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2. ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease

Author

David E. Winchester, David J. Maron, Ron Blankstein, Ian C. Chang, Ajay J. Kirtane, Raymond Y. Kwong, Patricia A. Pellikka, Jordan M. Prutkin, Raymond Russell, and Alexander T. Sandhu

Subjects
Appropriate Use Criteria, CCD, Chronic coronary disease, Multimodality, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Abstract The American College of Cardiology (ACC) Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of stress testing and anatomic diagnostic procedures for risk assessment and evaluation of known or suspected chronic coronary disease (CCD), formerly referred to as stable ischemic heart disease (SIHD). This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging, stress echocardiography (echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. As with the prior version of this document, rating of test modalities is provided side-by-side for a given clinical scenario. These ratings are explicitly not considered competitive rankings due to the limited availability of comparative evidence, patient variability, and the range of capabilities available in any given local setting1–4. This version of the AUC for CCD is a focused update of the prior version of the AUC for SIHD4. Key changes beyond the updated ratings based on new evidence include the following: 1. Clinical scenarios related to preoperative testing were removed and will be incorporated into another AUC document under development. 2. Some clinical scenarios and tables were removed in an effort to simplify the selection of clinical scenarios. Additionally, the flowchart of tables has been reorganized, and all clinical scenario tables can now be reached by answering a limited number of clinical questions about the patient, starting with the patient’s symptom status. 3. Several clinical scenarios have been revised to incorporate changes in other documents such as pretest probability assessment, atherosclerotic cardiovascular disease (ASCVD) risk assessment, syncope, and others. ASCVD risk factors that are not accounted for in contemporary risk calculators have been added as modifiers to certain clinical scenarios. The 64 clinical scenarios rated in this document are limited to the detection and risk assessment of CCD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines.5 These clinical scenarios do not specifically address patients having acute chest pain episodes. They may, however, be applicable in the inpatient setting if the patient is not having an acute coronary syndrome and warrants evaluation for CCD. Using standardized methodology, clinical scenarios were developed to describe common patient encounters in clinical practice focused on common applications and anticipated uses of testing for CCD. Where appropriate, the scenarios were developed on the basis of the most current ACC/American Heart Association guidelines. A separate, independent rating panel scored the clinical scenarios in this document on a scale of 1 to 9, following a modified Delphi process consistent with the recently updated AUC development methodology. 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 rarely appropriate.

Published
2023
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3. Informing Use of Telehealth for Managing Chronic Conditions: Mixed‐Methods Evaluation of Telehealth Use to Manage Heart Failure During COVID‐19

Author

Chelsea Leonard, Wenhui Liu, Ariel Holstein, Slande Alliance, Mary Nunnery, Carly Rohs, Marilyn Sloan, and David E. Winchester

Subjects
ambulatory care sensitive conditions, congestive heart failure, COVID‐19, mixed‐methods research, telehealth, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background The COVID‐19 pandemic forced Veterans Health Administration facilities to rapidly adopt and deploy telehealth alternatives to provide continuity of care to veterans while minimizing physical contact. The impact of moving to virtual visits on patients with congestive heart failure (HF) is unknown. The goal of this study was to understand how patients with HF and their providers experienced the shift to telehealth for managing a chronic condition, and to inform best practices for continued telehealth use. Methods and Results We identified Veterans Health Administration Medical Centers with high telehealth use before COVID‐19 and sites that were forced to adopt telehealth in response to COVID‐19, and interviewed cardiology providers and veterans with HF about their experiences using telehealth. Interviews were recorded, transcribed, and analyzed using team‐based rapid content analysis. We identified 3 trajectory patterns for cardiology telehealth use before and during COVID‐19. They were the low‐use class (low to low), high‐use class (relatively high to higher), and increased‐use class (low to high). The high‐use and increased‐use classes fit the criteria for sites that had high telehealth use before COVID‐19 and sites that rapidly adopted telehealth in response to COVID‐19. There were 12 sites in the high‐use class and 4 sites in the increased‐use class. To match with the number of sites in the increased‐use class, we selected the top 4 sites by looking at the months before COVID‐19. We identified 3 themes related to telehealth use among patients with HF and cardiology providers: (1) technology was the primary barrier for both patients and providers; (2) infrastructural support was the primary facilitator for providers; and (3) both patients and providers had largely neutral opinions on how telehealth compares to in‐person care but described situations in which telehealth is not appropriate. Conclusions Only 12 sites fit the criteria of high telehealth use in cardiology before COVID‐19, and 4 fit the criteria of low use that increased in response to COVID‐19. Patients and providers at both site types were largely satisfied using telehealth to manage HF. Understanding best practices for managing ambulatory care–sensitive conditions through virtual visits can help the Veterans Health Administration prepare for long‐term impacts of COVID‐19 on in‐person visits, as well as improve access to care for veterans who live remotely or who have difficulty traveling to in‐person appointments.

Published
2023
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4. Trends in pharmacotherapy utilization among patients with heart failure with preserved ejection fraction

Author

Munaza Riaz, Steven M. Smith, Eric A. Dietrich, David E. Winchester, Jingchuan Guo, and Haesuk Park

Subjects
Pharmacotherapy, Heart failure with preserved ejection fraction, Real-world data, Trends, Utilization, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Study objective: Half of patients with heart failure have preserved ejection fraction (HFpEF). Over the years, guidelines have recommended or advised against various therapies for HFpEF management. However, there is limited evidence on the trends in utilization of the various medications. The aim of this study was to examine the trends in the use of pharmacotherapies among patients with HFpEF from 2008 through 2020. Design: Retrospective cohort study of patients with HFpEF used MarketScan® Commercial and Medicare Supplemental Databases (2007–2020). Participants: Patients with HFpEF. Outcome measures: Utilization rates for angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), angiotensin receptor-neprilysin inhibitors (ARNIs), aldosterone receptor antagonists (ARAs), diuretics, β-blockers, calcium channel blockers (CCBs), phosphodiesterase 5 inhibitors (PDE5Is), nitrates, digoxin, and sodium glucose cotransporter-2 inhibitors (SGLT2i) within 90 days of the first HFpEF diagnosis. Results: We identified 156,730 patients with HFpEF (mean [SD] age, 73 [13.4] years; 57 % females). From 2008 to 2020, we found increased utilization rates for ARNIs (0.02 % vs. 0.17 % of all patients, p

Published
2023
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5. Prognostic impact of acute pulmonary triggers in patients with takotsubo syndrome: new insights from the International Takotsubo Registry

Author

Ken Kato, Victoria L. Cammann, L. Christian Napp, Konrad A. Szawan, Jozef Micek, Sara Dreiding, Rena A. Levinson, Vanya Petkova, Michael Würdinger, Alexandru Patrascu, Rafael Sumalinog, Sebastiano Gili, Christian F. Clarenbach, Malcolm Kohler, Manfred Wischnewsky, Rodolfo Citro, Carmine Vecchione, Eduardo Bossone, Michael Neuhaus, Jennifer Franke, Benjamin Meder, Milosz Jaguszewski, Michel Noutsias, Maike Knorr, Susanne Heiner, Fabrizio D'Ascenzo, Wolfgang Dichtl, Christof Burgdorf, Behrouz Kherad, Carsten Tschöpe, Annahita Sarcon, Jerold Shinbane, Lawrence Rajan, Guido Michels, Roman Pfister, Alessandro Cuneo, Claudius Jacobshagen, Mahir Karakas, Wolfgang Koenig, Alexander Pott, Philippe Meyer, Marco Roffi, Adrian Banning, Mathias Wolfrum, Florim Cuculi, Richard Kobza, Thomas A. Fischer, Tuija Vasankari, K.E. Juhani Airaksinen, Monika Budnik, Rafal Dworakowski, Philip MacCarthy, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Christina Chan, Paul Bridgman, Daniel Beug, Clément Delmas, Olivier Lairez, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, Ibrahim El‐Battrawy, Ibrahim Akin, Martin Kozel, Petr Tousek, David E. Winchester, Jan Galuszka, Christian Ukena, Gregor Poglajen, Pedro Carrilho‐Ferreira, Christian Hauck, Carla Paolini, Claudio Bilato, Masanori Sano, Iwao Ishibashi, Masayuki Takahara, Toshiharu Himi, Yoshio Kobayashi, Abhiram Prasad, Charanjit S. Rihal, Kan Liu, P. Christian Schulze, Matteo Bianco, Lucas Jörg, Hans Rickli, Gonçalo Pestana, Thanh H. Nguyen, Michael Böhm, Lars S. Maier, Fausto J. Pinto, Petr Widimský, Stephan B. Felix, Grzegorz Opolski, Ruediger C. Braun‐Dullaeus, Wolfgang Rottbauer, Gerd Hasenfuß, Burkert M. Pieske, Heribert Schunkert, Martin Borggrefe, Holger Thiele, Johann Bauersachs, Hugo A. Katus, John D. Horowitz, Carlo Di Mario, Thomas Münzel, Filippo Crea, Jeroen J. Bax, Thomas F. Lüscher, Frank Ruschitzka, Jelena R. Ghadri, and Christian Templin

Subjects
Takotsubo syndrome, Broken heart syndrome, Outcome, Acute respiratory insufficiency, Chronic obstructive pulmonary disease, InterTAK Registry, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Abstract Aims Acute pulmonary disorders are known physical triggers of takotsubo syndrome (TTS). This study aimed to investigate prevalence of acute pulmonary triggers in patients with TTS and their impact on outcomes. Methods and results Patients with TTS were enrolled from the International Takotsubo Registry and screened for triggering factors and comorbidities. Patients were categorized into three groups (acute pulmonary trigger, chronic lung disease, and no lung disease) to compare clinical characteristics and outcomes. Of the 1670 included patients with TTS, 123 (7%) were identified with an acute pulmonary trigger, and 194 (12%) had a known history of chronic lung disease. The incidence of cardiogenic shock was highest in patients with an acute pulmonary trigger compared with those with chronic lung disease or without lung disease (17% vs. 10% vs. 9%, P = 0.017). In‐hospital mortality was also higher in patients with an acute pulmonary trigger than in the other two groups, although not significantly (5.7% vs. 1.5% vs. 4.2%, P = 0.13). Survival analysis demonstrated that patients with an acute pulmonary trigger had the worst long‐term outcome (P = 0.002). The presence of an acute pulmonary trigger was independently associated with worse long‐term mortality (hazard ratio 2.12, 95% confidence interval 1.33–3.38; P = 0.002). Conclusions The present study demonstrates that TTS is related to acute pulmonary triggers in 7% of all TTS patients, which accounts for 21% of patients with physical triggers. The presence of acute pulmonary trigger is associated with a severe in‐hospital course and a worse long‐term outcome.

Published
2021
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6. Implementation effort: Reducing the ordering of inappropriate echocardiograms through a point-of-care decision support tool

Author

Hassan Ashraf, Cecil A. Rambarat, Michael L. Setteducato, and David E. Winchester

Subjects
Echocardiography, Clinical decision support systems, Unnecessary procedures, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Study objective: Reduce inappropriate transthoracic echocardiograms (TTEs) using a series of Plan-Do-Study-Act (PDSA) quality improvement cycles. Design: Three PDSA cycles were designed with the first integrating a previously published decision support tool (DST) into the electronic TTE order, the second tailoring the DST to reflect the most common inappropriately ordered TTEs at our institution, and the third integrating direct clinician education. Setting: Malcom Randall Veterans Administration Medical Center, Gainesville, Florida, USA. Participants: Consecutive patients were studied using the database of all TTEs performed at our institution without regard for specific patient characteristics. Interventions: Three PDSA Cycles as described above. Main outcome measure: Reduction in inappropriate TTEs at our institution. Results: After implementing our DST during the first cycle, no difference in inappropriate TTEs was observed (relative risk [RR] 0.71, p = 0.12, 95 % confidence interval [CI] 0.46–1.09). After the second cycle, we observed a reduction in the proportion of inappropriate TTEs (RR = 0.69, p = 0.014, 95 % CI 0.5–0.94), however two of the four inappropriate TTEs targeted by the DST increased. Feedback gathered from clinicians in the third cycle showed significant knowledge gaps regarding appropriate use criteria for TTE. Conclusion(s): At our facility, implementation of a DST failed to substantially reduce inappropriate TTEs, even when adapted to facility-specific ordering patterns. Gaps in clinician knowledge about TTEs may have contributed to the inefficacy of our DST.

Published
2022
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8. Home-Based Cardiac Rehabilitation (HBCR) In Post-TAVR Patients: A Prospective, Single-Center, Cohort, Pilot Study

Author

Gurjaspreet K. Bhattal, Ki E. Park, and David E. Winchester

Subjects
Aortic valve replacement, Cardiac rehabilitation, Home-based cardiac rehabilitation, TAVR, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Abstract Introduction Cardiac rehabilitation after transcatheter aortic valve replacement (TAVR) safely improves exercise tolerance, functional independence, and quality of life. However, barriers such as transportation, cost, and limited access to rehabilitation programs prohibits participation. In 2010, the Veterans Affairs Medical Center (VAMC) started a 12-week home-based cardiac rehabilitation (HBCR) program at 13 sites around the country to increase participation by reducing such barriers. We present the findings of HBCR in post-TAVR patients from the VAMC in Gainesville, FL, USA. Methods Fifty-nine patients who underwent TAVR between 2015 and 2018 at the Gainesville VA were offered HBCR. Forty-one patients enrolled, 28 completed the program, and 14 completed the surveys. We used various performance measures including Life’s Simple 7 survey, 6-min Walk (6-MW), Duke Activity Survey Index (DASI), and Short Form-36 (SF-36) health survey to assess the pre and post-HBCR changes in emotional, functional, and physical well-being of the patients. Results Paired comparison of pre and post-HBCR using Wilcoxon signed-rank test revealed a statistically significant difference in the pre and post-HBCR scores for DASI, DASI-Mets, and SF-36 physical functioning (p values 0.05, 0.034, and 0.016, respectively), suggesting an improvement in the patients’ physical functioning after participating in the HBCR program. Conclusions In conclusion, our pilot study offers novel insight into the role of HBCR in improving physical health and well-being in post-TAVR patients while eliminating the barriers of transportation and access to cardiac rehabilitation programs.

