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ImportancePatients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear.ObjectiveTo assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US.Design, Setting, and ParticipantsThis cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain–MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis.Main Outcomes and MeasuresIn-hospital mortality and time-to-reperfusion metrics.ResultsThis study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P P P P P P P P P Conclusions and RelevanceIn this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain–MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.

We sought to derive and validate a model to predict inpatient mortality after veno-arterial extracorporeal life support (VA-ECLS) based on readily available, precannulation clinical data.Refractory cardiogenic shock supported by VA-ECLS is associated with high morbidity and mortality.VA-ECLS cases at our institution from January 2014 through July 2019 were retrospectively reviewed. Exclusion criteria were cannulation: (1) at another institution; (2) for primary surgical indication; or (3) for extracorporeal cardiopulmonary resuscitation. Multivariable logistic regression compared those with and without inpatient mortality. Multiple imputation was performed and optimism-adjusted area under the curve (oAUC) values were computed.VA-ECLS cases from August 2019 through November 2020 were identified as a validation cohort. In the derivation cohort (n = 135), the final model included Lactate (mmol/L), hemoglobin (g/dl; Anemia), Coma (Glasgow Coma Scale [GCS] 8) and resusciTATEd cardiac arrest (LACTATE score; oAUC = 0.760). In the validation cohort (n = 30, LACTATE showed similar predictability [AUC = 0.710]). A simplified (LACT-8) score was derived by dichotomizing lactate (8) and hemoglobin (8) and summing together the number of components for each patient. LACT-8 performed similarly (derivation, oAUC = 0.724; validation, AUC = 0.725). In the derivation cohort, both scores outperformed SAVE (oAUC = 0.568) and SOFA (oAUC = 0.699) scores. A LACT-8 ≥ 3 had a specificity for mortality of 97.9% and 92.9%, in the derivation and validation cohorts, respectively.The LACT-8 score can predict inpatient mortality prior to before cannulation for VA-ECLS. LACT-8 can be implemented utilizing clinical data without the need for an online calculator.

Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common sustained supraventricular arrhythmias. An understanding of gender-related differences in AVNRT epidemiology, diagnosis, treatment, outcome, and complications can help guide a more effective diagnosis and treatment of the condition. The study aimed to perform a review of the available literature regarding all aspects of gender-related differences of AVNRT. We focused on all aspects of gender-related differences regarding AVNRT between men and women. A literature search was performed using Google Scholar, PubMed, Springer, Ovid, and Science Direct. Many investigations have demonstrated that the prevalence of AVNRT exhibited a twofold women-to-men predominance. The potential mechanism behind this difference due to sex hormones and autonomic tone. Despite being more common in women, there is a delay in offering and performing the first-line therapy (catheter ablation) compared to men. There were no significant gender-related discrepancies in patients who underwent ablation therapy for AVNRT, regarding the acute success rate of the procedure, long-term success rate, and recurrence of AVNRT. AVNRT is more common in women due to physiological factors such as sex hormones and autonomic tone. Catheter ablation is equally safe and efficacious in men and women; however, the time between the onset of symptoms and ablation is significantly prolonged in women. It is important for the medical community to be aware of this discrepancy and to strive to eliminate such disparities that are not related to patients' choices.

Background Although risk factors for atrial fibrillation (AF) and atrial flutter (AFL) are known, identifying patients who will develop AF/AFL within the near future remains challenging. We sought to evaluate if the CHA2DS2-VASc risk score (CVRS) can identify hospital readmissions with AF, AFL, or acute cerebrovascular accident (CVA) among hospitalized patients without prior history of AF/AFL. Methods Using the Nationwide Readmission Database, a study cohort included patients without prior AF/AFL or new diagnosis of AF/AFL at the index hospitalization from 2012 to 2014. Patients were stratified based on the CVRS into three groups: Low (CVRS ≤1), Intermediate (CVRS 2–5), and High (CVRS ≥6).The primary outcome of interest was 180-day readmission rate with a primary or secondary diagnosis of AF/AFL. Secondary outcomes of interest were acute CVA and 6-month mortality rate. Results A total of 17,820,640 patients were included in our study. Over a 6-month follow up duration from the index hospitalization, the overall re-admission rate for new onset atrial arrhythmias (AF/AFL) was 3.48% (n = 620,986), acute CVA 0.13% (n = 22,522), and all-cause mortality 0.31% (n = 55,632). When compared to other groups, patients with a higher CVRS were readmitted more frequently for AF/AFL [odds ratio (OR) 2.43; 95% confidence interval (CI) 2.41–2.45, P Conclusion In this large contemporary cohort, a CHADS2VA2SC score ≥ 6 identified patients without known prior atrial arrhythmias at an elevated risk of developing AF/AFL or acute CVA within 6 months of hospitalization.

There is a paucity of data regarding the contemporary changes in the uptake and outcomes of transcatheter mitral valve repair (TMVR) and surgical mitral valve repair/replacement (SMVR).We queried the NIS database (2012-2016) to identify hospitalizations for TMVR and SMVR. We reported the temporal trends for uptake of TMVR and SMVR and their in-hospital outcomes.The analysis included 77,645 hospitalizations: 8760 (11.3%) for TMVR and 68,885 (88.7%) for SMVR. Those undergoing TMVR were older and had a higher prevalence of comorbidities, but shorter length of stay (5.5 ± 8.8 vs. 14.3 ± 13.8, p 0.001) compared with SMVR. There was a marked increase in the number of TMVRs over time (from 420 in 2012 to 3850 in 2016; +917%; PReal world data showed a steady increase in the number of TMVR and SMVR procedures. Overall, TMVR was associated with low in-hospital mortality and complications rates. Despite older age and increased comorbidities, TMVR patients had lower in-hospital mortality and shorter length than their SMVR counterparts.

Background: There is a paucity of data regarding the comparative safety and effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patient...

