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In the recent years, there has been a burgeoning interest in Takotsubo syndrome (TTS), which is renowned as a specific form of reversible myocardial dysfunction. Despite the extensive literature available on TTS, clinicians still face several practical challenges associated with the diagnosis and management of this phenomenon. This potentially results in the underdiagnosis and improper management of TTS in clinical practice. The present paper, the first part (part-1) of the consensus report, aims to cover diagnostic and therapeutic challenges associated with TTS along with certain recommendations to combat these challenges.

Takotsubo syndrome (TTS) still remains as an enigmatic phenomenon. In particular, long-term challenges (including clinical recurrence and persistent symptoms) and specific entities in the setting of TTS have been the evolving areas of interest. On the other hand, a significant gap still exists regarding the proper risk-stratification of this phenomenon in the short and long terms. The present paper, the second part (part-2) of the consensus report, aims to discuss less well-known aspects of TTS including specific entities, challenges after recovery and risk-stratification.

Introduction: The COVID-19 pandemic disrupted healthcare delivery and increased cardiovascular morbidity and mortality. This study assesses whether cardiovascular mortality rates in the US have recovered post-pandemic and examines the equity of this recovery across different populations. Methods: We analyzed data from the CDC WONDER database, covering US residents’ mortality from 2018–2023. We focused on cardiovascular diseases, categorized by ischemic heart disease (IHD), heart failure (HF), hypertensive diseases (HTN), and cerebrovascular disease. Age-adjusted mortality rates were calculated for three periods: pre-COVID (2018–2019), during COVID (2020–2021), and post-COVID (2022–2023), stratified by demographic and geographic variables. Results: Cardiovascular age-adjusted mortality rates increased by 5.9% during the pandemic but decreased by 3.4% post-pandemic, resulting in a net increase of 2.4% compared to pre-COVID levels. When compared to pre COVID age-adjusted mortality rates, post COVID IHD mortality age-adjusted mortality rates decreased by 5.0%, while cerebrovascular and HTN age-adjusted mortality rates increased by 5.9% and 28.5%, respectively. Men and younger populations showed higher increases in cardiovascular Age-adjusted mortality rates. Geographic disparities were notable, with significant reductions in cardiovascular mortality in the Northeast and increases in states like Arizona and Oregon. Conclusion: The COVID-19 pandemic led to a surge in cardiovascular mortality, with partial recovery post-pandemic. Significant differences in mortality changes highlight the need for targeted healthcare interventions to address inequities across demographic and geographic groups.

Objective To investigate the use of sodium valproate in England and Wales, including during pregnancy, compared with other antiseizure drug treatments, based on national level electronic health records.Design Quantitative analysis of nationwide linked electronic health records.Setting Individual level, population scale data from NHS England's Secure Data Environment, from the British Heart Foundation Data Science Centre's CVD-COVID-UK/COVID-IMPACT Consortium (for England), and the Secure Anonymised Information Linkage Databank (for Wales), 1 January 2019 to 31 December 2023.Participants 1 200 000 individuals dispensed any selected antiseizure drug treatment (ie, sodium valproate, lamotrigine, levetiracetam, carbamazepine, or topiramate); 304 000 women, aged 15-49 years, dispensed any selected antiseizure drug treatment and 28 400 women, aged 15-49 years, dispensed sodium valproate.Main outcome measures Prevalent (current) and incident (new) uses of sodium valproate and other antiseizure drug treatments before and during the covid-19 pandemic (1 January 2019 to 31 December 2023), grouped by age and sex. Pregnancy rates per 1000 women, aged 15-49 years, who used antiseizure drug treatments, and timing and dose of sodium valproate dispensed during pregnancy. Geographical variation in use of sodium valproate and disease indications (epilepsy and bipolar affective disorder). Trends in deaths related to epilepsy for 2015-22.Results Prevalent use of sodium valproate in women of childbearing potential decreased and use of most other antiseizure drug treatments increased between 2019 and 2023. Incident use of sodium valproate per 100 000 women decreased from seven to five in women aged 15-19 years, from 11 to seven in women aged 20-29 years, and from 14 to seven in women aged 30-39 years between 2019 and 2022. Incident use also decreased in men of the same age but remained at much higher levels (from 53 to 43 in men aged 15-19 years, 59 to 47 in men aged 20-29 years, and 57 to 42 in men aged 30-39 years, per 100 000 men). Pregnancy rates decreased from 6.0 to 5.2 per 1000 women of childbearing potential who were dispensed sodium valproate over the same period. The number of pregnant women who used sodium valproate during pregnancy decreased from 140 in 2019 to 85 in 2023. Epilepsy was the most common indication, followed by bipolar affective disorder (751 and 193 per 1000 women of childbearing potential dispensed sodium valproate, respectively, in 2023). No clear evidence was found that deaths related to epilepsy increased in women aged 15-49 during 2015-22, but a slight increase was found in men aged 15-49 during the later period between April 2018 and December 2022.Conclusions Based on comprehensive national records, changes in the dispensing of antiseizure drug treatments in response to regulatory actions were tracked. Rates for use of sodium valproate by women, including during pregnancy, decreased before and continued to slowly decrease during the covid-19 pandemic. Incident use was also reduced in men but remained at much higher levels than in women. This approach, linking national dispensing data to health records at the individual level, could help monitor changes to medicines affected by regulatory changes, including in specific population groups, such as pregnant individuals, and their potential effect on health outcomes.

