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To provide an up-to-date analysis on the relationship between excise taxes and the prevalence of cigarette smoking in the United States. Linear mixed-effects models were used to model the relationship between excise taxes and prevalence of cigarette smoking in each state from 2001 through 2015. From 2001 through 2015, increases in state-level excise taxes were associated with declines in prevalence of cigarette smoking. The effect was strongest in young adults (age 18-24) and weakest in low-income individuals (<$25,000). Despite the shrinking pool of current smokers, excise taxes remain a valuable tool in public-health efforts to reduce the prevalence of cigarette smoking. States with high smoking prevalence may find increased excise taxes an effective measure to reduce population smoking prevalence. Since the effect is greatest in young adults, benefits of increased tax would likely accumulate over time by preventing new smokers in the pivotal young-adult years.

Few studies have evaluated outcomes after percutaneous coronary intervention (PCI) in patients with both anemia (hemoglobin < 12 g/dl in women; <13 in men) and chronic kidney disease (CKD, estimated glomerular filtration rate < 60 ml/min/1.73 m2). Patients with coronary artery disease who underwent PCI in our health system from 2010 to 2018 were included (n = 10,756), excluding those with ST-elevation myocardial infarction or shock. We evaluated the individual and combined effects of anemia and CKD on outcomes. Five-year mortality was highest in the cohort with both anemia and CKD and lowest in those with neither. After multivariate analysis, with the group with neither anemia nor CKD as a reference, the adjusted hazard ratio for mortality was 1.68 (95% confidence interval [CI] 1.45 to 1.95, p <0.001) for those with anemia alone, 1.33 (95% CI 1.15 to 1.53, p <0.001) for those with CKD alone, and 2.83 (95% CI 2.49 to 3.22, p <0.001) for those with both anemia and CKD. With respect to readmission and reintervention, similar tends were observed, with patients with both CKD and anemia having the highest risk for these outcomes. In conclusion, the combined effects of anemia and CKD on outcomes post-PCI appear to be worse than either of their effects individually.

In patients in a large registry who received coronary stents for off-label indications, there was no difference in mortality or rates of myocardial infarction at 1 year between those receiving bare-metal stents and those receiving drug-eluting stents. In the group receiving drug-eluting stents, there was a reduced need for revascularization. There was no difference in mortality or rates of myocardial infarction at 1 year between those receiving bare-metal stents and those receiving drug-eluting stents. In the group receiving drug-eluting stents, there was a reduced need for revascularization. In 2003, the Food and Drug Administration (FDA) approved drug-eluting stents for the treatment of coronary artery disease. This decision was based on the results of clinical trials that compared a bare-metal stent with a drug-eluting stent in highly selected patients. 1 – 10 Because of the magnitude of the treatment effect of drug-eluting stents in suppressing the recurrence of lesions, consistent positive reports from subsequent trials of small subgroups, and firsthand experiences, physicians extended the use of drug-eluting stents to patients with clinical and anatomical features beyond those of patients in the FDA-approval trials. The use of drug-eluting stents in this . . .