Published
2020
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10. Impact of Atrial Fibrillation on Outcome in Takotsubo Syndrome: Data From the International Takotsubo Registry

Author

Ibrahim El‐Battrawy, Victoria L. Cammann, Ken Kato, Konrad A. Szawan, Davide Di Vece, Aurelio Rossi, Manfred Wischnewsky, Julia Hermes‐Laufer, Sebastiano Gili, Rodolfo Citro, Eduardo Bossone, Michael Neuhaus, Jennifer Franke, Benjamin Meder, Milosz Jaguszewski, Michel Noutsias, Maike Knorr, Susanne Heiner, Fabrizio D’Ascenzo, Wolfgang Dichtl, Christof Burgdorf, Behrouz Kherad, Carsten Tschöpe, Annahita Sarcon, Jerold Shinbane, Lawrence Rajan, Guido Michels, Roman Pfister, Alessandro Cuneo, Claudius Jacobshagen, Mahir Karakas, Wolfgang Koenig, Alexander Pott, Philippe Meyer, Jose David Arroja, Adrian Banning, Florim Cuculi, Richard Kobza, Thomas A. Fischer, Tuija Vasankari, K. E. Juhani Airaksinen, L. Christian Napp, Monika Budnik, Rafal Dworakowski, Philip MacCarthy, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Christina Chan, Paul Bridgman, Daniel Beug, Clément Delmas, Olivier Lairez, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, Martin Kozel, Petr Tousek, David E. Winchester, Jan Galuszka, Christian Ukena, Gregor Poglajen, Pedro Carrilho‐Ferreira, Christian Hauck, Carla Paolini, Claudio Bilato, Yoshio Kobayashi, Abhiram Prasad, Charanjit S. Rihal, Kan Liu, P. Christian Schulze, Matteo Bianco, Lucas Jörg, Hans Rickli, Gonçalo Pestana, Thanh H. Nguyen, Michael Böhm, Lars S. Maier, Fausto J. Pinto, Petr Widimský, Stephan B. Felix, Grzegorz Opolski, Ruediger C. Braun‐Dullaeus, Wolfgang Rottbauer, Gerd Hasenfuß, Burkert M. Pieske, Heribert Schunkert, Holger Thiele, Johann Bauersachs, Hugo A. Katus, John D. Horowitz, Carlo Di Mario, Thomas Münzel, Filippo Crea, Jeroen J. Bax, Thomas F. Lüscher, Frank Ruschitzka, Firat Duru, Martin Borggrefe, Jelena R. Ghadri, Ibrahim Akin, and Christian Templin

Subjects
atrial fibrillation, broken heart syndrome, outcome, Takotsubo syndrome, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background Atrial fibrillation (AF) is a major risk factor for mortality. The prevalence, clinical correlates, and prognostic impact of AF in Takotsubo syndrome (TTS) have not yet been investigated in a large patient cohort. This study aimed to investigate the prevalence, clinical correlates, and prognostic impact of AF in patients with TTS. Methods and Results Patients with TTS were enrolled from the International Takotsubo Registry, which is a multinational network with 26 participating centers in Europe and the United States. Patients were dichotomized according to the presence or absence of AF at the time of admission. Of 1584 patients with TTS, 112 (7.1%) had AF. The mean age was higher (P

Published
2021
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11. Chronic elevation of cardiac troponin I predicts the extent of coronary disease in hemodialysis patients presenting with acute enzyme elevation

Author

Mohamad B. Taha, Ahmad B. Taha, Osama Dasa, Modar Alom, Yasir H. Abdelgadir, and David E. Winchester

Subjects
Cardiac troponin I, End-stage renal disease, Coronary artery disease, Coronary angiography, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Introduction: Elevation of cardiac troponin I (cTn-I) is associated with coronary artery disease (CAD) in asymptomatic patients with end-stage renal disease (ESRD) receiving hemodialysis. We aim to investigate the diagnostic value of chronically elevated cTn-I in ESRD patients presenting with an acute rise in serum cTn-I levels. Methods: We performed a retrospective analysis of 364 patients. Using coronary angiography, we correlated baseline elevation of cTn-I with the severity of CAD when hemodialysis patients present with acute symptomatic elevation in serum cTn-I. Results: In hemodialysis patients presenting with a rise in serum cTn-I above baseline levels, 59% had severe CAD, and 17% had no angiographic evidence of CAD. Hemodialysis patients with severe CAD had significantly higher baseline cTn-I levels compared to patients with non-severe CAD or normal coronaries (p < 0.0001). Baseline elevation of cTn-I in the severe CAD group was correlated with the degree of CAD occlusion (r2 0.56, p < 0.0001), fitting a positive linear model. Furthermore, baseline cTn-I differentiates between patients with and without severe CAD with a test accuracy of 0.72 (95% CI, 0.69–0.75, p < 0.001). At a value of ≥0.2 ng/mL (cutoff for myocardial necrosis), the specificity of baseline cTn-I for underlying severe CAD was 0.95. Conclusions: Elevated baseline cTn-I has good accuracy for anticipating more advanced angiographic CAD when hemodialysis patients present with a symptomatic rise in serum cTn-I above baseline levels. Baseline elevation of cTn-I can be used for cardiac disease risk management in hemodialysis patients presenting with symptoms suggestive of CAD.

Published
2021
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12. Perceptions of patients and providers on myocardial perfusion imaging for asymptomatic patients, choosing wisely, and professional liability

Author

Kristopher P. Kline, Leslee Shaw, Rebecca J. Beyth, Jared Plumb, Linda Nguyen, Tianyao Huo, and David E. Winchester

Subjects
Myocardial perfusion imaging, Appropriate use criteria, Choosing wisely, Medical liability, Public aspects of medicine, RA1-1270
Abstract

Abstract Background Despite efforts by professional societies to reduce low value care, many reports indicate that unnecessary tests, such as nuclear myocardial perfusion imaging (MPI), are commonly used in contemporary practice. The degree to which lack of awareness and professional liability concerns drive these behaviors warrants further study. We sought to investigate patient and provider perceptions about MPI in asymptomatic patients, the Choosing Wisely (CW) campaign, and professional liability concerns. Methods We administered an anonymous, paper-based survey with both discrete and open-response queries to subjects in multiple outpatient settings at our facilities. The survey was completed by 456 respondents including 342 patients and 114 physicians and advanced practice providers between May and August 2014. Our outcome was to compare patient and provider perceptions about MPI in asymptomatic patients and related factors. Results Patients were more likely than providers to report that MPI was justified for asymptomatic patients (e.g. asymptomatic with family history of heart disease 75% versus 9.2%, p

Published
2017
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13. Revascularization and outcomes in Veterans with moderate to severe ischemia on myocardial perfusion imaging

Author

David E. Winchester, Alexander J. Bolanos, Anita Wokhlu, Rebecca J. Beyth, and Leslee J. Shaw

Subjects
Myocardial ischemia, Nuclear myocardial perfusion imaging, Veterans, Revascularization, Medicine (General), R5-920, Military Science
Abstract

Abstract Background The prevalence of ischemia on nuclear myocardial perfusion imaging (MPI) has been decreasing. Recent research has questioned the benefit of invasive revascularization for patients with moderate to severe ischemia. We hypothesized that patients with moderate to severe ischemia could routinely undergo successful revascularization. Methods We analyzed data from 544 patients who underwent an MPI at a single academic Veterans Affairs Medical Center. Patients with moderate to severe ischemia, defined as a summed difference score (SDS) 8 or greater, were compared to the rest of the cohort. Results Of the total cohort (n = 544), 39 patients had MPI studies with resultant moderate to severe ischemia. Patients with ischemia were more likely to develop coronary artery disease (74.4% versus 38.8%, P

Published
2017
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14. Clinical Predictors and Prognostic Impact of Recovery of Wall Motion Abnormalities in Takotsubo Syndrome: Results From the International Takotsubo Registry

Author

Stjepan Jurisic, Sebastiano Gili, Victoria L. Cammann, Ken Kato, Konrad A. Szawan, Fabrizio D'Ascenzo, Milosz Jaguszewski, Eduardo Bossone, Rodolfo Citro, Annahita Sarcon, L. Christian Napp, Jennifer Franke, Michel Noutsias, Maike Knorr, Susanne Heiner, Christof Burgdorf, Wolfgang Koenig, Alexander Pott, Behrouz Kherad, Lawrence Rajan, Guido Michels, Roman Pfister, Alessandro Cuneo, Claudius Jacobshagen, Mahir Karakas, Philippe Meyer, Jose David Arroja, Adrian Banning, Florim Cuculi, Richard Kobza, Thomas A. Fischer, Tuija Vasankari, K. E. Juhani Airaksinen, Rafal Dworakowski, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Wolfgang Dichtl, Christina Chan, Paul Bridgman, Daniel Beug, Clément Delmas, Olivier Lairez, Martin Kozel, Petr Tousek, David E. Winchester, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, Ibrahim El‐Battrawy, Ibrahim Akin, Jan Galuszka, Christian Ukena, Gregor Poglajen, Carla Paolini, Claudio Bilato, Pedro Carrilho‐Ferreira, Fausto J. Pinto, Grzegorz Opolski, Philip MacCarthy, Yoshio Kobayashi, Abhiram Prasad, Charanjit S. Rihal, Petr Widimský, John D. Horowitz, Carlo Di Mario, Filippo Crea, Carsten Tschöpe, Burkert M. Pieske, Gerd Hasenfuß, Wolfgang Rottbauer, Ruediger C. Braun‐Dullaeus, Stephan B. Felix, Martin Borggrefe, Holger Thiele, Johann Bauersachs, Hugo A. Katus, Heribert Schunkert, Thomas Münzel, Michael Böhm, Jeroen J. Bax, Thomas F. Lüscher, Frank Ruschitzka, Jelena R. Ghadri, and Christian Templin

Subjects
outcome, recovery, takotsubo syndrome, wall motion abnormalities, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background Left ventricular (LV) recovery in takotsubo syndrome (TTS) occurs over a wide‐ranging interval, varying from hours to weeks. We sought to investigate the clinical predictors and prognostic impact of recovery time for TTS patients. Methods and Results TTS patients from the International Takotsubo Registry were included in this study. Cut‐off for early LV recovery was determined to be 10 days after the acute event. Multivariable logistic regression was used to assess factors associated with the absence of early recovery. In‐hospital outcomes and 1‐year mortality were compared for patients with versus without early recovery. We analyzed 406 patients with comprehensive and serial imaging data regarding time to recovery. Of these, 191 (47.0%) had early LV recovery and 215 (53.0%) demonstrated late LV improvement. Patients without early recovery were more often male (12.6% versus 5.2%; P=0.011) and presented more frequently with typical TTS (76.3% versus 67.0%, P=0.040). Cardiac and inflammatory markers were higher in patients without early recovery than in those with early recovery. Patients without early recovery showed unfavorable 1‐year outcome compared with patients with early recovery (P=0.003). On multiple logistic regression, male sex, LV ejection fraction

Published
2019
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15. Clinical Features and Outcomes of Patients With Malignancy and Takotsubo Syndrome: Observations From the International Takotsubo Registry

Author

Victoria L. Cammann, Annahita Sarcon, Katharina J. Ding, Burkhardt Seifert, Ken Kato, Davide Di Vece, Konrad A. Szawan, Sebastiano Gili, Stjepan Jurisic, Beatrice Bacchi, Jozef Micek, Antonio H. Frangieh, L. Christian Napp, Milosz Jaguszewski, Eduardo Bossone, Rodolfo Citro, Fabrizio D'Ascenzo, Jennifer Franke, Michel Noutsias, Maike Knorr, Susanne Heiner, Christof Burgdorf, Wolfgang Koenig, Holger Thiele, Carsten Tschöpe, Lawrence Rajan, Guido Michels, Roman Pfister, Alessandro Cuneo, Claudius Jacobshagen, Mahir Karakas, Adrian Banning, Florim Cuculi, Richard Kobza, Thomas A. Fischer, Tuija Vasankari, K. E. Juhani Airaksinen, Rafal Dworakowski, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Wolfgang Dichtl, Clément Delmas, Olivier Lairez, John D. Horowitz, Martin Kozel, Petr Widimský, Petr Tousek, David E. Winchester, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, Ibrahim El‐Battrawy, Ibrahim Akin, Christian Ukena, Johann Bauersachs, Burkert M. Pieske, Gerd Hasenfuß, Wolfgang Rottbauer, Ruediger C. Braun‐Dullaeus, Grzegorz Opolski, Philip MacCarthy, Stephan B. Felix, Martin Borggrefe, Carlo Di Mario, Filippo Crea, Hugo A. Katus, Heribert Schunkert, Thomas Münzel, Michael Böhm, Jeroen J. Bax, Abhiram Prasad, Jerold Shinbane, Thomas F. Lüscher, Frank Ruschitzka, Jelena R. Ghadri, and Christian Templin

