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Background Guidelines promote shared decision‐making (SDM) for anticoagulation in patients with atrial fibrillation. We recently showed that adding a within‐encounter SDM tool to usual care (UC) increases patient involvement in decision‐making and clinician satisfaction, without affecting encounter length. We aimed to estimate the extent to which use of an SDM tool changed adherence to the decided care plan and clinical safety end points. Methods and Results We conducted a multicenter, encounter‐level, randomized trial assessing the efficacy of UC with versus without an SDM conversation tool for use during the clinical encounter (Anticoagulation Choice) in patients with nonvalvular atrial fibrillation considering starting or reviewing anticoagulation treatment. We conducted a chart and pharmacy review, blinded to randomization status, at 10 months after enrollment to assess primary adherence (proportion of patients who were prescribed an anticoagulant who filled their first prescription) and secondary adherence (estimated using the proportion of days for which treatment was supplied and filled for direct oral anticoagulant, and as time in therapeutic range for warfarin). We also noted any strokes, transient ischemic attacks, major bleeding, or deaths as safety end points. We enrolled 922 evaluable patient encounters (Anticoagulation Choice=463, and UC=459), of which 814 (88%) had pharmacy and clinical follow‐up. We found no differences between arms in either primary adherence (78% of patients in the SDM arm filled their first prescription versus 81% in UC arm) or secondary adherence to anticoagulation (percentage days covered of the direct oral anticoagulant was 74.1% in SDM versus 71.6% in UC; time in therapeutic range for warfarin was 66.6% in SDM versus 64.4% in UC). Safety outcomes, mostly bleeds, occurred in 13% of participants in the SDM arm and 14% in the UC arm. Conclusions In this large, randomized trial comparing UC with a tool to promote SDM against UC alone, we found no significant differences between arms in primary or secondary adherence to anticoagulation or in clinical safety outcomes. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: clinicaltrials.gov. Identifier: NCT02905032.

Microbial induced carbonate precipitation (MICP) has emerged recently as a new approach of green and sustainable soil improvement technique. The main aim of this study was to determine the most suitable temperature for MICP to improve tropical residual soil. The physical and engineering properties of residual soil used in the study were determined through several laboratory experiments. A urease active strain of Sporosarcinapasteurii obtained from American Type Culture Collection (ATCC) was used to trigger the carbonate precipitation. Experimental parameters such as curing temperature, treatment duration and bacteria to cementation reagents ratios were evaluated. The results show that the optimum temperature for MICP treatment of residual soil is 55°C. It was also found that at this optimum temperature, specimens treated with bacteria and cementation reagents in proportion of 2:1 produces the highest strength improvement ratio of 1.27 relative to untreated sample and calcite content of 1.09% after 7-day curing. The shear strength of the treated soil also increases with the increase in treatment durations as the 7 days curing produces higher strength improvement for all the experimental conditions. The specimens cured under the atmospheric temperature recorded the lowest calcite content and hence the lower shear strength improvement ratio. Moreover, the experimental results obtained from this study also can be used as a guide in the future bio-geotechnology researches and lead to further scope in geotechnical applications.

Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, tools – sometimes called conversation aids or decision aids – are prepared by collating, curating, and presenting high quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Here, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.

Key Points Question What factors contribute to cost conversations about anticoagulation treatment between patients with atrial fibrillation and their clinicians, and what outcomes are associated with these conversations? Findings In this cohort study of 830 audiovisual recordings of encounters and participant surveys from a randomized trial comparing atrial fibrillation care with and without a shared decision-making (SDM) tool, cost conversations were associated with the use of an SDM tool, with middle-income patients, and with consultations conducted by female primary care staff clinicians. Cost conversations were associated with patients’ decision-making processes but not final treatment choice. Meaning These findings suggest that SDM tools may inform efforts to promote cost conversations in practice, an important consideration when increasing costs of care are being passed on to patients., This cohort study, a secondary analysis of a randomized clinical trial, assesses factors contributing to cost conversations about care plans between clinicians and patients with atrial fibrillation., Importance How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown. Objective To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations. Design, Setting, and Participants This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019. Main Outcomes and Measures The incidence of and factors associated with cost conversations, and the association of cost conversations with patients’ consideration of treatment cost burden and their choice of anticoagulation. Results A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients’ mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians’ mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent. Conclusions and Relevance Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients’ consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice. Trial Registration ClinicalTrials.gov Identifier: NCT02905032

