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Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.

Regardless of the cause, the failure of cardiology to attract women when the gender ratio of medical undergraduates is approximately balanced indicates that a substantial proportion of the talent pool is being lost to other specialties. If this is not corrected, it will prove increasingly difficult

Despite the increase in the number of female physicians across most specialties within cardiology, 10% of clinical cardiac electrophysiology (EP) fellows are women.This study sought to determine the factors that influence fellows-in-training (FITs) to pursue EP as a career choice and whether this differs by gender.The authors conducted an online multiple-choice survey through the American College of Cardiology to assess the decision factors that influence FITs in the United States and Canada to pursue cardiovascular subspecialties.A total of 933 (30.5%) FITs completed the survey; 129 anticipated specializing in EP, 259 in interventional cardiology (IC), and 545 in a different field or were unsure. A total of 1 in 7 (14%) FITs indicated an interest in EP. Of this group, more men chose EP than women (84% vs 16%; P 0.001). The most important factor that influenced FITs to pursue EP was a strong interest in the field. Women were more likely to be influenced by having a female role model (P = 0.001) compared with men. After excluding FITs interested in IC, women who deselected EP were more likely than men to be influenced by greater interest in another field (P = 0.004), radiation concerns (P = 0.001), lack of female role models (P = 0.001), a perceived "old boys' club" culture (P = 0.001) and discrimination/harassment concerns (P = 0.001).Women are more likely than men to be negatively influenced by many factors when it comes to pursuing EP as a career choice. Addressing those factors will help decrease the gender disparity in the field.

Introduction: The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease recommends adults engage in ≥ 150 minutes of moderate or ≥75 minutes of vigorous intensity aerobic activity per week to reduce cardiovascular risk. Cardiologist adherence to these guidelines is unknown. Methods: Electronic surveys were sent to 437 ACC CardioSurve cardiologists, a representative sample of current ACC members. Demographic data was collected. Respondents were asked to quantify and rate intensity of exercise in an average week. Results: Between February and March 2020, a total of 189 panelists completed the survey for a response rate of 43%, of which 13% were women. There was even representation in number of years in practice: 33% early career, 27% mid-career, and 35% late career. Cardiologists across all career stages were evenly represented; 33% early career, 27% mid-career, and 35% late career. Overall only 56% of cardiologists met exercise guidelines (Figure). Less than half participated in vigorous activity (46%) with higher prevalence among mid versus early career (58% vs 38%, p=0.035). Interventional cardiologists were less likely to meet the standards for exercise intensity compared to general cardiology (44% vs. 59%, p=0.09). Early career respondents were less likely to adhere to activity recommendations (39% vs 59%, p=0.018). Those who reported vigorous activity were more likely to strength train at least twice per week (43% vs. 15%, p < 0.001). Conclusions: Nearly half of cardiologists are not adherent to the ACC recommended guidelines for aerobic activity. The impact on cardiologists’ health was not quantified, but this study suggests there is room for improvement in prevention behaviors. Since physicians are known to serve as role models for their patients, we hypothesize lack of adherence to activity guidelines may also negatively impact our patients.

Background Cardiac rehabilitation is an established performance measure for adults with ischemic heart disease, but patient participation is remarkably low. Home‐based cardiac rehabilitation (HBCR) may be more practical and feasible, but evidence regarding its efficacy is limited. We sought to compare the effects of HBCR versus facility‐based cardiac rehabilitation (FBCR) on functional status in patients with ischemic heart disease. Methods and Results This was a pragmatic trial of 237 selected patients with a recent ischemic heart disease event, who enrolled in HBCR or FBCR between August 2015 and September 2017. The primary outcome was 3‐month change in distance completed on a 6‐minute walk test. Secondary outcomes included rehospitalization as well as patient‐reported physical activity, quality of life, and self‐efficacy. Characteristics of the 116 patients enrolled in FBCR and 121 enrolled in HBCR were similar, except the mean time from index event to enrollment was shorter for HBCR (25 versus 77 days; P P P Conclusions Patients enrolled in HBCR achieved greater 3‐month functional gains than those enrolled in FBCR. Our data suggest that HBCR may safely derive equivalent benefits in exercise capacity and overall program efficacy in selected patients. Registration URL: https://www.clini​caltr​ials.gov ; Unique identifier: NCT02105246.

