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Safety-net hospitals (SNHs) look after a higher proportion of uninsured patients and are often located in deprived areas. This study aimed to determine whether there are differences in the clinical characteristics, treatments and outcomes of patients presenting with acute myocardial infarction (AMI) in SNHs versus non-SNHs (N-SNHs).All hospitalizations with a principal diagnosis of AMI in the United States' National Inpatient Sample between 2016 and 2019 were stratified by safety-net hospital status. Multivariable logistic regression with adjusted odds ratios (aOR) and 95 % confidence intervals (95 % CI) was conducted to investigate invasive management and clinical outcomes.A total of 2,544,009 weighted discharge records were analyzed, including 601,719 records from SNHs (23.7 %). Compared with N-SNHs, SNH AMI patients were younger (median 66 years vs. 67 years, p0.001), and had a higher proportion in the lowest quartile of median household income (37.3 % vs. 28.5 %, p0.001). Patients from SNHs were less likely to receive coronary angiography (aOR 0.92, 95 % CI 0.91-0.93, p0.001), percutaneous coronary intervention (aOR 0.94, 95 % CI 0.93-0.95, p0.001), and coronary artery bypass grafting (aOR 0.93, 95 % CI 0.92-0.94, p0.001). In addition, they had increased all-cause mortality (aOR 1.11, 95 % CI 1.09-1.12, p0.001), major adverse cardiovascular/cerebrovascular events (composite of mortality, stroke and reinfarction) (aOR 1.11, 95 % CI 1.09-1.12, p0.001), and stroke (aOR 1.11, 95 % CI 1.08-1.14, p0.001), while there was no difference in major bleeding (aOR 1.02, 95 % CI 1.00-1.04, p = 0.107).Among AMI patients, treatment in SNHs was associated with lower utilization of coronary angiography and revascularization and worse clinical outcomes.

Aim This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. Methods A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

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.

Backgrounds Predicting left atrial appendage thrombus (LAAT) in non-valvular atrial fibrillation (NVAF) patients need more precisely quantified risk models. In this study, we attempted to review the risk markers for LAAT and develop a simple and reliable model for LAAT prediction. Methods The study included 307 patients with NVAF who were scheduled for transesophageal echocardiography (TEE) to exclude LAA thrombus before synchronized electrical cardioversion or radiofrequency ablation for atrial fibrillation (AF). We analyzed the relationship between echo, clinical parameters and the presence or absence of LAAT. Results A total of 33 patients were found having LAAT (10.7%, 33/307). The age, left atrial appendage emptying velocity (LAAEV), left atrial or left atrial appendage spontaneous echocardiographic contrast (SEC), less than moderate to severe mitral regurgitation (≤mild MR), and left atrial enlargement showed association with LAAT. The multivariate logistic regression analysis revealed that LAAEV, SEC and ≤mild MR were independent risk factors of the LAAT. We used LAAEV ≤ 21.5 cm/s, SEC and ≤mild MR to construct a combined predictive model for LAAT in NVAF patients (the area under receiver operator characteristic curve: 0.88; 95% confidence interval: 0.82–0.95, P Conclusion Comprehensive evaluation of LAAEV, SEC, and MR with associated LAAT may help risk stratifying the NVAF patients, especially if the LAA imaging quality was suboptimal for identifying thrombus. These parameters may facilitate the decision-making process at the time of TEE.

Social media platforms are increasingly used by professional societies for improved member engagement, to raise awareness, for advocacy and for widespread dissemination of scientific meeting highlights. This article describes the inaugural social media campaign implemented at the American Society of Nuclear Cardiology (ASNC) 2019 Scientific Meeting. Campaign strategies, including development of an interactive social media curriculum, dedicated social media ambassadors and implementation and announcement of a Tweetup, are described in detail. These efforts resulted in significantly uplifting the profile of the conference, improving attendee engagement, reinforced conference highlights, and expanded meeting reach across the world. This manuscript provides a blueprint for other professional societies considering the launch of a Social Media campaign at their scientific meetings.

