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Abstract Aims Heart failure (HF) is a clinical syndrome with no definitive diagnostic tests. HF registries are often based on manual reviews of medical records of hospitalized HF patients identified using International Classification of Diseases (ICD) codes. However, most HF patients are not hospitalized, and manual review of big electronic health record (EHR) data is not practical. The US Department of Veterans Affairs (VA) has the largest integrated healthcare system in the nation, and an estimated 1.5 million patients have ICD codes for HF (HF ICD‐code universe) in their VA EHR. The objective of our study was to develop artificial intelligence (AI) models to phenotype HF in these patients. Methods and results The model development cohort (n = 20 000: training, 16 000; validation 2000; testing, 2000) included 10 000 patients with HF and 10 000 without HF who were matched by age, sex, race, inpatient/outpatient status, hospital, and encounter date (within 60 days). HF status was ascertained by manual chart reviews in VA's External Peer Review Program for HF (EPRP‐HF) and non‐HF status was ascertained by the absence of ICD codes for HF in VA EHR. Two clinicians annotated 1000 random snippets with HF‐related keywords and labelled 436 as HF, which was then used to train and test a natural language processing (NLP) model to classify HF (positive predictive value or PPV, 0.81; sensitivity, 0.77). A machine learning (ML) model using linear support vector machine architecture was trained and tested to classify HF using EPRP‐HF as cases (PPV, 0.86; sensitivity, 0.86). From the ‘HF ICD‐code universe’, we randomly selected 200 patients (gold standard cohort) and two clinicians manually adjudicated HF (gold standard HF) in 145 of those patients by chart reviews. We calculated NLP, ML, and NLP + ML scores and used weighted F scores to derive their optimal threshold values for HF classification, which resulted in PPVs of 0.83, 0.77, and 0.85 and sensitivities of 0.86, 0.88, and 0.83, respectively. HF patients classified by the NLP + ML model were characteristically and prognostically similar to those with gold standard HF. All three models performed better than ICD code approaches: one principal hospital discharge diagnosis code for HF (PPV, 0.97; sensitivity, 0.21) or two primary outpatient encounter diagnosis codes for HF (PPV, 0.88; sensitivity, 0.54). Conclusions These findings suggest that NLP and ML models are efficient AI tools to phenotype HF in big EHR data to create contemporary HF registries for clinical studies of effectiveness, quality improvement, and hypothesis generation.

Background Little is known about hospital pricing for coronary artery bypass grafting (CABG). Using new price transparency data, we assessed variation in CABG prices across US hospitals and the association between higher prices and hospital characteristics, including quality of care. Methods and Results Prices for diagnosis related group code 236 were obtained from the Turquoise database and linked by Medicare Facility ID to publicly available hospital characteristics. Univariate and multivariable analyses were performed to assess factors predictive of higher prices. Across 544 hospitals, median commercial and self‐pay rates were 2.01 and 2.64 times the Medicare rate ($57 240 and $75 047, respectively, versus $28 398). Within hospitals, the 90th percentile insurer‐negotiated price was 1.83 times the 10th percentile price. Across hospitals, the 90th percentile commercial rate was 2.91 times the 10th percentile hospital rate. Regional median hospital prices ranged from $35 624 in the East South Central to $84 080 in the Pacific. In univariate analysis, higher inpatient revenue, greater annual discharges, and major teaching status were significantly associated with higher prices. In multivariable analysis, major teaching and investor‐owned status were associated with significantly higher prices (+$8653 and +$12 200, respectively). CABG prices were not related to death, readmissions, patient ratings, or overall Centers for Medicare and Medicaid Services hospital rating. Conclusions There is significant variation in CABG pricing, with certain characteristics associated with higher rates, including major teaching status and investor ownership. Notably, higher CABG prices were not associated with better‐quality care, suggesting a need for further investigation into drivers of pricing variation and the implications for health care spending and access.