When patients with implantable cardioverter defibrillators (ICD) develop symptomatic atrial fibrillation (AF), external direct current cardioversion (EDCCV), as well as internal cardioversion using their ICD, are the options available. It is currently unknown which of these two methods are more effective. We compared the effectiveness of EDCCV versus internal cardioversion to terminate AF in patients with a single-coil ICD. This randomized controlled trial (clinicaltrial.gov NCT03164395) enrolled consecutive patients with a single-coil ICD that presented with symptomatic AF of less than 1-year duration. They received either the maximum energy internal shock through the ICD or an EDCCV using transcutaneous pads of 200 J. The primary endpoint was a successful conversion to sinus rhythm after one shock. Crossover was permitted if the first shock was unsuccessful. Thirty-one patients were enrolled in the study, including 16 in the internal ICD cardioversion group. The study included patients with a mean age of 59.5 ± 16.0 years, 41.9% females, median AF duration 1 month (interquartile range 1–3), 45.2% non-ischemic cardiomyopathies, mean EF 28.6 ± 16.0%, and 45.2% biventricular ICD. There were no significant differences in baseline clinical characteristics between the two groups. In the internal cardioversion group, 5/16 patients (31.3%) met the primary endpoint versus 14/15 (93.3%) in the EDCCV group, p

Background: Hemodynamic values from right heart catheterization aid diagnosis and clinical decision-making but may not predict outcomes. Mixed venous oxygen saturation percentage and pulmonary capillary wedge pressure relate to cardiac output and congestion, respectively. We theorized that a novel, simple ratio of these measurements could estimate cardiovascular prognosis. Methods: We queried Veterans Affairs’ databases for clinical, hemodynamic, and outcome data. Using the index right heart catheterization between 2010 and 2016, we calculated the ratio of mixed venous oxygen saturation-to-pulmonary capillary wedge pressure, termed ratio of saturation-to-wedge (RSW). The primary outcome was time to all-cause mortality; secondary outcome was 1-year urgent heart failure presentation. Patients were stratified into quartiles of RSW, Fick cardiac index (CI), thermodilution CI, and pulmonary capillary wedge pressure alone. Kaplan-Meier curves and Cox proportional hazards models related comparators with outcomes. Results: Of 12 019 patients meeting inclusion criteria, 9826 had values to calculate RSW (median 4.00, interquartile range, 2.67–6.05). Kaplan-Meier curves showed early, sustained separation by RSW strata. Cox modeling estimated that increasing RSW by 50% decreases mortality hazard by 19% (estimated hazard ratio, 0.81 [95% CI, 0.79–0.83], P P Conclusions: In a large national database, RSW was superior to conventional right heart catheterization indices at assessing risk of mortality and urgent heart failure presentation. This simple calculation with routine data may contribute to clinical decision-making in this population.

Critical limb ischemia (CLI) represents the most severe form of peripheral artery disease. CLI is a grave diagnosis, associated with significant mortality, up to 20% at 6 months ([1][1]). CLI is also associated with significant morbidity and impairment of quality of life, with reported 6-month

Ventriculoatrial (VA) conduction is a critical component in many arrhythmias, has a diagnostic value in electrophysiology study (EPS), and is implicated in pacemaker-mediated arrhythmias. This study sought to characterize retrograde conduction during EPS and to utilize it as a diagnostic tool in patients without AV block. Patients with intact AV conduction undergoing EPS were included in this study to systematically evaluate baseline VA conduction. If absent, parahisian pacing was used to determine the level of block (nodal or infranodal). Recovery of VA conduction with increased sympathetic activity was assessed with isoproterenol infusion. Baseline characteristics and electrophysiological data were collected and analyzed. Among the 801 patients studied, VA conduction was present in 98% (81% at baseline and 17% after isoproterenol infusion). Parahisian pacing demonstrated that the block was at the AV node level among 150 patients with VA dissociation at baseline. Among patients presenting with supraventricular tachycardia (SVT), 98.7% with atrioventricular nodal reentrant tachycardia (AVNRT) had VA conduction at baseline versus 82.7% presenting with other SVT (atrial fibrillation excluded), P < 0.001. Thus, the absence of VA conduction at baseline during an EPS for SVT carries a negative predictive value (NPV) of 96.9% for AVNRT. VA conduction is present in most patients (98%) with intact AV conduction. The level of VA dissociation when present at baseline is always at the level of the AV node. Patients with SVT presenting for EPS that lacked VA conduction at baseline were unlikely to have AVNRT.

Introduction The outcomes of transfemoral (TF) compared with transapical (TA) access for transcatheter aortic valve replacement (TAVR) in diabetics are unknown. Methods We queried the NIS database (2011–2014) to identify diabetics who underwent TAVR. We performed a propensity matching analysis comparing TF-TAVR versus TA-TAVR. Results The analysis included 14.555 diabetics who underwent TAVR. After matching, in-hospital mortality was not different between TF-TAVR and TA-TAVR. (3.5 vs. 4.4%, p = 0.11). TF-TAVR was associated with lower rates of cardiogenic shock (2.7 vs. 4.7%, p = 0.02), use of mechanical circulatory support (2.0 vs. 2.9%, p = 0.03), acute renal failure (17.8 vs. 26.5%, p

Introduction Little is known about ethnic and gender disparities for transcatheter aortic valve replacement (TAVR) procedures in the United States. Methods We queried the Nationwide Inpatient Sample (NIS) database (2011–2014) to identify patients who underwent TAVR. We described the temporal trends in the uptake of TAVR procedures among various ethnicities and genders. Results Our analysis identified 39,253 records; 20,497 (52.2%) were men and 18,756 (47.8%) were women. Among all TAVRs, 87.2% were Caucasians, 3.9% were African Americans (AA), 3.7% were Hispanics, and 5.2% were of other ethnicities. We found a significant rise in the trend of TAVRs in all groups: in Caucasian men (coefficient = 0.946, p