Aim:This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.Methods:A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.Structure:Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Background Cardiovascular disease (CVD) remains the leading cause of death for females in the United States accounting for over 412 000 female deaths in 2016. CVD mortality in young women

Clinical Case Download : Download full-size image A 52-year-old female with a 15- year history of benign essential hypertension, type 2 diabetes mellitus, hyperlipidemia, and tobacco smoking presented with a 10- month history of exertional dyspnea and exertional chest pain. The chest pain was described as a burning substernal sensation that was moderate in intensity and relieved with rest. She also has noted a reduction in her functional capacity to less than two blocks over the last year. Her blood pressure on examination was 128/80 and heart rate was 70 beats/min. Her cardiovascular examination was unremarkable with normal heart sounds, regular rate, and rhythm with no audible murmurs and no gallops as well as no rubs. Chest was clear to auscultation bilaterally. There was no jugular venous distension. No pedal edema. Electrocardiogram (ECG) showed normal sinus rhythm with secondary ST-T changes. She gave a history of having a prior exercise nuclear stress test that was performed 15 months ago which was reported as being normal but it was noted that her exercise capacity was reduced for age at 6.4 metabolic equivalents (METs). She walked for less than 5 min on the treadmill; the test was stopped due to intolerable dyspnea after achieving 85% of maximum predicted heart rate for age. No ischemic ECG noted. Heart rate and blood pressure response were normal. Myocardial perfusion was described as being normal ( Figure 1 ) with normal systolic wall motion of the left ventricle, calculated left ventricular ejection fraction was 65%, normal. Patient presented for a second opinion for her symptoms but was reluctant to have any further tests that exposed her to radiation unless it was deemed to be necessary. How would you manage her going forward? Abstract Stable ischemic heart disease is defined as a condition in which patients with established or suspected ischemic heart disease have a myocardial fixed supply and demand mismatch resulting in chronic angina or chronic anginal equivalents such as exertional dyspnea occurring with a predictable workload with no suspected unstable or acute symptoms as to suggest an acute coronary syndrome. There are sex-specific differences in the pathophysiology and presentation of coronary artery disease (CAD). These differences determine the diagnostic and management strategy in women. Appreciation of these differences determines treatment outcomes. The prevalence of nonobstructive CAD is greater in women compared to men. However, the clinical outcomes are worse in these women with nonobstructive CAD compared to men. Therefore, the diagnostic strategy that emphasizes anatomic assessment with luminogram with coronary angiography rather than physiologic assessment to determine endothelial dysfunction will often result in missed diagnosis of women with nonobstructive CAD.

Transthyretin amyloid cardiomyopathy (ATTR-CM) results in a restrictive cardiomyopathy caused by extracellular deposition of transthyretin, normally involved in the transportation of the hormone thyroxine and retinol-binding protein, in the myocardium. Enthusiasm about ATTR-CM has grown as a result of 3 simultaneous areas of advancement: Imaging techniques allow accurate noninvasive diagnosis of ATTR-CM without the need for confirmatory endomyocardial biopsies; observational studies indicate that the diagnosis of ATTR-CM may be underrecognized in a significant proportion of patients with heart failure; and on the basis of elucidation of the mechanisms of amyloid formation, therapies are now approved for treatment of ATTR-CM. Because therapy for ATTR-CM may be most effective when administered before significant cardiac dysfunction, early identification of affected individuals with readily available noninvasive tests is essential. This scientific statement is intended to guide clinical practice and to facilitate management conformity by covering current diagnostic and treatment strategies, as well as unmet needs and areas of active investigation in ATTR-CM.

This information statement from the American Society of Nuclear Cardiology highlights advances in cardiac SPECT imaging and supports the incorporation of new technology and techniques in laboratories performing nuclear cardiology procedures. The document focuses on the application of the latest imaging protocols and the utilization of newer hardware and software options to perform high quality, state-of-the-art SPECT nuclear cardiology procedures. Recommendations for best practices of cardiac SPECT imaging are discussed, highlighting what imaging laboratories should be doing as the standard of care in 2018 to achieve optimal results (based on the ASNC 2018 SPECT guideline [Dorbala et al., J Nucl Cardiol. 2018. https://doi.org/10.1007/s12350-018-1283-y ]).