Abstract Aims The long‐term outcome in patients with heart failure (HF) after hospitalization may vary substantially depending on their age and left ventricular ejection fraction (LVEF). We aimed to assess the relative rates of cardiovascular death (CVD) and non‐CVD based on the age and how the rates differ under the updated LVEF classification system. Methods and results Consecutively registered hospitalized patients with HF (N = 3558; 39.7% women with a mean age of 73.9 ± 13.3 years) were followed for a median of 2 (interquartile range, 0.8–3.1) years. The CVDs and non‐CVDs were evaluated based on age [young (

Background There is a need to develop electronic health record–based predictive models for worsening heart failure (WHF) events across clinical settings and across the spectrum of left ventricular ejection fraction (LVEF). Methods and Results We studied adults with heart failure (HF) from 2011 to 2019 within an integrated health care delivery system. WHF encounters were ascertained using natural language processing and structured data. We conducted boosted decision tree ensemble models to predict 1‐year hospitalizations, emergency department visits/observation stays, and outpatient encounters for WHF and all‐cause death within each LVEF category: HF with reduced ejection fraction (EF) (LVEF

Abstract Background Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). CoPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. This study describes the conceptualization, creation, capacity-building and dissemination of a CoP sustained over 9 years, and evaluates its value and impact on EBP. Methods In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established within the United States Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. We assessed (formative) the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual level, and its distal impacts (outcomes) at the site level including implementation of new/improved EBPs at the systemwide level. Results The HF Network membership grew steadily over the 9 years. The CoP has involved a total of 1341 multidisciplinary and multilevel members at all 144 VA Health Care Systems (sites). Most members were practising clinicians (n = 891, 66.4%), followed by administrators (n = 342, 25.5%), researchers (n = 70, 5.2%) and others (n = 38, 2.8%). Participation was assessed to be “active” for 70.6% versus “passive” for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership. Conclusions Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Strong evidence shows that these members, particularly those who considered themselves influential in improving quality of care, noted multiple benefits of membership, which included confirmation of their own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programmes. Such CoPs have strong impacts on the quality of care being delivered for both mandated and non-mandated initiatives.

Despite the established role of low-density lipoprotein cholesterol (LDL-C) as a major risk factor for cardiovascular disease (CVD), and the persistence of CVD as the leading cause of morbidity and mortality in the United States, national quality assurance metrics no longer include LDL-C measurement as a required performance metric. This clinical perspective reviews the history of LDL-C as a quality and performance metric and the events that led to its replacement. It also presents patient, healthcare provider, and health system rationales for re-establishing LDL-C measurement as a performance measure to improve cholesterol control in high-risk groups and to stem the rising tide of CVD morbidity and mortality, cardiovascular care disparities, and related healthcare costs.

Background Oral anticoagulation reduces stroke and disability in atrial fibrillation (AF) but is underused. We evaluated the effects of a novel patient‐clinician shared decision‐making (SDM) tool in reducing oral anticoagulation patient's decisional conflict as compared with usual care. Methods and Results We designed and evaluated a new digital decision aid in a multicenter, randomized, comparative effectiveness trial, ENHANCE‐AF (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention). The digital AF shared decision‐making toolkit was developed using patient‐centered design with clear health communication principles (eg, meaningful images, limited text). Available in English and Spanish, the toolkit included the following: (1) a brief animated video; (2) interactive questions with answers; (3) a quiz to check on understanding; (4) a worksheet to be used by the patient during the encounter; and (5) an online guide for clinicians. The study population included English or Spanish speakers with nonvalvular AF and a CHA2DS2‐VASc stroke score ≥1 for men or ≥2 for women. Participants were randomized in a 1:1 ratio to either usual care or the shared decision‐making toolkit. The primary end point was the validated 16‐item Decision Conflict Scale at 1 month. Secondary outcomes included Decision Conflict Scale at 6 months and the 10‐item Decision Regret Scale at 1 and 6 months as well as a weighted average of Mann–Whitney U‐statistics for both the Decision Conflict Scale and the Decision Regret Scale. A total of 1001 participants were enrolled and followed at 5 different sites in the United States between December 18, 2019, and August 17, 2022. The mean patient age was 69±10 years (40% women, 16.9% Black, 4.5% Hispanic, 3.6% Asian), and 50% of participants had CHA2DS2‐VASc scores ≥3 (men) or ≥4 (women). The primary end point at 1 month showed a clinically meaningful reduction in decisional conflict: a 7‐point difference in median scores between the 2 arms (16.4 versus 9.4; Mann–Whitney U‐statistics=0.550; P=0.007). For the secondary end point of 1‐month Decision Regret Scale, the difference in median scores between arms was 5 points in the direction of less decisional regret (P=0.078). The treatment effects lessened over time: at 6 months the difference in medians was 4.7 points for Decision Conflict Scale (P=0.060) and 0 points for Decision Regret Scale (P=0.35). Conclusions Implementation of a novel shared decision‐making toolkit (afibguide.com; afibguide.com/clinician) achieved significantly lower decisional conflict compared with usual care in patients with AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096781.