Subjects
acute coronary syndrome, broken heart syndrome, cancer, malignancy, outcome, takotsubo syndrome, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background Clinical characteristics and outcomes of takotsubo syndrome (TTS) patients with malignancy have not been fully elucidated. This study sought to explore differences in clinical characteristics and to investigate short‐ and long‐term outcomes in TTS patients with or without malignancy. Methods and Results TTS patients were enrolled from the International Takotsubo Registry. The TTS cohort was divided into patients with and without malignancy to investigate differences in clinical characteristics and to assess short‐ and long‐term mortality. A subanalysis was performed comparing long‐term mortality between a subset of TTS patients with or without malignancy and acute coronary syndrome (ACS) patients with or without malignancy. Malignancy was observed in 16.6% of 1604 TTS patients. Patients with malignancy were older and more likely to have physical triggers, but less likely to have emotional triggers compared with those without malignancy. Long‐term mortality was higher in patients with malignancy (P

Published
2019
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17. Better Than You Think—Appropriate Use of Implantable Cardioverter-Defibrillators at a Single Academic Center: A Retrospective Review

Author

Nikhil H. Shah, Steven J. Ross, Steve A. Noutong Njapo, Justin Merritt, Andrew Kolarich, Michael Kaufmann, William M. Miles, David E. Winchester, Thomas A. Burkart, and Matthew McKillop

Subjects
Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background: Implantable cardioverter-defibrillators (ICDs) can be life-saving devices, although they are expensive and may cause complications. In 2013, several professional societies published joint appropriate use criteria (AUC) assessing indications for ICD implantation. Data evaluating the clinical application of AUC are limited. Previous registry-based studies estimated that 22.5% of primary prevention ICD implantations were “non-evidence-based” implantations. On the basis of AUC, we aimed to determine the prevalence of “rarely appropriate” ICD implantation at our institution for comparison with previous estimates. Methods: We reviewed 286 patients who underwent ICD implantation between 2013 and 2016. Appropriateness of each ICD implantation was assessed by independent review and rated on the basis of AUC. Results: Of 286 ICD implantations, two independent reviewers found that 89.5% and 89.2%, respectively, were appropriate, 5.6% and 7.3% may be appropriate, and 1.8% and 2.1% were rarely appropriate. No AUC indication was found for 3.5% and 3.4% of ICD implantations, respectively. Secondary prevention ICD implantations were more likely rarely appropriate (2.6% vs. 1.2% and 3.6% vs. 1.1%) or unrated (6.0% vs. 1.2% and 2.7% vs. 0.6%). The reviewers found 3.5% and 3.4% of ICD implantations, respectively, were non-evidence-based implantations. The difference in rates between reviewers was not statistically significant. Conclusion: Compared with prior reports, our prevalence of rarely appropriate ICD implantation was very low. The high appropriate use rate could be explained by the fact that AUC are based on current clinical practice. The AUC could benefit from additional secondary prevention indications. Most importantly, clinical judgement and individualized care should determine which patients receive ICDs irrespective of guidelines or criteria.

Published
2021
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18. The New Role of Telehealth in Contemporary Medicine

Author

Morgan H. Randall and David E. Winchester

Subjects
SARS-CoV-2, COVID-19, Humans, Cardiology and Cardiovascular Medicine, Pandemics, Telemedicine, Medication Adherence
Abstract

Understand the current uses for telehealth as well as future directions as it relates to the COVID-19 pandemic and cardiovascular medicine.Telehealth interventions in various forms have proven to be efficacious in the management of obesity, hypertension, glycemic control in diabetes, hyperlipidemia, medication adherence, and ICU length of stay and mortality. The use and study of such interventions have been greatly expanded during the pandemic partly due to the expanded coverage by payers. However, heterogenous interventions and a relative lack of cost analyses are barriers to more widespread adoption. Telehealth has proven efficacy for modifying risk factors for cardiovascular disease. To date, this has not been shown to translate to a reduction in hard cardiovascular endpoints such as mortality. With ongoing research and expanded funding, the role of telehealth is likely to evolve as the COVID pandemic continues.

Published
2022
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19. The Impact of American College of Cardiology Chest Pain Center Accreditation on Guideline Recommended Acute Myocardial Infarction Management

Author

Phillip D. Levy, Deborah B. Diercks, Tracy Y. Wang, Anwar Osborne, L. Kristin Newby, Michael C. Kontos, Michael A. Ross, David E. Winchester, Shuang Li, W. Frank Peacock, James McCord, Deepak L. Bhatt, and Steven Deitelzweig

Subjects
Aspirin, medicine.medical_specialty, medicine.drug_class, business.industry, medicine.medical_treatment, Percutaneous coronary intervention, Guideline, Chest pain, Revascularization, medicine.disease, Internal medicine, Conventional PCI, medicine, Cardiology, Myocardial infarction, medicine.symptom, Cardiology and Cardiovascular Medicine, business, Beta blocker, medicine.drug
Abstract

BACKGROUND Whether American College of Cardiology (ACC) Chest Pain Center (CPC) accreditation alters guidelines adherence rates is unclear. METHODS We analyzed patient-level, hospital-reported, quality metrics for myocardial infarction (MI) patients from 644 hospitals collected in the ACC's Chest Pain-MI Registry from January 1, 2019, to December 31, 2020, stratified by CPC accreditation for >1 year. RESULTS Of 192,374 MI patients, 67,462 (35.1%) received care at an accredited hospital. In general, differences in guideline adherence rates between accredited and nonaccredited hospitals were numerically small, although frequently significant. Patients at accredited hospitals were more likely to undergo coronary angiography (98.6% vs. 97.9%, P < 0.0001), percutaneous coronary intervention for NSTEMI (55.4% vs. 52.3%, P < 0.0001), have overall revascularization for NSTEMI (63.5% vs. 61.0%, P < 0.0001), and receive P2Y12 inhibitor on arrival (63.5% vs. 60.2%, P < 0.0001). Nonaccredited hospitals more ECG within 10 minutes (62.3% vs. 60.4%, P < 0.0001) and first medical contact to device activation ≤90 minutes (66.8% vs. 64.8%, P < 0.0001). Accredited hospitals had uniformly higher discharge medication guideline adherence, with patients more likely receiving aspirin (97.8% vs. 97.4%, P < 0.0001), angiotensin-converting enzyme inhibitor (46.7% vs. 45.3%, P < 0.0001), beta blocker (96.6% vs. 96.2%, P < 0.0001), P2Y12 inhibitor (90.3% vs. 89.2%, P < 0.0001), and statin (97.8% vs. 97.5%, P < 0.0001). Interaction by accredited status was significant only for length of stay, which was slightly shorter at accredited facilities for specific subgroups. CONCLUSIONS ACC CPC accreditation was associated with small consistent improvement in adherence to guideline-based treatment recommendations of catheter-based care (catheterization and PCI) for NSTEMI and discharge medications, and shorter hospital stays.

Published
2021
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20. Assessment of Cardiovascular Risk for Noncardiac and Nonsurgical Activities

Author

Christopher Perry, Jeffery B. Budweg, Andrew P. Stein, Jonathan Harder, Shishir Gupta, Alex J. Nusbickel, Madeline Smoot, Keval Patel, and David E. Winchester

Subjects
General Medicine
Abstract

Cardiovascular risk stratification is a frequent evaluation performed by health professionals. Not uncommonly, requests for risk stratification involve activities or procedures that fall outside of the scope of current evidence-based guidelines. Estimating risk and providing guidance for these requests can be challenging due to limited available evidence. This review focuses on some of these unique requests, each of which are real examples encountered in our practice. We offer guidance by synthesizing the available medical literature and formulating recommendations on topics such as the initiation of testosterone and erectile dysfunction therapy, SCUBA and skydiving, polygraphy, and electroconvulsive therapy.

Published
2022

21. Quality metrics for single-photon emission computed tomography myocardial perfusion imaging: an ASNC information statement

Author

Fadi G. Hage, Andrew J. Einstein, Karthikeyan Ananthasubramaniam, Jamieson M. Bourque, James Case, E. Gordon DePuey, Robert C. Hendel, Milena J. Henzlova, Nishant R. Shah, Brian G. Abbott, Wael Al Jaroudi, Nathan Better, Rami Doukky, W. Lane Duvall, Saurabh Malhotra, Robert Pagnanelli, Amalia Peix, Eliana Reyes, Ibrahim M. Saeed, Rupa M. Sanghani, Piotr J. Slomka, Randall C. Thompson, Vikas Veeranna, Kim A. Williams, and David E. Winchester