Therapeutic Area: ASCVD/CVD in Special Populations Background: The impact of the COVID-19 pandemic on potential racial disparities in ST-segment elevation myocardial infarction (STEMI) treatment is still unclear. We investigated various revascularization methods for STEMI patients, such as percutaneous coronary intervention (PCI), fibrinolytic therapy, and coronary artery bypass grafting (CABG), during the pandemic's initial nine months. Our study compared patients with and without COVID-19 and further stratified the data to assess potential differences based on race. Methods: We identified all patients hospitalized for STEMI in 2020 using the National Inpatient Sample (NIS), identifying those with or without concurrent COVID-19. Logistic and linear regression was used for analyses of associations, with adjustment for potential confounders. Results: After accounting for confounding factors, patients with both STEMI and COVID-19 had lower odds of PCI (aOR 0.73, 95% CI 0.58-0.91) and higher odds of undergoing thrombolytic therapy (aOR 3.23, 95% CI 1.69-6.14). In contrast, the odds of receiving either PCI or thrombolytic therapy were lower (aOR 0.77, 95% CI 0.62-0.96) for these patients compared to those diagnosed with STEMI without COVID-19 (Figure 1). Black and Asian/Pacific Islander patients had significantly lower odds of receiving PCI compared to White patients, with aORs of 0.83 (95% CI 0.58-0.90) and 0.78 (95% CI 0.66-0.90), respectively. Furthermore, Black patients were less likely to undergo coronary artery bypass grafting (CABG) surgery compared to White patients (aOR 0.68, 95% CI 0.53-0.87) (Table 1). Conclusions: Our research uncovered lower revascularization rates for COVID-19 patients with STEMI and identified notable racial disparities affecting Black and Asian/Pacific Islander patients. To foster health equity, it is imperative to implement urgent and targeted measures that address these disparities, such as increasing access to healthcare and fostering a culturally sensitive care environment.

Therapeutic Area: ASCVD/CVD in Special Populations Background: The influence of the COVID-19 pandemic on possible racial disparities in the management and outcomes of acute myocardial infarction (AMI) remains uncertain. We investigated the management and outcomes of AMI patients during the first nine months of the pandemic, comparing cases with and without COVID-19. Methods: We identified all patients hospitalized for AMI in 2020 using the National Inpatient Sample (NIS), identifying those with or without concurrent COVID-19. Logistic and linear regression was used for analyses of associations, with adjustment for potential confounders. Results: Patients with both AMI and COVID-19 experienced higher in-hospital mortality rates (aOR 3.19, 95% CI 2.63-3.88), increased mechanical ventilation usage (aOR 1.90, 95% CI 1.54-2.33), and more frequent hemodialysis (aOR 1.38, 95% CI 1.05-1.89) compared to those without COVID-19 (Figure 1). Black and Asian/Pacific Islander patients faced higher in-hospital mortality than White patients, with aORs of 2.13 (95% CI 1.35-3.59) and 3.41 (95% CI 1.5-8.37), respectively. Furthermore, Black, Hispanic, and Asian/Pacific Islander patients demonstrated higher odds of initiating hemodialysis, with aORs of 5.48 (95% CI 2.13-14.1), 2.99 (95% CI 1.13-7.97), and 7.84 (95% CI 1.55-39.5), respectively, and were less likely to receive PCI for AMI, with aORs of 0.71 (95% CI 0.67-0.74), 0.81 (95% CI 0.77-0.86), and 0.82 (95% CI 0.75-0.90), respectively. Additionally, Black patients were less likely to undergo CABG surgery for AMI (aOR 0.55, 95% CI 0.49-0.61) (Figure 2). Conclusions: Our study revealed increased mortality and complications in COVID-19 patients with AMI, highlighting significant racial disparities. Urgent measures addressing healthcare disparities, such as enhancing access and promoting culturally sensitive care, are needed to improve health equity.