This study aims to evaluate trends in guideline-directed medical therapy (GDMT) for patients with recent-onset heart failure with reduced ejection fraction (HFrEF) following the onset of the COVID-19 pandemic using an interrupted time series analysis in the Veteran's Affairs Healthcare System. Among 71,428 patients with recent-onset HFrEF between 1/1/2018 and 2/28/2021, we found the pandemic was not associated with differences in treatment rates for beta-blockers, renin-angiotensin-aldosterone system inhibitors, or mineralocorticoid receptor antagonists; there was a 2.6 % absolute decrease (95 % CI: 0.5 %–4.7 %) in ARNI rates in April 2020; which decreased over the pandemic. Despite the changes to healthcare delivery, the COVID-19 pandemic was associated with minimal changes in GDMT rates among patients with recent-onset HFrEF.

Summary: Background: Measuring the quality of care has been central for improving the outcomes of patients undergoing percutaneous coronary intervention (PCI). This study described the performance rates and regional variations in quality metrics for PCI using a representative national Japanese registry. Methods: Overall, 760,854 patients across 714 institutions (2016–2018) were analysed. Quality metrics included preprocedural antiplatelet therapy use, door-to-balloon time ≤90 min for ST-elevation myocardial infarction, transradial approach, and preprocedural noninvasive stress testing for elective cases in 47 Japanese prefectures. Coronary computed tomography angiography (CCTA) and fractional flow reserve (FFR) were also evaluated. Factors associated with preprocedural testing rates were evaluated using multivariable linear regression. Findings: Rates of preprocedural antiplatelet therapy use were high with low variations (96·4% [94·7–97·2%]), but there was still substantial room for improvement in the rates of door-to-balloon time (74·7% [71·2–78·9%]) and transradial approach use (70·9% [65·1–73·4%]). Rates of preprocedural noninvasive stress testing were low with substantial variation (36·6% [27·1–49·7%]). Additionally, we found substantial variations in CCTA (50·0% [39·5–55·1%]) and FFR measurement (15·7% [113·–18·3%]) rates. The number of scintigraphy scanners/ prefecture was associated with the performance of noninvasive stress testing (13·4% [95% CI, 2·45–24·4%] increase for every 1/100,000 population increase in scanners). Interpretations: We observed substantial regional variation in the use of preprocedural testing, and its performance was directly related to nuclear-scanner availability. These findings suggest the need for targeted efforts in improving testing rates, whether by optimising resource allocation or additional education or feedback mechanisms. Funding: This study was funded by the Japan Society for the Promotion of Science (Grant Nos. 20H03915, 16H05215, 16KK0186, and 20K22883) and by the Ministry of Health, Labor and Welfare Grants-in-Aid for Scientific Research Program (Grant No. 21FA1015). The J-PCI registry is led and supported by the Japanese Association of Cardiovascular Intervention and Therapeutics.

