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Background Cardiovascular rehabilitation has been shown to improve morbidity and mortality in patients with cardiac illnesses; however, the referral rate for eligible patients at Tulane Medical Center has remained below best practice standards. Methods This is a single-center, quality improvement study conducted from January 2020 through December 2020 with historical controls from 2019. Using Plan-Do-Study-Act cycle methodology, interventions were designed to improve referrals rates for cardiac rehabilitation eligible patients. Interventions included a presentation about the importance of cardiac rehabilitation and the current state of referrals, weekly reminders to residents and fellows on inpatient services with eligible patients, and an admission order set that included a default order for cardiac rehabilitation. Results The primary outcome was referral rate which was measured by the total number of referrals compared to the total number of patients eligible for cardiac rehabilitation. In this quality improvement study of 770 patients, there was a significant increase in the referral rate for cardiac rehabilitation eligible patients. When comparing the referral rate in 2020 following institution of quality improvement interventions, to that from 2019, there was an increase from 27% to 70%. Conclusions This quality improvement study found that various interventions significantly increased the cardiac rehabilitation referral rate through an straightforward and simple strategy. Further efforts are underway to promote additional referrals, in order to meet or exceed the >90% best practice standard.

Retinopathy is a microvascular complication of diabetes mellitus (DM); however, it is also increasingly recognized in persons without DM. The microvascular diseases may play a prominent role in coronary heart disease (CHD) development in individuals with DM. We performed the study to evaluate the relation between non-DM retinopathy and CHD and also the association between baseline retinopathy and incidence and progression of CHD in individuals with and without DM. We included 5709 subjects with and without DM from the Multi-Ethnic Study of Atherosclerosis, who had retinal photos and coronary artery calcium score (CACS) available. We studied the association between baseline retinopathy and incidence and progression of coronary artery calcification (CAC) in subjects with and without DM. In DM group, the presence of retinopathy was significantly associated with an increased rate of CAC (RR 1.3 (95% CI [1.02, 1.66]) after adjusting for age, sex, race, follow-up time, and CHD risk factors. In non-DM group, the presence of retinopathy was not significantly associated with increased risk of CAC, however, the interaction between presence of retinopathy and DM status was not statistically significant. Within the DM group with CAC present at baseline, the presence of retinopathy was significantly associated with greater CAC progression (113 Agatson units (AU) greater, (95% CI [51-174]). In the non-DM group with present CAC at baseline; the presence of retinopathy was associated with 24 (95% CI [-0.69, 48.76]) AU higher CAC progression. All findings were adjusted for CHD risk factors. In conclusion, after adjustment for major CHD risk factors, retinopathy was associated with progression of CAC in both DM and non-DM individuals. However, the association was stronger in those with DM.

Eosinophilic myocarditis is a rare and frequently fatal disease that is often undiagnosed until autopsy. We report a case of eosinophilic myocarditis with an unusual initial presentation of palpitations that subsequently evolved into ventricular tachycardia storm and death within 4 days. (Level of Difficulty: Beginner.), Graphical abstract

As the severe acute respiratory syndrome coronavirus 2 virus pandemic continues to grow globally, an association is apparent between patients with underlying cardiovascular disease comorbidities and the risk of developing severe COVID-19. Furthermore, there are potential cardiac manifestations of severe acute respiratory syndrome coronavirus 2 including myocyte injury, ventricular dysfunction, coagulopathy, and electrophysiologic abnormalities. Balancing management of the infection and treatment of underlying cardiovascular disease requires further study. Addressing the increasing reports of health care worker exposure and deaths remains paramount. This review summarizes the most contemporary literature on the relationship of the cardiovascular system and COVID-19 and society statements with relevance to protection of health care workers, and provides illustrative case reports in this context.

Biykem Bozkurt, MD, FACC, FAHA, Chair Hani Jneid, MD, FACC, FAHA, Chair-Elect Srinath Adusumalli, MD, MSc, FACC Sana Al-Khatib, MD, MHS, FACC, FAHA[‖][1] H. Vernon Anderson, MD, FACC, FAHA[‖][1] Deepak L. Bhatt, MD, MPH, FACC, FAHA Bruce E. Bray, MD, FACC Grant Nigel Graham, MD, FACC

Significant disparities exist in the prevalence and clinical presentation of cardiovascular disease among individuals of different ethnicity/race and sex, with minority populations being affected in a disproportionate manner. The use and value of various imaging modalities for the assessment of cardiovascular disease are clearly impacted by such inequalities. In contemporary medicine, with the goal of patient-centered practice, we must aim to provide valuable medical care by acknowledging these variations and tailoring our assessment to each individual patient with consideration of these factors and their impact in their care. In this chapter, we discuss the available data regarding the advantages and limitations of specific imaging techniques. Additionally, differences related to minority populations must be recognized, so as to allow an appropriate use of these resources and foster more accurate conclusions, leading to the establishment of a proper and individualized treatment strategy for patients of diverse populations.