Subjects
Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine
Published
2022

22. Initial Invasive or Conservative Strategy for Stable Coronary Disease

Author

Maron D. J., Hochman J. S., Reynolds H. R., Bangalore S., O'Brien S. M., Boden W. E., Chaitman B. R., Senior R., Lopez-Sendon J., Alexander K. P., Lopes R. D., Shaw L. J., Berger J. S., Newman J. D., Sidhu M. S., Goodman S. G., Ruzyllo W., Gosselin G., Maggioni A. P., White H. D., Bhargava B., Min J. K., John Mancini G. B., Berman D. S., Picard M. H., Kwong R. Y., Ali Z. A., Mark D. B., Spertus J. A., Krishnan M. N., Elghamaz A., Moorthy N., Hueb W. A., Demkow M., Mavromatis K., Bockeria O., Peteiro J., Miller T. D., Szwed H., Doerr R., Keltai M., Selvanayagam J. B., Gabriel Steg P., Held C., Kohsaka S., Mavromichalis S., Kirby R., Jeffries N. O., Harrell F. E., Rockhold F. W., Broderick S., Bruce Ferguson T., Williams D. O., Harrington R. A., Stone G. W., Rosenberg Y, ISCHEMIA Research Group: Joseph Ricci, A Tello Montoliu, A I Robero Aniorte, Abbey Mulder, Abhay A Laddu, Abhinav Goyal, Abhishek Dubey, Abhishek Goyal, Abigail Knighton, Abraham Oomman, Adam J Jaskowiak, Adam Kolodziej, Adam Witkowski, Adnan Hameed, Adriana Anesini, Afshan Hussain, Agne Juceviciene, Agne Urboniene, Agnes Jakal, Agnieszka Szramowska, Ahmad Khairuddin, Ahmed Abdel-Latif, Ahmed Adel, Ahmed Aljzeeri, Ahmed Kamal, Ahmed Talaat, Aimee Mann, Aira Contreras, Ajit Kumar, V K Kumar, Akemi Furukawa, Akshay Bagai, Akvile Smigelskaite, Alain Furber, Alain Rheault, Alaine Melanie Loehr, Alan Rosen, Albert Varga, Albertina Qelaj, Alberto Barioli, Aldo Russo, Alec Moorman, Alejandro Gisbert, Aleksandra Fratczak, Aleksandras Laucevicius, Alena Kuleshova, Alessandro Sionis, Alexander A Sirker, Alexander M Chernyavskiy, Alexandra Craft, Alexandra Vazquez, Alexandre Ciappina Hueb, Alexandre S Colafranseschi, Alexandre Schaan de Quadros, Alexandre Tognon, Ali Alghamdi, Alice Manica Muller, Aline Nogueira Rabaça, Aline Peixoto Deiro, Alison Hallam, Allegra Stone, Allison Schley, Almudena Castro, Alvaro Rabelo Ales, Amanda Germann, Amanda O'Malley, Amar Uxa, Amarachi Ojajuni, Amarino C Oliveira Jr, Amber B Hull, Ambuj Roy, Amer Zarka, Amir Janmohamed, Ammani Brown, Ammy Malinay, Amparo Martinez Monzonis, Amy J Richards, Amy Iskandrian, Amy Ollinger, Ana D Djordjevic-Dikic, Ana Fernández Martínez, Ana Gomes Almeida, Ana Paula Batista, Ana Rita Francisco, Ana S Mladenovic, Ana Santana, Anam Siddiqui, Anastasia M Kuzmina-Krutetskaya, Andras Vertes, Andre S Sousa, Andre Gabriel, André Schmidt, Andrea M Lundeen, Andrea Bartykowszki, Andrea Lorimer, Andrea Mortara, Andrea Pascual, Andreia Coelho, Andreia Rocha, Andrés García-Rincón, Andrew G Howarth, Andrew J Moriarty, Andrew Docherty, Andrew Starovoytov, Andrew Zurick, Andrzej Łabyk, Andrzej Swiatkowski, Andy Lam, Anelise Kawakami, Angela Hoye, Angela Kim, Angelique Smit, Angelo Nobre, Anil V Shah, Anja Ljubez, Anjali Anand, Ankush Sachdeva, Ann Greenberg, Ann Luyten, Ann Ostrander, Anna Di Donato, Anna Cichocka-Radwan, Anna Fojt, Anna Plachcinska, Anna Proietti, Anna Teresinska, Anne Marie Webb, Anne Cartwright, Anne Heath, Anne Mackin, Anong Amaritakomol, Anong Chaiyasri, Anoop Chauhan, Anoop Mathew, Anthony Gemignani, Anto Luigi Andres, Antonia Vega, Antonietta Hansen, Antonino Ginel Iglesias, Antonio Carlos Carvalho, Antonio Di Chiara, Antonio Serra Peñaranda, Antonio Carvalho, Antonio Colombo, Antonio Fiarresga, Anupama Rao, Aquiles Valdespino-Estrada, Araceli Boan, Areef Ishani, Ariel Diaz, Arijit Ghosh, Arintaya Prommintikul, Arline Roberts, Arnold H Seto, Arnold P Good, Arshed Quyyumi, Arthur J Labovitz, Arthur Kerner, Arturo S Campos-Santaolalla, Arunima Misra, Ashok Mukherjee, Ashok Seth, Ashraf Seedhom, Asim N Cheema, Asker Ahmed, Atul Mathur, Atul Verma, Audrey W Leong, Axel Åkerblom, Axelle Fuentes, Aynun Naher, Badhma Valaiyapathi, Baljeet Kaur, Bandula Guruge, Barbara Brzezińska, Barbara Nardi, Bartosz Czarniak, Bebek Singh, Begoña Igual, Bela Merkely, Belen Cid Alvarez, Benjamin J Spooner, Benjamin J W Chow, Benjamin Cheong, Benoy N Shah, Bernard de Bruyne, Bernardas Valecka, Bernhard Jäger, Beth A Archer, Beth Abramson, Beth Jorgenson, Bethany Harvey, Betsy O'Neal, Bev Atkinson, Bev Bozek, Bevin Lang, Bijulal Sasidharan, Bin Yang, Bin Zhang, Binoy Mannekkattukudy Kurian, Bjoern Goebel, Bob Hu, Bogdan A Popescu, Bogdan Crnokrak, Bolin Zhu, Bonnie J Kirby, Brandi D Zimbelman, Brandy Starks, Branko D Beleslin, Brenda Hart, Brian P Shapiro, Brian McCandless, Brianna Wisniewski, Brigham R Smith, Brooks Mirrer, Bruce McManus, Bruce Rutkin, Bruna Edilena Paulino, Bruna Maria Ascoli, Bryn Smith, Byron J Allen, C Michael Gibson, C Noel Bairey Merz, Calin Pop, Cameron Hague, Camila Thais de Ormundo, Candace Gopaul, Candice P Edillo, Carísi A Polanczyk, Carita Krannila, Carla Vicente, Carl-Éric Gagné, Carlo Briguori, Carlos Peña Gil, Carlos Alvarez, Carly Ohmart, Carmen C Beladan, Carmen Ginghina, Carol M Kartje, Caroline Alsweiler, Caroline Brown, Caroline Callison, Caroline Pinheiro, Caroline Rodgers, Caroline Spindler, Carolyn Corbett, Carrie Drum, Casey Riedberger, Catherine Bone, Catherine Fleming, Catherine Gordon, Catherine Jahrsdorfer, Catherine Lemay, Catherine Weick, Cathrine Patten, Cecilia Goletto, Cezary Kepka, Chandini Suvarna, Chang Xu, Chantale Mercure, Charle A Viljoen, Charlene Wiyarand, Charles Jia-Yin Hou, Charles Y Lui, Charles Cannan, Charles Cornet, Charlotte Pirro, Chataroon Rimsukcharoenchai, Chen Wang, Cheng-Ting Tsai, Chen-Yen Chien, Cheryl A Allardyce, Chester M Hedgepeth, Chetan Patel, Chiara Attanasio, Chih-Hsuan Yen, Chi-Ming Chow, Ching Min Er, Ching-Ching Ong, Cholenahally Nanjappa Manjunath, Chris Beck, Chris Buller, Christel Vassaliere, Christian Hamm, Christiano Caldeira, Christie Ballantyne, Christina Björklund, Christine R Hinton, Christine Bergeron, Christine Masson, Christine Roraff, Christine Shelley, Christophe Laure, Christophe Thuaire, Christopher Kinsey, Christopher McFarren, Christopher Spizzieri, Christopher Travill, Chun-Chieh Liu, Chung-Lieh Hung, Chunguang Li, Chun-Ho Yun, Chunli Xia, Ciarra Heard, Cidney Schultz, Clare Venn-Edmonds, Claudia P Hochberg, Claudia Wegmayr, Claudia Cortés, Claudia Escobar, Cláudia Freixo, Claudio T Mesquita, Clemens T Kadalie, Colin Berry, Constance Philander, Corine Thobois, Costantino Costantini, Courtney Page, Craig Atkinson, Craig Barr, Craig Paterson, Cristina Bare, Cynthia Baumann, Cynthia Burman, Dalisa Espinosa, Damien Collison, Dan Deleanu, Dan Elian, Dan Gao, Dana Oliver, Daniel P Vezina, Daniel O'Rourke, Daniele Komar, Danielle Schade, Darrel P Francis, Dastan Malaev, David A Bull, David E Winchester, David P Faxon, David Booth, David Cohen, David DeMets, David Foo, David Schlichting, David Taggart, David Waters, David Wohns, Davis Vo, Dawid Teodorczyk, Dawn Shelstad, Dawn Turnbull, Dayuan Li, Dean Kereiakes, Deborah O'Neill, Deborah Yip, Debra K Johnson, Debra Dees, Deepak L Bhatt, Deepika Gopal, Deepti Kumar, Deirdre Mattina, Deirdre Murphy, Delano R Small, Delsa K Rose, Dengke Jiang, Denis Carl Phaneuf, Denise Braganza, Denise Fine, Derek Cyr, Desiree Tobin, Diana Cukali, Diana Parra, Diane Camara, Diane Minshall Liu, Diego Adrián Vences, Diego Franca de Cunha, Dimitrios Stournaras, Dipti Patel, Dongze Li, Donna Exley, Dorit Grahl, Dragana Stanojevic, Duarte Cacela, Dwayne S G Conway, E Pinar Bermudez, Eapen Punnoose, Edgar L Tay, Edgar Karanjah, Edoardo Verna, Eduardo Hernandez-Rangel, Edward D Nicol, Edward O McFalls, Edward T Martin, Edyta Kaczmarska, Ekaterina I Lubinskaya, Elena A Demchenko, Elena Refoyo Salicio, Eli Feen, Elihú Durán-Cortés, Elisabeth M Janzen, Elise L Hannemann, Elise van Dongen, Elissa Restelli Piloto, Eliza Kaplan, Elizabeta Srbinovska Kostovska, Elizabeth Capasso-Gulve, Elizabeth Congdon, Elizabeth Ferguson, Elizaveta V Zbyshevskaya, Ellen Magedanz, Ellie Fridell, Ellis W Lader, Elvin Kedhi, Emanuela Racca, Emilie Tachot, Emily DeRosa, Encarnación Alonso-Álvarez, Eric Nicollet, Eric Peterson, Erick Alexánderson Rosas, Erick Donato Morales, Erin Orvis, Ermina Moga, Estelle Montpetit, Estevao Figueiredo, Eugene Passamani, Eugenia Nikolsky, Eunice Yeoh, Evgeniy I Kretov, Ewa Szczerba, Ewelina Wojtala, Expedito Eustáquio Ribeiro Silva, F Marin Ortuño, Fabio R Farias, Fabio Fimiani, Fabrizio Rolfo, Fa-Chang Yu, Fadi Hage, Fadi Matar, Fahim Haider Jafary, Fang Feng, Fang Liu, Fatima Ranjbaran, Fatima Rodriguez, Fausto J Pinto, Fauzia Rashid, Federica Ramani, Fei Wang, Fernanda Igansi, Filipa Silva, Filippo Ottani, Fiona Haines, Firas Al Solaiman, Flávia Egydio, Flavio Lyra, Florian Egger, Fran Farquharson, Frances Laube, Francesc Carreras Costa, Francesca de Micco, Francesca Bianchini, Francesca Pezzetta, Francesca Pietrucci, Francesco Orso, Francesco Pisano, Francis Burt, Francisca Patuleia Figueiras, Francisco Fernandez-Aviles, Francois Pierre Mongeon, Frans Van de Werf, Franziska Guenther, Fraser N Witherow, Fred Mohr, Frederico Dall'Orto, Fumiyuki Otsuka, G De La Morena, G Karthikeyan, Gabor Dekany, Gabor Kerecsen, Gabriel Galeote, Gabriel Grossmann, Gabriel Vorobiof, Gabriela Sanchez de Souza, Gabriela Guzman, Gabriela Zeballos, Gabriele Gabrielli, Gabriele Jakl-Kotauschek, Gail A Shammas, Gail Brandt, Gang Chen, Gary E Lane, Gary J Luckasen, Gautam Sharma, Gelmina Mikolaitiene, Gennie Yee, Georg Nickenig, George E Revtyak, George J Juang, Gerald Fletcher, Gerald Leonard, Gerard Patrick Devlin, Gerard Esposito, Gergely Ágoston, Gervasio Lamas, Geza Fontos, Ghada Mikhail, Gia Cobb, Gian Piero Perna, Gianpiero Leone, Giles Roditi, Gilles Barone-Rochette, Girish Mishra, Giuseppe Tarantini, Glenda Wong, Glenn S Hamroff, Glenn Rayos, Gong Cheng, Gonzalo Barge-Caballero, Goran Davidović, Goran Stankovic, Gordana Stevanovic, Grace Jingyan Wang, Grace M Young, Graceanne Wayser, Graciela Scaro, Graham S Hillis, Graham Wong, Grazyna Anna Szulczyk, Gregor Simonis, Gregory Kumkumian, Gretchen Ann Peichel, Grzegorz Gajos, Gudrun Steinmaurer, Guilherme G Rucatti, Guilherme Portugal, Guilhermina Cantinho Lopes, Guillem Pons Lladó, Gunnar Frostfelt, Gurpreet S Wander, Gurpreet Gulati, Gustavo Pucci, Hafidz Abd Hadi, Haibo Zhang, Haitao Wang, Halina Marciniak, Han Chen, Hanan Kerr, Hani Najm, Hanna Douglas, Hannah Phillips, Hao Dai, Haojian Dong, Haqeel Jamil, Harikrishnan Sivadasanpillai, Harry Suryapranata, Hassan Reda, Hayley Pomeroy, Heather Barrentine, Heather Golden, Heather Hurlburt, Heidi Wilson, Helen C Tucker, Helene Abergel, Hemalata Siddaram, Hermine Osseni, Herwig Schuchlenz, Hesong Zeng, Hicham Skali, Hilda Solomon, Hollie Horton, Holly Hetrick, Holly Little, Holly Park, Hongjie Chi, Hossam Mahrous, Howard A Levite, Hristo Pejkov, Huajun Li, Hugo Bloise-Adames, Hugo Marques, Hui Zhong, Hui-Min Zhang, Humayrah Hashim, Hung-I Yeh, Hussien El Fishawy, Ian Webb, Iftikhar Kullo, Igor O Grazhdankin, Ihab Hamzeh, Ikraam Hassan, Ikuko Ueda, Ileana L Pina, Ilona Tamasauskiene, Ilse Bouwhuis, Imran Arif, Ina Wenzelburger, Inês Zimbarra Cabrita, Ines Rodrigues, Inga H Robbins, Inga Soveri, Ingela Schnittger, Iqbal Karimullah, Ira M Dauber, Iram Rehman, Irena Peovska Mitevska, Irene Marthe Lang, Irina Subbotina, Irma Kalibataite-Rutkauskiene, Irni Yusnida, Isabel Estela Carvajal, Isabella C Palazzo, Isabelle Hogan, Isabelle Roy, Ishba Syed, Ishita Tejani, Ivan A Naryshkin, Ivana Jankovic, Iwona Niedzwiecka, J David Knight, Jacek Kusmierek, Jackie M White, Jackie Chow, Jacob Udell, Jacqueline E Tamis-Holland, Jacqueline Fannon, Jacquelyn A Quin, Jacquelyn Do, Jaekyeong Heo, Jakub Maksym, James E Davies, James H O'Keefe Jr, James J Jang, James Cha, James Harrison, James Hirsch, James Stafford, James Tatoulis, Jamie Rankin, Jan Henzel, Jan Orga, Jana Tancredi, Janaina Oliveira, Jane Burton, Jane Eckstein, Jane Marucci, Janet P Knight, Janet Blount, Janet Halliday, Janetta Kourzenkova, Janitha Raj, Jan-Malte Sinning, Jaqueline Pozzibon, Jaroslaw Drozdz, Jaroslaw Karwowski, Jason D Glover, Jason Loh Kwok, Jason T Call, Jason Linefsky, Jassira Gomes, Jati Anumpa, Javier J Garcia, Javier Courtis, Jay Meisner, K Jayakumar, Jayne Scales, Jean E Denaro, Jean Michel Juliard, Jean Ho, Jeanette K Stansborough, Jean-Michel Juliard, Jeanne Russo, Jeannette J M Schoep, Jeet Thambyrajah, Jeff Leimberger, Jeffery A Breall, Jeffrey A Kohn, Jeffrey C Milliken, Jeffrey Anderson, Jeffrey Blume, Jeffrey Kanters, Jeffrey Lorin, Jeffrey Moses, Jelena J Stepanovic, Jelena Celutkiene, Jelena Djokic, Jelena Stojkovic, Jenne M Jose, Jenne Manchery, Jennifer A Mull, Jennifer H Czerniak, Jennifer L Stanford, Jennifer Gillis, Jennifer Horst, Jennifer Isaacs, Jennifer Langdon, Jennifer Thomson, Jennifer Tomfohr, Jennifer White, Jen-Yuan Kuo, Jeremy Rautureau, Jerome Fleg, Jessica Berg, Jessica Rodriguez, Jessica Waldron, Jhina Patro, Jia Li, Jiajia Mao, Jiamin Liu, Jian'an Wang, Jianhua Li, Jianxin Zhang, Jie Qi, Jihyun Lyo, Jill Marcus, Jim Blankenship, Jing Zhang, Jingjing Liu, Jing-Yao Fan, Jiun-Yi Li, Jiwan Pradhan, Jiyan Chen, J M Rivera Caravaca, Jo Evans, Joan Garcia Picart, Joan Hecht, Joanna Jaroch, Joanna Zalewska, Joanne Kelly, Joanne Taaffe, João Reynaldo Abbud, João V Vitola, Joaquín V Peñafiel, Jocelyne Benatar, Jody Bindeman, Joe Sabik, Joel Klitch, Johann Christopher, Johannes Aspberg, John D Friedman, John F Beltrame, John F Heitner, John Joseph Graham, John R Davies, John Doan, John Kotter, John Kurian, John Mukai, John Pownall, Jolanta Sobolewska, Jon Kobashigawa, Jonathan L Goldberg, Jonathan W Bazeley, Jonathan Byrne, Jonathan Himmelfarb, Jonathan Leipsic, Jonean Thorsen, Jorge F Trejo Gutierrez, Jorge Escobedo, Jorik Timmer, José A Ortega-Ramírez, José Antonio Marin-Neto, Jose D Salas, Jose Enrique Castillo, Jose Francisco Saraiva, José J Cuenca-Castillo, Jose L Diez, José Luis Narro Villanueva, José Luiz da Vieira, José M Flores-Palacios, Jose Ramon Gonzalez, Jose Seijas Amigo, Jose Fragata, Josep Maria Padró, Josheph F X McGarvey Jr, Joseph Hannan, Joseph Sacco, Joseph Sweeny, Joseph Wiesel, Josephine D Abraham, Joshua P Loh, Joy Burkhardt, Joyce R White, Joyce Riestenberg-Smith, Judit Sebo, Judith L Meadows, Judith Wright, Judy Mae Foltz, Judy Hung, Judy Otis, Juergen Stumpf, Jui-Peng Tsai, Julia S Dionne, Julia de Aveiro Morata, Julie Bunke, Julie Morrow, Julio César Figal, Jun Fujita, Jun Jiang, Junhua Li, Junqing Yang, Juntima Euathrongchit, Jyotsna Garg, K Manjula Rani, K Preethi, Kaatje Goetschalckx, Kai Eggers, Kamalakar Surineni, Kanae Hirase, T R Kapilamoorthy, Karen Calfas, Karen Gratrix, Karen Hallett, Karen Hultberg, Karen Nugent, Karen Petrosyan, Karen Swan, Karolina Kryczka, Karolina Wojtczak-Soska, Karolina Wojtera, Karsten Lenk, Karthik Ramasamy, Katarzyna Łuczak, Katarzyna Malinowska, Kate Pointon, Kate Robb, Katherine Martin, Kathleen Claes, Kathryn Carruthers, Kathy E Siegel, Katia Drouin, Katie Fowler-Lehman, Kavita Rawat, Kay Rowe, Keiichi Fukuda, Keith A A Fox, Ken Mahaffey, Kendra Unterbrink, Kenneth Giedd, Kerrie Van Loo, Kerry Lee, Kerstin Bonin, Kevin R Bainey, Kevin T Harley, Kevin Anstrom, Kevin Chan, Kevin Croce, Kevin Landolfo, Kevin Marzo, Keyur Patel, Khaled Abdul-Nour, Khaled Alfakih, Khaled Dajani, Khaled Ziada, Khaula Baloch, Khrystyna Kushniriuk, Kian-Keong Poh, Kim F Ireland, Kim Holland, Kimberly Ann Byrne, Kimberly E Halverson, Kimberly Elmore, Kimberly Miller-Cox, Kiran Reddy, Kirsten J Quiles, Kirsty Abercrombie, Klaus Matschke, Konrad Szymczyk, Koo Hui Chan, Kotiboinna Preethi, Kozhaya Sokhon, Krissada Meemuk, Kristian Thygesen, Kristin M Salmi, Kristin Newby, Kristina Wippler, Kristine Arges, Kristine Teoh, Krystal Etherington, Krystyna Łoboz-Grudzień, Krzysztof W Reczuch, Krzysztof Bury, Krzysztof Drzymalski, Krzysztof Kukuła, Kuo-Tzu Sung, Kurt Huber, Ladda Douangvila, Lance Sullenberger, Larissa Miranda Trama, Laszlone Matics, Laura Drew, Laura Flint, Laura Keinaite, Laura Sarti, Laurel Kolakaluri, Lawrence M Phillips, Lawrence Friedman, Lawrence Phillips, Lazar Velicki, Leah Howell, Leandro C Maranan, Leanne Cox, Ledjalem Daba, Lei Zhang, Lekshmi Dharmarajan, Leo Bockeria, Leonardo Pizzol Caetano, Leonardo Bridi, Leonid L Bershtein, Leszek Sokalski, Li Hai Yan, Li Li, Lia Nijmeijer, Lidia Sousa, Lihong Xu, Lihua Zhang, Lili Zhang, Lilia Schiavi, Lilian Mazza Barbosa, Lillian L Khor, Lina Felix-Stern, Linda L Hall, Linda M Hollenweger, Linda Arcand, Linda Davidson-Ray, Linda Schwarz, Lindsey N Sikora, Lingping Chi, Lino Patricio, Liping Zhang, Lisa Chaytor, Lisa Hatch, Lisa McCloy, Lisa Wong, Liselotte Persson, Lixin Jiang, Liz Low, Ljiljana Pupic, Loïc Bière, Lorenzo Monti, Lori Christensen, Lori Pritchard, Loriane Black, Lori-Ann Desimone, Lori-Ann Larmand, Lorraine McGregor, Louise Morby, Louise Thomson, Luc Harvey, Luciana de Pádua Baptista, Lucilla Garcia, Ludivine Eliahou, Ludmila Helmer, Luis F Smidt, Luis Bernanrdes, Luis Guzman, Luiz A Carvalho, Luyang Xiong, Lynette L Teo, Lynn M Neeson, Lynne Winstanley, M Barbara Srichai-Parsia, M Quintana Giner, M Sowjanya Reddy, M Valdés Chávarri, M Grazia Rossi, Maarten Simoons, Maayan Konigstein, Maciej Lesiak, Maciej Olsowka, Mafalda Selas, Magalie Corfias, Magdalena Madero Rovalo, Magdalena Łanocha, Magdalena Miller, Magdalena Misztal-Teodorczyk, Magdalena Rantinella, Magdy Abdelhamid, Magnolia Jimenez, Mahboob Alam, Mahevamma Mylarappa, Mahfouz El Shahawy, Mahmoud Mohamed, Mahmud Al-Bustami, Majo X Joseph, Malgorzata Frach, Małgorzta Celińska-Spodar, Malte Helm, Manas Chacko, Mandy Murphy, Manitha Vinod, Manjula Rani, Manu Dhawan, Manuela Mombelli, Marcel Weber, Marcello Galvani, Marcelo Jamus Rodrigues, Marcia F Dubin, Marcia F Werner Bayer, Marcin Szkopiak, Marco Antonio Monsalve, Marco Bizzaro Santos, Marco Magnoni, Marco Marini, Marco Sicuro, Marco Zenati, Marcos Valério Coimbra Resende, Marek Roik, Margalit Bentzvi, Margaret Gilsenan, Margaret Iraola, Margot C Quinn, Maria A Alfonso, Maria Antonieta Pereira Moraes, María Dolores Martínez-Ruíz, María Fernanda Canales, Maria Inês Caetano, Maria P Corral, Maria Pérez García, Maria Victoria Actis, Maria Aguirre, Maria Andreasson, Maria Aprile, Maria Colton, Maria Eugenia Martin, Maria Lasala, Maria Lorenzo, Maria Posada, Maria Shier, Maria Thottam, Mariana V Furtado, Mariana Yumi Okada, Marianna D A Dracoulakis, Marianne De Andrade, Mariano Rubio, Marie Essermark, Marielle Scherrer-Crosbie, Marija T Petrovic, Marija Zdravkovic, Marilyn Black, Marina Garcia, Mario J Garcia, Mariola Szulik, Marisa Orgera, Mark A de Belder, Mark Harbinson, Mark Hyun, Mark Peterson, Mark Xavier, Marlowe Mosley, Marta Capinha, Marta Marcinkiewicz-Siemion, Marta Swiderek, Martha Meyer, Martina Ceseri, Martina Tricoli, Marvin Kronenberg, Mary Williams, Mary Ann Champagne, Mary Colleen Rogge, Mary R Soltau, Mary Streif, Massimo Villella, Massoud Leesar, Matei Claudia, Mateusz Solecki, Matías Nicolás Mungo, Matthew Wall 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Wu, Yu Kunwu, Yu Zhao, Yudong Peng, Yueh-Hung Lin, Yulan Zhao, Yumei Dong, Yunhai Zhao, Yutthaphan Wannasopha, Yvonne Taul, Zakir Sahul, Zalina Kudzoeva, Zbigniew Kalarus, Zeljko Z Markovic, Zhen Huang, Zheng Ji, Zhenyu Liu, Zhou Yue, Zhulin Zhang, Zhuxi Li, Zile Singh Meharwal, Ziliang Bai, Zixiang Yu, Zohra Huda, Zoltan Davidovits