Abstract Aims Sodium–glucose co‐transporter (SGLT)‐2 inhibitors have been shown to reduce the risk of cardiovascular death and heart failure (HF) hospitalization in patients with type 2 diabetes mellitus (DM) and high cardiovascular risk in two large clinical outcome trials: empagliflozin in EMPA‐REG OUTCOME and canagliflozin in CANVAS. The scope of eligibility for SGLT‐2 inhibitors (empagliflozin and canagliflozin) among patients with type 2 DM and HF, based on clinical trial criteria and current US Food and Drug Administration (FDA) labelling criteria, remains unknown. Methods and results Using data from the US Get With The Guidelines (GWTG)—Heart Failure registry, we evaluated the proportion of patients with DM and HF eligible for SGLT‐2 inhibitor therapy based on the clinical trial criteria and the US FDA labelling criteria. The GWTG‐HF registry is a quality improvement registry of patients admitted in hospital with HF in the USA. We included GWTG‐HF registry participants meeting eligibility criteria hospitalized between August 2014 and 30 June 2017 from sites fully participating in the registry. The initial inclusion time point reflects when both drugs had FDA approval. Among the 139 317 patients (out of 407 317) with DM hospitalized with HF (in 460 hospitals; 2014 to 2017), the median age was 71 years, 47% (n = 65 685) were female, and 43% (n = 59 973) had HF with reduced ejection fraction. Overall, 43% (n = 59 943) were eligible for the EMPA‐REG OUTCOME trial, 45% (n = 62 818) were eligible for the CANVAS trial, and 34% (n = 47 747) of patients were eligible for either SGLT‐2 inhibitors based on the FDA labelling criteria. Among the FDA‐eligible patients, 91.5% (n = 43 708) were eligible for either the EMPA‐REG OUTCOME trial or the CANVAS trial. Patients who were FDA eligible, compared with those who were not, were younger (70.0 vs. 72.0 years of age), more likely to be male (57.7 vs. 50.3%), and had less burden of co‐morbidities. Conclusions The majority of patients with DM who are hospitalized with HF are not eligible for SGLT‐2 inhibitor therapies. Ongoing studies evaluating the safety and efficacy of SGLT‐2 inhibitors among patients with HF may potentially broaden the population that may benefit from these therapies.

Background Reduced time in international normalized ratio therapeutic range (TTR) limits warfarin safety and effectiveness. In patients switched from warfarin to direct oral anticoagulants (DOACs), patient factors associated with low TTR could also increase risk of DOAC nonadherence. We investigated the relationship between warfarin TTR and DOAC adherence in warfarin‐treated patients with atrial fibrillation switched to DOAC. Methods and Results Using data from the Veterans Health Administration, we identified patients with atrial fibrillation switched from warfarin to DOAC (switchers) or treated with warfarin alone (non‐switchers). Logistic regression was used to evaluate association between warfarin TTR and DOAC adherence. We analyzed 128 605 patients (age, 71±9; 1.6% women; CHA2DS2‐VASc 3.5±1.6); 32 377 switchers and 96 228 non‐switchers. In 8016 switchers with international normalized ratio data to calculate 180‐day TTR before switch, TTR was low (median 0.45; IQR, 0.26–0.64). Patients with TTR

Background: We established an IV outpatient diuresis (IVOiD) clinic and conducted a quality improvement project to evaluate safety, effectiveness and costs associated with outpatient versus inpatient diuresis for patients presenting with acute decompensated heart failure (ADHF) to the emergency department (ED). Methods: Patients who were clinically diagnosed with ADHF in the ED, but did not have high-risk features, were either diuresed in the hospital or in the outpatient IVOiD clinic. The dose of IV diuretic was based on their home maintenance diuretic dose. The outcomes measured were the effects of diuresis (urine output, weight, hemodynamic and laboratory abnormalities), 30–90 day readmissions, 30–90 day death and costs. Results: In total, 36 patients (22 inpatients and 14 outpatients) were studied. There were no significant differences in the baseline demographics between groups. The average inpatient stay was six days and the average IVOiD clinic days were 1.2. There was no significant difference in diuresis per day of treatment (1159 vs. 944 ml, p = 0.46). There was no significant difference in adverse outcomes, 30–90 day readmissions or 30–90 day deaths. There was a significantly lower cost in the IVOiD group compared to the inpatient group ($839.4 vs. $9895.7, p=

