalities and ischemic burden were associated with a stepwise increase in MACE risk. Abnormal MPI (SSS ≥ 4) was associated with increased MACE risk, independent and incremental to relevant clinical covariates; adjusted hazard ratio, 1.95; 95% confidence interval, 1.15-3.32; ΔχIn the largest cohort to date, we demonstrated the incremental prognostic value of abnormal MPI in predicting MACE risk in ESRD patients. Given its size, our study provides improved risk estimates in this population compared to previous reports.

This study evaluated outcomes in younger patients, specifically aged 50 years and younger, after mechanical aortic valve replacement (mAVR) and bioprosthetic AVR (bAVR).From 1994 to 2016, 643 patients underwent AVR (411 mAVR and 232 bAVR) at age 50 or younger. Concomitant coronary artery bypass grafting and mitral valve procedures were also included. Propensity score-matching methods resulted in 170 evenly matched patient pairs. Primary end points were operative mortality and long-term survival. Secondary end points were stroke, major bleeding, and redo AVR. Median observation time was 8.1 years (range, 0 to 23.6 years).Overall, mean age was 41.9 years, and 29.3% were women, with an increasing trend toward use of bAVR. Mean age in the matched patients was 43.3 years for both cohorts (p = 0.68). Operative mortality, stroke, atrial fibrillation, reoperation for bleeding, and readmission rates within 30 days were all similar between the two groups. bAVR patients were at higher risk for redo AVR (13% vs 1.6%, p0.001), and mAVR patients were at higher risk for major bleeding events (8.5% vs 2.2%, p = 0.006). However, when adjusted, there were no differences in midterm and long-term survival between unmatched and matched cohorts.The increased risk of reoperation for bAVR and major bleeding incidents for mAVR was not reflected in midterm and long-term survival differences between the two groups. Our results suggest that bAVR may be an acceptable prosthesis choice for some patients aged 50 years and younger, although the results should be taken with caution.