Background More than a million diagnostic cardiac catheterizations are performed annually in the US for evaluation of coronary artery anatomy and the presence of atherosclerosis. Nearly half of these patients have no significant coronary lesions or do not require mechanical or surgical revascularization. Consequently, the ability to rule out clinically significant coronary artery disease (CAD) using low cost, low risk tests of serum biomarkers in even a small percentage of patients with normal coronary arteries could be highly beneficial. Methods Serum from 359 symptomatic subjects referred for catheterization was interrogated for proteins involved in atherogenesis, atherosclerosis, and plaque vulnerability. Coronary angiography classified 150 patients without flow-limiting CAD who did not require percutaneous intervention (PCI) while 209 required coronary revascularization (stents, angioplasty, or coronary artery bypass graft surgery). Continuous variables were compared across the two patient groups for each analyte including calculation of false discovery rate (FDR ≤ 1%) and Q value ( P value for statistical significance adjusted to ≤ 0.01). Results Significant differences were detected in circulating proteins from patients requiring revascularization including increased apolipoprotein B100 (APO-B100), C-reactive protein (CRP), fibrinogen, vascular cell adhesion molecule 1 (VCAM-1), myeloperoxidase (MPO), resistin, osteopontin, interleukin (IL)-1β, IL-6, IL-10 and N-terminal fragment protein precursor brain natriuretic peptide (NT-pBNP) and decreased apolipoprotein A1 (APO-A1). Biomarker classification signatures comprising up to 5 analytes were identified using a tunable scoring function trained against 239 samples and validated with 120 additional samples. A total of 14 overlapping signatures classified patients without significant coronary disease (38% to 59% specificity) while maintaining 95% sensitivity for patients requiring revascularization. Osteopontin (14 times) and resistin (10 times) were most frequently represented among these diagnostic signatures. The most efficacious protein signature in validation studies comprised osteopontin (OPN), resistin, matrix metalloproteinase 7 (MMP7) and interferon γ (IFNγ) as a four-marker panel while the addition of either CRP or adiponectin (ACRP-30) yielded comparable results in five protein signatures. Conclusions Proteins in the serum of CAD patients predominantly reflected (1) a positive acute phase, inflammatory response and (2) alterations in lipid metabolism, transport, peroxidation and accumulation. There were surprisingly few indicators of growth factor activation or extracellular matrix remodeling in the serum of CAD patients except for elevated OPN. These data suggest that many symptomatic patients without significant CAD could be identified by a targeted multiplex serum protein test without cardiac catheterization thereby eliminating exposure to ionizing radiation and decreasing the economic burden of angiographic testing for these patients.

The optimal duration of dual-antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is an important, unanswered question. This study was designed to evaluate the association of varying durations of DAPT on clinical outcomes after DES implantation for the treatment of coronary artery disease. Using the National Heart, Lung, and Blood Institute Dynamic Registry, patients enrolled in the last 2 waves after index percutaneous coronary intervention with DES and who were event free at the time of landmark analysis were included. Landmark analysis was performed 12 and 24 months after percutaneous coronary intervention, and patients were stratified according to continued use of DAPT or not. Subjects were evaluated for rates of death, myocardial infarction, and stent thrombosis at 4 years from their index procedures. The numbers of evaluable patients were 2,157 and 1,918 for the 12- and 24-month landmarks, respectively. In both landmark analyses, there was a significantly lower 4-year rate of death or myocardial infarction in the group that continued DAPT compared to the group that did not (12 months: 10.5% vs 14.5%, p = 0.01; 24 months: 5.7% vs 8.6%, p = 0.02). Beneficial differences in the group that continued on DAPT were preserved after multivariate and propensity adjustment. There were no significant differences in definite stent thrombosis in either landmark analysis. In conclusion, at 12 and 24 months after DES implantation, continued use of DAPT was associated with lower 4-year risk for death and myocardial infarction.

In the practice of percutaneous coronary intervention, post-dilation often is performed after stent deployment to improve stent expansion. However, aggressive mechanical expansion is a risk factor of distal embolization and microvascular injury, especially for patients with acute myocardial infarction (AMI). Few studies have investigated the effects of post-dilation on medium-term clinical outcomes. Patients enrolled in the multicenter NHLBI Dynamic Registry between 2001 and 2006 were evaluated. Patients who were treated with ≥1 stent were studied. Patients with cardiogenic shock or history of coronary artery bypass graft surgery were excluded. Patients were followed up to 1 year. Because of the significant statistical interaction ( P = .02) between post-dilation and AMI status on the hazard of death/myocardial infarction (MI), post-dilation effects were estimated separately for patients who did and did not present with an AMI. Among the 1,358 patients who presented with an AMI, post-dilation was associated with a significantly higher risk of death/MI (hazard ratio [HR] = 1.78, 95% CI 1.12-2.83, P = .01), not associated with the risk of repeat revascularization (HR = 1.15, 95% CI 0.81-1.62, P = .43). Among the 3,001 patients who did not present with AMI, post-dilation was not associated with risks of death/MI (HR = 1.08, 95% CI 0.77-1.50, P = .67) or repeat revascularization (HR = 1.17, 95% CI 0.93-1.47, P = .19). Similar effects were observed for the restricted analysis with additional adjustment for lesion characteristics among the 1,039 AMI patients and 2,179 non-AMI patients with a single lesion treated. Stent post-dilation is associated with an increased risk of death/MI in AMI patients but not in non-AMI patients. Further investigation is warranted.