Background Sacubitril/Valsartan has been highly efficacious in randomized trials of heart failure with reduced ejection fraction (HFrEF). However, the effectiveness of sacubitril/valsartan in older patients hospitalized for HFrEF in real‐world US practice is unclear. Methods and Results This study included Medicare beneficiaries age ≥65 years who were hospitalized for HFrEF ≤40% in the Get With The Guidelines–Heart Failure registry between October 2015 and December 2018, and eligible for sacubitril/valsartan. Associations between discharge prescription of sacubitril/valsartan and clinical outcomes were assessed after inverse probability of treatment weighting and adjustment for other HFrEF medications. Overall, 1551 (10.9%) patients were discharged on sacubitril/valsartan. Of those not prescribed sacubitril/valsartan, 7857 (62.0%) were prescribed an angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker. Over 12‐month follow‐up, compared with a discharge prescription of angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker, sacubitril/valsartan was independently associated with lower all‐cause mortality (adjusted hazard ratio [HR], 0.82; 95% CI, 0.72–0.94; P=0.004) but not all‐cause hospitalization (adjusted HR, 0.97; 95% CI, 0.89–1.07; P=0.55) or heart failure hospitalization (adjusted HR, 1.04; 95% CI, 0.91–1.18; P=0.59). Patients prescribed sacubitril/valsartan versus those without a prescription had lower risk of all‐cause mortality (adjusted HR, 0.69; 95% CI, 0.60–0.79; P

Background Acute kidney injury (AKI) is a common complication of percutaneous coronary intervention. This risk can be minimized with reduction of contrast volume via preprocedural risk assessment. We aimed to identify quality gaps for implementing the available risk scores introduced to facilitate more judicious use of contrast volume. Methods and Results We grouped 14 702 patients who underwent percutaneous coronary intervention according to the calculated NCDR (National Cardiovascular Data Registry) AKI risk score quartiles (Q1 [lowest]–Q4 [highest]). We compared the used contrast volume by the baseline renal function and NCDR AKI risk score quartiles. Factors associated with increased contrast volume usage were determined using multivariable linear regression analysis. The overall incidence of AKI was 8.9%. The used contrast volume decreased in relation to the stages of chronic kidney disease (168 mL [SD, 73.8 mL], 161 mL [SD, 75.0 mL], 140 mL [SD, 70.0 mL], and 120 mL [SD, 73.7 mL] for no, mild, moderate, and severe chronic kidney disease, respectively; P

Background: Novel structural heart procedures offer life-saving treatment advantages, yet little is known about pre-procedural barriers to care by race/ethnicity. Methods: All echocardiograms performed at a Veterans Affairs hospital from 2015 to 2019 were reviewed to identify patients with severe aortic stenosis and their access to transcatheter aortic valve replacement (TAVR) by race/ethnicity. Results: From 19,403 echocardiograms, 355 individuals were identified to have severe aortic stenosis (72.6% White, 9.8% Hispanic, 3.9% Black). There was a non-significant trend towards increased TAVR treatment among White compared to non-White patients (OR 2.02, CI 0.96–4.24, p = 0.063), which attenuated after adjustment for age and comorbidities. Reasons for not undergoing replacement included poor procedural candidacy (25.3%), loss of follow-up (17.8%), and patient refusal (16.4%). Conclusions: Racial/ethnic inequities were not detected in novel structural heart treatment within the VA. However, a high proportion of eligible patients did not receive procedural treatment due to patient refusal or loss of follow-up, highlighting barriers that require further study.

