Explore the vast range of titles available.

Although sex differences exist in the management of acute coronary syndromes, less is known about the management and outcomes of women and men with suspected coronary artery disease being evaluated with noninvasive testing (NIT). We investigated sex-based differences in NIT results and subsequent clinical management in 4,720 women and 4,246 men randomized to CT angiography versus stress testing in the PROMISE trial. Logistic regression models assessed relationships between sex and referral for catheterization, revascularization, and aspirin or statin use. Cox regression models assessed the relationship between sex and the composite of all-cause death, myocardial infarction, or unstable angina. Women more often had normal NITs than men (61.0% vs 49.6%, P < .001) and less often had mild (29.3% vs 35.4%, P < .001), moderate (4.0% vs 6.8%, P < .001), or severe abnormalities (5.7% vs 8.3%, P < .001) found on NIT. Women were less likely to be referred for catheterization than men (7.6% vs 12.6%, adjusted OR 0.75 [0.62-0.90]; P = .002). Of those who underwent catheterization within 90 days of randomization (358 women, 534 men), fewer women than men had obstructive coronary artery disease (40.8% vs 60.9%, P < .001). At a 60-day visit, women were significantly less likely than men to report statin use when indicated (adjusted OR 0.81 [0.73-0.91]; P < .001) but were similarly likely to report aspirin use when indicated (adjusted OR 0.78 [0.56-1.08]; P = .13). Over a median follow-up of 25 months, women had better outcomes than men (adjusted OR 0.73 [0.57-0.94]; P = .017). Although women more frequently had normal NITs compared with men, those with abnormalities on NIT were less likely to be referred for catheterization or to receive statin therapy. The high rates of negative NIT in women, coupled with the better outcomes compared with men, strongly support the need for a sex-specific algorithm to guide NIT and chest pain management.

The ICTUS trial was a study that compared an early invasive with a selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome (nSTE-ACS). The study reported no difference between the strategies for frequency of death, myocardial infarction, or rehospitalisation after 1 year. We did a follow-up study to assess the effects of these treatment strategies after 4 years. 1200 patients with nSTE-ACS and an elevated cardiac troponin were enrolled from 42 hospitals in the Netherlands. Patients were randomly assigned either to an early invasive strategy, including early routine catheterisation and revascularisation where appropriate, or to a more selective invasive strategy, where catheterisation was done if the patient had refractory angina or recurrent ischaemia. The main endpoints for the current follow-up study were death, recurrent myocardial infarction, or rehospitalisation for anginal symptoms within 3 years after randomisation, and cardiovascular mortality and all-cause mortality within 4 years. Analysis was by intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN82153174. The in-hospital revascularisation rate was 76% in the early invasive group and 40% in the selective invasive group. After 3 years, the cumulative rate for the combined endpoint was 30·0% in the early invasive group compared with 26·0% in the selective invasive group (hazard ratio 1·21; 95% CI 0·97–1·50; p=0·09). Myocardial infarction was more frequent in the early invasive strategy group (106 [18·3%] vs 69 [12·3%]; HR 1·61; 1·19–2·18; p=0·002). Rates of death or spontaneous myocardial infarction were not different (76 [14·3%] patients in the early invasive and 63 [11·2%] patients in the selective invasive strategy [HR 1·19; 0·86–1·67; p=0·30]). No difference in all-cause mortality (7·9%vs 7·7%; p=0·62) or cardiovascular mortality (4·5%vs 5·0%; p=0·97) was seen within 4 years. Long-term follow-up of the ICTUS trial suggests that an early invasive strategy might not be better than a more selective invasive strategy in patients with nSTE-ACS and an elevated cardiac troponin, and implementation of either strategy might be acceptable in these patients.