Several factors contribute to the risk of percutaneous coronary intervention–related major entry site (MES) complications. We sought to examine the trends in MES among unselected patients during the stent era. Data from the Dynamic Registry including 5 distinct recruitment waves from 1997 to 2006 (n = 10,932) were used to assess baseline characteristics and MES among consecutive patients undergoing percutaneous coronary intervention. MES was defined as bleeding requiring transfusion, pseudoaneurysm, arterial thrombosis or dissection, vascular complication requiring surgery, or retroperitoneal bleed. Uncomplicated hematomas were not included. Several trends were observed in baseline characteristics including an increase from wave 1 to wave 5 in body mass index >30 kg/m2 (30.2% to 40.4%), renal disease (3.5% to 9.1%), diabetes (28.0% to 34.1%), and hypertension (59.4% to 78%; ptrend <0.001 for all). The use of a thienopyridine increased significantly from wave 1 (49.7%) to wave 5 (84%), whereas glycoprotein IIb/IIIa inhibitor use peaked in wave 3 (53.1%) and then decreased (p <0.001). Access site was predominately femoral, but radial access increased over time (0.3% wave 1, 6.6% wave 5, p ≤0.0001). The rates of MES (2.8% to 2.2%, ptrend = 0.01) and MES requiring transfusion (2.0% to 0.74%, ptrend <0.001) were low and decreased with time. The trend in less risk for MES in later time periods remained after adjustment. In conclusion, MES has decreased over time; however, opportunity for bleeding avoidance strategies still exists.

Patients with atrial fibrillation (AF) commonly have impaired renal function. The safety and efficacy of direct oral anticoagulants (DOACs) in patients with chronic kidney disease (CKD) and end-stage renal disease has not been fully elucidated. This study evaluated and compared the safety outcomes of DOACs versus warfarin in patients with nonvalvular AF and concomitant CKD. Patients in our health system with AF prescribed oral anticoagulants during 2010 to 2017 were identified. All-cause mortality, bleeding and hemorrhagic, and ischemic stroke were evaluated based on degree of renal impairment and method of anticoagulation. There were 21,733 patients with a CHA2DS2-VASc score of ≥2 included in this analysis. Compared with warfarin, DOAC use in patients with impaired renal function was associated with lower risk of mortality with a hazard ratio (HR): 0.76 (95% confidence interval [CI] 0.70 to 0.84, p value <0.001) in patients with eGFR >60, HR 0.74 (95% CI 0.68 to 0.81, p value <0.001) in patients with eGFR >30 to 60, and HR 0.76 (95% CI 0.63 to 0.92, p value <0.001) in patients with eGFR ≤30 or on dialysis. Bleeding requiring hospitalization was also less in the DOAC group with a HR 0.93 (95% CI 0.82 to 1.04, p value 0.209) in patients with eGFR >60, HR 0.83 (95% CI 0.74 to 0.94, p value 0.003) in patients with eGFR >30 to 60, and HR 0.69 (95% CI 0.50 to 0.93, p value 0.017) in patients with eGFR ≤30 or on dialysis. In conclusion, in comparison to warfarin, DOACs appear to be safe and effective with a lower risk of all-cause mortality and lower bleeding across all levels of CKD.