Background The aim of this study was to determine whether frailty is associated with increased admission and mortality risk in the setting of heart failure. Methods and Results This retrospective cohort analysis included patients treated within the Veterans Affairs Health System who had International Classification of Diseases, Ninth Revision (ICD‐9) codes for heart failure on 2 or more dates over a 2‐year period. The clinical variables identifiable in claims data, such as demographic variables and markers of physical and cognitive dysfunction, were used to identify patients meeting the frailty phenotype. Of 388 785 extracted patients with coding of heart failure between 2015 and 2018, 163 085 patients (41.9%) with ejection fraction (EF) measurement were included in the present analysis (38.3% with reduced EF and 61.7% with preserved EF). There were 16 660 patients (10.2%) who were identified as frail (9.1% in heart failure with reduced EF and 10.9% in heart failure with preserved EF). Frail patients were older, more often depressed, and were likely to have been admitted in the previous year. One‐year all‐cause mortality rate was 9.7% and 28.1%, and admission rate was 58.1% and 79.5% for nonfrail and frail patients, respectively. Frailty was associated with mortality and admission risk compared with the nonfrail group (adjusted odds ratio [OR], 1.71; 95% CI, 1.65–1.77 for mortality; adjusted OR, 1.29; 95% CI, 1.24–1.34 for admission) independent of EF. Conclusions Frailty based on diagnostic coding was associated with particularly higher risk of mortality despite adjustment for known clinical variables. Our findings underscore the importance of nontraditional parameters in the prognostic assessment.

Background Risk prediction for hospitalised heart failure (HF, HHF) patients remains suboptimal. We aimed to determine the prognostic value of hospital food intake (FI) immediately before discharge among HHF patients.Method We analysed the data of 255 HHF patients extracted from the records of a single university hospital. The FI percentage of the three meals the day before hospital discharge was averaged. Patients were stratified into adequate FI (100% consumption) and inadequate FI (less than 100% consumption) groups. The primary outcome was the composite of all-cause mortality and/or HF readmission within 1 year.Results Only 49.3% of HHF patients consumed 100% of their meals. Patients with inadequate FI were older; predominantly women; and had a lower body mass index, higher brain natriuretic peptide levels and Clinical Frailty Scale scores at discharge than those with adequate FI. Inadequate FI was significantly associated with adverse outcomes after adjustments (HR 2.00; 95% CI 1.09 to 3.67; p=0.026). The effect of interaction by ejection fraction (EF) was highly significant: HF with preserved EF (≥40%) was significantly associated with inadequate FI with adverse outcomes (HR 4.95; 95% CI 1.71 to 14.36; p=0.003) but HF with reduced EF (

Background There are conflicting data regarding the benefit of primary prevention implantable cardioverter‐defibrillators (ICDs) in patients with diabetes mellitus and heart failure (HF) with reduced ejection fraction. We aimed to assess the comparative effectiveness of ICD placement in patients with diabetes mellitus and HF with reduced ejection fraction. Methods and Results Data were obtained from the Get With the Guidelines–Health Failure registry, linked with claims from the Centers for Medicare & Medicaid Services. We used a Cox proportional hazards model censored at 5 years with propensity score matching. Of the 17 186 patients with HF with reduced ejection fraction from the Centers for Medicare & Medicaid Services claims database (6540 with diabetes mellitus; 38%), 1677 (646 with diabetes mellitus; 39%) received an ICD during their index HF hospitalization or were prescribed an ICD at discharge. Patients with diabetes mellitus and an ICD (n=646), as compared with those without an ICD (n=1031), were more likely to be younger (74 versus 78 years of age) and have coronary artery disease (68% versus 60%). After propensity matching, ICD use among patients with diabetes mellitus, as compared with those without an ICD, was associated with a reduced risk of all‐cause mortality at 5 years after HF discharge (54% versus 59%; multivariable hazard ratio, 0.73; 95% CI, 0.64–0.82; P