Background Severe aortic valve stenosis (AS) is a major cause of morbidity and mortality worldwide. The definitive management for severe AS is aortic valve replacement (AVR). The choice of transcatheter approach versus open-heart surgery for AVR in people with severe AS and low surgical risk remains a matter of debate. Objectives To assess the benefits and harms of transcatheter aortic valve implantation (TAVI) compared to surgical aortic valve replacement (SAVR) in people with severe AS and low surgical risk. Search methods We searched the following databases for randomised controlled trials (RCTs) on 29 April 2019: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science Core Collection. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We searched all databases from inception to present and imposed no restriction on language or date of publication. Selection criteria We included RCTs that compared TAVI and SAVR in adults (18 years of age or older) with severe AS and low surgical risk. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Two authors independently screened titles and abstracts for inclusion, performed data extraction, and assessed risk of bias in the studies included. We analysed dichotomous data using the risk ratio (RR) and continuous data using the mean difference (MD), with respective 95% confidence intervals (CI). We assessed the certainty of evidence for each outcome using the GRADE approach. Our outcomes of interest were assessed in the short term (i.e. during hospitalisation and up to 30 days of follow-up). Primary outcomes were all-cause mortality, stroke, and rehospitalisation. Secondary outcomes were myocardial infarction (MI), cardiac death, length of hospital stay (LOS), permanent pacemaker (PPM) implantation, new-onset atrial fibrillation, acute kidney injury (AKI), and any bleeding. Main results We identified four studies (13 reports), with 2818 participants, and one ongoing study. Overall certainty of evidence ranged from high to very low. There is probably little or no difference between TAVI and SAVR for the following short-term outcomes: all-cause mortality (RR 0.69, 95% CI 0.33 to 1.44; SAVR 11 deaths per 1000, TAVI 8 deaths per 1000 (95% CI 4 to 16); 2818 participants; 4 studies; moderate-certainty evidence); stroke (RR 0.73, 95% CI 0.42 to 1.25; SAVR 21 strokes per 1000, TAVI 16 strokes per 1000 (95% CI 9 to 27); 2818 participants; 4 studies; moderate-certainty evidence); MI (RR 0.82, 95% CI 0.42 to 1.58; SAVR 14 MI per 1000, TAVI 11 MI per 1000 (95% CI 6 to 21); 2748 participants; 3 studies; moderate-certainty evidence); and cardiac death (RR 0.71, 95% CI 0.32 to 1.56; SAVR 10 cardiac deaths per 1000, TAVI 7 cardiac deaths per 1000 (95% CI 3 to 16); 2818 participants; 4 studies; moderate-certainty evidence). TAVI may reduce the risk of short-term rehospitalisation, although the confidence interval also includes the possibility of no difference in risk between groups (RR 0.64, 95% CI 0.39 to 1.06; SAVR 30 cases per 1000, TAVI 19 cases per 1000 (95% CI 12 to 32); 2468 participants; 2 studies; low-certainty evidence). TAVI, compared with SAVR, probably increases the risk of PPM implantation (RR 3.65, 95% CI 1.50 to 8.87; SAVR 47 per 1000, TAVI 170 cases per 1000 (95% CI 70 to 413); number needed to treat for an additional harmful outcome (NNTH) = 7; 2683 participants; 3 studies; moderate-certainty evidence). We are uncertain whether TAVI, compared with SAVR, affects the LOS in days, although it appears to be associated with shorter LOS. TAVI, compared with SAVR, reduces the risk of atrial fibrillation (RR 0.21, 95% CI 0.15 to 0.30; 2683 participants; 3 studies), AKI (RR 0.30, 95% CI 0.16 to 0.58; 2753 participants; 4 studies), and bleeding (RR 0.31, 95% CI 0.16 to 0.62; 2753 participants; 4 studies) (all high-certainty evidence). Authors' conclusions Our meta-analysis indicates that, in the short term, TAVI probably has little or no mortality difference compared to SAVR for severe AS in individuals with low surgical risk. Similarly, there is probably little or no difference in risk of stroke, MI, and cardiac death between the two approaches. TAVI may reduce the risk of rehospitalisation, but we are uncertain about the effects on LOS. TAVI reduces the risk of atrial fibrillation, AKI, and bleeding. However, this benefit is offset by the increased risk of PPM implantation. Long-term follow-up data are needed to further assess and validate these outcomes, especially durability, in the low surgical risk population.

Importance Questions have recently arisen as to whether 30-day mortality is a reasonable metric for understanding institutional practice differences after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Objective To examine the utility of 30-day vs 90-day mortality after TAVR and SAVR as a mortality quality metric. Design, Setting, and Participants This nationally representative, multicenter, cohort study analyzed data from Medicare beneficiaries undergoing TAVR and SAVR procedures from January 1, 2012, to December 31, 2015. Concomitant coronary artery bypass grafting and other heart valve or other major open-heart procedures were excluded. Hospitals that performed fewer than 50 TAVR or 70 SAVR procedures per year were excluded to ensure reliable estimates and to reduce the risks of inflated results because of small institutional sample sizes. Data were analyzed from October 2018 to August 2019. Exposures Hospitals were ranked into top- (10%), middle- (80%), and bottom-performing (10%) groups based on their 4-year mean 30-day mortality. Main Outcomes and Measures Changes in hospital performance rankings at 90 days and 1 year and correlation of 30- and 90-day mortality with 1-year mortality were examined. Results A total of 30 329 TAVR admissions at 184 hospitals and 26 021 SAVR admissions at 191 hospitals were evaluated. For TAVR, 40 hospitals (21.7%) changed performance rankings at 90 days: 13 (48.1%) in the top-performing group and 8 (29.6%) in the bottom-performing group. At 1 year, 56 hospitals (30.4%), which included 21 (77.8%) in the top-performing group and 12 (44.4%) in the bottom-performing group, changed rankings. Similar findings were observed for SAVR, with an overall 90-day conversion rate of 17.3% and a 1-year rate of 30.3%. These findings persisted after adjusting for the differences in patient risk profiles among the 3 groups. Capturing 90-day events was also more robustly informative regarding expected 1-year outcomes after both TAVR and SAVR, largely owing to the observed plateau in the instantaneous hazard observed beyond this point. Conclusions and Relevance The findings suggest that evaluation of hospital performance based on 30-day mortality may underestimate outcomes and therefore substantially misrepresent institutional performance after TAVR and SAVR compared with 90-day mortality, even after risk adjustment. Although 30-day mortality has been validated, 90-day mortality may be a more reliable outcome metric for measuring hospital performance and capturing procedure-related mortality.