The secondary prevention of coronary artery disease can be defined as a long-term management strategy for patients who have sustained an acute coronary syndrome or have chronic coronary heart disease. Goals of secondary prevention include: (1) long-term survival, (2) enhanced quality of life by restoring and maintaining normal activities and psychosocial function, (3) prevention of recurrent coronary events, and (4) reduction of new lesion formation and rate of coronary disease progression.

Women are a consistent minority in the field of cardiology, with concerns regarding balancing career and parenting responsibilities often cited as a contributing factor to this under-representation. To investigate the impact that a career in cardiology may have on the family planning decisions of female cardiologists, the Women in Cardiology section of the American College of Cardiology conducted a voluntary anonymous survey. The following perspective highlights lessons learned from the survey, and potential solutions to the issues surrounding maternity leave, radiation exposure during pregnancy, and breastfeeding accommodations raised by these data. Given that most female cardiologists are pregnant at some point during their careers, particularly during the vulnerable periods of training and early career, improving the experience of pregnancy and early parenthood for all cardiologists may secure the best possible candidates to the field of cardiology.

Background: In the U.S. civilian population, sex differences have been identified in cardiovascular health; these differences have been used to inform care. Our objective is to determine i...

Physician burnout has a negative impact on patient care, productivity and job retention, whereas the cost of recruiting and replacing burned-out physicians can be steep [(1)][1]. The current health care environment places strong emphasis on accomplishing the triple aim: improving population health

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document

Cardiovascular disease is the leading cause of death in women in the United States. Although awareness of coronary artery disease (CAD) risk and presentation in women has increased over the last 3 decades, sex-related disparities persist. Women continue to be underrepresented in clinical trials, and this affects the accuracy of cardiovascular risk assessment models, diagnostic modalities, and treatments for this population. More women than men present with atypical symptoms during an acute coronary syndrome, and this may be attributed to a gender-specific pathophysiology of disease. Nonobstructive CAD and plaque erosion is more common in women who present with acute myocardial infarction compared to men. Further studies are needed to determine whether sex-based diagnostic modalities and therapy can improve the morbidity and mortality of women with CAD. However, until these studies are performed, it is imperative that the current, gender-neutral guidelines be applied for women just as for men. This chapter reviews the differences in awareness, risk factors, pathophysiology, clinical presentation, diagnostic evaluation, and management between men and women with CAD.

Background: Despite advances in the representation of women in medical training, women continue to be underrepresented in cardiology, academic medicine, and more specifically, in senior positions within academic medicine. Identifying disparities in research productivity and acknowledgment can highlight barriers to female representation in academic cardiology leadership, as well as in academic promotion. Methods and Results: This bibliometric analysis included all authors of original research articles between 1980 and 2017 from 3 high-impact cardiology journals ( Journal of the American College of Cardiology , Circulation , and European Heart Journal ). We identified 71 345 unique authors of 55 085 primary research articles during our study period. Female authors accounted for 33.1% of all authors; however, they represented only 26.7% of first authors and 19.7% of senior authors. Looking at the most prolific authors within this time period, female authors were not well represented, accounting for only 5% of the top 100 authors. Articles with a female senior author had more female middle authors than articles with a male senior author (mean 1.41 versus 0.97, P P P Conclusions: Using a large database of published manuscripts, we found that female representation in published cardiology research has increased over the past 4 decades. However, women continue to be not well represented as first authors, senior authors, and in the number of publications. When women were senior authors, they published more articles with female first authors and had more female authors. In addition to recruiting more women into the field of cardiology, additional work is needed to identify and address barriers to academic advancement for female physician-scientists.

Introduction: Cardiac rehabilitation (CR) remains underutilized in patients with ischemic heart disease (IHD). Home-based CR (CR) has been promulgated as a model of delivery that may improve participation, but its impact on functional status is unclear. Hypothesis: We sought to compare change in 6-minute-walk-distance (6MWD) among patients enrolled in home-based vs. facility-based CR after myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery. Methods: We evaluated change in 6MWD among 231 Veterans with IHD via home-based vs. facility-based CR after an IHD event. Between 9/2015 and 9/2017, all eligible patients enrolling in home-based (San Francisco VA) or facility-based CR (VA Ann Arbor and VA Pittsburgh) were invited to participate. 6MWD was assessed at baseline, 3-, and 6-months. Results: Median baseline 6MWD were similar in 116 patients who completed home-based vs. facility-based CR (1155 vs. 1160 ft, p=0.52). Median time from referral to enrollment was shorter for home-based vs. facility-based CR (14 vs. 42 days, p Conclusions: Participants in home-based CR experienced faster time to enrollment and greater 3-month increases in 6MWD than those in facility-based CR, but differences were no longer significant at 6 months. The early superiority of HBCR may relate to shorter delay from referral to participation. Both groups demonstrated similar safety and efficacy. These findings suggest that among selected patients who cannot attend facility-based CR, home-based CR may provide a reasonable alternative.