A literature on systematic treatment protocols for patients after resuscitation for cardiac arrest is lacking. We evaluated a systematic protocol, including ECG, echocardiogram, urgent cardiac catheterisation (“STEMI-like” workflow), CT scans, laboratory findings, IABP, hypothermia, and cMRI, prospectively over 5 years. The primary endpoint was the Cerebral Performance Category Scale (CPCS). During the period from January 2008 to December 2012, 212 patients were included. The mean age was 66.7 years, n  = 151 (71.2 %) were male, mean time from the first medical contact to start of catheterisation was 76.6 min, and ventricular fibrillation (VF) was present in n  = 99 (46.7 %). A significant coronary artery stenosis was seen in n  = 130 (61.3 %), PCI was performed in n  = 101 (47.6 %), an ACS was found in n  = 100 (47.2 %), n  = 91 patients (42.9 %) had another cardiac cause, an extra-cardiac cause was found in n  = 12 (5.7 %, mostly a cerebral process), and in 9 patients (4.3 %), no cause was identifiable. A significant difference in mortality was found for patients with TIMI flow 2/3 vs. 0/1 (65.4 vs. 95.7 %, p  < 0.01). The difference of intra-aortic balloon pumping vs. no pumping was not significant, performing hypothermia reduced mortality significantly (52.7 vs. 68.2 %, p  = 0.04). The survival rate was n  = 76 (35.9 %), a CPCS of 1/2 was reached in n  = 68 pts (32.1 %), patients with ongoing resuscitation had a 100 % mortality ( n  = 41), and VF had a lower mortality (54.6 vs. 72.6 %, p  < 0.01). A systematic algorithm may improve the outcome of patients after reanimation compared with classically reported outcomes. The data are hypothesis generating for further studies.

Purpose Cryoballoon ablation of the pulmonary veins (CAPV) is a new technique that could have similar results to radiofrequency procedures, but with fewer complications. We analyzed the outcomes and safety of this technique in a consecutive cohort of patients with atrial fibrillation (AF). Methods A total of 63 patients with paroxysmal ( n  = 40) or persistent ( n  = 23) AF were studied. Patient follow-up was performed at 3 months and then every 6 months with 72-h continuous electrocardiographic recordings. Results A total of 262 pulmonary veins were treated; 60.3 % of the cases presented normal pulmonary vein drainage with 4 pulmonary veins, and 23.8 % of the cases presented a common left-sided antrum. Complete isolation of all veins was achieved in 95.2 % of cases with 10.3 ± 2.8 (mean ± standard deviation) applications per patient. Transient right phrenic nerve injury was the most common complication (4.7 %). Median follow-up was 5.5 months. The probability of being free of recurrence at 1 and 2 years was, respectively, 86.2 and 72.2 % for paroxysmal AF and 49 and 36.4 % for persistent AF ( P  = 0.012). Patients with structural heart disease experienced recurrence more often than patients with a normal heart (62.5 versus 24.5 %; P  = 0.03). Conclusions CAPV appears to be a safe and effective procedure for the treatment of patients with AF, particularly those with paroxysmal AF and no structural heart disease.

Despite advancements in cardiogenic shock (CS) management, mortality remains high. While hospital volume has been linked to reduced mortality across myriad complex procedures, the cross-volume effects of mechanical circulatory support (MCS) and cardiac catheterization laboratory (CCL) procedures on CS patients not receiving these interventions remain unexplored. Using the 2016 to 2022 Nationwide Readmissions Database, we analyzed nonelective adult CS admissions at MCS- and CCL-capable hospitals. Hospitals were stratified into quartiles by annual volumes of MCS (intra-aortic balloon pump, percutaneous ventricular assist device, extracorporeal membrane oxygenation) and CCL procedures (coronary angiography, percutaneous coronary intervention), with the top quartile classified as high-volume (HVH-MCS or HVHCCL). Multivariable logistic and linear regression models were constructed to evaluate the independent association of high-volume status with mortality, complications, and resource utilization. Among 130,822 CS hospitalizations, 48.2% were treated at HVH-MCS and 46.1% at HVHCCL. Unadjusted mortality was lower at HVH-MCS (24.8% vs 30.7%, p <0.001) and HVHCCL (26.6% vs 29.0%, p <0.001). Following adjustment, HVH-MCS remained associated with reduced mortality (Adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.82 to 0.93), while HVHCCL showed no significant benefit (p = 0.10). HVH-MCS also had lower respiratory (AOR 0.82, 95% CI 0.78 to 0.86) and infectious (AOR 0.85, 95% CI 0.80 to 0.90) complications, but longer hospital stays (β +1.75 days, 95% CI 1.48 to 2.01) and higher costs (+$8,600, 95% CI 7,100 to 10,100). Increasing MCS volume appears independently correlated with improved CS outcomes, highlighting the cross-volume effect of institutional expertise. Contrastingly, CCL volume was not associated with in-hospital mortality, supporting centralization of CS care at high-volume MCS centers.