Background Although 30‐day readmission is thought to be an important quality indicator in patients with hospitalized heart failure, its prognostic impact and comparison of patients who were readmitted beyond 30 days has not been investigated. We assessed early (0–30 days) versus midrange (31–90 days) readmission in terms of incidence and distribution, and elucidated whether the timing of readmission could have a different prognostic significance. Methods and Results We examined patients with hospitalized heart failure registered in the WET‐HF (West Tokyo Heart Failure) registry. The primary outcomes analyzed were all‐cause death and HF readmission. Data of 3592 consecutive patients with hospitalized heart failure (median follow‐up, 2.0 years [interquartile range, 0.8–3.1 years]; 39.6% women, mean age 73.9±13.3 years) were analyzed. Within 90 days after discharge, HF readmissions occurred in 11.1% patients. Of them, patients readmitted within 30 and 31 to 90 days after discharge accounted for 43.1% and 56.9%, respectively. Independent predictors of 30‐ and 90‐day readmission were almost identical, and after adjustment, readmission for HF within 90 days (including both early and midrange readmission) was an independent predictor of subsequent all‐cause death (hazard ratio, 2.36; P

Background Limited data exist to guide treatment for patients with heart failure with preserved ejection fraction and atrial fibrillation, including the important decision regarding rate versus rhythm control. Methods and Results We analyzed the Get With The Guidelines—Heart Failure (GWTG‐HF) registry linked to Medicare claims data from 2008 to 2014 to describe current treatments for rate versus rhythm control and subsequent outcomes in patients with heart failure with preserved ejection fraction and atrial fibrillation using inverse probability weighted analysis. Rhythm control was defined as use of an antiarrhythmic medication, cardioversion, or AF ablation or surgery. Rate control was defined as use of any combination of β‐blocker, calcium channel blocker, and digoxin without evidence of rhythm control. Among 15 682 fee‐for‐service Medicare patients, at the time of discharge, 1857 were treated with rhythm control and 13 825 with rate control, with minimal differences in baseline characteristics between groups. There was higher all‐cause death at 1 year in the rate control compared with the rhythm control group (37.5% and 30.8%, respectively, P

Objectives: The relationship between prior glycemic status and outcomes in intracerebral hemorrhage (ICH) is not established. We hypothesized that higher hemoglobin (Hb) A1c is associated with worse outcomes in ICH. Patients and methods: Using the GWTG-Stroke registry, data on patients with ICH between April 1, 2003 and September 30, 2015 were harvested. Patients were divided into four ordinal groups based on HbA1c values of 8.0%. Outcomes (mortality, modified Rankin Scale (mRS), home discharge and independent ambulatory status) were analyzed for patients overall and separately for patients with or without history of diabetes using multivariable regression models. Results: Among 75,455 patients with ICH (with available HbA1c data), patients with lower HbA1c (8.0%), (15.0%; 205/1364) were associated with higher in-hospital mortality. Lower HbA1c was also associated with higher mRS, less chance of going home, and lower likelihood of having independent ambulatory status in patients with prior history of diabetes. Conclusions: Among patients with no reported history of diabetes, both very low and very high HbA1c were directly associated with higher in-hospital mortality. Only very low HbA1c was associated with higher mortality in known diabetic patients. Further studies are needed to better define the relationship between HbA1c and outcomes, for it may have important implications for care of ICH patients.