Subjects
Male, Cardiac Catheterization, Computed Tomography Angiography, medicine.medical_treatment, Myocardial Ischemia, Coronary Disease, Coronary Artery Disease, Kaplan-Meier Estimate, 030204 cardiovascular system & hematology, Coronary Angiography, ISCHEMIA Research Group, law.invention, Angina, Coronary artery disease, 0302 clinical medicine, Randomized controlled trial, law, Cardiovascular Disease, Myocardial Revascularization, 030212 general & internal medicine, Coronary Artery Bypass, 11 Medical and Health Sciences, Cardiac catheterization, General Medicine, Middle Aged, humanities, Cardiovascular Diseases, Cardiology, Female, Human, medicine.medical_specialty, Ischemia, Article, 03 medical and health sciences, Geriatric cardiology, Percutaneous Coronary Intervention, General & Internal Medicine, Internal medicine, medicine, Humans, Angina, Unstable, Aged, business.industry, Coronary Artery Bypa, Percutaneous coronary intervention, Bayes Theorem, medicine.disease, Heart failure, Quality of Life, business
Abstract

BACKGROUND: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).

Published
2020
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23. Promoting Cardiac Rehabilitation in Acute Coronary Syndrome Patients: Quality Initiative Based on Education, Automated Referral, and Multidisciplinary Rounds

Author

Catarina Canha, Jeffrey M. Plasschaert, Eldon Matthia, David E. Winchester, Morgan H. Randall, Elizabeth Warren, Hassan Ashraf, Ashley Mohadjer, and Ellen C. Keeley

Subjects
Acute coronary syndrome, medicine.medical_specialty, Cardiac Rehabilitation, Rehabilitation, Quality management, Referral, business.industry, medicine.medical_treatment, medicine.disease, Quality Improvement, Patient Discharge, Multidisciplinary approach, Intervention (counseling), Emergency medicine, medicine, Hospital discharge, Humans, Acute Coronary Syndrome, Cardiology and Cardiovascular Medicine, business, Referral and Consultation, House staff
Abstract

Cardiac rehabilitation is a class 1 recommendation for acute coronary syndrome (ACS) patients according to the American College of Cardiology/American Heart Association. However, only 1 in 5 ACS patients are referred for cardiac rehabilitation nationally, and even fewer at our institution. We sought to improve the number of referrals to cardiac rehabilitation for post-ACS patients admitted to our inpatient cardiology service, and ultimately their participation in the program. We designed a quality improvement initiative that included education of patients and house staff, automated referral order, and participation of cardiac rehabilitation staff members on multidisciplinary rounds. We compared the number of patients who received a referral to cardiac rehabilitation, had the first appointment scheduled before hospital discharge, and attended the program before and after our intervention. Six months after initiation of the project, the proportion of ACS patients referred to cardiac rehabilitation before hospital discharge increased from 10% to 43% (P < 0.001). The mean number of patients with a cardiac rehabilitation appointment scheduled before discharge was 2 before and 5 after the intervention (P < 0.001), and the mean number of patients who attended their scheduled appointment was 1 before and 3 after the intervention (P = 0.001). Run charts demonstrated that the number of referrals and the number of scheduled appointments remained above the median following the intervention. In conclusion, an initiative that included education, automated referrals, and direct one-on-one contact with cardiac rehabilitation staff before discharge increased the number of cardiac rehabilitation referrals, and appointments scheduled and attended in post-ACS patients.

Published
2021
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24. Quality Improvement in Cardiovascular Imaging

Author

David E. Winchester and R. Beyth

Subjects
Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Implementation of quality improvement (QI) activities is growing in health care settings across the world. Within cardiovascular imaging, areas for improvement include consistency of result reporting, greater patient safety through reductions in radiation exposure, and greater efficiency of care delivery by elimination of wasteful practices and elimination of low-value or rarely appropriate testing. QI in health care is often driven through one of several endorsed frameworks, such as Lean, Six Sigma, and the Model for Improvement. Multiple examples of how to teach QI to medical trainees and physicians have been published. In this narrative review, we explore the growth and impact of QI in cardiovascular imaging, providing specific examples of successful projects, barriers to conducting QI, and rewards of persistent effort toward improving care.