Biykem Bozkurt, MD, FACC, FAHA, Chair Hani Jneid, MD, FACC, FAHA, Chair-Elect Srinath Adusumalli, MD, MSc, FACC Sana Al-Khatib, MD, MHS, FACC, FAHA[‖][1] H. Vernon Anderson, MD, FACC, FAHA[‖][1] Deepak L. Bhatt, MD, MPH, FACC, FAHA Bruce E. Bray, MD, FACC Grant Nigel Graham, MD, FACC

In this review, we highlight the need for innovation and creativity to reinvent the field of nuclear cardiology. Revolutionary ideas brought forth today are needed to create greater value in patient care and highlight the need for more contemporary evidence supporting the use of nuclear cardiology practices. We put forth discussions on the need for disruptive innovation in imaging-guided care that places the imager as a central force in care coordination. Value-based nuclear cardiology is defined as care that is both efficient and effective. Novel testing strategies that defer testing in lower risk patients are examples of the kind of innovation needed in today's healthcare environment. A major focus of current research is the evolution of the importance of ischemia and the prognostic significance of non-obstructive atherosclerotic plaque and coronary microvascular dysfunction. Embracing novel paradigms, such as this, can aid in the development of optimal strategies for coronary disease management. We hope that our article will spurn the field toward greater innovation and focus on transformative imaging leading the way for new generations of novel cardiovascular care.

John U. Doherty, MD, FACC, Co-Chair Gregory J. Dehmer, MD, MACC, Co-Chair Nicole M. Bhave, MD, FACC Stacie L. Daugherty, MD, MSPH, FACC Larry S. Dean, MD, FACC Milind Y. Desai, MBBS, FACC Claire S. Duvernoy, MD, FACC[∗][1] Linda D. Gillam, MD, FACC Praveen Mehrotra, MD, FACC Ritu

Background Although human mesenchymal stem cells (hMSCs) have been tested in ischemic cardiomyopathy, few studies exist in chronic nonischemic dilated cardiomyopathy (NIDCM). Objectives The authors conducted a randomized comparison of safety and efficacy of autologous (auto) versus allogeneic (allo) bone marrow-derived hMSCs in NIDCM. Methods Thirty-seven patients were randomized to either allo- or auto-hMSCs in a 1:1 ratio. Patients were recruited between December 2011 and July 2015 at the University of Miami Hospital. Patients received hMSCs (100 million) by transendocardial stem cell injection in 10 left ventricular sites. Treated patients were evaluated at baseline, 30 days, and 3-, 6-, and 12-months for safety (serious adverse events [SAE]), and efficacy endpoints: ejection fraction, Minnesota Living with Heart Failure Questionnaire, 6-min walk test, major adverse cardiac events, and immune biomarkers. Results There were no 30-day treatment-emergent SAEs. Twelve-month SAE incidence was 28.2% with allo-hMSCs versus 63.5% with auto-hMSCs (p = 0.1004 for the comparison). One allo-hMSC patient developed an elevated (>80) donor-specific calculated panel reactive antibody level. The ejection fraction increased in allo-hMSC patients by 8.0 percentage points (p = 0.004) compared with 5.4 with auto-hMSCs (p = 0.116; allo vs. auto p = 0.4887). The 6-min walk test increased with allo-hMSCs by 37.0 m (p = 0.04), but not auto-hMSCs at 7.3 m (p = 0.71; auto vs. allo p = 0.0168). MLHFQ score decreased in allo-hMSC (p = 0.0022) and auto-hMSC patients (p = 0.463; auto vs. allo p = 0.172). The major adverse cardiac event rate was lower, too, in the allo group (p = 0.0186 vs. auto). Tumor necrosis factor-α decreased (p = 0.0001 for each), to a greater extent with allo-hMSCs versus auto-hMSCs at 6 months (p = 0.05). Conclusions These findings demonstrated safety and clinically meaningful efficacy of allo-hMSC versus auto-hMSC in NIDCM patients. Pivotal trials of allo-hMSCs are warranted based on these results. (Percutaneous Stem Cell Injection Delivery Effects on Neomyogenesis in Dilated Cardiomyopathy [PoseidonDCM]; NCT01392625)

Cardiovascular magnetic resonance (CMR) has evolved from a pioneering research tool to an established noninvasive imaging method for detecting inducible myocardial perfusion deficits. In this consensus document, experts of different imaging techniques summarize the existing body of evidence regarding CMR perfusion as a viable complement to other established noninvasive tools for the assessment of perfusion and discuss the advantages and pitfalls of the technique. A rapid, standardized CMR perfusion protocol is described, which is safe, clinically feasible, and cost-effective for centers with contemporary magnetic resonance equipment. CMR perfusion can be recommended as a routine diagnostic tool to identify inducible myocardial ischemia.