Data on the prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) is limited and based on small cohorts.We conducted a single-center, retrospective cohort study of 10,275 consecutive patients who underwent regadenoson SPECT-MPI. Among the study subjects, 28.7% had abnormal MPI and 25.5% had myocardial ischemia. Patients were followed for a mean of 2.4 ± 2.2 years for major adverse cardiac events (MACE), defined as cardiac death or myocardial infarction. There was a significant stepwise increase in MACE with an increasing burden of perfusion abnormality (P .001) and myocardial ischemia (P .001). Abnormal MPI (adjusted HR 1.52; 95% CI 1.21 to 1.91) and myocardial ischemia (adjusted HR 1.53; 95% CI 1.25 to 1.89) were associated with MACE, independent of and incremental to clinical covariates and left ventricular ejection fraction (LVEF). Moreover, post-stress LVEF, LVEF reserve, and left ventricular end-diastolic volume added significant prognostic information. Transient ischemic dilation ≥ 1.31 did not provide incremental prognostic value (adjusted HR 1.02; P = .906).In the largest cohort to date, we demonstrated that the presence and severity of perfusion abnormality and myocardial ischemia on regadenoson stress SPECT-MPI are associated with an independent increase in MACE.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of TAVR compared to SAVR in people with severe AS and low surgical risk.

The present study is a sub-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) that aimed to evaluate the role of intensive vs. standard hypertensive treatment on cardiovascular outcomes according to the body mass indices of trial participants. SPRINT participants were categorized according to their baseline BMI values into normal (BMI ≥ 18.5 to25), overweight (BMI ≥ 25 to30), and obese (BMI ≥ 30) groups. The primary cardiovascular outcome was a composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular cause. Cox regression analysis was used to calculate hazard ratios for the study outcome in intensive and standard BP treatment among those with varying BMI. Among 9237 participants with, 1682, 3599, and 3956 were normal, overweight and obese, respectively. After a median follow-up of 3.26 years, the hazard ratios for the primary endpoint were 0.82 (95% CI 0.58, 1.16), 0.71 (95% CI 0.54, 0.94), and 0.76 (95% CI 0.59, 0.98) for the normal, overweight, and obese participants, respectively (P value for interaction 0.79). The effect of intensive versus standard SBP treatment for the other secondary endpoints and serious adverse events were all similar in participants of different BMI (all P-interaction 0.05). In this sub-analysis of the SPRINT trial, intensive blood pressure control had a beneficial effect in reducing the primary endpoint and all-cause mortality irrespective of the participants' BMI.

A lower rate of permanent pacemaker (PPM) has been linked to a target aortic implantation height (AIH)0.70, following transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve. Based on clinical experience, it was hypothesized that a higher AIH (≥0.85) would lower the rate of PPM implantation.A total of 127 patients (66 females, 61 males; mean age 82 ± 8 years) underwent TAVR with the SAPIEN 3 valve between May 2015 and July 2016. AIH was defined as the proportion of the valve frame above the aortic annulus in the post-deployment aortogram. A target AIH (≥0.70) was achieved in 113 patients (89%). Cases were stratified into a High Implantation (HI) group (AIH ≥0.85; 33 patients) or a Standard Implantation (SI) group (AIH0.85; 94 patients).The mean Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score of all patients was 6.4 ± 3.5%. Preoperative right bundle branch block (RBBB) was prevalent in 13% of SI patients, and in 18% of HI patients (p = 0.56). There were no significant differences in operative mortality (3.2% versus 0%), median length of stay (2 days versus 3 days) and incidence of moderate-to-severe paravalvular leak (3.2% versus 0%; all p0.410) between SI and HI patients, respectively. Likewise, the incidence of new PPM did not differ between the two groups (12% in HI versus 13% in SI; p ≥0.99). The mean AIH was similar for patients with PPM implantation (0.80 ± 0.08) compared to those without (0.78 ± 0.06; p = 0.520). Preoperative RBBB was significantly associated with PPM implantation (odds ratio (OR) 10.1; p = 0.002), and patients who underwent PPM implantation had a higher operative mortality (12.5% versus 1%; p = 0.040).Among TAVR patients who received the SAPIEN 3 heart valve, a higher AIH (≥0.85) was not associated with a lower rate of PPM implantation or increased operative mortality. Prior RBBB was the only independent risk factor for new PPM implantation. Long-term follow up is crucial in determining the clinical significance of PPM implantation.

Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide. Cardiac tissue, or heart muscle, relies on blood supply from coronary arteries for oxygen and nutrient delivery. When the coronary arteries are narrowed, or blocked, restoration of blood flow is essential for preservation of heart tissue and avoidance of myocardial infarction (i.e., dead heart muscle). Coronary artery bypass grafting (CABG) has long been the standard surgical treatment option for patients with CAD. The principle of the operation is to create a new route for nutrients and oxygen-rich blood to reach the heart muscle by using a conduit, either a vein or an artery. The most commonly used conduits are the internal mammary arteries or the great saphenous veins. In this chapter, we shed light on this important surgical technique, with emphases on its indications, outcomes, and complications. We also highlight some special considerations and discuss the emergence of new, less invasive techniques like minimally invasive bypass procedures, hybrid CABG, as well as the evolution of technology to include robotic techniques.

Introduction: Spontaneous Coronary Artery Dissection (SCAD) is reported to occur predominantly in young women. Gender differences in the clinical presentation and outcomes of patients with SCAD have not been studied on a population level. We sought to compare the in-hospital outcomes of men and women presenting with acute myocardial infarction (AMI) and SCAD. Methods: We identified patients from the National Inpatient Sample (NIS) between 2005 and 2015 who presented with primary diagnoses of AMI and SCAD. We identified SCAD with ICD-9 code 414.12. A 1:1 propensity-matched cohort was created to examine the outcomes between men and women. Primary endpoint was in-hospital mortality. Secondary endpoints included in-hospital cardiac and non-cardiac complications. Results: Of the 6617 (32017 weighted national estimates) patients with SCAD over the study period, majority were males 3667 (55.4%). Males were younger than females (60.32 yr vs. 61.59 yr) and presented more often with ST-elevation myocardial infarction (STEMI) (53.0% vs. 45.9% P= Conclusion: In our large population-based analysis, compared to females, males were more likely to present with STEMI as compared to females. With the except of V-Tach, which was higher in males, there were no significant gender differences in hospital outcomes namely inpatient mortality, cardiogenic, Vfib or acute heart failure.

Total anomalous pulmonary venous return (TAPVR) is an uncommon cyanotic congenital heart disease characterized by lack of connection between the pulmonary veins and the left atrium. TAPVR typically presents during infancy and diagnosis in adulthood is unusual. A 30 year old man presented to the

Rheumatoid arthritis (RA) is a chronic autoimmune disorder known to cause premature atherosclerosis and coronary artery disorder. However, little is known about the impact of RA on the outcomes of acute myocardial infarction (AMI). We studied all adult patients with a primary diagnosis of AMI from

Management of tuberculosis (TB) has witnessed several changes over the past decades. While medical management is now the mainstay of therapy, surgical intervention was once the only treatment option physicians had to offer. We discuss some historical surgical procedures and take a quick glance at the evolution of TB therapy. We note the importance of adequate history-taking and the implications of what seemingly obsolete techniques may have in contemporary practice. We also highlight the re-emergence of surgical options in the modern era with the rise of multidrug-resistance.