BACKGROUND Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common type of supraventricular tachycardia (SVT). Similar to other cardiac tests and interventions, gender bias may influence clinical decision making in providing appropriate care for AVNRT patients. We assessed for gender differences in the diagnosis and management of AVNRT patients who underwent catheter ablation. METHODS Patients who underwent catheter ablation for AVNRT were included. We explored the gender difference on various clinical parameters such as the time from SVT symptoms, SVT diagnosis, and first electrophysiology consult to time of catheter ablation. RESULTS Among 140 patients screened, 116 patients met the inclusion criteria, including 67.2% women. Median time from symptoms onset to SVT diagnosis was 18.5 months (interquartile range [IQR] 4.0-58.5) in women versus 4.0 months (0.75-34.7) in men, P = .005. Once SVT was diagnosed, women took a median of 12.5 months (IQR 3.0-57.0) to proceed with ablation versus 3.0 months (1.0-7.0) for men, P ≤ .001. It took a longer time from the first electrophysiology consultation to ablation: 54.5 days (20.75-144.75) for women versus 20.5 days (6.0-46.25) for men, P = .008. Overall, it took 60.0 months (IQR 12.8-132.0) for women to have an ablation from initial symptoms onset versus 15 months (IQR 4.6-48.0) for men, P = .001. Prior to ablation, women had 3.78 ± 3.79 (mean ± SD) emergency department visits for SVT versus men 1.52 ± 1.72 and women tried 1.28 ± 0.82 medications versus men 0.76 ± 0.68, P

Introduction Malignancy is a common cause of morbidity and mortality in the United States and around the world and the second leading cause of death in the United States. There is little data on the impact of metastatic cancer on the risk of hemorrhagic stroke or mortality among patients undergoing fibrinolytic therapy (FT) for acute PE. Methods Using the National Inpatient Sample (NIS) database, we extracted admissions with a primary diagnosis of acute pulmonary embolism that underwent FT from 2010 to 2014. We performed a case control matched analysis between patients with and without metastatic cancer. Our primary outcome of interest was Mortality and our secondary outcome of interest was hemorrhagic stroke (HS). Results Of the 883,183 patients with a primary diagnosis of acute PE between 2010 and 12014, 23,690 patients (2.7%) underwent FT. After exclusion, 22,592 patients were included in the analysis. Of these, 941 patients (4.2%) were reported to have metastatic cancer. There was a higher incidence of cerebrovascular accidents and intubation/mechanical ventilation in the metastatic cancer arm. Mortality was significantly higher in the metastatic cancer arm with no difference in the incidence of HS. In multivariate regression analysis , among all patients that underwent FT for acute PE, metastatic cancer was associated with a significant odds for mortality (OR 1.91, 95% CI 1.11–5.82, p Conclusion The presence of metastatic cancer in patients undergoing fibrinolytic therapy for acute pulmonary embolism is associated with increase mortality.

Surgical ablation procedure is commonly performed in patients with atrial fibrillation (AF) undergoing cardiac surgeries; however, the evidence regarding its impact on in-hospital cardiovascular outcomes is controversial.We queried the Nationwide Inpatient Sample Database for patients with AF who underwent cardiac surgeries from 1998 to 2013. We performed a propensity-score matching including 21 various baseline characteristics to compare those who underwent surgical ablation with those who had not.A total of 47,964 hospitalizations were included in our final analysis. On propensity matching, 23,975 were in the surgical ablation group and 23,990 in the control group. The primary outcome of in-hospital mortality was lower in the surgical ablation group compared with the control group (3.6% versus 4.2%, p 0.001). The surgical ablation group was associated with lower in-hospital cerebrovascular accident (2.0% versus 2.8%, p0.001), cardiogenic shock (2.6% versus 3.6%, p0.001), use of intraaortic balloon pump (5.1% versus 5.8%, p = 0.001), and shorter length of hospital stay (12.3 ± 10.1 versus 12.5 ± 10.3 days, p = 0.008). There was no difference between the surgical ablation and control groups in the incidence of cardiac tamponade (0.4% versus 0.3%, p = 0.296). The surgical ablation group was associated with a higher rate of complete heart block (5.2% versus 4.3%, p0.001) and permanent pacemaker insertion (8.6% versus 8.0%, p = 0.01).In this large analysis of almost 50,000 patients with AF undergoing cardiac surgery, surgical ablation appears to be safe in the short term. Future studies should focus on evaluating the long-term effectiveness of this procedure.

Hemorrhagic stroke (HS) is a feared complication of Fibrinolytic therapy (FT). Risk assessment scores may help in risk stratification to reduce this complication. Patients (admissions) ≥18 years with a primary diagnosis of ST-elevation myocardial infarction (STEMI) who received systemic thrombolysis were extracted from Nationwide Inpatient Sample database and stratified and compared based on CHA2DS2VASC score 0 to 3, 4 to 6, and 7 to 9 as low, intermediate and high risk, respectively. The primary outcomes of interest were HS and mortality. We performed logistic regression analysis with a composite of HS and mortality as the primary end point. Of the 917,307 admissions with a primary diagnosis of STEMI, 39,579 (4.3%) underwent FT. The median score was 3 (interquartile range 1 to 5). The rate of HS significantly increased in the risk category compared with the low and intermediate groups (0.5% and 0.6% vs 4.1%; p

Introduction There is paucity of data on the outcomes of hospitalization for bicuspid aortic valve (BAV)-related aortopathies. Methods We queried the NIS database (2012–2016) for hospitalizations for elective thoracic aortic repair or acute aortic syndrome (AAS) among those with BAV versus trileaflet aortic valve (TAV). Results Our analysis yielded 38,010 hospitalizations for elective aortic repair, of whom 34.4% had BAV, as well as 81,875 hospitalizations for thoracic AAS, of whom 1.1% had BAV. Hospitalizations for BAV were younger and had fewer comorbidities compared with their TAV counterparts. The number of hospitalizations for BAV during the observational period was unchanged. After propensity matching, elective aortic repair for BAV was associated with lower mortality (0.5% versus 1.7%, odds ratio = 0.28; 95% CI 1.5–0.50, p