Background The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the extent of coronary disease. Objectives This study sought to determine whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Methods Baseline SYNTAX scores were retrospectively calculated for BARI-2D patients without prior revascularization (N = 1,550) by angiographic laboratory investigators masked to patient characteristics and outcomes. The primary outcome was major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years. Results A mid/high SYNTAX score (≥23) was associated with a higher risk of major cardiovascular events (hazard ratio: 1.36, confidence interval: 1.07 to 1.75, p = 0.01). Patients in the CABG stratum had significantly higher SYNTAX scores: 36% had mid/high SYNTAX scores compared with 13% in the PCI stratum (p Conclusions Among patients with diabetes and stable ischemic heart disease, higher SYNTAX scores predict higher rates of major cardiovascular events and were associated with more favorable outcomes of revascularization compared with medical therapy among patients suitable for CABG. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes; NCT00006305)

Background— Consumer-reported patient–provider communication (PPC) assessed by Consumer Assessment of Health Plans Survey in ambulatory settings is incorporated as a complementary value metric for patient-centered care of chronic conditions in pay-for-performance programs. In this study, we examine the relationship of PPC with select indicators of patient-centered care in a nationally representative US adult population with established atherosclerotic cardiovascular disease. Methods and Results— The study population consisted of a nationally representative sample of 6810 individuals (aged ≥18 years), representing 18.3 million adults with established atherosclerotic cardiovascular disease (self-reported or International Classification of Diseases, Ninth Edition diagnosis) reporting a usual source of care in the 2010 to 2013 pooled Medical Expenditure Panel Survey cohort. Participants responded to questions from Consumer Assessment of Health Plans Survey that assessed PPC, and we developed a weighted PPC composite score using their responses, categorized as 1 (poor), 2 (average), and 3 (optimal). Outcomes of interest were (1) patient-reported outcomes: 12-item Short Form physical/mental health status, (2) quality of care measures: statin and ASA use, (3) healthcare resource utilization: emergency room visits and hospital stays, and (4) total annual and out-of-pocket healthcare expenditures. Atherosclerotic cardiovascular disease patients reporting poor versus optimal were over 2-fold more likely to report poor outcomes; 52% and 26% more likely to report that they are not on statin and aspirin, respectively, had a significantly greater utilization of health resources (odds ratio≥2 emergency room visit, 1.41 [95% confidence interval, 1.09–1.81]; odds ratio≥2 hospitalization, 1.36 [95% confidence interval, 1.04–1.79]), as well as an estimated $1243 ($127–$2359) higher annual healthcare expenditure. Conclusions— This study reveals a strong relationship between PPC and patient-reported outcomes, utilization of evidence-based therapies, healthcare resource utilization, and expenditures among those with established atherosclerotic cardiovascular disease.

Readmission and length of stay (LOS) are increasingly accepted as quality measures for surgical care. Centers for MedicareMedicaid Services will soon assess penalties for excessive readmissions after coronary artery bypass graft (CABG) surgery and hip and knee replacements.To determine and compare population level changes in LOS and relationship with 30-day readmission over time for patients undergoing CABG and hip and knee replacements. Secondary objective was to determine relationship between LOS and discharge disposition as well as mortality.Observational cohort study of patients undergoing CABG and hip and knee replacements in New York and California. Temporal trends in LOS, discharge disposition, 30-day readmission, and mortality were examined. Generalized linear-mixed models, accounting for hospital clustering, were used to assess differences in outcomes.Patients undergoing CABG and hip and knee replacements in New York and California between 2005 and 2011.Trends in LOS, discharge disposition, 30-day readmission and mortality, and risk-adjusted odds of all-cause 30-day readmission.We identified 206,784, 336,271, and 416,391 patients who underwent CABG, hip, and knee replacements, respectively, in New York State and California between 2005 and 2011. The risks of readmission within 30 days decreased over time in both states. LOS decreased by 1 day after hip and knee surgery and remained unchanged after CABG. Adjusted analysis confirmed these trends. In secondary analyses patients in New York had higher overall odds of 30-day readmission compared with patients in California.We found no evidence of inverse relationship between LOS and readmission over time. In hip and knee replacement there is strong evidence that both LOS and readmission have been reduced simultaneously.