Objectives To compare the annual and period prevalence of modifiable cardiovascular risk factors (MCVRFs) between populations with and without osteoarthritis (OA) in the UK over 25 years.Methods 215 190 patients aged 35 years and over from the UK Clinical Practice Research Datalink GOLD database who were newly diagnosed OA between 1992 and 2017, as well as 1:1 age-matched, sex-matched, practice-matched and index year-matched non-OA individuals, were incorporated. MCVRFs including smoking, hypertension, type 2 diabetes, obesity and dyslipidaemia were defined by Read codes and clinical measurements. The annual and period prevalence and prevalence rate ratios (PRRs) of individual and clustering (≥1, ≥2 and ≥3) MCVRFs were estimated by Poisson regression with multiple imputations for missing values.Results The annual prevalence of MCVRFs increased in the population with OA between 1992 and 2017 and was consistently higher in the population with OA compared with the population without OA between 2004 and 2017. Trends towards increased or stable annual PRRs for individuals and clustering of MCVRFs were observed. A 26-year period prevalence of single and clustering MCVRFs was significantly higher in individuals with OA compared with non-OA individuals. Period PRRs were higher in Southern England, women and increased with age for most MCVRFs except for obesity, which has the higher PRR in the youngest age group.Conclusions A consistently higher long-term prevalence of MCVRFs was observed in individuals with OA compared to those without OA. The higher prevalence of obesity in the youngest age group with OA highlights the need for public health strategies. Further research to understand MCVRF management in OA populations is necessary.

BackgroundThe prevalence of multimorbidity in patients with acute myocardial infarction (AMI) is increasing. It is unclear whether comorbidities cluster into distinct phenogroups and whether are associated with clinical trajectories.MethodsSurvey-weighted analysis of the United States Nationwide Inpatient Sample (NIS) for patients admitted with a primary diagnosis of AMI in 2018. In-hospital outcomes included mortality, stroke, bleeding, and coronary revascularisation. Latent class analysis of 21 chronic conditions was used to identify comorbidity classes. Multivariable logistic and linear regressions were fitted for associations between comorbidity classes and outcomes.ResultsAmong 416,655 AMI admissions included in the analysis, mean (±SD) age was 67 (±13) years, 38% were females, and 76% White ethnicity. Overall, hypertension, coronary heart disease (CHD), dyslipidaemia, and diabetes were common comorbidities, but each of the identified five classes (C) included ≥1 predominant comorbidities defining distinct phenogroups: cancer/coagulopathy/liver disease class (C1); least burdened (C2); CHD/dyslipidaemia (largest/referent group, (C3)); pulmonary/valvular/peripheral vascular disease (C4); diabetes/kidney disease/heart failure class (C5). Odds ratio (95% confidence interval [CI]) for mortality ranged between 2.11 (1.89-2.37) in C2 to 5.57 (4.99-6.21) in C1. For major bleeding, OR for C1 was 4.48 (3.78; 5.31); for acute stroke, ORs ranged between 0.75 (0.60; 0.94) in C2 to 2.76 (2.27; 3.35) in C1; for coronary revascularization, ORs ranged between 0.34 (0.32; 0.36) in C1 to 1.41 (1.30; 1.53) in C4.ConclusionsWe identified distinct comorbidity phenogroups that predicted in-hospital outcomes in patients admitted with AMI. Some conditions overlapped across classes, driven by the high comorbidity burden. Our findings demonstrate the predictive value and potential clinical utility of identifying patients with AMI with specific comorbidity clustering.

In the past few decades, the accelerated improvement in technology has allowed the development of new and effective coronary and structural heart disease interventions. There has been inequitable patient access to these advanced therapies and significant disparities have affected patients from low socioeconomic positions. In the US, these disparities mostly affect women, black and hispanic communities who are overrepresented in low socioeconomic. Other adverse social determinants of health influenced by structural racism have also contributed to these disparities. In this article, we review the literature on disparities in access and use of coronary and structural interventions; delineate the possible reasons underlying these disparities; and highlight potential solutions at the government, healthcare system, community and individual levels.