Published
2019
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26. Diabetes is still a CAD risk equivalent, now what?

Author

Christopher Perry and David E. Winchester

Subjects
medicine.medical_specialty, business.industry, Diabetes mellitus, MEDLINE, Medicine, Radiology, Nuclear Medicine and imaging, CAD, Cardiology and Cardiovascular Medicine, business, medicine.disease, Intensive care medicine
Published
2021
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27. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease

Author

Ritu Sachdeva, Anne Marie Valente, Aimee K. Armstrong, Stephen C. Cook, B. Kelly Han, Leo Lopez, George K. Lui, Sarah S. Pickard, Andrew J. Powell, Nicole M. Bhave, Jeanne M. Baffa, Puja Banka, Scott B. Cohen, Julie S. Glickstein, Joshua P. Kanter, Ronald J. Kanter, Yuli Y. Kim, Alaina K. Kipps, Larry A. Latson, Jeannette P. Lin, David A. Parra, Fred H. Rodriguez, Elizabeth V. Saarel, Shubhika Srivastava, Elizabeth A. Stephenson, Karen K. Stout, Ali N. Zaidi, Ty J. Gluckman, Niti R. Aggarwal, Gregory J. Dehmer, Olivia N. Gilbert, Dharam J. Kumbhani, Andrea L. Price, David E. Winchester, Martha Gulati, John U. Doherty, Stacie L. Daugherty, Larry S. Dean, Milind Y. Desai, Linda D. Gillam, and Praveen Mehrotra

Subjects
medicine.medical_specialty, Heart disease, business.industry, Internal medicine, Medicine, Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine, business, medicine.disease, Follow up care, Appropriate Use Criteria, Multimodality
Published
2020
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28. Appropriate Use Criteria for PET Myocardial Perfusion Imaging

Author

Ronald G. Schwartz, Panithaya Chareonthaitawee, Marcelo F. Di Carli, Sharmila Dorbala, David E. Winchester, Lorraine E. De Blanche, Terrence D. Ruddy, Daniel S. Berman, Hein Verberne, Thomas H. Schindler, Prem Soman, Robert J. Gropler, Timothy M. Bateman, Venkatesh L. Murthy, Vasken Dilsizian, Rob S. Beanlands, Sukhjeet Ahuja, Leslee J. Shaw, Radiology and Nuclear Medicine, and ACS - Amsterdam Cardiovascular Sciences

Subjects
Quality Control, Risk, medicine.medical_specialty, MEDLINE, CAD, 030204 cardiovascular system & hematology, Appropriate Use Criteria, Coronary artery disease, 03 medical and health sciences, Myocardial perfusion imaging, 0302 clinical medicine, Internal medicine, medicine, Humans, Radiology, Nuclear Medicine and imaging, 030212 general & internal medicine, Reference standards, medicine.diagnostic_test, business.industry, Myocardial Perfusion Imaging, Reference Standards, medicine.disease, Clinical routine, Positron-Emission Tomography, Risk stratification, Cardiology, business
Abstract

In the last decade, myocardial perfusion imaging (MPI) with PET has emerged to play a pivotal role in the clinical routine process for the detection of hemodynamically significant obstructive coronary artery disease (CAD) and cardiovascular risk stratification ([1][1]–[5][2]). The high spatial and

Published
2020
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29. Myocardial infarction classification and its implications on measures of cardiovascular outcomes, quality, and racial/ethnic disparities

Author

David E. Winchester, Aaron Hilliard, Tanya D. Russell, and Rosland D. Hilliard

Subjects
medicine.medical_specialty, Quality management, Heart disease, diagnostic codes, cardiac, Ethnic group, Myocardial Infarction, Reviews, Review, 030204 cardiovascular system & hematology, quality improvement, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, medicine, Ethnicity, Prevalence, Humans, myocardial injury, 030212 general & internal medicine, Myocardial infarction, Medical diagnosis, Healthcare Disparities, Intensive care medicine, Cause of death, Quality of Health Care, business.industry, troponin, plan‐do‐check‐adjust, Racial Groups, General Medicine, myocardial infarction < ischemic heart disease, medicine.disease, Health equity, United States, Diagnosis code, international statistical classification of diseases ICD 10, Cardiology and Cardiovascular Medicine, business
Abstract

Heart disease continues to be the leading cause of death in the United States, with approximately 805 000 cumulative deaths from myocardial infarctions (MI) from 2005 to 2014. Gender and racial/ethnic disparities in MI diagnoses are becoming more evident in quality review audits. Although recent changes in diagnostic codes provided an improved framework, clinically distinguishing types of MI remains a challenge. MI misdiagnoses and health disparities contribute to adverse outcomes in cardiac medicine. We conducted a literature review of relevant biomedical sources related to the classification of MI and disparities in cardiovascular care and outcomes. From the studies analyzed, African Americans and women have higher rates of mortality from MI, are more probably to be younger and present with other comorbidities and are less probably to receive novel therapies with respect to type of MI. As high‐sensitivity troponin assays are adopted in the United States, implementation should account for how race and sex differences have been demonstrated in the reference range and diagnostic threshold of the newer assays. More research is needed to assess how the complexity of health disparities contributes to adverse cardiovascular outcomes. Creating dedicated medical quality teams (physicians, nurses, clinical documentation improvement specialists, and medical coders) and incorporating a plan‐do‐check‐adjust quality improvement model are strategies that could potentially help better define and diagnose MI, reduce financial burdens due to MI misdiagnoses, reduce cardiovascular‐related health disparities, and ultimately improve and save lives.

Published
2020

30. Overuse of Cardiac Troponin Among Hospitalized Patients: A Cohort Study of Biomarker 'Superusers'

Author

David E. Winchester and Sean M. Taasan

Subjects
Acute coronary syndrome, medicine.medical_specialty, Cardiac troponin, biology, Medical overuse, business.industry, Hospitalized patients, Brief Report, medicine.disease, Troponin, Internal medicine, RC666-701, biology.protein, Medicine, Biomarker (medicine), Diseases of the circulatory (Cardiovascular) system, Cardiology and Cardiovascular Medicine, business, Cohort study
Published
2020

31. Effect of Elevated Calcium Score on Normal Myocardial Perfusion Study on Clinician Management of Coronary Artery Disease Risk Factors

Author

Anita Wokhlu, Vicente Taasan, David E. Winchester, and David Wymer

Subjects
Male, medicine.medical_specialty, Coronary Artery Disease Risk, Coronary Artery Disease, Documentation, Disease, 030204 cardiovascular system & hematology, Cohort Studies, 03 medical and health sciences, Myocardial perfusion imaging, chemistry.chemical_compound, 0302 clinical medicine, Internal medicine, medicine, Humans, cardiovascular diseases, 030212 general & internal medicine, Practice Patterns, Physicians', Vascular Calcification, Contraindication, Antihypertensive Agents, Aged, Retrospective Studies, Subclinical infection, Aspirin, medicine.diagnostic_test, business.industry, Cholesterol, Anticholesteremic Agents, Myocardial Perfusion Imaging, nutritional and metabolic diseases, Middle Aged, chemistry, Heart Disease Risk Factors, Exercise Test, Cardiology, Female, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Cardiology and Cardiovascular Medicine, business, Platelet Aggregation Inhibitors, Cohort study, medicine.drug
Abstract

Elevated coronary artery calcification (CAC) scores are associated with higher cardiovascular (CV) risk even with normal stress myocardial perfusion imaging (MPI). Whether referring providers appropriately manage subclinical CV disease is unclear. We hypothesized that ordering clinicians would intensify medical therapy for CV disease in response to normal MPI and CAC ≥ 300. We conducted a cohort study on patients without known CV disease who underwent MPI and CAC scoring. Medical management of CV disease and clinical outcomes were assessed. Of 299 patients who underwent stress MPI, 62 patients had normal MPI and CAC ≥ 300. Documentation of elevated CAC score was noted in the final interpretation for 52% (n = 32) of MPI reports. During follow-up, treatment change in aspirin, cholesterol medications, and/or antihypertensive medication was made in 40% of these patients. Aspirin use increased from 71% to 82% (P < 0.001); statin use increased from 68% to 76% (P < 0.001). Several patients remained on suboptimal lipid or antiplatelet regimens without documented contraindication. Among patients with normal MPI, many have CAC ≥ 300. Not all MPI reports adequately call attention to this finding associated with elevated CV risk. Despite the elevated CAC score, some patients were not optimized medically.

Published
2020
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32. Physician thoughts on unnecessary noninvasive imaging and decision support software: A qualitative study

Author

Kimberly Findley, Ivette Magaly Freytes, Rebecca J. Beyth, David E. Winchester, and Magda Schmitzberger

Subjects
Noninvasive imaging, medicine.medical_specialty, Decision support system, business.industry, 030503 health policy & services, Medicine (miscellaneous), 03 medical and health sciences, Philosophy, Issues, ethics and legal aspects, 0302 clinical medicine, Unnecessary Procedure, Medical imaging, Medicine, Medical physics, 030212 general & internal medicine, 0305 other medical science, business, Qualitative research
Abstract

Objective Gather information from physicians about factors contributing to unnecessary noninvasive imaging and impact of possible solutions. Methods Qualitative study of 14 physicians using a phenomenological approach and the Theoretical Domains Framework. Results Most participants ( n = 9) self-reported that >10% of the imaging tests they order are unnecessary. External sources of pressure included: peer-review, patient demands, nursing expectations, specialist requests (social demands), as well as prior experience with patient advocates, and the compensation and pension system (environmental context). Internal sources of pressure included reliance on anecdote (emotion), self-doubt about diagnoses (beliefs about capabilities), and fear of missing a diagnosis and of professional liability (beliefs about consequences). Participants expressed both optimism and concern about potential solutions, such as adopting decision support software. Conclusion Physicians are under pressure from multiple sources to order unnecessary imaging. Peer review, nursing expectations, and perceptions about Veteran compensation and pension are newly reported contributing factors.

Published
2020
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33. Implementation of appropriate use criteria for cardiology tests and procedures: a systematic review and meta-analysis

Author

Hannah F. Norton, Justin Merritt, Nishant R. Shah, Veena Manja, David E. Winchester, Christian D. Helfrich, and Nida Waheed

Subjects
medicine.medical_specialty, Funnel plot, business.industry, Health Policy, Cardiology, Diagnostic Techniques, Cardiovascular, MEDLINE, Publication bias, CINAHL, Appropriate Use Criteria, law.invention, Randomized controlled trial, Computerized physician order entry, law, Meta-analysis, Internal medicine, Humans, Medicine, Cardiology and Cardiovascular Medicine, business
Abstract

Aims The American College of Cardiology appropriate use criteria (AUC) provide clinicians with evidence-informed recommendations for cardiac care. Adopting AUC into clinical workflows may present challenges, and there may be specific implementation strategies that are effective in promoting effective use of AUC. We sought to assess the effect of implementing AUC in clinical practice. Methods and results We conducted a meta-analysis of studies found through a systematic search of the MEDLINE, Web of Science, Cochrane, or CINAHL databases. Peer-reviewed manuscripts published after 2005 that reported on the implementation of AUC for a cardiovascular test or procedure were included. The main outcome was to determine if AUC implementation was associated with a reduction in inappropriate/rarely appropriate care. Of the 18 included studies, the majority used pre/post-cohort designs; few (n = 3) were randomized trials. Most studies used multiple strategies (n = 12, 66.7%). Education was the most common individual intervention strategy (n = 13, 72.2%), followed by audit and feedback (n = 8, 44.4%) and computerized physician order entry (n = 6, 33.3%). No studies reported on formal use of stakeholder engagement or ‘nudges’. In meta-analysis, AUC implementation was associated with a reduction in inappropriate/rarely appropriate care (odds ratio 0.62, 95% confidence interval 0.49–0.78). Funnel plot suggests the possibility of publication bias. Conclusion We found most published efforts to implement AUC observed reductions in inappropriate/rarely appropriate care. Studies rarely explored how or why the implementation strategy was effective. Because interventions were infrequently tested in isolation, it is difficult to make observations about their effectiveness as stand-alone strategies. Study registration PROSPERO 2018 CRD42018091602. Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018091602.

Published
2020
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34. Multimodality imaging: Bird’s eye view from the 2019 American College of Cardiology Scientific Sessions

Author

David E. Winchester, Mouaz H. Al-Mallah, Muhamed Saric, Steven G. Lloyd, Ron Blankstein, and Lawrence M. Phillips

Subjects
medicine.medical_specialty, Cardiac computed tomography, business.industry, Nuclear imaging, Psychological intervention, 030204 cardiovascular system & hematology, 030218 nuclear medicine & medical imaging, Multimodality, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, medicine, Cardiology, Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine, business, Cardiac magnetic resonance
Abstract

The 2019 American College of Cardiology Scientific Sessions displayed innovation in many areas for the evaluation and management of cardiovascular disease from preventive evaluation and care to advanced interventions. Imaging played a central role in these developments with a highlight of the conference being the imaging research presented. This review will summarize key imaging studies which were presented at this scientific meeting which will lead to innovation in the evaluation and management of cardiovascular disease. Experts in nuclear imaging (DW/MA), echocardiography (MS), cardiac magnetic resonance (SL), and cardiac computed tomography (RB) selected abstracts which they found to be of particular interest to the multimodality imaging audience and were integrated into this review (LP).