Background: Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospitals, clinicians, and policymakers. Evidence suggests hospital organizational culture is linked to patient outcomes; however, few studies have attempted to change organizational culture in order to improve patient outcomes, and none have addressed mortality for patients with AMI. We seek to address these gaps through a novel longitudinal intervention study, Leadership Saves Lives (LSL). We hypothesize that we will observe: 1) positive shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) increased use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) reduced in-hospital AMI mortality. Methodology and Results: We describe the methodology of LSL, a 3-year intervention study using a concurrent mixed methods design, guided by open systems theory and the AIDED model of diffusion, implemented in a national sample of 10 diverse U.S. hospitals and hospitals in their peer networks. Intervention hospital teams participate in: 1) annual convenings of the 10 hospitals; 2) semiannual workshops at each intervention hospital; and 3) a web-based learning community that includes a discussion board and a repository for resources and tools. We describe features of program design that allow us to promote and measure intervention fidelity, while also allowing for tailoring of the intervention to the unique local context in each hospital. We quantify changes in hospital practices, culture, and mortality through annual surveys of both intervention hospitals in their peer networks. In-person, in-depth interviews and selective observations of key interactions in care for patients with AMI allow us to describe the change process. The intervention began with an annual meting of the 10 intervention hospitals in June 2014. The first wave of survey data collection, hospital-specific workshops and qualitative data collection were completed between September and November 2014. Conclusions: LSL is novel in its use of a prospective longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, its attention to maintaining fidelity of the intervention across diverse hospital settings, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This study adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change, with direct impact on patients with AMI.

Background Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospital leadership, clinicians, and policymakers. Evidence suggests links between hospital organizational culture and hospital performance; however, few studies have attempted to shift organizational culture in order to improve performance, fewer have focused on patient outcomes, and none have addressed mortality for patients with AMI. We sought to address this gap through a novel longitudinal intervention study, Leadership Saves Lives (LSL). Methods This manuscript describes the methodology of LSL, a 2-year intervention study using a concurrent mixed methods design, guided by open systems theory and the Assess, Innovate, Develop, Engage, Devolve (AIDED) model of diffusion, implemented in 10 U.S. hospitals and their peer hospital networks. The intervention has three primary components: 1) annual convenings of the ten intervention hospitals; 2) semiannual workshops with guiding coalitions at each hospital; and 3) continuous remote support across all intervention hospitals through a web-based platform. Primary outcomes include 1) shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) in-hospital AMI mortality. Quantitative data include annual surveys of guiding coalition members in the intervention hospitals and peer network hospitals. Qualitative data include in-person, in-depth interviews with all guiding coalition members and selective observations of key interactions in care for patients with AMI, collected at three time points. Data integration will identify patterns and major themes in change processes across all intervention hospitals over time. Conclusions LSL is novel in its use of a longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This paper adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0218-0) contains supplementary material, which is available to authorized users.

Hospitals have been under increasing scrutiny regarding potentially inappropriate PCI. However, little is known about contemporary patterns of institutional review of PCI appropriateness and the impact of these programs on procedural appropriateness. The TOP PCI study surveyed 500 hospitals

Background.Research has shown less aggressive treatment and poorer control of cardiovascular disease (CVD) risk factors in women than men.Methods.We analyzed sex differences in pharmacotherapy strategies and attainment of goals for hemoglobin A1c (HbA1c), blood pressure (BP), and low density lipoprotein cholesterol (LDL-C) in patients with type 2 diabetes and established coronary artery disease enrolled into the BARI 2D trial.Results.Similar numbers of drugs were prescribed in both women and men. Women were less frequent on metformin or sulfonylurea and more likely to take insulin and to be on higher doses of hydroxymethylglutaryl-CoA reductase inhibitors (statins) than men. After adjusting for baseline differences and treatment prescribed, women were less likely to achieve goals for HbA1c (OR = 0.71, 95% CI 0.57, 0.88) and LDL-C (OR = 0.64, 95% CI 0.53, 0.78). More antihypertensives were prescribed to women, and yet BP ≤ 130/80 mmHg did not differ by sex.Conclusions.Women entering the BARI 2D trial were as aggressively treated with drugs as men. Despite equivalent treatment, women less frequently met targets for HbA1c and LDL-C. Our findings suggest that there may be sex differences in response to drug therapies used to treat diabetes, hypertension, and hyperlipidemia.