Abstract Aims The LE index (Length of hospitalization plus number of Emergent visits ≤6 months) predicts 30 day all‐cause readmission or death following hospitalization for heart failure (HF). We combined N‐terminal pro‐B type natriuretic peptide (NT‐proBNP) levels with the LE index to derive and validate the LENT index for risk prediction at the point of care on the day of hospital discharge. Methods and results In this prospective cohort sub‐study of the Patient‐centred Care Transitions in HF clinical trial, we used log‐binomial regression models with LE index and either admission or discharge NT‐proBNP as the predictors and 30 day composite all‐cause readmission or death as the primary outcome. No other variables were added to the model. We used regression coefficients to derive the LENT index and bootstrapping analysis for internal validation. There were 772 patients (mean [SD] age 77.0 [12.4] years, 49.9% female). Each increment in the LE index was associated with a 25% increased risk of the primary outcome (RR 1.25, 95% CI 1.16–1.35; C‐statistic 0.63). Adjusted for the LE index, every 10‐fold increase in admission and discharge NT‐proBNP was associated with a 48% (RR 1.48; 95% CI 1.10, 1.99; C‐statistic 0.64; net reclassification index [NRI] 0.19) and 56% (RR 1.56; 95% CI 1.08, 2.25; C‐statistic 0.64; NRI 0.21) increased risk of the primary outcome, respectively. The predicted probability of the primary outcome increased to a similar extent with incremental LENT, regardless of whether admission or discharge NT‐proBNP level was used. Conclusions The point‐of‐care LENT index predicts 30 day composite all‐cause readmission or death among patients hospitalized with HF, with improved risk reclassification compared with the LE index. The performance of this simple, 3‐variable index ‐ without adjustment for comorbidities ‐ is comparable to complex risk prediction models in HF. Trial Registration: ClinicalTrials.gov Identifier: NCT02112227

BackgroundAtrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent underuse of OACs in AF patients. The objective of this study is to describe nonvalvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the underprescribing of OACs.Methods and findingsWe conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into the following: OAC, aspirin only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia [RRR 0.52 (0.47; 0.59)], liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. Practices located in the East of England were associated with higher risk of prescribing aspirin only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs.ConclusionsThe incidence of NVAF increased between 2009 and 2015, before plateauing. Underprescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity, and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients.

The elderly constitute a major proportion of patients admitted with acute coronary syndrome (ACS) in the US. Due to pre-existing comorbidities, frailty, and increased risk of complications from medical and invasive therapies, management of ACS in the elderly population poses challenges. In patients with ST-elevation MI, urgent revascularization with primary percutaneous coronary intervention remains the standard of care irrespective of age. However, an early invasive approach in elderly patients with non-ST-elevation MI is based on individual evaluation of risks versus benefits. In this review, the authors discuss the unique characteristics of elderly patients presenting with ACS, specific geriatric conditions that need to be considered while making treatment decisions in these situations, and available evidence, current guidelines, and future directions for invasive management of elderly patients with ACS.

BackgroundDeaths in the first year of the Coronavirus Disease 2019 (COVID-19) pandemic in England and Wales were unevenly distributed socioeconomically and geographically. However, the full scale of inequalities may have been underestimated to date, as most measures of excess mortality do not adequately account for varying age profiles of deaths between social groups. We measured years of life lost (YLL) attributable to the pandemic, directly or indirectly, comparing mortality across geographic and socioeconomic groups.Methods and findingsWe used national mortality registers in England and Wales, from 27 December 2014 until 25 December 2020, covering 3,265,937 deaths. YLLs (main outcome) were calculated using 2019 single year sex-specific life tables for England and Wales. Interrupted time-series analyses, with panel time-series models, were used to estimate expected YLL by sex, geographical region, and deprivation quintile between 7 March 2020 and 25 December 2020 by cause: direct deaths (COVID-19 and other respiratory diseases), cardiovascular disease and diabetes, cancer, and other indirect deaths (all other causes). Excess YLL during the pandemic period were calculated by subtracting observed from expected values. Additional analyses focused on excess deaths for region and deprivation strata, by age-group. Between 7 March 2020 and 25 December 2020, there were an estimated 763,550 (95% CI: 696,826 to 830,273) excess YLL in England and Wales, equivalent to a 15% (95% CI: 14 to 16) increase in YLL compared to the equivalent time period in 2019. There was a strong deprivation gradient in all-cause excess YLL, with rates per 100,000 population ranging from 916 (95% CI: 820 to 1,012) for the least deprived quintile to 1,645 (95% CI: 1,472 to 1,819) for the most deprived. The differences in excess YLL between deprivation quintiles were greatest in younger age groups; for all-cause deaths, a mean of 9.1 years per death (95% CI: 8.2 to 10.0) were lost in the least deprived quintile, compared to 10.8 (95% CI: 10.0 to 11.6) in the most deprived; for COVID-19 and other respiratory deaths, a mean of 8.9 years per death (95% CI: 8.7 to 9.1) were lost in the least deprived quintile, compared to 11.2 (95% CI: 11.0 to 11.5) in the most deprived. For all-cause mortality, estimated deaths in the most deprived compared to the most affluent areas were much higher in younger age groups, but similar for those aged 85 or over. There was marked variability in both all-cause and direct excess YLL by region, with the highest rates in the North West. Limitations include the quasi-experimental nature of the research design and the requirement for accurate and timely recording.ConclusionsIn this study, we observed strong socioeconomic and geographical health inequalities in YLL, during the first calendar year of the COVID-19 pandemic. These were in line with long-standing existing inequalities in England and Wales, with the most deprived areas reporting the largest numbers in potential YLL.