Background There is a paucity of data on the contemporary outcomes and trends of elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. Methods We queried the National Inpatient Sample (NIS) database years 2012-2016 to identify hospitalizations for elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. The main study outcome was in-hospital mortality. Results The analysis yielded 24,295 hospitalizations for elective thoracic aortic aneurysm repair and 8875 hospitalizations for aneurysm-associated acute aortic syndrome. The number of hospitalizations for elective aortic repair significantly increased from 4375 in 2012 to 5450 in 2016 (Ptrend = .01). The number of hospitalizations for acute aortic syndrome numerically increased from 1545 in 2012 to 2340 in 2016 (Ptrend = .10). Overall in-hospital mortality for elective aortic repair was 2.4% with no change over time. In-hospital mortality for acute aortic rupture was 39.4% and for acute aortic dissection was 6.2% with no change over time. Hospitalizations for elective aortic repair had lower incidence of complications compared with those for aneurysm-associated acute aortic syndrome, including cardiogenic shock, cardiac arrest, acute stroke, and shorter length of stay. Factors associated with higher mortality among admissions undergoing elective aortic repair included older age, heart failure, valvular disease, and chronic kidney disease. Older age, coagulopathy, and fluid/ electrolytes disorders were associated with increased mortality among those with acute aortic syndrome. Conclusion Contemporary elective thoracic aortic aneurysm repair is associated with lower in-hospital mortality and morbidity when compared with a clinical presentation for an aneurysm-associated acute aortic syndrome. This should be taken into account when deciding the timing of elective aortic aneurysm repair and balancing the risks and benefits.

Introduction: There is paucity of data on the outcomes of coronary artery bypass grafting (CABG) among patients presenting with ST-segment elevation myocardial infarction (STEMI). Methods: We queried the National Inpatient Sample database (2002-2016) for patients with STEMI who underwent CABG. We reported the trends in utilization of CABG for STEMI, and the associated in-hospital outcomes. Using multivariable analysis, we compared in-hospital outcomes in patients undergoing CABG on hospitalization day 1 vs. day 2 vs. day ≥3 , in the early (2002 to 2009) and contemporary cohorts (2012 to 2016). Results: Our analysis yielded 2,910,960 patients with STEMI, of whom 7.6% underwent CABG (9.6% in 2002 versus 3.9% in 2016, P trend trend Conclusions: There was a downtrend in performing CABG for STEMI, and an uptrend in in-hospital mortality after CABG. Patients undergoing emergent CABG on day 1 were more likely to have mechanical complications and cardiogenic shock and were associated with higher in-hospital mortality.

BACKGROUND There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) among solid-organ transplant recipients. METHODS Temporal trends in hospitalizations for aortic valve replacement among solid-organ transplant recipients were determined using the National Inpatient Sample database years 2012-2017. Propensity matching was conducted to compare admissions who underwent TAVR versus SAVR. The primary outcome was in-hospital mortality. RESULTS The analysis included 1,730 hospitalizations for isolated AVR; 920 (53.2%) underwent TAVR and 810 (46.7%) underwent SAVR. TAVR was increasingly utilized for solid-organ transplant recipients (Ptrend = 0.01), while there was no change in the number of SAVR procedures (Ptrend = 0.20). The predictors of undergoing TAVR for solid-organ transplant recipients included older age, diabetes, and prior coronary artery bypass surgery, while TAVR was less likely utilized in small-sized hospitals. TAVR was associated with lower in-hospital mortality after matching (0.9 vs. 4.7%, odds ratio [OR] 0.19; 95% confidence interval [CI] 0.11-0.35, p

There is a paucity of data on the outcomes and revascularization strategies for critical limb ischemia (CLI) among patients with chronic kidney disease (CKD). Hence, we conducted a nationwide analysis to evaluate the trends and outcomes of hospitalizations for CLI with CKD. The National Inpatient Sample database (2002–2015) was queried for hospitalizations for CLI. The trends of hospitalizations for CLI with CKD were reported, and endovascular versus surgical revascularization strategies for CLI with CKD were compared. The main study outcome was in-hospital mortality. The analysis included 2,139,640 hospitalizations for CLI, of which 484,224 (22.6%) had CKD. There was an increase in hospitalizations for CLI with CKD (Ptrend = 0.01), but a reduction in hospitalizations for CLI without CKD (Ptrend = 0.01). Patients with CLI and CKD were less likely to undergo revascularization compared with patients without CKD. CLI with CKD had higher rates of in-hospital mortality (4.8% vs 2.5%, adjusted odds ratio (OR) 2.01; 95% CI 1.93–2.11) and major amputation compared with no CKD. Revascularization for CLI with CKD was associated with lower rates of mortality (3.7% vs 5.3%, adjusted-OR 0.78; 95% CI 0.72–0.84) and major amputation compared with no revascularization. Compared with endovascular revascularization, surgical revascularization for CLI with CKD was associated with higher rates of in-hospital mortality (4.7% vs 2.7%, adjusted-OR 1.67; 95% CI 1.43–1.94). In conclusion, this contemporary observational analysis showed an increase in hospitalizations for CLI among patients with CKD. CLI with CKD was associated with higher in-hospital mortality compared with no CKD. Compared with endovascular therapy, surgical revascularization for CLI with CKD was associated with higher in-hospital mortality.

During the ongoing COVID-19 pandemic, national societies have suggested various levels of reliance on fibrinolytic therapy because of anticipated delays in primary percutaneous coronary intervention (PPCI), resource limitations, and hazards to health care workers ([1][1]). Studies examining

Background There is a paucity of data on the trends and outcomes of reoperative coronary artery bypass graft ( CABG ) surgery during the current decade in the United States. Methods and Results We queried the National Inpatient Sample database (2002–2016) for all hospitalizations with isolated CABG procedure. We reported the temporal trends and outcomes of reoperative CABG versus primary CABG procedures. The main outcome was in‐hospital mortality. Among 3 212 768 hospitalizations with CABG , 46 820 (1.5%) had reoperative CABG . Over the 15‐year study period, there were no changes in the proportion of reoperative CABG (1.8% in 2002 versus 2.2% in 2016, P tren =0.08), and the related in‐hospital mortality (3.7% in 2002 versus 2.7% in 2016, P trend =0.97). Reoperative CABG was performed in patients with increasingly higher risk profile. Compared with primary CABG , hospitalizations for reoperative CABG were associated with higher in‐hospital mortality (3.2% versus 1.9%, P CABG , the predictors of higher mortality included history of heart failure and chronic kidney disease. Conclusions In this 15‐year nationwide analysis, reoperative CABG procedures were increasingly performed in patients with higher risk profile. In‐hospital mortality rates were relatively low and did not change during the examined period. Compared with primary CABG , reoperative CABG is associated with higher in‐hospital mortality.