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document

Catheter ablation for atrial fibrillation (AF) has emerged as a popular procedure. The purpose of this study was to examine whether there exist differences or disparities in ablation utilization across gender, socioeconomic class, insurance, or race. Using the Nationwide Inpatient Sample (2000 to 2012), we identified adults hospitalized with a principal diagnosis of AF by ICD 9 code 427.31 who had catheter ablation (ICD 9 code-37.34). We stratified patients by race, insurance status, age, gender, and hospital characteristics. A hierarchical multivariate mixed-effect model was created to identify the independent predictors of AF ablation. Among an estimated total of 3,508,122 patients (extrapolated from 20% Nationwide Inpatient Sample) hospitalized with a diagnosis of AF in the United States from the year 2000 to 2012, 102,469 patients (2.9%) underwent catheter ablations. The number of ablations was increased by 940%, from 1,439 in 2000 to 15,090 in 2012. There were significant differences according to gender, race, and health insurance status, which persisted even after adjustment for other risk factors. Female gender (0.83 [95% CI 0.79 to 0.87; p0.001]), black (0.49 [95% CI 0.44 to 0.55; p0.001]), and Hispanic race (0.64 [95% CI 0.56 to 0.72; p0.001]) were associated with lower likelihoods of undergoing an AF ablation. Medicare (0.93, 0.88 to 0.98,0.001) or Medicaid (0.67, 0.59 to 0.76,0.001) coverage and uninsured patients (0.55, 0.49 to 0.62,0.001) also had lower rates of AF ablation compared to patients with private insurance. In conclusion we found differences in utilization of catheter ablation for AF based on gender, race, and insurance status that persisted over time.

Despite advances in evidence-based treatments, the morbidity and mortality of congestive heart failure remain exceedingly high. In addition, the costs associated with recurrent hospitalizations and advanced therapies, such as implantable cardiac defibrillators (ICDs), left ventricular assist devices, and heart transplantation, place a substantial financial burden on the health care system. The present criteria for risk stratification in patients with heart failure are inadequate and often prevent the allocation of appropriate treatment. Patients who have received ICDs as primary prevention for sudden cardiac death often receive no device therapy in their lifetime, whereas other patients with left ventricular dysfunction die suddenly without meeting criteria for ICD implantation.

This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Rationale: Cell dose and concentration play crucial roles in phenotypic responses to cell-based therapy for heart failure. Objective: To compare the safety and efficacy of 2 doses of allogeneic bone marrow–derived human mesenchymal stem cells identically delivered in patients with ischemic cardiomyopathy. Methods and Results: Thirty patients with ischemic cardiomyopathy received in a blinded manner either 20 million (n=15) or 100 million (n=15) allogeneic human mesenchymal stem cells via transendocardial injection (0.5 cc per injection × 10 injections per patient). Patients were followed for 12 months for safety and efficacy end points. There were no treatment-emergent serious adverse events at 30 days or treatment-related serious adverse events at 12 months. The Major Adverse Cardiac Event rate was 20.0% (95% confidence interval [CI], 6.9% to 50.0%) in 20 million and 13.3% (95% CI, 3.5% to 43.6%) in 100 million ( P =0.58). Worsening heart failure rehospitalization was 20.0% (95% CI, 6.9% to 50.0%) in 20 million and 7.1% (95% CI, 1.0% to 40.9%) in 100 million ( P =0.27). Whereas scar size reduced to a similar degree in both groups: 20 million by −6.4 g (interquartile range, −13.5 to −3.4 g; P =0.001) and 100 million by −6.1 g (interquartile range, −8.1 to −4.6 g; P =0.0002), the ejection fraction improved only with 100 million by 3.7 U (interquartile range, 1.1 to 6.1; P =0.04). New York Heart Association class improved at 12 months in 35.7% (95% CI, 12.7% to 64.9%) in 20 million and 42.9% (95% CI, 17.7% to 71.1%) in 100 million. Importantly, proBNP (pro-brain natriuretic peptide) increased at 12 months in 20 million by 0.32 log pg/mL (95% CI, 0.02 to 0.62; P =0.039), but not in 100 million (−0.07 log pg/mL; 95% CI, −0.36 to 0.23; P =0.65; between group P =0.07). Conclusions: Although both cell doses reduced scar size, only the 100 million dose increased ejection fraction. This study highlights the crucial role of cell dose in the responses to cell therapy. Determining optimal dose and delivery is essential to advance the field, decipher mechanism(s) of action and enhance planning of pivotal Phase III trials. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02013674.