In type I diabetes (T1DM), alterations in LV function may occur due to changes in innervation, metabolism, and efficiency.We evaluated the association between sympathetic nerve function, oxidative metabolism, resting blood flow, LV efficiency and function in healthy diabetics, and assessed gender differences.Cross-sectional study of 45 subjects with T1DM, 60% females, age 34 ± 13 years, and 10 age-matched controls. Positron emission tomography (PET) imaging with [(11)C]acetate and [(11)C]meta-hydroxyephedrine was performed, in addition to cardiac magnetic resonance imaging.There were no significant differences in LV function, innervation, or oxidative metabolism between T1DM and controls. Cardiac oxidative metabolism was positively associated with higher levels of sympathetic activation, particularly in women. Diabetic women had significantly lower efficiency compared with diabetic men. Resting flow was significantly higher in diabetic women compared with diabetic men, and tended to be higher in female controls as well.Measures of myocardial function, metabolism, blood flow, and sympathetic activation were preserved in young, otherwise healthy, T1DM patients. However, T1DM women presented with greater myocardial oxidative metabolism requirements than men. Ongoing studies are evaluating changes over time.

The authors sought to determine the factors that influence fellows-in-training (FITs) to pursue a career in interventional cardiology (IC) and how these differ by sex.Despite increases in the proportion of women across numerous medical and surgical specialties over the last decade, IC still ranks at the bottom in terms of representation of women. It is unclear why this maldistribution persists.An online survey of cardiovascular FITs was conducted under the direction of the American College of Cardiology Women in Cardiology Leadership Council to assess FIT perspectives regarding subspecialty choices.Of 574 respondents, 33% anticipated specializing in IC. Men were more likely to choose IC than women (39% men, 17% women, odds ratio: 3.98 [95% confidence interval: 2.38 to 6.68]; p 0.001). Men were more likely to be married (p = 0.005) and have children (p = 0.002). Among married FITs, male IC FITs were more likely to have spouses who do not work (p = 0.003). Although men were more likely to be influenced by positive attributes to pursue IC, women were significantly more likely to be influenced negatively against pursuing the field by attributes including greater interest in another field (p = 0.001), little job flexibility (p = 0.02), physically demanding nature of job (p = 0.004), radiation during childbearing (p 0.001), "old boys' club" culture (p 0.001), lack of female role models (p 0.001), and sex discrimination (p 0.001).Many factors uniquely dissuade women from pursuing IC compared with men, largely related to the culture of IC as a subspecialty. Targeted resolution of these specific factors may provide the most impact in reducing sex imbalances in the field.

Importance Few data exist on internal medicine trainees’ selection of cardiology training, although this is important for meeting future cardiology workforce needs. Objective To discover trainees’ professional development preferences and perceptions of cardiology, and their relationship to trainees’ career choice. Design, Setting, and Participants We surveyed trainees to discover their professional development preferences and perceptions of cardiology and the influence of those perceptions and preferences on the trainees’ career choices. Participants rated 38 professional development needs and 19 perceptions of cardiology. Data collection took place from February 2009, through January 2010. Data analysis was conducted from May 2017 to December 2017. Main Outcomes and Measures Multivariable models were used to determine the association of demographics and survey responses with prospective career choice. Results A total of 4850 trainees were contacted, and 1123 trainees (of whom 625 [55.7%] were men) in 198 residency programs completed surveys (23.1% response; mean [SD] age, 29.4 [3.5] years). Principal component analysis of survey responses resulted in 8-factor and 6-factor models. Professional development preferences in descending order of significance were stable hours, family friendliness, female friendliness, the availability of positive role models, financial benefits, professional challenges, patient focus, and the opportunity to have a stimulating career. The top perceptions of cardiology in descending order of significance were adverse job conditions, interference with family life, and a lack of diversity. Women and future noncardiologists valued work-life balance more highly and had more negative perceptions of cardiology than men or future cardiologists, who emphasized the professional advantages available in cardiology. Professional development factors and cardiology perceptions were strongly associated with a decision to pursue or avoid a career in cardiology in both men and women. Conclusions and Relevance Alignment of cardiology culture with trainees’ preferences and perceptions may assist efforts to ensure the continued attractiveness of cardiology careers and increase the diversity of the cardiology workforce.