Objectives This study sought to evaluate the trends and outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) among patients with prior mediastinal radiation from a national database. Background There is a paucity of data about the temporal trends and outcomes of TAVR versus SAVR in patients with prior mediastinal radiation. Methods The National Inpatient Sample database years 2012 to 2017 was queried for hospitalizations of patients with prior mediastinal radiation who underwent isolated AVR. Using multivariable analysis, the study compared the outcomes of TAVR versus SAVR. The main study outcome was in-hospital mortality. Results The final analysis included 3,675 hospitalizations for isolated AVR; of whom 2,170 (59.1%) underwent TAVR and 1,505 (40.9%) underwent isolated SAVR. TAVR was increasingly performed over time (ptrend = 0.01), but there was no significant increase in the rates of utilization of SAVR. The following factors were independently associated with TAVR utilization: older age, chronic lung disease, coronary artery disease, chronic kidney disease, prior cerebrovascular accidents, prior coronary artery bypass grafting, and larger-sized hospitals, while women were less likely to undergo TAVR. Compared with SAVR, TAVR was associated with lower in-hospital mortality (1.2% vs. 2.0%, adjusted odds ratio: 0.27; 95% confidence interval: 0.09 to 0.79; p = 0.02). TAVR was associated with lower rates of acute kidney injury, use of mechanical circulatory support, bleeding and respiratory complications, and shorter length of hospital stay. TAVR was associated with higher rates of pacemaker insertion. Conclusions This nationwide observational analysis showed that TAVR is increasingly performed among patients with prior mediastinal radiation. TAVR provides an important treatment option for this difficult patient population with desirable procedural safety when using SAVR as a benchmark.

There is paucity of data regarding the temporal trends and outcomes of coronary atherectomy in the United States.We queried the National Inpatient Sample database (2011-2016) for hospitalizations of patients undergoing coronary atherectomy procedures. We also compared outcomes of non-orbital vs orbital coronary atherectomy in a more contemporary cohort.Our analysis included 2,990,223 hospitalizations with PCI, of which 114,462 (3.8%) included an atherectomy procedure. A significant increase in coronary atherectomy procedures was observed over time (0.66% in 2011 vs 8.9% in 2016; Ptrend=.04). There was an increase in in-hospital mortality associated with atherectomy procedures from 3.2% in 2011 to 4.7% in 2016 (Ptrend=.04), which paralleled the increase in patient comorbidities, use of mechanical circulatory devices (Ptrend.001), and procedural complications. While several predictors of increased mortality after an atherectomy procedure were identified, the use of intravascular ultrasound (IVUS) was associated with lower mortality during atherectomy procedures (adjusted odds ratio [OR] = 0.61; 95% confidence interval [CI], 0.42-0.89), although its overall use was low (10.4%). Compared with other atherectomy procedures, orbital atherectomy was associated with lower in-hospital mortality (3.2% vs 4.7%; adjusted OR = 0.50; 95% CI, 0.30-0.81).Our large national database analysis demonstrates an increase in the number of coronary atherectomy procedures and in their in-hospital mortality and complications over time. Orbital atherectomy appears to be associated with favorable outcomes compared with non-orbital atherectomy, and IVUS use was associated with lower mortality during atherectomy procedures. These associations do not necessarily imply causality and need to be confirmed in future randomized clinical trials.

OBJECTIVE. Atrial fibrillation (AF) is a major risk factor for stroke. The CHA(2)DS(2)-VASc score is used to risk stratify patients, and the score includes known coronary artery disease (CAD) as a variable. The aim of this study was to assess if the presence of incidental coronary artery calcification (CAC), without known CAD, is associated with stroke independent of CHA(2)DS(2)-VASc variables. MATERIALS AND METHODS. A retrospective review of health records was performed for patients who had AF, a chest CT scan performed within 1 year, and a subsequent visit for stroke. Patients with CAD and other vascular disease, a mechanical valve, or who were older than 74 years old were excluded. Included patients were one-to-one matched by age and CHA(2)DS(2)-VASc risk factors to patients who had had similar follow-up but who did not have a stroke. Nongated CT images were reviewed for CAC. Univariate and Cox regression analyses were performed. RESULTS. A total of 203 patients met the study criteria, and 203 matched patients without stroke were identified. Median age was 61 years old with stroke and 62 years old without stroke (p = 0.99). In both groups, 82 (39.0%) were women and the median CHA(2)DS(2)-VASc was 2 (interquartile range, 1–2). Anticoagulation medication was prescribed to 46 (22.7%) patients in the group who had had a stroke and 52 (25.6%) in the group without stroke (p = 0.49). On Cox regression analysis, CAC was associated with stroke (hazard ratio [HR], 1.47; 95% CI, 1.10–1.97; p < 0.01) and mortality (adjusted HR, 1.41; 95% CI, 1.02–1.95; p = 0.04). CONCLUSION. Patients with AF and incidental CAC depicted on chest CT have an increased risk of stroke and mortality beyond established risk factors.

Background Women are undertreated and have worse clinical outcomes than men after acute myocardial infarction. It remains uncertain whether the sex disparities in treatments and outcomes persist in the contemporary era and whether they affect all age groups equally. Methods Using the National Inpatient Sample (NIS) registry, we evaluated 1,260,200 hospitalizations for ST-elevation myocardial infarction (STEMI) between 2010 and 2016, of which 32% were for women. The age-stratified sex differences in care measures and mortality were examined. Stepwise multivariable adjustment models, including baseline comorbidities, hospital characteristics, and reperfusion and revascularization therapies, were used to compare measures and outcomes between women and men across different age subgroups. Results Overall, women with STEMI were older than men and had more comorbidities. Women were less likely to receive fibrinolytic therapy, percutaneous coronary intervention (PCI), and coronary artery bypass surgery across all age subgroups. Women with STEMI overall experienced higher unadjusted in-hospital mortality (11.1% vs 6.8%; adjusted odds ratio [OR] = 1.039, 95% confidence interval [CI]: 1.003-1.077), which persisted after multivariable adjustments. However, when stratified by age, the difference in mortality became non-significant in most age groups after stepwise multivariable adjustment, except among the youngest patients 19-49 years of age with STEMI (women vs men: 3.9% vs 2.6%; adjusted odds ratio = 1.259, 95% confidence interval: 1.083-1.464). Conclusions Women with STEMI were less likely to receive reperfusion and revascularization therapies and had higher in-hospital mortality and complications compared with men. Younger women with STEMI (19-49 years of age) experienced higher in-hospital mortality that persisted after multivariable adjustment.