BackgroundAsthma is a prevalent chronic respiratory condition and remains a common cause for hospitalization. However, contemporary data on asthma hospitalization rates, comorbidity burden, and in-hospital outcomes are lacking.MethodsSurvey-weighted analysis of hospitalization records with a primary diagnosis of asthma using data from the US National (Nationwide) Inpatient Sample between 2004 and 2017. Outcomes were number of hospitalizations per 100,000 population and in-hospital outcomes including receipt of ventilation, length of stay, and hospital costs. Patient and admission characteristics and comorbidity burden were examined over time. Multivariable logistic and linear regression models were fitted for over-time risks of the outcomes.ResultsAmong 3,098,863 asthma admissions between 2004 and 2017, mean (±SD) age was 29 (±25), 57% females, 36% White, 40% had Medicaid as primary payer. During 2004-2017, asthma hospitalizations declined from 89 to 56 per 100,000 population; length of stay remained overall stable; median (interquartile range IQR) inflation-adjusted hospital costs doubled from $8,446 (9,227) in 2004 to $17,756 (19,434) in 2017. Common comorbidities in patients admitted with asthma were hypertension and diabetes in adults, but gastroesophageal reflux disease, obstructive sleep apnoea, anemia, and obesity in children. Over time, the prevalence of mental illness increased by >50%. Severe asthma (IRR, 2.48; 95%CI: 2.27-2.72) and psychoses (IRR, 1.10; 1.05-1.14) were predictors of prolonged hospitalization. Asian/Pacific Islanders were more likely to receive ventilation (OR: 2.35; 1.73-3.20) than White patients. Hospital costs were significantly higher in females and adults with hypertension (coefficient, 1405.2; 283.1-2527.4) or psychoses (coefficient, 1978.4; 674.9-3282.0).ConclusionsUS asthma hospitalization rates fluctuated in earlier years but declined over time, which may reflect improvements in community care and declining asthma prevalence. Comorbidity burden, including mental illness, increased over time and is associated with in-hospital outcomes. This highlights the changing landscape of asthma admissions which may inform redesigning services to support pre-hospitalization asthma care and help further reduce admissions, particularly among patients with multimorbidity.

Frailty is an established risk factor for adverse outcomes following non-cardiac surgery. The Hospital Frailty Risk Score (HFRS) is a recently described frailty assessment tool that harnesses administrative data and is composed of 109 International Classification of Disease variables. We aimed to examine the incremental prognostic utility of the HFRS in a generalizable surgical population. Using linked administrative databases, a retrospective cohort of patients admitted for non-cardiac surgery between October 1st, 2008 and September 30th, 2019 in Alberta, Canada was created. Our primary outcome was a composite of death, myocardial infarction or cardiac arrest at 30-days. Multivariable logistic regression was undertaken to assess the impact of HFRS on outcomes after adjusting for age, sex, components of the Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI) and peri-operative biomarkers. The final cohort consisted of 712,808 non-cardiac surgeries, of which 55·1% were female and the average age was 53·4 +/- 22·4 years. Using the HFRS, 86.3% were considered low risk, 10·7% were considered intermediate risk and 3·1% were considered high risk for frailty. Intermediate and high HFRS scores were associated with increased risk of the primary outcome with an adjusted odds ratio of 1·61 (95% CI 1·50-1.74) and 1·55 (95% CI 1·38-1·73). Intermediate and high HFRS were also associated with increased adjusted odds of prolonged hospital stay, in-hospital mortality, and 1-year mortality. The HFRS is a minimally onerous frailty assessment tool that can complement perioperative risk stratification in identifying patients at high risk of short- and long-term adverse events.