Despite advances in the diagnosis and treatment of coronary artery disease (CAD), gender-related disparities continue to exist, and ischemic heart disease mortality in women remains higher than in men. This review will highlight gender-specific differences in the treatment of CAD that may impact outcomes for women. Further studies are needed to clarify the unique pathophysiology of CAD in women and, in turn, create more specific guidelines for its diagnosis, management, and treatment in this patient population.

Cardiac MRI tagging is a valuable technique for evaluating regional heart function. Currently, there are a number of different techniques for analyzing the tagged images. Specifically, k-space-based analysis techniques showed to be much faster than image-based techniques, where harmonic-phase (HARP) and sine-wave modeling (SinMod) stand as two famous techniques of the former group, which are frequently used in clinical studies. In this study, we compared HARP and SinMod and studied inter-observer variability between the two techniques for evaluating myocardial strain and apical-to-base torsion in numerical phantom, nine healthy controls, and thirty diabetic patients. Based on the ground-truth numerical phantom measurements (strain = −20% and rotation angle = −4.4°), HARP and SinMod resulted in overestimation (in absolute value terms) of strain by 1% and 5% (strain values), and of rotation angle by 0.4° and 2.0°, respectively. For the in-vivo results, global strain and torsion ranges were −10.6% to −35.3% and 1.8°/cm to 12.7°/cm in patients, and −17.8% to −32.7% and 1.8°/cm to 12.3°/cm in volunteers. On average, SinMod overestimated strain measurements by 5.7% and 5.9% (strain values) in the patients and volunteers, respectively, compared to HARP, and overestimated torsion measurements by 2.9°/cm and 2.5°/cm in the patients and volunteers, respectively, compared to HARP. Location-wise, the ranges for basal, mid-ventricular, and apical strain in patients (volunteers) were −8.4% to −31.5% (−11.6% to −33.3%), −6.3% to −37.2% (−17.8% to −33.3%), and −5.2% to −38.4% (−20.0% to −33.2%), respectively. SinMod overestimated strain in the basal, mid-ventricular, and apical slices by 4.7% (5.7%), 5.9% (5.5%), and 8.9% (6.8%), respectively, compared to HARP in the patients (volunteers). Nevertheless, there existed good correlation between the HARP and SinMod measurements. Finally, there were no significant strain or torsion measurement differences between patients and volunteers. There existed good inter-observer agreement, as all measurement differences lied within the Bland-Altman ± 2 standard-deviation (SD) difference limits. In conclusion, despite the consistency of the results by either HARP or SinMod and acceptable agreement of the generated strain and torsion patterns by both techniques, SinMod systematically overestimated the measurements compared to HARP. Under current operating conditions, the measurements from HARP and SinMod cannot be used interchangeably.

Recognition of ischemic heart disease (IHD) is often delayed or deferred in women. Thus, many at risk for adverse outcomes are not provided specific diagnostic, preventive, and/or treatment strategies. This lack of recognition is related to sex-specific IHD pathophysiology that differs from traditional models using data from men with flow-limiting coronary artery disease (CAD) obstructions. Symptomatic women are less likely to have obstructive CAD than men with similar symptoms, and tend to have coronary microvascular dysfunction, plaque erosion, and thrombus formation. Emerging data document that more extensive, nonobstructive CAD involvement, hypertension, and diabetes are associated with major adverse events similar to those with obstructive CAD. A central emerging paradigm is the concept of nonobstructive CAD as a cause of IHD and related adverse outcomes among women. This position paper summarizes currently available knowledge and gaps in that knowledge, and recommends management options that could be useful until additional evidence emerges.

Peripartum cardiomyopathy is a form of heart failure occurring at the end of pregnancy or early in the postpartum period. Women may recover, have persistent cardiac dysfunction or suffer complications and death. Women who are African-American, older, hypertensive or have multiple gestation pregnancies have increased risk. Diagnosis and treatment may be delayed due to similarities between symptoms of normal pregnancy and heart failure. Echocardiography is essential for the diagnosis, and B-type natriuretic peptide can be helpful. Treatment for systolic heart failure must be adjusted during pregnancy, and anticoagulation may be indicated. Even after recovery, subsequent pregnancy confers substantial risk of worsening heart failure. Further investigations into the etiology, duration of treatment and risks for relapse are needed.