Background There is paucity of data on racial disparities in the utilization and outcomes of transcatheter mitral valve repair (TMVR). Methods We queried the National inpatient Sample database (2012–2016) for TMVR hospitalizations among Caucasian and African American patients. We conducted a propensity score matching analysis to compare outcomes of Caucasians versus African Americans. The main study outcome was in-hospital mortality. Results Among 7940 TMVR procedures performed, 680 (8.6%) were performed in African Americans. TMVR was increasingly performed for both Caucasians and African Americans (Ptrend = 0.01), although the proportion of African Americans did not change significantly over time (Ptrend = 0.45). Compared to African Americans, Caucasians undergoing TMVR were significantly older (77.7 ± 10.8 vs. 67.2 ± 14.28, p Conclusion This nationwide observational analysis showed a steady increase in number of TMVRs among Caucasians and African Americans. TMVR was performed in a select cohort of African Americans who were significantly younger and more likely to be women compared with Caucasians. Caucasians undergoing TMVR had higher in-hospital mortality compared with African Americans. Further research is needed to explore the reasons behind the racial disparities in the utilization and outcomes of TMVR.

Background There is a paucity of data on the outcomes of acute myocardial infarction in patients with rheumatoid arthritis in the contemporary era. Methods We queried the National Inpatient Sample database (2002–2016) for hospitalizations with acute myocardial infarction. We described the trends and outcomes of acute myocardial infarction-rheumatoid arthritis compared with acute myocardial infarction-no rheumatoid arthritis. Results The analysis included 9,359,546 hospitalizations with acute myocardial infarction, of whom 123,783 (1.3%) had rheumatoid arthritis. There was an increase in the number of hospitalizations with acute myocardial infarction-rheumatoid arthritis (Ptrend Conclusion In this nationwide analysis, we found an increase in hospitalizations for acute myocardial infarction-rheumatoid arthritis. Among patients with acute myocardial infarction, rheumatoid arthritis was independently associated with lower in-hospital mortality, particularly in cases of STEMI.

Atrial fibrillation (AF) can present with non-ST-segment elevation myocardial infarction (NSTEMI). The incidence, characteristics, outcomes, and treatment of this subgroup of patients with AF remains poorly studied. Using data from the National Inpatient Sample database, we (1) compared baseline characteristics of patients with AF with/without NSTEMI, (2) evaluated their outcomes and associated trends over the study period (2004-2013), and (3) evaluated revascularization (by percutaneous coronary intervention or coronary artery bypass graft [CABG]) and the impact on patient outcomes. Of the 3 923 436 patients admitted with a primary diagnosis of AF, 47 785 (1.2%) had a secondary diagnosis of NSTEMI. In this subgroup with AF and NSTEMI, there was a significant trend toward a decrease in mortality ( P = .002), stroke ( P < .001), and gastrointestinal bleeding ( P < .001) during the study period. Compared to unrevascularized patients, revascularized patients were more likely to be younger (72.2 ± 10.2 vs 77.0 ± 11.8 years old, P < .001), male (57.8 vs 42.7%, P < .001), and had a much higher incidence of coronary risk factors. Revascularization was associated with increased survival in multivariable analysis (odds ratio: 0.562, 95% confidence interval: 0.334-0.946, P = .03). In conclusion, among patients admitted with AF, 1.2% were diagnosed with NSTEMI. A minority of patients with AF and NSTEMI underwent revascularization and had better in-hospital outcomes.

Background Sickle cell disease (SCD) is the most common inheritable hematologic disorder in the USA and is associated with ischemic organ diseases. SCD-associated ischemic bowel disease is increasing being recognized, and studies on the hospitalization outcomes of such patients are limited. Objective This study aimed to compare the inpatient outcomes of ischemic bowel disease among patients with SCD compared with patients without SCD. Materials and methods This is a case-control study using data from the National Inpatient Sample Database (2007-2014). We analyzed and compared outcomes between cases (ischemic bowel disease with SCD) and controls (ischemic bowel disease without SCD), matched in a 1 : 5 ratio. The primary outcome was in-hospital mortality, and the secondary outcomes were healthcare resource utilization including mechanical ventilation, hemodialysis, transfusion, length of stay, and hospital charges. Results Of the 194 262 patients admitted with ischemic bowel disease, 98 had a diagnosis of SCD and were matched successfully to the controls. In multivariate analysis, patients with SCD had twice the mortality odds of those without (adjusted odds ratio=2.06, 95% confidence intervals: 1.13-3.74). They were more likely to require mechanical ventilation and blood transfusion, and to be discharged to secondary health facilities [1.68 (1.02-2.76), 3.32 (2.15-5.12), and 1.84 (1.02-3.35)]. Patients with SCD also had a higher frequency of pneumonia, acute respiratory failure, and hemodialysis for acute renal failure. There was no significant difference in the length of stay or the total hospital charge between the two groups. Conclusion In patients hospitalized with ischemic bowel disease, SCD is associated with significantly increased mortality and healthcare burden.