Published
2020
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36. Core Cardiology Training Symposium (COCATS) Standards and Board Certifications: Implications for Fellows-in-Training Seeking Employment

Author

David E. Winchester and Omkar Betageri

Subjects
Employment, medicine.medical_specialty, Certification, 030505 public health, ComputingMilieux_THECOMPUTINGPROFESSION, Health Policy, 05 social sciences, Cardiology, 050401 social sciences methods, Training (civil), United States, 03 medical and health sciences, Core (game theory), Cross-Sectional Studies, 0504 sociology, Internal medicine, medicine, Humans, Fellowships and Scholarships, 0305 other medical science, Seeking employment, Psychology
Abstract

The Core Cardiology Training Symposium (COCATS) standards are recommendations endorsed by the American College of Cardiology to assist cardiology fellowship program training directors in curricular design. In addition to seeking COCATS standards as evidence of proficiency in cardiovascular skills, Fellows-In-Training (FITs) often pursue board certifications to maximize their hiring potential. The costs and barriers with COCATS standards and board certification processes are not insignificant, however the degree to which the job marketplace demands them has not been well characterized. The intent of this investigation study was to estimate the demand for COCATS standards and board certification in cardiology job advertisements. We conducted a cross-sectional survey of job listings on the American College of Cardiology’s “Cardiology Careers” page, to establish how often advanced COCATS standards and certifications are requested. Of a total of 314 total cardiology job postings (including 133 academic positions), only eight (2.5%) job postings explicitly noted COCATS standards. Aside from American Board of Internal Medicine subspecialty certification, only 8.60% required certification in another cardiology related board certification. Despite the perception that COCATS standards and subspecialty certifications are vital to the cardiology job application process, our analysis suggests that few job postings require them. Concern regarding COCATS standards and subspecialty certification of FITs may be out of proportion to the relevance of these achievements on the current job market.

Published
2021
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37. Abstract 9719: Structured Patient Education Improves Adherence with Wearable Cardiac Defibrillators

Author

Eldon L Matthia, Michael L Setteducato, Steven J Ross, Aaron E Brice, Mark E Panna, and David E Winchester

Subjects
Physiology (medical), Cardiology and Cardiovascular Medicine
Abstract

Background: The wearable-cardioverter defibrillator (WCD) tradename LifeVest has emerged as a temporary alternative to implantable cardioverter-defibrillator therapy. However, patient adherence can be variable. We sought to investigate if standardized device education and patient follow-up phone calls could lead to increased adherence. Methods: Patients prescribed a WCD from July 2017 to July 2018 comprised the pre-intervention group. The initial post-intervention group from January 2019 to May 2019 enrolled 32 patients. Each patient received standardized device education using a video presentation, and we sought to call each patient within 7 days of discharge to answer questions and administer a questionnaire. 14 patients comprised the second post-intervention group from March 2020 to May 2020, which received refined education with both a video presentation and 30-minute, standardized, hands-on training with the LifeVest representative, as well as similar follow-up phone calls for all patients within 7 days of discharge. Results: The pre-intervention group had a median wear time of 19.46 hours/day. In the first post-intervention group, all patients received standardized education; however, only 17 patients were contacted via phone due to time constraints. Patients with standardized education-only had a median wear time 21.55 hours/day, while patients who received both interventions had a median wear time of 23.01 hours/day. The increase in median wear time in pre-intervention compared to post-intervention groups was statistically significant (p= 0.0056) There was no significant difference between the two post-intervention groups (p=0.5485). In the second intervention group, median wear time significantly increased to 22.00 hours/day compared to the pre-intervention group (p=0.0244). Conclusions: Implementing standardized device education can improve median WCD wear time. The addition of post-discharge follow-up phone call did lead to improved mean and median wear times, but this was not statistically significant. Similar strategies could be cheaply and easily adopted at other centers in an effort to improve WCD adherence.

Published
2021
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38. Pneumopericardium Develops After Pacemaker Implantation

Author

David E. Winchester, Christopher Austin, Ramil Goel, and Edward D Staples

Subjects
medicine.medical_specialty, Pacemaker, Artificial, business.industry, Prosthesis Implantation, Pneumopericardium, medicine.disease, Pacemaker implantation, Surgery, Medicine, Humans, Cardiology and Cardiovascular Medicine, business, Images in Cardiovascular Medicine
Published
2021

39. The Impact of American College of Cardiology Chest Pain Center Accreditation on Guideline Recommended Acute Myocardial Infarction Management

Author

W Frank, Peacock, Phillip D, Levy, Deborah B, Diercks, Shuang, Li, Tracy Y, Wang, James, McCord, L Kristin, Newby, Anwar, Osborne, Michael, Ross, David E, Winchester, Michael C, Kontos, Steven, Deitelzweig, and Deepak L, Bhatt

Subjects
Chest Pain, Percutaneous Coronary Intervention, Cardiology, Myocardial Infarction, Humans, Pain Clinics, Guideline Adherence, United States, Accreditation
Abstract

Whether American College of Cardiology (ACC) Chest Pain Center (CPC) accreditation alters guidelines adherence rates is unclear.We analyzed patient-level, hospital-reported, quality metrics for myocardial infarction (MI) patients from 644 hospitals collected in the ACC's Chest Pain-MI Registry from January 1, 2019, to December 31, 2020, stratified by CPC accreditation for1 year.Of 192,374 MI patients, 67,462 (35.1%) received care at an accredited hospital. In general, differences in guideline adherence rates between accredited and nonaccredited hospitals were numerically small, although frequently significant. Patients at accredited hospitals were more likely to undergo coronary angiography (98.6% vs. 97.9%, P0.0001), percutaneous coronary intervention for NSTEMI (55.4% vs. 52.3%, P0.0001), have overall revascularization for NSTEMI (63.5% vs. 61.0%, P0.0001), and receive P2Y12 inhibitor on arrival (63.5% vs. 60.2%, P0.0001). Nonaccredited hospitals more ECG within 10 minutes (62.3% vs. 60.4%, P0.0001) and first medical contact to device activation ≤90 minutes (66.8% vs. 64.8%, P0.0001). Accredited hospitals had uniformly higher discharge medication guideline adherence, with patients more likely receiving aspirin (97.8% vs. 97.4%, P0.0001), angiotensin-converting enzyme inhibitor (46.7% vs. 45.3%, P0.0001), beta blocker (96.6% vs. 96.2%, P0.0001), P2Y12 inhibitor (90.3% vs. 89.2%, P0.0001), and statin (97.8% vs. 97.5%, P0.0001). Interaction by accredited status was significant only for length of stay, which was slightly shorter at accredited facilities for specific subgroups.ACC CPC accreditation was associated with small consistent improvement in adherence to guideline-based treatment recommendations of catheter-based care (catheterization and PCI) for NSTEMI and discharge medications, and shorter hospital stays.

Published
2021

40. Implementation of a High-Sensitivity Troponin-I Assay in an Academic Medical Center: A Qualitative and Quantitative Assessment

Author

David E, Winchester, Omkar, Betageri, Patrick, Perche, Brandon, Allen, and Ryan, Theis

Subjects
Hospitalization, Academic Medical Centers, Troponin I, Humans, Emergency Service, Hospital, Biomarkers
Abstract

To describe the clinical impact and lessons learned through implementation of a high sensitivity troponin (hsTn) assay.hsTn assays have received regulatory approval for use in the United States, and healthcare facilities are beginning to adopt these new assays. Questions remain about how to implement them and what effect they may have on demand for cardiovascular services.We conducted a mixed-methods implementation science-based investigation of hsTn adoption at a single academic medical center. We designed the investigation based on the Consolidated Framework for Implementation Research, exploring clinicians' perspectives on intervention characteristics, inner setting, individual characteristics, and process of implementation domains. Focus groups were conducted with clinicians from multiple service lines.Participants reported that the new hsTn assay did not fundamentally change processes of care such as cardiology consultations or inpatient admissions. Implementation was facilitated by leveraging the electronic medical record to provide useful suggestions for hsTn management at the point-of-care. The use of case-based teaching was considered most effective. Areas of ongoing concern included management of high-risk patients, outpatient follow-up, and feasibility of accelerated diagnostic protocols for early discharge from the emergency department. A decrease in the number of hsTn assays ordered was observed; no change was noted for admissions, cardiology consultations, or noninvasive cardiac imaging.A comprehensive educational campaign, based on multidisciplinary collaboration can effectively prepare clinicians for implementation of hsTn. New hsTn assays may not have any substantial effect on acute management of patients with cardiac complaints.

Published
2021

43. Estimates of radiation exposure and subsequent risk of malignancy due to cardiac imaging in the emergency department for evaluation of chest pain: a cohort study

Author

Daniel J Cordiner, Brandon Allen, David E. Winchester, Mohammad Al-Ani, Xiaoming Jia, and Michael R. Marchick

Subjects
Adult, Male, medicine.medical_specialty, Neoplasms, Radiation-Induced, Time Factors, Computed Tomography Angiography, Risk of malignancy, MEDLINE, Coronary Angiography, Radiation Dosage, Chest pain, Risk Assessment, Article, Angina Pectoris, Predictive Value of Tests, Risk Factors, Multidetector Computed Tomography, Humans, Medicine, Cardiac imaging, business.industry, Myocardial Perfusion Imaging, General Medicine, Emergency department, Middle Aged, Radiation Exposure, Predictive value of tests, Emergency medicine, Female, Cardiology Service, Hospital, medicine.symptom, Emergency Service, Hospital, Cardiology and Cardiovascular Medicine, business, Risk assessment, Cohort study
Published
2019
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44. Quality Improvement in Cardiology Practice

Author

David E. Winchester

Subjects
Quality management, Scrutiny, business.industry, MEDLINE, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Balance (accounting), Documentation, Nursing, Health care, Medicine, 030212 general & internal medicine, Prior authorization, Early career, Cardiology and Cardiovascular Medicine, business
Abstract

Early career physicians are finding themselves under scrutiny from payers to demonstrate that they deliver high-quality health care. Physicians are expected to balance this on top of competing pressures from patient care, prior authorization, clinical documentation, and electronic health records

Published
2019
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45. Implementation and Impact of Home-Based Cardiac Rehabilitation in a Veterans Affair Medical Center

Author

Cecil A. Rambarat, David E. Winchester, Ki Park, and Sahil Prasada

Subjects
medicine.medical_specialty, SF-36, medicine.medical_treatment, Myocardial Infarction, 030204 cardiovascular system & hematology, Metabolic equivalent, 03 medical and health sciences, 0302 clinical medicine, medicine, Humans, 030212 general & internal medicine, health care economics and organizations, Veterans, Heart Failure, Cardiac Rehabilitation, Rehabilitation, business.industry, Medical record, Public Health, Environmental and Occupational Health, General Medicine, Institutional review board, Hospitals, Physical therapy, Smoking cessation, business, Nutrition counseling, Psychosocial
Abstract

Introduction In patients with prior myocardial infarction (MI), cardiac rehabilitation (CR) has been shown to reduce all-cause mortality, cardiac mortality, and risk of recurrent MI. Medically supervised cardiac rehab has challenges such as increased patient and center cost, patient transportation issues, patient time commitment, and increased need for resources. Home-based cardiac rehabilitation (HBCR) is an innovative alternative to medically supervised CR which can help to address some of the aforementioned issues. HBCR has been shown to have similar patient outcomes when compared to medically supervised CR; however, implantation efforts and experiences within Veteran Affair (VA) facilities were limited. Thus, we sought to describe our implementation efforts and outcomes of HBCR at our VA medical center, since our VA medical center does not offer an on-site medically supervised CR program. Materials and Methods The project was not reviewed by our institutional review board as this quality improvement project was determined by our VA medical service chief to not qualify as human subjects research. Veterans eligible for CR in our VA medical system were enrolled in a 12-week HBCR program. Veterans performed exercise training at home with equipment provided at no cost. In addition, participating veterans received nutrition counseling, smoking cessation encouragement, stress management, and psychosocial consultation through weekly telephone calls performed by registered nurses. Progress was measured using Life’s Simple 7, Duke Activity status index, 6-minute walk test, and Short Form Health Survey (SF-36) before and after HBCR. Medical records were monitored for death, MI, and readmission to the hospital for CHF within the VA medical system for 1 year after the program was complete. SAS and R were used for data input and analysis. Results Data from 213 veterans were available for analysis and 136 of these veterans completed the HBCR program; the 95 veterans who did not complete the program either declined enrollment, discontinued follow-up with this program, or failed to actively participate and thus were removed from the program. Veterans who completed the 12-week HBCR program reported significant improvement, when compared before and after HBCR program, in Simple 7, Duke Activity status index metabolic equivalent of tasks, 6-minute walk test, SF-36 physical functioning, SF-36 bodily pain, and SF-36 vitality. Overall survival and recurrent MIs were similar between the veterans who completed and the veterans who did not complete the HBCR program in the 1 year follow-up. Hospital admission for heart failure in the 1-year follow-up was lower among veterans who completed the HBCR program when compared to the veterans who did not complete the HBCR program. Conclusions HBCR is an effective alternative to facility-based CR. Veterans who completed the program showed improvement in physical capacity and functional status. Compared to those who were eligible but did not complete the program, hospitalization for heart failure was reduced after completing HBCR.