This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Increased awareness of cardiovascular disease in women has prompted studies to investigate gender-related disparities in acute coronary syndromes (ACSs). In this review, we discuss findings from current literature on the clinical presentation, pathophysiology, diagnosis, and management of ACS in women as compared to men.Emerging data show that cardiovascular disease (CVD) continues to be the leading cause of death in women and the annual mortality rate from CVD remains higher in women compared to men. Recent studies demonstrate sex-specific differences in patients presenting with ACS. Comorbidities, especially diabetes, are more common in young women compared with age-matched men who develop acute myocardial infarction (AMI). Women are more likely to have atypical symptoms and nonobstructive coronary disease on angiography. Women are less likely to receive guideline-based therapies. They have higher rates of peri-procedural complications with PCI and are less likely to be referred to cardiac rehabilitation. Awareness of differences in the underlying pathophysiology of coronary disease in women compared to men may lead to improved gender-based diagnostic and treatment modalities. However, until more studies are performed, efforts should be directed toward improving delivery of current, gender-neutral guidelines in women just as in men.

Microvascular angina, also known as cardiac syndrome X, is characterized by anginal chest pain, at least one cardiovascular risk factor, an abnormal stress test and normal coronary arteries on angiography. It is significantly more common in women than in men. A definitive diagnosis of microvascular angina can be made by invasive or noninvasive methods; a presumptive diagnosis can also be made based on fulfillment of diagnostic criteria. Effective treatment of microvascular angina requires aggressive risk factor modification; exercise is one of the most effective treatment modalities. Several other treatment strategies have been shown to relieve anginal symptoms as well as improve vascular function; these include β-blockers, angiotensin-converting enzyme inhibitors, ranolazine, L-arginine, statin drugs and potentially estrogen replacement therapy. Nitrates may be effective for symptom relief. Further studies are required to determine whether specific treatments are associated with improved survival as well as decreased symptoms.

Women are a consistent minority in the field of cardiology, with concerns regarding balancing career and parenting responsibilities often cited as a contributing factor to this under-representation. To investigate the impact that a career in cardiology may have on the family planning decisions of female cardiologists, the Women in Cardiology section of the American College of Cardiology conducted a voluntary anonymous survey. The following perspective highlights lessons learned from the survey, and potential solutions to the issues surrounding maternity leave, radiation exposure during pregnancy, and breastfeeding accommodations raised by these data. Given that most female cardiologists are pregnant at some point during their careers, particularly during the vulnerable periods of training and early career, improving the experience of pregnancy and early parenthood for all cardiologists may secure the best possible candidates to the field of cardiology.

The American College of Cardiology third decennial Professional Life Survey was completed by 2,313 cardiologists: 964 women (42%) and 1,349 men (58%). Compared with 10 and 20 years ago, current results reflect a substantially lower response rate (21% vs. 31% and 49%, respectively) and an aging workforce that is less likely to be in private practice. Women continue to be more likely to practice in academic centers, be pediatric cardiologists, and have a noninvasive subspecialty. Men were more likely to indicate that family responsibilities negatively influenced their careers than previously, whereas women remained less likely to marry or have children. Men and women reported similar, high levels of career satisfaction, with women reporting higher satisfaction currently. However, two-thirds of women continue to experience discrimination, nearly 3 times the rate in men. Personal life choices continue to differ substantially for men and women in cardiology, although differences have diminished.

Magnetic resonance imaging (MRI) tagging is a valuable technique for evaluating regional heart function. Currently, there are a number of different techniques for analyzing the tagged images. The purpose of this study is to compare the harmonic-phase (HARP) and sine-wave modeling (SinMod) tagging analysis techniques for evaluating myocardial strain and torsion in healthy controls and type-1 diabetes patients. All SinMod measurements were significantly larger than those by HARP (P

More women die of cardiovascular disease than any other cause. Effective primary prevention depends on accurate assessment of risk status. While most risk factors are similar for men and women, risk factors may differ in magnitude between the sexes, and recognition of gender-specific risk factors such as gestational diabetes, hypertensive syndromes of pregnancy and polycystic ovarian syndrome provides opportunities for early intervention and prevention. Obesity, hypertension and hyperlipidemia affect both genders; however, women often postpone addressing these risk factors until later in life. The American Heart Association emphasizes that all women are at cardiovascular risk and should maintain a healthy lifestyle and avoid smoking. Blood pressure, hyperlipidemia and diabetes should be aggressively treated. Current available data regarding proposed preventive drug therapies including daily aspirin, HRT, vitamin D and omega-3 fatty acid supplements will be reviewed.