This study sought to evaluate the impact of chronic thrombocytopenia (cTCP) on clinical outcomes after percutaneous coronary intervention (PCI).The impact of cTCP on clinical outcomes after PCI is not well described. Results from single-center observational studies and subgroup analysis of randomized trials have been conflicting and these patients are either excluded or under-represented in randomized controlled trials.Using the 2012 to 2014 National (Nationwide) Inpatient Sample database, the study identified patients who underwent PCI with or without cTCP as a chronic condition variable indicator. Propensity score matching was performed using logistic regression to control for differences in baseline characteristics. The primary outcome of interest was in-hospital mortality. Secondary outcomes of interest included in-hospital post-PCI bleeding events, post-PCI blood and platelet transfusion, vascular complications, ischemic cerebrovascular accidents (CVAs), hemorrhagic CVAs, and length of stay.Propensity matching yielded a cohort of 65,130 patients (32,565 with and without cTCP). Compared with those without cTCP, PCI in patients with cTCP was associated with higher risk for bleeding complications (odds ratio [OR]: 2.40; 95% confidence interval [CI]: 2.05 to 2.72; p 0.0001), requiring blood transfusion (OR: 2.10; 95% CI: 1.80 to 2.24; p 0.0001), requiring platelet transfusion (OR: 11.70; 95% CI: 6.00 to 22.60; p 0.0001), higher risk for vascular complications (OR: 1.94; 95% CI: 1.43 to 2.63; p 0.0001), ischemic CVA (OR: 1.60; 95% CI: 1.20 to 2.10; p = 0.01), and higher in-hospital mortality (OR: 2.30; 95% CI: 1.90 to 2.70; p 0.0001), but without a significant difference in hemorrhagic CVA (OR: 1.50; 95% CI: 0.70 to 3.10; p = 0.27).In this large contemporary cohort, patients with cTCP were at higher risk of a multitude of complications, including higher risk of in-hospital mortality.

Introduction This study compared inpatient outcomes related to the use of these two devices among patients who developed cardiogenic shock not due to acute myocardial infarction or coronary revascularization. Methods We extracted admission-level records of patients with a diagnosis of cardiogenic shock who underwent either PVAD or IABP implantation from the National Inpatient Sample (NIS) database from 2010 to 2014. Our outcomes of interest were mortality and length of stay. Results Inpatient mortality was significantly higher in the PVAD cohort. In multivariate analysis, PVAD use in these patients was associated with higher mortality. There was no difference in the length of stay between both groups among patients that survived to discharge. Conclusion In our analysis of the NIS database, the use of PVADs in patients with cardiogenic shock of non-ischemic origin was associated with higher mortality when compared to IABP use.

Background Ablation is an effective treatment for atrioventricular nodal reentrant tachycardia (AVNRT). The occurrence of junctional ectopic rhythm (JER), including junctional ectopic tachycardia, following AVNRT ablation has been described as an extremely rare phenomenon, but may be underestimated. We aimed to determine the incidence of JER following AVNRT ablation within our institution, as well as that reported in the literature via an extensive review. Methods We reviewed our adult ablation institutional experience for the occurrence of JER after AVNRT ablation from 2009 to 2016. Additionally, we conducted an extensive literature search using different databases looking for AVNRT ablation case series. The individually reported complications of these studies were reviewed, with a primary endpoint defined as the occurrence of JER shortly after AVNRT ablation. The study was approved by our institutional review board. Results Our institutional data revealed 6/126 patients (prevalence 4.8%) developed non-preexisting JER post-AVNRT ablation. Four patients were asymptomatic. Two patients had persistent symptoms lasting over a year, with one patient requiring repeat ablation. The literature review included 149 adult and pediatric studies. There were three cases of reported JER, out of a total of 37,541 patients (31,768 adults and 5,773 pediatric; prevalence 0.008%). The three JER patients were pediatric, and all required further therapeutic intervention. Conclusion JER might be an underreported complication of AVNRT ablation. It seems most often to be transient and self-limited, occurring days to weeks after ablation, but may also be debilitating, requiring more aggressive management.

BACKGROUND Although coronary artery bypass graft surgery (CABG) has been proven to have mortality and morbidity benefits in patients with non-ST elevation myocardial infarction and multivessel disease, the appropriate timing of this procedure remains unclear. Therefore, we proposed a propensity score-matched analysis comparing the clinical outcomes between patients who underwent CABG within the first 48 h of admission (early CABG) and patients who underwent CABG after 48 h of admission (delayed CABG). PATIENTS AND METHODS Using the largest inpatient care database in the USA, the Nationwide Inpatient Sample, we identified patients with a primary diagnosis of acute myocardial infarction using the ICD 9-DM diagnosis codes. We then performed propensity score-matching analysis to control for 24 possible confounders. RESULTS We identified 31 969 patients in the Nationwide Inpatient Sample database with a primary diagnosis of acute myocardial infarction who underwent CABG. The mean age of the cohort was 64.5±11.5 years and 33.4% were female. After performing propensity-matching analysis, we obtained a subset of 1555 patients in each group, with a mean age of 64.7±10.1 years; the male to female ratio was ~4 : 1. The incidence of hemorrhage, shock, and cardiac, pulmonary, and renal complications was comparable between the two groups. The incidence of mortality was not statistically significant between the two groups (2% in the early CABG vs. 1.8% in the delayed CABG, P=0.695). The mortality risk factors were as follows: age more than 70 years [odds ratio (OR): 3.42, 95% confidence interval (CI): 1.85-6.34, P

Von Willebrand Factor (VWF) levels are known to increase with age in the general population, but that effect is unclear in von Willebrand disease (VWD) patients. Thus, it is important to assess the trends of VWF levels with age, and the extent and rate of their normalization in patients with VWD. In a retrospective cohort study, we reviewed the medical records of 126 patients between 1996 and 2016 who met the NHLBI diagnostic criteria for type 1 VWD or "Low VWF" (LVWF). We followed all their historically documented VWF antigen (VWF:Ag), VWF activity (VWF:RCo), and Factor VIII (FVIII) levels longitudinally over time, correlating data with clinical setting at time of testing. The average duration of follow-up was 10.5 ± 3.7 years (SD). Out of the total study population, 27.8% achieved the primary outcome of complete normalization (CN) of both VWF:Ag and VWF:RCo levels, including 19.6% and 32.5% of those with VWD and LVWF, respectively. Linear regression demonstrated statistically significant positive trends of VWF:Ag, VWF:RCo, FVIII with time, calculated at 2.4, 1.4, and 1.4 U dL-1/year, respectively (P