Background The angiotensin‐receptor/neprilysin inhibitor (ARNI) sacubitril/valsartan reduces hospitalization and mortality for patients with heart failure with reduced ejection fraction. However, adoption of ARNI into clinical practice has been slow. Factors influencing use of ARNI have not been fully elucidated. Using data from the Get With The Guidelines‐Heart Failure registry, Hospital Compare, Dartmouth Atlas, and the American Hospital Association Survey, we sought to identify hospital characteristics associated with patient‐level receipt of an ARNI prescription. Methods and Results We analyzed patients with heart failure with reduced ejection fraction who were eligible for ARNI prescription (ejection fraction≤40%, no contraindications) and hospitalized from October 1, 2015 through December 31, 2016. We used logistic regression to estimate the associations between hospital characteristics and patient ARNI prescription at hospital discharge, accounting for clustering of patients within hospitals using generalized estimating equation methods and adjusting for patient‐level covariates. Of 16 674 eligible hospitalizations from 210 hospitals, 1020 patients (6.1%) were prescribed ARNI at discharge. The median hospital‐level proportion of patients prescribed ARNI was 3.3% (Q1, Q3: 0%, 12.6%). After adjustment for patient‐level covariates, for‐profit hospitals had significantly higher odds of ARNI prescription compared with not‐for‐profit hospitals (odds ratio, 2.53; 95% CI, 1.05–6.10; P=0.04), and hospitals located in the Western United States had lower odds of ARNI prescription compared with those in the Northeast (odds ratio, 0.33; 95% CI, 0.13–0.84; P=0.02). Conclusions Relatively few hospital characteristics were associated with ARNI prescription at hospital discharge, in contrast to what has been observed in early adoption in other disease areas. Additional evaluation of barriers to implementing new evidence into heart failure practice is needed.

Background Although admission heart rate predicts higher mortality after acute myocardial infarction (AMI), less is known about discharge heart rate. We tested the hypothesis that higher discharge heart rate after AMI is related to increased long‐term mortality independent of admission heart rate, and assessed whether β blockers modify this relationship. Methods and Results In 2 prospective US multicenter registries of AMI, we evaluated the associations of discharge and admission heart rate with 3‐year mortality using Cox models. Among 6576 patients with AMI, discharge heart rate was modestly associated with initial heart rate (r=0.28), comorbidities, and infarct severity. In this cohort, 10.7% did not receive β blockers at discharge. After full adjustment for demographic, psychosocial, and clinical covariates, discharge heart rate (hazard ratio [HR]=1.14 per 10 beats per minute [bpm]; 95% CI=1.07–1.21 per 10 bpm) was more strongly associated with risk of death than admission heart rate (HR=1.05 per 10 bpm; 95% CI=1.02–1.09 per 10 bpm) when both were entered in the same model (P=0.043 for comparison). There was a significant interaction between discharge heart rate and β‐blocker use (P=0.004) on mortality, wherein risk of death was markedly higher among those with high discharge heart rate and not on β blockers (HR=1.35 per 10 bpm; 95% CI=1.19–1.53 per 10 bpm) versus those with a high discharge heart rate and on β blockers at discharge (HR=1.10 per 10 bpm; 95% CI=1.03–1.17 per 10 bpm). Conclusions Higher discharge heart rate after AMI was more strongly associated with 3‐year mortality than admission heart rate, and the risk associated with higher discharge heart rate was modified by β blockers at discharge. These findings highlight opportunities for risk stratification and intervention that will require further investigation.

Background The objective was to explore the efficacy of ablation lesion sets in addition to pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation. The optimal strategy for catheter ablation of paroxysmal atrial fibrillation is debated. Methods and Results The SMASH‐AF (Systematic Review and Meta‐analysis of Ablation Strategy Heterogeneity in Atrial Fibrillation) study cohort includes trials and observational studies identified in PubMed, Scopus, and Cochrane databases from January 1 1990, to August 1, 2016. We included studies reporting single procedure paroxysmal atrial fibrillation ablation success rates. Exclusion criteria included insufficient reporting of outcomes, ablation strategies that were not prespecified and uniform, and a sample size of fewer than 40 patients. We analyzed lesion sets performed in addition to PVI (PVI plus) using multivariable random‐effects meta‐regression to control for patient, study, and procedure characteristics. The analysis included 145 total studies with 23 263 patients (PVI‐only cohort: 115 studies, 148 treatment arms, 16 500 patients; PVI plus cohort: 39 studies; 46 treatment arms, 6763 patients). PVI plus studies, as compared with PVI‐only studies, included younger patients (56.7 years versus 58.8 years, P=0.001), fewer women (27.2% versus 32.0% women, P=0.002), and were more methodologically rigorous with longer follow‐up (29.5 versus 17.1 months, P 0.004) and more randomization (19.4% versus 11.8%, P