Raloxifene use in postmenopausal women with osteoporosis increases the risk of venous thromboembolic events (VTE) 2-fold compared with placebo. Platelet activation is involved in the pathophysiology of arterial thromboses more than venous thromboses, but aspirin may reduce VTE risk associated with estrogen use. This analysis examines the effects of concomitant antiplatelet therapy on VTE risk in raloxifene-treated women.In the Raloxifene Use for the Heart (RUTH) trial, 10,101 postmenopausal women from 177 sites in 26 countries at increased risk of coronary heart disease (CHD) (primary prevention cohort) or with CHD (secondary prevention cohort) were randomized to placebo or raloxifene 60 mg/day and followed for a median 5.6 years. Reports of clinical symptoms of VTE were assessed. Concomitant use of antiplatelet agents (aspirin, clopidogrel, ticlopidine, dipyridamole) was allowed. Cox proportional hazard models, with use of warfarin, presence of fracture, and hospitalization as covariates, were used to estimate hazard ratios (HR) with 95% confidence intervals (CI).Overall, raloxifene use was associated with an increased VTE risk (HR 1.44, 95% CI 1.06-1.95) vs. placebo. Most women (72%) reported using aspirin, and 14.2% reported using nonaspirin antiplatelet agents during the study period. Users of antiplatelet agents were older, more likely to have CHD, and more likely to be hyperlipidemic. They had a higher VTE risk than nonusers. No difference in VTE risk was observed in women who used raloxifene alone vs. those who used raloxifene with antiplatelet agents during the study. The increase in VTE risk with raloxifene compared with placebo was not different between women who used antiplatelet agents at baseline (HR 1.44, 95% CI 0.98, 2.10) and those who did not use antiplatelet agents (HR 1.37, 95% CI 0.83, 2.27) (interaction p = 0.88). Similar conclusions were noted for aspirin and nonaspirin antiplatelet use.In RUTH, postmenopausal women treated with raloxifene had an increased risk of VTE compared with placebo. Concomitant use of aspirin or nonaspirin antiplatelet agents along with raloxifene did not change VTE risk.

This study examines whether implementing new home-based cardiac rehabilitation programs is associated with cardiac rehabilitation participation in the Veterans Health Administration.

Background We sought to determine the risk of obstructive coronary artery disease (oCAD) associated with noncoronary atherosclerosis (cerebrovascular disease [CVD] or peripheral arterial disease [PAD]) and major adverse cardiac events following percutaneous coronary intervention (PCI). Methods Rates of the angiographic end point of oCAD were compared among patients with and without noncoronary atherosclerosis undergoing coronary angiography within the Veterans Health Administration between October 2007 and August 2015. The primary angiographic end point of oCAD was defined as left main stenosis ≥50% or any stenosis ≥70% in 1, 2, or 3 vessels. In patients who proceeded to PCI, the rate of the composite clinical end point of death, myocardial infarction, or stroke was compared among those with concomitant noncoronary atherosclerosis (CVD, PAD, or CVD + PAD) versus isolated CAD. Results Among 233,353 patients undergoing angiography, 9.6% had CVD, 12.4% had PAD, and 6.1% had CVD + PAD. Rates of oCAD were 57.9% for neither CVD nor PAD, 66.4% for CVD, 73.6% for PAD, and 80.9% for CVD + PAD. Compared with patients without noncoronary atherosclerosis, the adjusted risk of oCAD with CVD, PAD, or CVD + PAD was 1.03 (95% CI 1.02-1.04), 1.10 (95% CI 1.09-1.11), and 1.12 (95% CI 1.11-1.13), respectively. In patients who underwent PCI, the adjusted hazard for death, myocardial infarction, or stroke among those with CVD, PAD, or CVD + PAD was 1.36 (95% CI 1.26-1.45), 1.53 (95% CI 1.45-1.62), and 1.72 (95% CI 1.59-1.86), respectively. Conclusions In patients undergoing coronary angiography, noncoronary atherosclerosis was associated with increased burden of oCAD and adverse events post-PCI.

Little is known about factors contributing to subspecialty choice among internal medicine (IM) trainees, including choosing or avoiding a career in cardiology. Surveys were emailed to 4,850 IM trainees and also circulated by 44 US Program Directors. Respondents rated 38 contributors to professional