Published
2019
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46. Prediction of short‐ and long‐term mortality in takotsubo syndrome: the InterTAK Prognostic Score

Author

Thomas Münzel, Yoshio Kobayashi, Wolfgang Koenig, Hugo A. Katus, Paul Bridgman, Christina Chan, Ioana Sorici-Barb, Eduardo Bossone, Gregor Poglajen, Abhiram Prasad, Fabrizio D'Ascenzo, Jelena R. Ghadri, Monika Budnik, Konrad A. Szawan, Fausto J. Pinto, David E. Winchester, Guido Michels, Carlo Di Mario, Thomas Fischer, Matteo Bianco, Jerold S. Shinbane, Burkert Pieske, Alessandro Candreva, Rodolfo Citro, P. Christian Schulze, Annahita Sarcon, Kan Liu, Christian Ukena, Christoph Kaiser, Martin Borggrefe, Florim Cuculi, Stefan Osswald, Behrouz Kherad, Heribert Schunkert, Jeroen J. Bax, Maike Knorr, Ken Kato, Petr Widimský, Alexandra Shilova, Frank Ruschitzka, Martin Kozel, Victoria L. Cammann, Roman Pfister, Olivier Lairez, Michael Neuhaus, Alessandro Cuneo, Wolfgang Rottbauer, Ibrahim Akin, Lucas Jörg, Christian Hauck, L. Christian Napp, Holger Thiele, Manfred Wischnewsky, K.E. Juhani Airaksinen, Hans Rickli, Tuija Vasankari, Carla Paolini, Lars S. Maier, Philippe Meyer, Adrian P. Banning, Richard Kobza, Beatrice Bacchi, Miłosz Jaguszewski, Rafal Dworakowski, Michael Böhm, Claudio Bilato, Mahir Karakas, Philip MacCarthy, Mikhail Gilyarov, Charanjit S. Rihal, Alexander Pott, Claudius Jacobshagen, Clément Delmas, Jose David Arroja, Ibrahim El-Battrawy, Filippo Crea, Carsten Tschöpe, Pedro Carrilho-Ferreira, Ekaterina Gilyarova, Jennifer Franke, Daniel Beug, Ruediger C. Braun-Dullaeus, John D. Horowitz, Thanh H Nguyen, Sebastiano Gili, Christof Burgdorf, Jan Galuszka, Leonarda Galiuto, Grzegorz Opolski, Susanne Heiner, Johann Bauersachs, Christian Templin, Petr Tousek, Michel Noutsias, Lawrence Rajan, Stephan B. Felix, Wolfgang Dichtl, Thomas F. Lüscher, Gerd Hasenfuß, Wischnewsky, Mb, Candreva, A, Bacchi, B, Cammann, Vl, Kato, K, Szawan, Ka, Gili, S, D'Ascenzo, F, Dichtl, W, Citro, R, Bossone, E, Neuhaus, M, Franke, J, Sorici-Barb, I, Jaguszewski, M, Noutsias, M, Knorr, M, Heiner, S, Burgdorf, C, Kherad, B, Tschope, C, Sarcon, A, Shinbane, J, Rajan, L, Michels, G, Pfister, R, Cuneo, A, Jacobshagen, C, Karakas, M, Koenig, W, Pott, A, Meyer, P, Arroja, Jd, Banning, A, Cuculi, F, Kobza, R, Fischer, Ta, Vasankari, T, Airaksinen, Kej, Napp, Lc, Budnik, M, Dworakowski, R, Maccarthy, P, Kaiser, C, Osswald, S, Galiuto, L, Chan, C, Bridgman, P, Beug, D, Delmas, C, Lairez, O, El-Battrawy, I, Akin, I, Gilyarova, E, Shilova, A, Gilyarov, M, Kozel, M, Tousek, P, Winchester, De, Galuszka, J, Ukena, C, Poglajen, G, Carrilho-Ferreira, P, Hauck, C, Paolini, C, Bilato, C, Prasad, A, Rihal, C, Liu, K, Schulze, Pc, Bianco, M, Jorg, L, Rickli, H, Nguyen, Th, Kobayashi, Y, Bohm, M, Maier, L, Pinto, Fj, Widimsky, P, Borggrefe, M, Felix, Sb, Opolski, G, Braun-Dullaeus, Rc, Rottbauer, W, Hasenfuss, G, Pieske, Bm, Schunkert, H, Thiele, H, Bauersachs, J, Katus, Ha, Horowitz, J, Di Mario, C, Munzel, T, Crea, F, Bax, Jj, Luscher, Tf, Ruschitzka, F, Ghadri, Jr, Templin, C, and Repositório da Universidade de Lisboa

Subjects
Male, Research design, medicine.medical_specialty, MEDLINE, 030204 cardiovascular system & hematology, Prognostic score, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, Takotsubo Cardiomyopathy, Internal medicine, medicine, Humans, 030212 general & internal medicine, Survival analysis, Aged, Aged, 80 and over, Takotsubo syndrome, business.industry, Stroke Volume, Stroke volume, Middle Aged, Prognosis, medicine.disease, Survival Analysis, 3. Good health, Research Design, Heart failure, Cardiology, Female, Long term mortality, Cardiology and Cardiovascular Medicine, business
Abstract

© 2019 The Authors European Journal of Heart Failure © 2019 European Society of Cardiology, Recent evidence suggests comparable in‐hospital and long‐term outcomes between takotsubo syndrome (TTS) and acute coronary syndrome. Medical scoring systems are practical tools for decision making and prognostic assessment. However, TTS‐specific scoring systems for risk stratification have not yet been established. Recently, classification based on triggering conditions proved useful in predicting adverse outcomes in TTS (InterTAK Classification).1 Since clinical parameters other than triggering conditions can be associated with adverse outcomes in TTS, such as systolic blood pressure and heart rate, the present study aimed to establish a scoring system combining triggering factors with other important but easily‐ obtainable clinical parameters of daily clinical practice., C.T. has been supported by the H.H. Sheikh Khalifa bin Hamad Al-Thani Research Programme and the Swiss Heart Foundation. L.S.M. was supported by EU HORIZON 2020 (SILICOFCM ID777204). The InterTAK Registry is supported by the Biss Davies Charitable Trust.

Published
2019
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47. Assessing Prognosis of Acute Coronary Syndrome in Recent Clinical Trials: A Systematic Review

Author

Steven H. Yale, David E. Winchester, Carolyn Stalvey, Michael Jansen, Fan Ye, Arthur Lee, Burton V. Silverstein, Matheen Khuddus, and Joseph J. Mazza

Subjects
Male, 030213 general clinical medicine, Acute coronary syndrome, medicine.medical_specialty, Time Factors, Review, Disease, Disease-Free Survival, Angina, 03 medical and health sciences, Sex Factors, 0302 clinical medicine, Internal medicine, medicine, Animals, Humans, ST segment, Myocardial infarction, Acute Coronary Syndrome, Aged, Community and Home Care, business.industry, Mortality rate, General Medicine, Middle Aged, medicine.disease, Survival Rate, Clinical trial, Disease Models, Animal, Heart failure, ST Elevation Myocardial Infarction, Female, business
Abstract

There is no recent comprehensive overview of contemporary clinical trials assessing short and long-term outcomes in patients with acute coronary syndrome (ACS). This paper reviews factors from recent clinical trials that influenced prognosis in patients with ACS. Cochrane and PubMed databases were screened systematically for clinical trials published in the English literature reporting on ACS prognosis. Two authors independently screened titles, abstracts, and full text. Studies meeting inclusion criteria evaluated the impact of modern practice on prognosis. In vitro and animal models studies, conference abstracts, imaging studies, and review articles were excluded. Disagreement in inclusion criteria was resolved by consensus. A large study of 8,859 patients showed no difference in all-cause mortality between 31 days and 2 years in patients with ST segment elevation myocardial infarction (STEMI) compared to those with non-ST segment elevation myocardial infarction (NSTEMI) or stable ischemic heart disease (SIHD). Other studies showed a significant increase in all-cause mortality in patients with STEMI within the first 30 days, with NSTEMI patients exhibiting a higher mortality rate compared to those with SIHD during the 2-year follow-up period. Our review found that women have a poorer short-term prognosis compared to men. Additionally, reports from patients receiving comprehensive and coordinated care showed longer survival rates. In view of the improved prognosis demonstrated for patients suffering from ACS, assessing prognosis in patients represents a formidable task in modern practice. Our review highlights the need for further evidence-based studies evaluating long-term outcomes on diagnostic and treatment strategies.

Published
2019
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48. Use of Cardiac Troponin Testing in the Outpatient Setting

Author

Steven J. Ross, Steve A. Noutong Njapo, Daniel J Cordiner, David E. Winchester, and Nikhil H Shah

Subjects
Male, medicine.medical_specialty, Myocardial Infarction, 01 natural sciences, Electrocardiography, 03 medical and health sciences, 0302 clinical medicine, Troponin T, Outpatients, medicine, Humans, 030212 general & internal medicine, Myocardial infarction, 0101 mathematics, health care economics and organizations, Retrospective Studies, business.industry, Troponin I, 010102 general mathematics, Retrospective cohort study, General Medicine, Emergency department, Middle Aged, medicine.disease, Heart failure, Emergency medicine, Cohort, Female, Myocardial infarction diagnosis, Emergency Service, Hospital, business, Biomarkers, Follow-Up Studies, Kidney disease
Abstract

Objectives Cardiac troponin (cTn) measurement is useful for diagnosing myocardial infarction (MI), particularly in the inpatient setting. A growing body of literature suggests that cTn may be useful for evaluating chronic conditions in the outpatient environment; however, little is known regarding cTn ordering patterns in this setting. We sought to investigate patterns of care and outcomes for patients evaluated with cTn in the outpatient setting. We hypothesized that a majority of outpatient cTn orders would be for the purpose of diagnosing possible MI. Methods We analyzed 228 patients who had outpatient orders for standard-sensitivity troponin T assays placed at our institution between January 1, 2013 and December 18, 2015. Data were divided into two cohorts based on the intended utility of cTn measurement: orders placed to evaluate for possible MI versus orders placed for some other purpose. Results Of the 228 patients, 161 were evaluated for possible MI and 67 for other reasons. Risk factors (hypertension P = 0.32, diabetes mellitus P = 0.41, coronary disease P = 0.38, heart failure P = 0.098, and chronic kidney disease P = 0.70) were similar between the cohorts. In the suspected MI cohort, an electrocardiogram was obtained in only 77% of patients, and only 13.1% were sent to the emergency department (ED) for further evaluation. Within the suspected MI cohort, 10.5% (n = 17) had elevated cTn and the majority of these patients (n = 10) were not sent to the ED. Conclusions The majority of outpatient cTn orders were intended to evaluate for MI, although electrocardiograms were frequently not ordered and few patients were sent for further ED evaluation. Providers should be encouraged to use cTn testing in a manner that minimizes the potential risk to patients with possible MI.

Published
2019
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49. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease

Author

John U. Doherty, Smadar Kort, Roxana Mehran, Paul Schoenhagen, Prem Soman, Gregory J. Dehmer, Thomas M. Bashore, Nicole M. Bhave, Dennis A. Calnon, Blase Carabello, John Conte, Timm Dickfeld, Daniel Edmundowicz, Victor A. Ferrari, Michael E. Hall, Brian Ghoshhajra, Praveen Mehrotra, Tasneem Z. Naqvi, T. Brett Reece, Randall C. Starling, Molly Szerlip, Wendy S. Tzou, John B. Wong, Steven R. Bailey, Alan S. Brown, Stacie L. Daugherty, Larry S. Dean, Milind Y. Desai, Claire S. Duvernoy, Linda D. Gillam, Robert C. Hendel, Christopher M. Kramer, Bruce D. Lindsay, Warren J. Manning, Manesh R. Patel, Ritu Sachdeva, L. Samuel Wann, David E. Winchester, and Michael J. Wolk

Subjects
Pulmonary and Respiratory Medicine, medicine.medical_specialty, Heart disease, business.industry, medicine.disease, Appropriate Use Criteria, Multimodality, Internal medicine, medicine, Cardiology, Surgery, Radiology, Nuclear Medicine and imaging, Cardiac structure, Cardiology and Cardiovascular Medicine, business
Published
2019
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50. Quality Improvement in Cardiovascular Imaging

Author

Rebecca J. Beyth and David E. Winchester

Subjects
medicine.medical_specialty, lcsh:Diseases of the circulatory (Cardiovascular) system, Quality management, business.industry, cardiovascular, General Medicine, graduate medical education, non-invasive imaging, quality improvement, lcsh:RC666-701, Medicine, audit and feedback, business, Intensive care medicine
Abstract

Implementation of quality improvement (QI) activities is growing in health care settings across the world. Within cardiovascular imaging, areas for improvement include consistency of result reporting, greater patient safety through reductions in radiation exposure, and greater efficiency of care delivery by elimination of wasteful practices and elimination of low-value or rarely appropriate testing. QI in health care is often driven through one of several endorsed frameworks, such as Lean, Six Sigma, and the Model for Improvement. Multiple examples of how to teach QI to medical trainees and physicians have been published. In this narrative review, we explore the growth and impact of QI in cardiovascular imaging, providing specific examples of successful projects, barriers to conducting QI, and rewards of persistent effort toward improving care.

Published
2019

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