Introduction. There is increasing evidence supporting the use of intracoronary imaging to optimize the outcomes of percutaneous coronary intervention (PCI). However, there are no studies examining the impact of imaging on PCI outcomes in cases utilising rotational atherectomy (RA-PCI). Our study examines the determinants and outcomes of using intracoronary imaging in RA-PCI cases including 12-month mortality. Methods. Using the British Cardiac Intervention Society database, data were analysed on all RA-PCI procedures in the UK between 2007 and 2014. Descriptive statistics and multivariate logistic regressions were used to examine baseline, procedural, and outcome associations with intravascular imaging. Results. Intracoronary imaging was used in 1,279 out of 8,417 RA-PCI cases (15.2%). Baseline covariates associated with significantly more imaging use were number of stents used, smoking history, previous CABG, pressure wire use, proximal LAD disease, laser use, glycoprotein inhibitor use, cutting balloons, number of restenosis attempted, off-site surgery, and unprotected left main stem (uLMS) PCI. Adjusted rates of in-hospital major adverse cardiac/cerebrovascular events (IH-MACCE), its individual components (death, peri-procedural MI, stroke, and major bleed), or 12-month mortality were not significantly altered by the use of imaging in RA-PCI. However, subgroup analysis demonstrated a signal towards reduction in 12-month mortality in uLMS RA-PCI cases utilising intracoronary imaging (OR 0.67, 95% CI 0.44–1.03). Conclusions. Intracoronary imaging use during RA-PCI is associated with higher risk of baseline and procedural characteristics. There were no differences observed in IH-MACCE or 12-month mortality with intracoronary imaging in RA-PCI.

Objective Most current cardiovascular disease (CVD) risk stratification tools are for people without CVD, but very few are for prevalent CVD. In this study, we developed and validated a CVD severity score in people with coronary heart disease (CHD) and evaluated the association between severity and adverse outcomes.Methods Primary and secondary care data for 213 088 people with CHD in 398 practices in England between 2007 and 2017 were used. The cohort was randomly divided into training and validation datasets (80%/20%) for the severity model. Using 20 clinical severity indicators (each assigned a weight=1), baseline and longitudinal CVD severity scores were calculated as the sum of indicators. Adjusted Cox and competing-risk regression models were used to estimate risks for all-cause and cause-specific hospitalisation and mortality.Results Mean age was 64.5±12.7 years, 46% women, 16% from deprived areas, baseline severity score 1.5±1.2, with higher scores indicating a higher burden of disease. In the training dataset, 138 510 (81%) patients were hospitalised at least once, and 39 944 (23%) patients died. Each 1-unit increase in baseline severity was associated with 41% (95% CI 37% to 45%, area under the receiver operating characteristics (AUROC) curve=0.79) risk for 1 year for all-cause mortality; 59% (95% CI 52% to 67%, AUROC=0.80) for cardiovascular (CV)/diabetes mortality; 27% (95% CI 26% to 28%) for any-cause hospitalisation and 37% (95% CI 36% to 38%) for CV/diabetes hospitalisation. Findings were consistent in the validation dataset.Conclusions Higher CVD severity score is associated with higher risks for any-cause and cause-specific hospital admissions and mortality in people with CHD. Our reproducible score based on routinely collected data can help practitioners better prioritise management of people with CHD in primary care.

Summary: Background: Heart failure is an important public health issue affecting about 1 million people in the UK, but contemporary trends in cause-specific outcomes among different population groups are unknown. Methods: In this retrospective, population-based study, we used the UK Clinical Practice Research Datalink and Hospital Episodes Statistics databases to identify a cohort of patients who had a diagnosis of incident heart failure between Jan 1, 1998, and July 31, 2017. Patients were eligible for inclusion if they were aged 30 years or older with a first code for heart failure in their primary care or hospital record during the study period. We assessed cause-specific admission to hospital (ie, hospitalisation) and mortality, by age, sex, socioeconomic status, and place of diagnosis (ie, hospital vs community diagnosis). We calculated outcome rates separately for the first year (first-year rates) and for the second-year onwards (subsequent-year rates). Patients were followed up until death or study end. This study is registered with Clinical Practice Research Datalink Independent Scientific Advisory Committee, protocol number 18_037R. Findings: We identified 88 416 individuals with incident heart failure over the study period, of whom 43 461 (49%) were female. The mean age was 77·8 years (SD 11·3) and median follow-up was 2·4 years (IQR 0·5 to 5·7). Age-adjusted first-year rates of hospitalisation increased by 28% for all-cause admissions, from 97·1 (95% CI 94·3 to 99·9) to 124·2 (120·9 to 127·5) per 100 person-years; by 28% for heart failure-specific admissions, from 17·2 (16·2 to 18·2) to 22·1 (20·9 to 23·2) per 100 person-years; and by 42% for non-cardiovascular admissions, from 59·2 (57·2 to 61·2) to 83·9 (81·3 to 86·5) per 100 person-years. 167 641 (73%) of 228 113 hospitalisations were for non-cardiovascular causes and annual rate increases were higher for women (3·9%, 95% CI 2·8 to 4·9) than for men (1·4%, 0·6 to 2·1; p