Sickle-cell disease (SCD) affects millions worldwide. Sickle-cell anemia (SCA), the most severe form of this disease, is the most common inherited blood disorder in the United States. There are limited data on the incidence, clinical characteristics, and outcomes of acute myocardial infarction (AMI) in these patients. Using data from the National Inpatient Sample database, we matched cases (AMI with SCA) with controls (AMI without SCA) in a 1:1 ratio for age, gender, race, and year of admission. We compared both groups in terms of clinical characteristics and inpatient outcomes and performed a logistic regression with mortality as the primary outcome. Using weighted samples, we also described trends of SCA in the general population of patients with AMI. Of the 2,386,657 admissions with AMI, SCA was reported in 501 (0.02%) patients, and 495 were successfully matched to controls. Patients with SCA were less likely to have risk factors for coronary artery disease than those without SCA. Patients with SCA were more likely to develop pneumonia, respiratory failure, and acute renal failure, and require mechanical ventilation, hemodialysis for acute renal failure and blood transfusion. In-hospital mortality was significantly higher in patients with SCA. In a multivariate analysis, SCA was an independent predictor of mortality (odds ratio 3.49; 95% confidence interval 1.99 to 6.12; p = .001). In conclusion, myocardial infarction occurs in patients with SCA at a relatively early age. These patients do not typically have the traditional risk factors for the acute coronary syndrome. Mortality in these patients is significantly higher in age-, gender-, and race-matched controls.

The efficacy and safety of glycoprotein IIb/IIIa inhibitors via intracoronary (IC) route versus the intravenous (IV) route are not well known. We conducted this meta-analysis of randomized trials evaluating the role of IC versus IV glycoprotein IIb/IIIa in patients undergoing primary percutaneous coronary intervention. The analysis included 14 trials with a total of 3,754 patients. The primary outcome of major adverse cardiac events (MACE) had no statistically significant difference between the IC and the IV groups (relative risk [RR] 0.74, 95% confidence interval [CI] 0.51 to 1.10). Subgroup analysis showed that short-term MACE (i.e., ≤3 months) was reduced in the IC compared with the IV group; however, long-term MACE (>3 months) was not. IC group was superior in achievement of post-procedural Thrombolysis In Myocardial Infarction 3 flow (RR 1.06, 95% CI 1.01 to 1.11), myocardial blush grade II to III (RR 1.15, 95% CI 1.08 to 1.23), ST-segment resolution rates (RR 1.15, 95% CI 1.03 to 1.29; p = 0.01), and improvement of left ventricular ejection fraction (standardized mean difference = 4.32, 95% CI 0.91 to 7.74). There was a trend for lower stent thrombosis with IC route (RR 0.50, 95% CI 0.24 to 1.03). There was no significant difference between the 2 groups in all-cause mortality, re-infarction, and major bleeding. In conclusion, despite lack of significant difference in overall MACE outcome, IC glycoprotein IIb/IIIa inhibitors may improve short -term MACE, Thrombolysis In Myocardial Infarction 3 flow, myocardial blush grade II- to III rates, ST-segment resolution, and left ventricular ejection fraction compared with the IV route.

Bleeding is a major complication in patients presenting with ST-segment elevation myocardial infarction (STEMI). Several studies suggested that Asians are more susceptible to bleeding when treated with antiplatelets, anticoagulants, and thrombolytic agents. In our study, we aimed to investigate the association between Asian ethnicity and bleeding events in patients who presented with STEMI. We analyzed the Nationwide Inpatient Sample database from 2002 to 2013 and identified patients hospitalized with a primary diagnosis of STEMI. We compared clinical outcomes between patients of Asian and white ethnicity. Primary outcome was inhospital major bleeding defined as a composite of intracranial hemorrhage and blood transfusions for bleeding events. After exclusions, an estimated 1 695 680 white and 46 563 Asian patients with STEMI were included in the analysis. Asian patients had a higher incidence of inhospital major bleeding (3.6% vs 2.2%, P < .001) without a significant difference in inhospital mortality (9.3% vs 8.7%, P = .06). Asian ethnicity was an independent predictor for major bleeding (estimated odds ratio: 1.32; 95% confidence interval: 1.16-1.51; P < .001). This increased risk of bleeding would warrant further investigation of optimal treatment strategies tailored for patients with STEMI of Asian ethnicity.

Background Dormant conduction unmasked by adenosine predicts clinical recurrences of cavotricuspid isthmus (CTI) dependent atrial flutter following catheter ablation. Conventional practice involves a waiting period of 20 to 30 minutes after achievement of a bidirectional line of block (BDB) to monitor for recovery of conduction. Objective Assess whether abolition of dormant conduction with adenosine immediately after CTI ablation and BDB can predict the lack of CTI conduction recovery during the following 30 minutes. Methods Consecutive patients undergoing catheter ablation for CTI-dependent atrial flutter were studied. Following the completion of CTI ablation and documentation of BDB, adenosine (≥12 mg IV) was administered immediately. In cases of dormant conduction, the CTI was ablated again until its abolition. After the achievement of BDB without dormant conduction, spontaneous CTI reconnection during the following 30 minutes and dormant conduction with adenosine at 30 minutes were evaluated. Results A CTI block was achieved in 171 patients. Nine patients (5.3%) had dormant conduction across the CTI immediately after ablation and BDB, and required further ablation. Two patients (1.2%) had subsequent spontaneous time-dependent reconnection within 30 minutes. Two other patients (1.2%) developed late dormant conduction with adenosine at 30 minutes. All 4 patients underwent further ablation. Conclusion A negative adenosine challenge immediately after CTI ablation with bidirectional block, or after abolition of dormant conduction with further ablation, strongly predicted the absence of subsequent spontaneous reconnection within 30 minutes. Based on these results, the conventional waiting period is unnecessary in 97.6% patients without dormant conduction after CTI-dependent flutter ablation.

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have emerged as helpful intravascular imaging tools to guide revascularization decisions during percutaneous coronary intervention (PCI). Studies have demonstrated that intravascular imaging is associated with improved clinical