Objective: Multiple large population based observational studies have evaluated the association of various ECG changes with long term adverse outcomes demonstrating conflicting results regarding the significance of right bundle branch block (RBBB). Therefore, we conducted a systematic review and meta-analysis to determine the prognostic significance of RBBB in healthy population. Methods: This systematic review follows an a priori established protocol and is reported following the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). We systematically searched EMBASE, Web of Science and Scopus through January 2014. We also consulted with content experts to recommend studies for screening. Reviewers working independently and in duplicate screened all eligible abstracts, selecting randomized trials and prospective cohort studies that described all cause mortality or cardiovascular death in patients with RBBB. We excluded studies that reported unadjusted outcome or unadjusted event rates. For statistical analysis, hazard ratios were considered to approximate risk ratios. The main outcomes of the study are all-cause mortality and cardiovascular mortality. Results: Based on the eligibility, four large cohorts, with total patient count > 100,000 were included in the meta-analysis. Risk of bias was assessed using the Newcastle-Ottawa scale and included studies were deemed to be of high quality. As demonstrated in Figure 1, RBBB was not associated increase in all-cause mortality (RR 1.05; 95% CI 0.89-1.25) or cardiovascular mortality (RR 1.09; 95% CI 0.70-1.69). Conclusion: In asymptomatic healthy patients, RBBB is not associated with poor outcome.

Background: While concerns about the safety and procedural success of radial, as opposed to femoral, access for PCI have largely been abated, the association of radial access with patients’ health status recovery has not been explored. To address this gap in knowledge, we compared the symptoms, physical function and quality of life 1 year after PCI in patients treated with radial, as compared with femoral, access. Methods: This is a 10-center study of PCI, in whom 48 of 139 (35%) interventionalists used both radial and femoral approaches between 2009-2010. A total 2628 patients without prior CABG were interviewed and followed for one year. The previously validated Seattle Angina Questionnaire (SAQ) was used to assess disease-specific health status and the EQ-5D was used to quantify generic quality of life. Clinical characteristics and health status outcomes were compared between 296 radial and 2332 femoral PCI procedures. Results: Radial access was used in 11.2% of patients. No demographic (age, gender, race) or clinical factors (e.g. BMI, smoking, diabetes, hypertension, renal disease or prior cardiac history) were associated with radial use, except for an increased use among those with PAD (10.5% radial vs. 6.8% femoral, p=0.022) but reduced use among those with prior PCI (38.3% vs. 32.1%, p=0.037). There was no difference in health status outcomes based on SAQ angina frequency and quality of life, or the EQ-5D at baseline, 6 months or one year (table). Conclusion: In this multi-center observational registry, there was no association of radial access with long-term health status outcomes. These data suggest that there are no offsetting concerns about patients’ long-term health status benefits to counterbalance the peri-procedural safety benefits of a radial approach.

The use of novel oral anticoagulants (NOACs) such as direct thrombin inhibitors and direct activated Factor X inhibitors in routine clinical practice is not well described. We undertook this study to characterize the adoption and patterns of use of NOACs in a sample of outpatient cardiology

Background: Shared decision-making with decision aids (DA) improves patient knowledge and reduces decisional conflict. The extent to which they do so across sociodemographic subgroups remains unknown. Methods: An encounter-level meta-analysis of five DA randomized trials examined the impact of sociodemographic variables on knowledge transfer and decisional conflict using a generalized linear model stratified by study and adjusted by treatment arm. Results: We analyzed 595 patient-clinician encounters. Significantly higher knowledge transfer with DA occurred in nearly all patient subgroups when compared to usual care (UC). Patients with more formal education tended to have greater knowledge transfer with UC; this was diminished with DA. There was a trend towards improved decisional conflict in all subgroups with the use of DA; overall decisional conflict was low. (see Table) Conclusion: The use of DA compared to UC significantly increases knowledge transfer across diverse subgroups and there is a tendency towards reduced decisional conflict. Differences at baseline, such as knowledge transfer across educational strata, may be mitigated with use of DA. In conclusion, DA are found to be effective across patient subgroups and may represent a novel strategy to lessen disparities.