OBJECTIVES To define the national rate of complete heart block (CHB) after transcatheter aortic valve replacement (TAVR) and its impact on procedural mortality, overall cost, and length of hospital stay. BACKGROUND CHB leading to permanent pacemaker (PPM) implantation is one of the most common complications post TAVR. National data on the temporal trend of CHB post TAVR are lacking. METHODS We queried the 2012-2014 National Inpatient Sample databases to identify all patients who underwent TAVR. Patients with preoperative pacemakers or implantable cardioverter-defibrillators were excluded. Association between CHB and outcomes, and overall trends in rate of CHB, PPM implantation, and inpatient mortality were examined. RESULTS Of 35,500 TAVR procedures, 3,675 (10.4%) had CHB. Overall, occurrence of CHB significantly increased from 8.4% in 2012 to 11.8% in 2014 (adjusted OR per year: 1.23; 95% confidence interval [CI]: 1.17-1.29, P trend

The world celebrates over 50 years since the first human-to-human heart transplant. Bibliometric analysis is a statistical concept that has recently evolved, enabling scientists to study citation patterns and identify characteristics of highly cited scholarly work in different fields. Although it has been widely utilized, such analyses have not been conducted to date on heart transplant literature. We sought to assess the characteristics of the top 100 most referenced citations in the field of heart transplantation. We searched the Scopus database (www.scopus.com) to identify all articles relating to heart transplantation. The articles were arranged in descending order from most cited to least cited and selected articles were scrutinized for data extraction. One hundred articles were included in the final list. Of the total 40,660 citations identified, 3,210 (8.0%) were self-citations, which impacted the final rank order. The articles were published in 25 different journals between 1960 and 2013. The most productive 5-year time period was between 2000 and 2005, when 24 of the 100 most cited publications were produced. There was no correlation between the journals' impact factors and the number of articles produced per journal. The presence and type of funding were not associated with the number of citations. Over 85% of first and senior investigators were men. In conclusion, our study highlights key features of the most highly cited scientific literature on heart transplantation and provides insights into trends of published work in this field. Additionally, this work may serve as a useful guide to researchers and funding bodies by highlighting the most prolific areas of cardiac transplant research to date.

Peripheral artery disease (PAD) is a prevalent global problem with increased mortality. Affects about one in four patients with end stage renal disease (ESRD). Intermittent pneumatic compression (IPC) has shown improvement of lower extremity hemodynamics and symptoms and may be implemented during hemodialysis (HD). We designed a trial to test the utility of IPC in the ESRD population by assessing improvement in quality of life (QOL) and functional limitation from PAD-related symptoms. We aim to present our design and initial results. Methods: This is a prospective single cohort study for paired analysis undergoing recruitment of outpatients at the HD unit of John H. Stroger, Jr. Hospital of Cook County. A sample size of 78 yields a power of 80% and alpha of 0.05, assuming an average peak walking time of five minutes and 25% improvement after supervised exercise. PAD is confirmed by ankle-brachial index (ABI) and demographics collected. A baseline Six-minute Walk Test (6MWT), Peripheral Artery Questionnaire (PAQ) and Walking Impairment Questionnaire (WIQ) are administered and will be compared with their performance post intervention. The IPC device (Bio Arterial Plus) will be used for intervention during each HD for two months average. We present continuous variables as mean±SD and categorical variables as percentage. Results: From 10 recruited patients in the first month, 60% are men, age 54.6±13.1 years, the majority Hispanic (80%). 70% of ABI were abnormal, all due to non-compressible PAD (1.44±0.20). All patients have HTN, 50% diabetes, 20% hyperlipidemia, 10% had a stroke and 10% revascularization for PAD. At baseline 6MWT, distance walked was 357.7±59.5 m, with 600±52.5 total steps and fatigue as main symptom (30%) and no typical claudication. QOL questionnaires showed WIQ walking distance 68.58±18.04, WIQ walking speed 72.5±26.36, and WIQ stair climbing 50.04±30.04 points; PAQ physical limitation 61±21.4, PAQ symptoms 62.79±18.7, PAQ satisfaction 68.67±27.9, PAQ quality of life 64±13.04, and PAQ social limitation 70±23.13 points. Conclusion: Non-compressible PAD is prevalent in ESRD, and QOL seems significantly compromised from it. Our trial will provide insight of an alternative therapy, and optimize the time in HD even further.