Introduction To investigate if β-adrenoreceptor blocking drug (β-blocker) prescription reduces the risk of knee or hip osteoarthritis, total joint replacement and analgesic prescription.Setting Primary care.Methods and analysis This is a cohort study using data from the Clinical Practice Research Datalink. Two separate analyses will be performed. Study 1 will be on the association between β-blocker prescription and incident knee/hip osteoarthritis. Inclusion criteria will be age ≥40 years. Exposed participants will be those with ≥2 continuous β-blocker prescriptions, and the index date will be the date of the first prescription of β-blocker. Unexposed participants will include up to four controls matched for age, sex, general practice surgery and propensity score for β-blocker prescription. Exclusion criteria will include contraindications to β-blockers, consultations for osteoarthritis or potent analgesic prescription before the index date. Outcomes will be knee osteoarthritis (primary outcome), hip osteoarthritis, knee pain and hip pain. Study 2 will be on the association between β-blocker prescription and total joint replacement and analgesic prescription in people with osteoarthritis. Inclusion criteria will be age ≥40 years, knee or hip osteoarthritis, and index date will be as in study 1. Unexposed participants will be as in study 1, additionally matched for consultation for knee or hip osteoarthritis prior to the index date. Exclusion criteria will include contraindications to β-blockers and osteoarthritis in other joints prior to the index date. Outcomes will be total knee replacement (primary outcome), total hip replacement and new analgesic prescription.Statistical analysis Kaplan-Meier curves will be plotted, and Cox proportional HRs and 95% CIs will be calculated. Stratified analysis will be performed by class of β-blocker, intrinsic sympathomimetic effect and indication(s) for prescription.Ethics and dissemination This study was ethically approved by the Independent Scientific Advisory Committee of the Medicines and Healthcare Authority (Ref 18_227R). The results of this study will be published in peer-reviewed journals and presented at conferences.Summary This prospective cohort study will evaluate the analgesic potential of commonly used drugs for osteoarthritis pain.

BackgroundThere are limited reports outlining the financial cost of treating cardiac implantable electronic device (CIED) infection outside the United States. This study aimed to determine the average treatment cost of CIED infection in a large UK tertiary referral centre and compared costs of different treatment pathways that are recognised in the management of CIED infection (early versus delayed re-implantation).MethodsWe retrospectively analysed cost and length of stay (LOS) data for consecutive patients undergoing infected CIED extraction with cardiac resynchronization therapy (CRT-D [with defibrillator], CRT-P [with pacemaker]), implantable cardioverter-defibrillators (ICDs) and permanent pacemakers (PPMs).ResultsBetween January 2013 and March 2015, complete data was available for 84 patients (18 [21.4%] CRT-D, 24 [28.6%] ICDs and 42 [50.0%] PPMs). When all cases were considered the cost of infection ranged from £5,139 (PPM) to £24,318 (CRT-D). Considering different treatment strategies; 41 (48.8%) underwent CIED extraction and re-implantation during the same admission (early re-implant strategy (ER). 43 (51.2%) underwent extraction, but were then discharged home to be re-admitted for day-case re-implantation (delayed re-implant strategy (DR)). Median LOS was significantly shorter in DR compared to ER (5.0 vs. 18.0 days, pConclusionCIED infections are expensive and associated with significant health-economic burden. When all device types were considered, a DR strategy is associated with reduced LOS without an increased cost penalty.

[This corrects the article DOI: 10.1371/journal.pone.0206611.].