Background The optimal initial noninvasive diagnostic testing strategy for stable coronary artery disease (CAD) is unknown. Although American guidelines recommend an exercise stress test as the first‐line test, European guidelines suggest that stress imaging (myocardial perfusion imaging or stress echocardiography) or coronary computed tomography angiography may be preferable. Understanding the relationship between the initial strategy and downstream yield of obstructive CAD and major adverse cardiac events may provide insight as to the optimal strategy. Methods and Results We conducted a population‐based retrospective cohort study of adults in Ontario, Canada, using health administrative and clinical data. The relationship between the initial testing strategy and obstructive CAD on invasive angiography was examined. Patients were then followed from their angiogram onward to determine whether they developed a composite end point of major adverse cardiac events. After adjusting for covariates, patients with initial myocardial perfusion imaging (odds ratio: 0.92; 95% confidence interval, 0.85, 1.00), coronary computed tomography angiography (odds ratio: 1.51; 95% confidence interval, 0.91, 2.49), or stress echo (odds ratio: 0.95; 95% confidence interval, 0.84, 1.08) did not a have significantly different yield of obstructive CAD compared with those with an initial exercise stress test. Furthermore, there was no significant difference in downstream major adverse cardiac events after invasive angiography among the 4 initial testing strategies after adjusting for clinically relevant covariates. Conclusions Our study found no evidence to suggest significant differences in either yield of obstructive CAD or downstream major adverse cardiac events in patients undergoing an initial noninvasive testing strategy with stress or anatomical imaging compared with those undergoing an initial exercise stress test.

The extraordinary advances in medical care during the past several decades have impacted both the quality and longevity of an individual’s life. However, impressions of modern health care have been adversely impacted by runaway expenses and the high cost of care delivery. Medical imaging, including nuclear cardiology, has demonstrated excellent value with regards to diagnosis and risk stratification, but has limited date to support its impact on patient outcome, thereby becoming the focus of public and payer attention due to concerns of overuse. This has lead to multiple initiatives to limit test performance and reduce overall spending, including pre-authorization and test substitution. As a response to fiscal pressures and with a goal of optimizing test/patient selection, appropriate use criteria (AUC) have been developed by several organizations, including the American College of Cardiology (ACC) and American Society of Nuclear Cardiology (AS]NC). Unfortunately, adoption of these AUC by private and federal health plans has been more limited than desired; many private insurers continue to use radiology benefits managers with their proprietary algorithms for test selection, often lacking consistency with medical literature and expert opinion. However, the AUC were specifically designed to serve as guidance documents for clinicians and others with regards to a variety of cardiac tests and procedures. Positron emission tomography (PET) MPI has been shown to provide improved image quality, superior interpretative confidence, and higher diagnostic accuracy than SPECT and has been considered by many to be a ‘‘gold standard’’ of non-invasive testing. In addition to its value as a diagnostic study, the independent and incremental value of myocardial perfusion PET has also been demonstrated in multiple studies, including a multicenter registry involving more than 7,000 patients. PET possesses a greater discriminatory power than other non-invasive modalities with regards to cardiac events. Furthermore, rubidium-82 perfusion PET is associated with a lower radiation burden and more rapid test performance, making this procedure an attractive test for the evaluation of known or suspect ischemic heart disease. However, the costs associated with this procedure are high, as is the level of reimbursement, which although justifiable based on procedural costs, places additional strain on an already financially overburden health system. The AUC for radionuclide imaging that were initially published in 2005 were revised and expanded in 2009 as a result of technologic advances in nuclear cardiology, feedback from ASNC and individual providers, and improvements in the development of AUC. All of the indications for radionuclide imaging (RNI) are intended for application for both SPECT and PET, unless specifically identified as being germane only to SPECT. The only stipulation regarding the AUC indications impacting PET is that exercise testing is the preferred stress modality for RNI. As exercise PET myocardial perfusion imaging is currently not an option in most centers, this preference is not applicable to PET, although the development of new PET perfusion agents, such as F-18 flurpiridaz, will make exercise testing an option in the future. Notably, there are no ‘‘pure’’ PET AUC, largely due in part to the similar applications of Reprint requests: Robert C. Hendel, MD, 1120 NW 14th Street, CRB Suite 1123, Miami, FL 33136; rhendel@med.miami.edu J Nucl Cardiol 2015;22:16–21. 1071-3581/$34.00 Copyright 2014 American Society of Nuclear Cardiology.