Although guidelines recommend low-density lipoprotein cholesterol (LDL-C) to be < 70 mg/dL in patients with atherosclerotic cardiovascular disease (ASCVD), the rate of achieving this goal remains suboptimal. We sought to understand real world contemporary practice patterns of LDL-C management in patients with ASCVD, and whether LDL-C testing influenced management across US health systems. A retrospective cohort study utilizing electronic medical record data from five health systems participating in the CardioHealth Alliance was performed on patients with an LDL-C measurement in 2021 and prior ASCVD. Multivariable regression modeling was used to determine the relationship of clinical factors with achievement of guideline directed LDL-C target. Changes in lipid lowering therapy (LLT) after LDL-C testing were also described. Among 216,074 patients with ASCVD, 129,886 (60.1%) had uncontrolled LDL-C (i.e. ≥ 70 mg/dL). Compared with participants with controlled LDL-C (< 70 mg/dL), those with uncontrolled LDL-C were more frequently female (50.9% vs. 35.1%), or Black (13.7% vs. 10.3%), and less commonly had coronary artery disease as the form of vascular disease (73.0% vs. 83.5% %), heart failure (21.3% vs. 29.1% %), diabetes (34.1% vs. 48.2%), atrial fibrillation (19.3% vs. 26.1%), or chronic kidney disease (25.1% vs. 32.2%). In multivariable analyses, the factors most strongly associated with failure to achieve LDL-C control were female sex (RR 1.13 [95% CI 1.12-1.14] P < .001) and Black race (1.15 [1.14-1.17] P < .001). Among the 53,957 (41.5%) of those with uncontrolled LDL-C ≥70 mg/dL not on lipid lowering therapy (LLT) at baseline, only 21% were initiated on any LLT within 6 months of the uncontrolled LDL-C value. Within 5 diverse large health systems in the CardioHealth Alliance, more than half of the patients with ASCVD had uncontrolled LDL-C with significant disparities based on sex and race at baseline. The vast majority were not initiated on any lipid lowering therapy within 6 months of an elevated test result indicating persistent gaps in care that will likely worsen health inequities in outcomes. This highlights the urgent need for implementation efforts to improve equitable care.

•ML models outperformed conventional scores in predicting major bleeding in AF.•Random forest achieved an AUC of 0.76 vs HAS-BLED's AUC of 0.57 (p < 0.001).•SHAP analysis identified new bleeding risk factors like BMI and cholesterol profile.•Study included 24,468 AF patients on DOACs with a 5-year follow-up for bleeding events.•ML models offer more personalized bleeding risk assessment for AF patients on DOACs. Predicting major bleeding in nonvalvular atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) is crucial for personalized care. Alternatives like left atrial appendage closure devices lower stroke risk with fewer nonprocedural bleeds. This study compares machine learning (ML) models with conventional bleeding risk scores (HAS-BLED, ORBIT, and ATRIA) for predicting bleeding events requiring hospitalization in AF patients on DOACs at their index cardiologist visit. This retrospective cohort study used electronic health records from 2010 to 2022 at the University of Pittsburgh Medical Center. It included 24,468 nonvalvular AF patients (age ≥18) on DOACs, excluding those with prior significant bleeding or warfarin use. The primary outcome was hospitalization for bleeding within one year, with follow-up at one, two, and five years. ML algorithms (logistic regression, classification trees, random forest, XGBoost, k-nearest neighbor, naïve Bayes) were compared for performance. Of 24,468 patients, 553 (2.3%) had bleeding within one year, 829 (3.5%) within two years, and 1,292 (5.8%) within five years. ML models outperformed HAS-BLED, ATRIA, and ORBIT in 1-year predictions. The random forest model achieved an AUC of 0.76 (0.70 to 0.81), G-Mean of 0.67, and net reclassification index of 0.14 compared to HAS-BLED's AUC of 0.57 (p < 0.001). ML models showed superior results across all timepoints and for hemorrhagic stroke. SHAP analysis identified new risk factors, including BMI, cholesterol profile, and insurance type. In conclusion, ML models demonstrated improved performance to conventional bleeding risk scores and uncovered novel risk factors, offering potential for more personalized bleeding risk assessment in AF patients on DOACs.