Summary: Background: Since the mid-1990s, excess mortality has increased markedly for adults aged 25–44 years in the north compared with the south of England. We examined the underlying causes of this excess mortality and the contribution of socioeconomic deprivation. Methods: Mortality data from the Office of National Statistics for adults aged 25–44 years were aggregated and compared between England's five most northern versus five most southern government office regions between Jan 1, 1981, and Dec 31, 2016. Poisson regression models, adjusted for age and sex, were used to quantify excess mortality in the north compared with the south by underlying cause of death (accidents, alcohol related, cardiovascular disease and diabetes, drug related, suicide, cancer, and other causes). The role of socioeconomic deprivation, as measured by the 2015 Index of Multiple Deprivation, in explaining the excess and regional variability was also explored. Findings: A mortality divide between the north and south appeared in the mid-1990s and rapidly expanded thereafter for deaths attributed to accidents, alcohol misuse, and drug misuse. In the 2014–16 period, the northern excess was incidence rate ratio (IRR) 1·47 (95% CI 1·39–1·54) for cardiovascular reasons, 2·09 (1·94–2·25) for alcohol misuse, and 1·60 (1·51–1·70) for drug misuse, across both men and women aged 25–44 years. National mortality rates for cardiovascular deaths declined over the study period but a longstanding gap between north and south persisted (from 33·3 [95% CI 31·8–34·8] in 1981 to 15·0 [14·0–15·9] in 2016 in the north vs from 23·5 [22·3–24·8] to 9·9 [9·2–10·5] in the south). Between 2014 and 2016, estimated excess numbers of death in the north versus the south for those aged 25–44 years were 1881 (95% CI 726–2627) for women and 3530 (2216–4511) for men. Socioeconomic deprivation explained up to two-thirds of the excess mortality in the north (IRR for northern effect reduced from 1·15 [95% CI 1·14–1·15; unadjusted] to 1·05 [1·04–1·05; adjusted for Index of Multiple Deprivation]). By 2016, in addition to the persistent north–south gap, mortality rates in London were lower than in all other regions, with IRRs ranging from IRR 1·13 (95% CI 1·12–1·15) for the East England to 1·22 (1·20–1·24) for the North East, even after adjusting for deprivation. Interpretation: Sharp relative rises in deaths from cardiovascular reasons, alcohol misuse and drug misuse in the north compared with the south seem to have created new health divisions between England's regions. This gap might be due to exacerbation of existing social and health inequalities that have been experienced for many years. These divisions might suggest increasing psychological distress, despair, and risk taking among young and middle-aged adults, particularly outside of London. Funding: Medical Research Council and Wellcome Trust.

BackgroundThere is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI.Methods and findingsThis national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0-40.0], 38.2 [27.7-26.8], and 26.6 [25.2-26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; β-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3-2.5) and 1.5-fold (95% CI 1.4-1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population.ConclusionsMultimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes.Trial registrationClinicalTrials.gov NCT03037255.

BACKGROUND:Prior studies have reported inconsistencies in the baseline risk profile, comorbidity burden and their association with clinical outcomes in women compared to men. More importantly, there is limited data around the sex differences and how these have changed over time in contemporary percutaneous coronary intervention (PCI) practice. METHODS AND RESULTS:We used the Nationwide Inpatient Sample to identify all PCI procedures based on ICD-9 procedure codes in the United States between 2004-2014 in adult patients. Descriptive statistics were used to describe sex-based differences in baseline characteristics and comorbidity burden of patients. Multivariable logistic regressions were used to investigate the association between these differences and in-hospital mortality, complications, length of stay and total hospital charges. Among 6,601,526 patients, 66% were men and 33% were women. Women were more likely to be admitted with diagnosis of NSTEMI (non-ST elevation acute myocardial infarction), were on average 5 years older (median age 68 compared to 63) and had higher burden of comorbidity defined by Charlson score ≥3. Women also had higher in-hospital crude mortality (2.0% vs 1.4%) and any complications compared to men (11.1% vs 7.0%). These trends persisted in our adjusted analyses where women had a significant increase in the odds of in-hospital mortality men (OR 1.20 (95% CI 1.16,1.23) and major bleeding (OR 1.81 (95% CI 1.77,1.86). CONCLUSION:In this national unselected contemporary PCI cohort, there are significant sex-based differences in presentation, baseline characteristics and comorbidity burden. These differences do not fully account for the higher in-hospital mortality and procedural complications observed in women.

Contemporary data remains limited regarding mortality and major adverse cardiac events (MACE) outcomes in patients undergoing PCI for different manifestations of coronary artery disease.We evaluated mortality and MACE outcomes in patients treated with PCI for STEMI (ST-elevation myocardial infarction), NSTEMI (non ST-elevation myocardial infarction) and stable angina through analysis of data derived from the Nobori-2 study.Clinical endpoints were cardiac mortality and MACE (a composite of cardiac death, myocardial infarction and target vessel revascularization).1909 patients who underwent PCI were studied; 1332 with stable angina, 248 with STEMI and 329 with NSTEMI. Age-adjusted Charlson co-morbidity index was greatest in the NSTEMI cohort (3.78±1.91) and lowest in the stable angina cohort (3.00±1.69); P