As we continue to be able to put an increasing number of transistors on a single chip, the answer to the perpetual question of what the best processor we could build with the transistors is remains uncertain. Past work has shown that heterogeneous multiprocessor systems provide benefits in performance and efficiency. This thesis explores heterogeneous systems composed of a traditional sequential processor (CPU) and highly parallel graphics processors (GPU). This thesis presents a tightly-coupled heterogeneous chip multiprocessor architecture for general-purpose non-graphics computation and a limit study exploring the potential benefits of GPU-like cores for accelerating a set of general-purpose workloads. Pangaea is a heterogeneous CMP design for non-rendering workloads that integrates IA32 CPU cores with GMA X4500 GPU cores. Pangaea introduces a resource partitioning of the GPU, where 3D graphics-specific hardware is removed to reduce area or add more processing cores, and a 3-instruction extension to the IA32 ISA that supports fast communication between CPU and GPU by building user-level interrupts on top of existing cache coherency mechanisms. By removing graphics-specific hardware on a 65 nm process, the area saved is equivalent to 9 GPU cores, while the power saved is equivalent to 5 cores. Our FPGA prototype shows thread spawn latency improvements from thousands of clock cycles to 26. A set of non-graphics workloads demonstrate speedups of up to 8.8x. This thesis also presents a limit study, where we measure the limit of algorithm parallelism in the context of a heterogeneous system that can be usefully extracted from a set of general-purpose applications. We measure sensitivity to the sequential performance (register read-after-write latency) of the low-cost parallel cores, and latency and bandwidth of the communication channel between the two cores. Using these measurements, we propose system characteristics that maximize area and power efficiencies. As in previous limit studies, we find a high amount of parallelism. We show, however, that the potential speedup on GPU-like systems is low (2.2x - 12.7x) due to poor sequential performance. Communication latency and bandwidth have comparatively small performance effects (

Background — Although severe chronic kidney disease (CKD) is an independent predictor of mortality among patients with coronary artery disease, the impact of mild CKD on morbidity and mortality has not been fully defined. Methods and Results — Morbidity and mortality for the 3608 patients with multivessel coronary artery disease enrolled in the Bypass Angioplasty Revascularization Investigation randomized trial and registry were compared on the basis of the presence and absence of CKD, defined as a preprocedure serum creatinine level of >1.5 mg/dL. Seventy-six patients had CKD. Patients with renal insufficiency were older and more likely to have a history of diabetes, hypertension, and other comorbidities. Among patients undergoing PTCA, patients with CKD had a greater frequency of in-hospital death and cardiogenic shock ( P P =0.079). Patients with CKD had more cardiac admissions ( P =0.003 and P =0.01). CKD was associated with a higher risk of death at 7 years, both of all causes (relative risk 2.2, P P Conclusions — CKD is associated with an increased risk of recurrent hospitalization, subsequent CABG, and mortality. This increased risk of death is independent of and additive to the risk associated with diabetes.

The ABIM has offered a certification exam in Interventional Cardiology (IC) since 1999, but limited information is available regarding its association with outcomes of patients undergoing percutaneous coronary intervention (PCI). We examined whether PCI outcomes varied by IC certification status.

Shared decision-making with decision aids (DA) improves patient knowledge and reduces decisional conflict. The extent to which they do so across sociodemographic subgroups remains unknown. An encounter-level meta-analysis of five cardiovascular DA randomized trials examined the impact of

OBJECTIVES The study compared the safety and efficacy of ticlopidine with clopidogrel in patients receiving coronary stents. BACKGROUND Stent thrombosis is reduced when ticlopidine is administered with aspirin. Clopidogrel is similar to ticlopidine in chemical structure and function but has fewer side effects; few data are available about its use in stent patients. METHODS We compared 30-day event rates in 500 consecutive coronary stent patients treated with aspirin and clopidogrel (300 mg loading dose immediately prior to stent placement, and 75 mg/day for 14 days) to 827 consecutive stent patients treated with aspirin and ticlopidine (500 mg loading dose and 250 mg twice daily for 14 days). RESULTS Patients treated with clopidogrel had more adverse clinical characteristics including older age, more severe angina, and more frequent infarction within the prior 24 h. Nonetheless, mortality was 0.4% in clopidogrel patients versus 1.1% in ticlopidine patients; nonfatal myocardial infarction occurred in 0% versus 0.5%, stent thrombosis in 0.2% versus 0.7%, bypass surgery or repeat angioplasty in 0.4% versus 0.5%, and any event occurred in 0.8% versus 1.6% of patients, respectively (p = NS). Based on the observed 30-day event rate of 1.6% with ticlopidine, the statistical power of the study was 43% to detect an even rate of 0.5% with clopidogrel, and 75% to detect an event rate with of 4% with clopidogrel, with a p value of 0.05. CONCLUSIONS These data indicate that clopidogrel can be safely substituted for ticlopidine in patients receiving coronary stents.