The use of standardized language is essential for all communication in medicine, with the ultimate goal of improved patient care. This is the driving force for enhanced use of clinical data and standardization of the lexicon of cardiovascular medicine to enhance the use of clinical data. The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Data Standards (Task Force) is at the fulcrum of these efforts, bringing together the 2 largest professional organizations that represent the House of Cardiology. The mission statements of the ACC (“to transform cardiovascular care and improve heart health”) and the AHA (“building healthier lives, free of cardiovascular diseases and stroke”) have direct …

The current paper details the recommendations arising from an NIH-NHLBI/NCI-sponsored symposium held in November 2012, aiming to identify key components of a radiation accountability framework fostering patient-centered imaging and shared decision-making in cardiac imaging. Symposium participants, working in 3 tracks, identified key components of a framework to target critical radiation safety issues for the patient, the laboratory, and the larger population of patients with known or suspected cardiovascular disease. The use of ionizing radiation during an imaging procedure should be disclosed to all patients by the ordering provider at the time of ordering, and reinforced by the performing provider team. An imaging protocol with effective dose ≤3mSv is considered very low risk, not warranting extensive discussion or written informed consent. However, a protocol effective dose >20mSv was proposed as a level requiring particular attention in terms of shared decision-making and either formal discussion or written informed consent. Laboratory reporting of radiation dosimetry is a critical component of creating a quality laboratory fostering a patient-centered environment with transparent procedural methodology. Efforts should be directed to avoiding testing involving radiation, in patients with inappropriate indications. Standardized reporting and diagnostic reference levels for computed tomography and nuclear cardiology are important for the goal of public reporting of laboratory radiation dose levels in conjunction with diagnostic performance. The development of cardiac imaging technologies revolutionized cardiology practice by allowing routine, noninvasive assessment of myocardial perfusion and anatomy. It is now incumbent upon the imaging community to create an accountability framework to safely drive appropriate imaging utilization.

The American College of Cardiology Foundation (ACCF), in partnership with key specialty and subspecialty societies, conducted a review of common clinical scenarios where noninvasive vascular testing (venous ultrasound and physiological testing) is frequently considered. The indications (clinical

Resource-sensitive and quality-centered imaging begins with the selection of the appropriate patient and test. Appropriate use criteria have been developed to aid clinicians but are often not available in an easily accessible format. FOCUS (Formation of Optimal Cardiovascular Utilization Strategies), a Web-based community and quality improvement instrument, was developed to increase the feasibility of measuring and improving practice patterns based on the appropriate use criteria. The FOCUS instrument proposed to reduce inappropriate imaging by 15% in 1 year and by 50% within 3 years. Between April 2010 and December 2011, data were voluntarily collected through the FOCUS radionuclide imaging performance improvement module (PIM). Appropriateness rates were compared between phases of the PIM. For the 55 participating sites that had completed the PIM by December 2011, the proportion of inappropriate cases decreased from 10% to 5% (p < 0.0001). These preliminary data from initial participating sites suggest that through the use of a self-directed, quality improvement software and an interactive community, physicians may be able to significantly decrease the proportion of tests not meeting appropriate use criteria.

The American College of Radiology (ACR) and the American College of Cardiology Foundation (ACCF) have jointly developed a method to define appropriate utilization of cardiovascular imaging. The primary role of this method is to create a series of documents to define the utility of cardiovascular imaging procedures in relation to specific clinical questions, with the aim of defining what, if any, imaging tests are indicated to help to determine diagnosis, treatment, or outcome. The methodology accomplishes this aim through the application of systematic evidence reviews integrated with expert opinion by means of a rigorous Delphi process. By obtaining broad input during the development process from radiologists, cardiologists, primary care physicians, and other stakeholders, these documents are intended to provide practical evidence-based guidance to ordering providers, imaging laboratories, interpreting physicians, patients, and policymakers as to optimal cardiovascular imaging utilization. This document details the history, rationale, and methodology for developing these joint documents for appropriate utilization of cardiovascular imaging.