IMPORTANCE: Although cardiovascular (CV) disease represents the leading cause of morbidity and mortality that increases with age, the best noninvasive test to identify older patients at risk for CV events remains unknown. OBJECTIVE: To determine whether the prognostic utility of anatomic vs functional testing varies based on patient age. DESIGN, SETTING, AND PARTICIPANTS: Prespecified analysis of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) study, which used a pragmatic comparative effectiveness design. Participants were enrolled from 193 sites across North America and comprised outpatients without known coronary artery disease (CAD) but with symptoms suggestive of CAD. Data were analyzed between October 2018 and April 2019. INTERVENTIONS: Randomization to noninvasive testing with coronary computed tomographic angiography or functional testing. MAIN OUTCOMES AND MEASURES: The composite of CV death/myocardial infarction (MI) over a median follow-up of 25 months. RESULTS: Among 10 003 PROMISE patients, we included the 8966 who received the noninvasive test to which they were randomized and had interpretable results; 6378 (71.1%) were younger than 65 years, 2062 (23.0%) were between ages 65 and 74 years, and 526 (5.9%) were 75 years and older. More than half of participants were women (4720 of 8966 [52.6%]). Only a minority of patients were of nonwhite race/ethnicity, a proportion that was lower among the older age groups (1071 of 6378 [16.8%] for

Graphical abstract, Highlights • The suprasternal view on TTE is essential in assessing great vessel stenosis. • Duplex Doppler sonography has lower sensitivity and positive predictive value. • Echocardiography has good spatial and temporal resolution.

Objectives The aim of this study was to determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD). Background Although established CAD presentations differ by sex, little is known about stable, suspected CAD. Methods The characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial were compared using chi-square and Wilcoxon rank-sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression. Results Women were older (62.4 years of age vs. 59.0 years of age) and were more likely to be hypertensive (66.6% vs. 63.2%), dyslipidemic (68.9% vs. 66.3%), and to have a family history of premature CAD (34.6% vs. 29.3) (all p values Conclusions Patient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches for the evaluation of CAD.

This expert consensus statement from the Society of Cardiovascular Computed Tomography (SCCT) provides an evidence synthesis on the use of computed tomography (CT) imaging for diagnosis and risk stratification of coronary artery disease in women. From large patient and population cohorts of asymptomatic women, detection of any coronary artery calcium that identifies females with a 10-year atherosclerotic cardiovascular disease risk of >7.5% may more effectively triage women who may benefit from pharmacologic therapy. In addition to accurate detection of obstructive coronary artery disease (CAD), CT angiography (CTA) identifies nonobstructive atherosclerotic plaque extent and composition which is otherwise not detected by alternative stress testing modalities. Moreover, CTA has superior risk stratification when compared to stress testing in symptomatic women with stable chest pain (or equivalent) symptoms. For the evaluation of symptomatic women both in the emergency department and the outpatient setting, there is abundant evidence from large observational registries and multi-center randomized trials, that CT imaging is an effective procedure. Although radiation doses are far less for CT when compared to nuclear imaging, radiation dose reduction strategies should be applied in all women undergoing CT imaging. Effective and appropriate use of CT imaging can provide the means for improved detection of at-risk women and thereby focus preventive management resulting in long-term risk reduction and improved clinical outcomes.

Transthyretin type cardiac amyloidosis (ATTR-CA) is prevalent in ~16% of the elderly with severe calcific aortic valve stenosis (AoS) being considered for TAVR. Tc-99m PYP cardiac imaging is useful in identifying ATTR-CA in these patients. An 87 year old male presented with decompensated combined

Background and Significance: Heart dis­ease is the leading cause of death for wom­en living in the United States; this disease claims more female lives than all cancers combined. Additionally, according to the Centers of Disease Control data between the years 1979 and 2006, while cardiac-related mortality among men decreased significantly, only a modest decline was found among women. This disparity is great­est among minority females including Blacks and Hispanics who have an even greater prevalence of CVD and its risk factorsPrevention: There are several risk factors for coronary artery disease (CAD). Modifi­able risk factors include: tobacco smoking, hypertension, diabetes, hyperlipidemia, obesity and physical inactivity. The preven­tion of CAD is grounded in decreasing or removing these modifiable risk factors.Detection: Accurately diagnosing CAD is dependent on an accurate assessment of the patient’s pre-test probability to determine the best diagnostic approach to pursue. The patient’s functional status, resting EKG and cardiac risk factors also assist in determining the best non-invasive cardiac test to pursue.Management: The goals and mainstay in the management of minority females with stable CAD includes surveillance for CAD symptoms, management of hypertension, diabetes mellitus and hyperlipidemia, as well as encouraging healthy habits.Conclusion: Heart disease remains the leading cause of death in minority females. Providers must be diligent to aggressively decrease patients’ cardiovascular risk and, when patients do present with cardiovascu­lar symptoms, providers must be aggressive in accurately diagnosing and treating these patients to decrease cardiac morbidity and mortality. Ethn Dis. 2015;25(4):499-506; doi:10.18865/ed.25.4.499

BACKGROUND AND OBJECTIVE: Hospital-acquired venous thromboembolic events (VTEs) in medically ill patients account for a significant percentage of in-hospital mortality. Unfractionated heparin and low-molecular-weight heparin have been shown to be effective in the prevention of VTEs. However, use of these medications for thromboprophylaxis remains suboptimal. The objective of this article is to report the impact of a continuous quality improvement project on adherence with DVT prophylaxis guidelines and on the subsequent incidence of hospital-acquired DVT in medical patients at a teaching hospital between 2002 and 2005. METHODS: In November 2002, Kings County Hospital Center Department of Medicine embarked on a project to increase the rate of thromboprophylaxis use. Quality improvement strategies included an active, multifaceted, layered combination of provider education, provider reminders with decision support, and audit with feedback. RESULTS: The DVT prophylaxis rate on the general medicine house-staff service increased from a baseline of 63% in 2002 to 96% in 2005. The number of hospital-acquired DVTs decreased from a baseline of 14 in 2002 to 1 in 2005. The hospital-acquired DVT rate fell significantly, from 2.6 per 1000 discharges in 2002 (95% CI 1.5–4.4) to 0.2 per 1000 discharges in 2005 (95% CI 0.0–1.1), P = .007. CONCLUSIONS: A layered combination of provider education, provider reminders with decision support, and audit with feedback increased the DVT prophylaxis rate and decreased the rate of hospital-acquired DVTs in the medicine department at a tertiary-care hospital center. Journal of Hospital Medicine 2008;3:148–155. © 2008 Society of Hospital Medicine.

A 49-year-old male with chronic kidney disease and history of renal transplantation in 2006 on chronic immunosuppressant therapy presented with a 1-week history of chills and generalized myalgia. He had a temperature of 101°F. One set of blood cultures grew methicillin-sensitive Staphylococcus aureus. Transesophageal echo (TEE) revealed a mobile mass that was 2 cm in length attached by a thin stalk to the base of the anterior leaflet of the mitral valve. The surgical diagnosis was a left atrial myxoma. The echocardiographic as well as the surgical findings were consistent with an atrial myxoma. However, the histopathology of the specimen showed no evidence of myxoma as the characteristic stellate mesenchymal cells were absent. Instead the milieu of inflammatory cells, fibrin and multimicrobial colonization of both Gram-positive and Gram-negative cocci suggested a super infected vegetative mass. It is interesting that the mitral valve was intact as de novo vegetation being formed on a structurally normal native valve is rare. In some instances, the echocardiographic distinction between atrial masses such as vegetation, thrombus or an atrial myxoma may be ambiguous. Not only does surgical removal allow histological determination of the diagnosis that is critical for treatment, but in cases where an infected mass is mobile and greater than 15 mm, as in this case, there is high potential for embolization. Surgical removal significantly decreases the risk of an embolic event. (Echocardiography 2010;27:E62-E64)

Adult congenital heart disease (ACHD) has become increasingly important in adult cardiology. A 54-year-old female presented with symptoms and signs of new onset heart failure. Echocardiography showed congenitally corrected transposition of the great arteries (CCTGA) with systolic dysfunction of the systemic right ventricle, ejection fraction was 15 to 20% and no other associated abnormalities. CCTGA is often missed in cardiology practice due to failure to recognize the abnormal position of the ventricles and the associated AV valves. One percent of patients with CCTGA are uncomplicated without VSD, PS or Ebstein's anomaly of the systemic AV valve; this was the case for our patient. Most patients present in early adulthood. The mechanism of systemic ventricular failure has been related to fibrosis due to oxygen supply and demand mismatch.

Although the presentation and pathobiology of acute coronary syndromes differ significantly by sex, there have been few studies of sex differences in stable symptomatic outpatients with suspected coronary artery disease (CAD). We compared demographics, risk profiles, presentation and provider’s

A 49-year-old male with chronic kidney disease and history of renal transplantation in 2006 on chronic immunosuppressant therapy presented with a 1-week history of chills and generalized myalgia. He had a temperature of 101 degrees F. One set of blood cultures grew methicillin-sensitive Staphylococcus aureus. Transesophageal echo (TEE) revealed a mobile mass that was 2 cm in length attached by a thin stalk to the base of the anterior leaflet of the mitral valve. The surgical diagnosis was a left atrial myxoma. The echocardiographic as well as the surgical findings were consistent with an atrial myxoma. However, the histopathology of the specimen showed no evidence of myxoma as the characteristic stellate mesenchymal cells were absent. Instead the milieu of inflammatory cells, fibrin and multimicrobial colonization of both Gram-positive and Gram-negative cocci suggested a super infected vegetative mass. It is interesting that the mitral valve was intact as de novo vegetation being formed on a structurally normal native valve is rare. In some instances, the echocardiographic distinction between atrial masses such as vegetation, thrombus or an atrial myxoma may be ambiguous. Not only does surgical removal allow histological determination of the diagnosis that is critical for treatment, but in cases where an infected mass is mobile and greater than 15 mm, as in this case, there is high potential for embolization. Surgical removal significantly decreases the risk of an embolic event.

Low-molecular-weight heparin (LMWH) has been a mainstay for the management of acute coronary syndromes (ACS) for almost a decade. However, several recent developments have seriously threatened the prominence of this drug class: (i) the adoption of an early invasive strategy, frequently leading to percutaneous coronary intervention (PCI) where the dosing and monitoring of LMWH is unfamiliar to most operators, (ii) the results of the SYNERGY trial, which not only failed to establish the superiority of enoxaparin over unfractionated heparin with respect to efficacy, but also demonstrated more bleeding with LMWH, and (iii) the results of the REPLACE-2 and ACUITY trials, which have demonstrated the advantages of an ACS and PCI treatment strategy based on direct thrombin inhibition with bivalirudin. To confront these challenges, cardiologists committed to the continued use of LMWH must develop safe and user-friendly approaches to transition patients from the noninvasive to invasive settings. This review summarizes an approach that takes advantage of the fact that LMWH can be readily monitored with the point-of-care activated clotting time (ACT) assay. This assay is inexpensive, available in virtually every catheterization laboratory, and familiar to most operators who monitor unfractionated heparin (UFH). A key concept that is presented is that the ACT is a more accurate measure of LMWH-induced anticoagulation than of UFH-induced anticoagulation. Our preliminary work suggests that during PCI operators should target an ACT of 175 seconds in the presence, and 200 seconds in the absence, of adjunctive glycoprotein IIb/IIIa inhibition. Sheath removal is recommended at an ACT160. These guidelines may facilitate continued use of LMWH, which has the potential to reduce cost (less expensive than bivalirudin), diminish the need for intravenous medication (can be administered subcutaneously in the noninvasive setting with minimal to no monitoring), and provide an ideal anticoagulant during PCI (easy to monitor with the ACT, at least partially reversible with protamine in the event of coronary perforation, effective antithrombin with no platelet activation, thereby potentially reducing the need for routine adjunctive IIb/IIIa inhibition).