We investigate whether physicians' financial incentives influence health care supply, technology diffusion, and resulting patient outcomes. In 1997, Medicare consolidated the geographic regions across which it adjusts physician payments, generating area-specific price shocks. Areas with higher payment shocks experience significant increases in health care supply. On average, a 2 percent increase in payment rates leads to a 3 percent increase in care provision. Elective procedures such as cataract surgery respond much more strongly than less discretionary services. Non-radiologists expand their provision of MRIs, suggesting effects on technology adoption. We estimate economically small health impacts, albeit with limited precision.

Guidelines recommend noninvasive tests (NITs) to risk stratify and identify patients with higher likelihood of coronary artery disease (CAD) prior to elective coronary angiography. However, a high percentage of patients are found to have nonobstructive CAD. We aimed to understand the relationship between patient characteristics, NIT findings, and the likelihood of nonobstructive CAD. Patients undergoing elective catheterization without history of CAD were identified from 1,128 hospitals in National Cardiovascular Data Registry's CathPCI Registry between July 2009 and December 2011. Noninvasive tests included stress electrocardiogram, stress echocardiogram, stress radionuclide, stress cardiac magnetic resonance, and computed tomographic angiography. Patient demographics, risk factors, symptoms, and NIT results were correlated with the presence of nonobstructive CAD, defined as all native coronary stenoses <50%. Of 661,063 patients undergoing elective angiography, 386,003 (58.4%) had nonobstructive CAD. Preprocedure NIT was performed in 64% of patients; 51.9% were reported to be abnormal, but only 9% had high-risk findings. Independent factors associated with nonobstructive CAD were younger age, female sex, atypical chest pain, and a low-risk NIT. Patients with high-risk findings on NIT were more likely to have obstructive CAD (adjusted odds ratio 3.03 [2.86-3.22]). Noninvasive test findings had minimal incremental value beyond clinical factors for predicting obstructive disease (C index = 0.75 for clinical factors vs 0.74 for NIT findings). In current practice, about two-thirds of patients undergo NIT prior to elective cardiac catheterization, yet most patients have nonobstructive CAD. The weak correlation between most NIT results and the likelihood of obstructive CAD provides further impetus for improving preangiography assessment of likelihood of disease.

Purpose The effect of Transcatheter Aortic Valve Implantation (TAVI) on left ventricular (LV) geometry and function was compared to traditional aortic replacement (AVR) by major surgery. Methods 45 patients with aortic stenosis (AS) undergoing TAVI and 33 AVR were assessed by standard echo Doppler the day before and 2 months after the implantation. 2D echocardiograms were performed to measure left ventricular (LV) mass index (LVMi), relative wall thickness (RWT), ejection fraction (EF) and the ratio between transmitral E velocity and early diastolic velocity of mitral annulus (E/e’ ratio). Valvular-arterial impedance (Zva) was also calculated. Results At baseline, the 2 groups were comparable for blood pressure, heart rate, body mass index mean transvalvular gradient and aortic valve area. TAVI patients were older (p<0.0001) and had greater LVMi (p<0.005) than AVR group. After 2 months, both the procedures induced a significant reduction of transvalvular gradient and Zva but the decrease of LVMi and RWT was significant greater after TAVI (both p<0.0001). E/e’ ratio and EF were significantly improved after both the procedure but E/e’ reduction was greater after TAVI (p<0.0001). TAVI exhibited greater percent reduction in mean transvalvular gradient (p<0.05), Zva (p<0.02), LVMi (p<0.0001), RWT (p<0.0001) and E/e’ ratio (p<0.0001) than AVR patients. Reduction of E/e’ ratio was positively related with reduction of RWT (r = 0.46, p<0.002) only in TAVI group, even after adjusting for age and percent reduction of Zva (r =0.43, p<0.005). Conclusions TAVI induces a greater improvement of estimated LV filling pressure in comparison with major prosthetic surgery, due to more pronounced recovery of LV geometry, independent on age and changes of hemodynamic load.

Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.

Purpose Propensity score matching is vital in epidemiological studies using observational data, yet its estimates relies on correct model-specification. This study assesses supervised deep learning models and unsupervised autoencoders for propensity score estimation, comparing them with traditional methods for bias and variance accuracy in treatment effect estimations. Methods Utilizing a plasmode simulation based on the Right Heart Catheterization dataset, under a variety of settings, we evaluated (1) a supervised deep learning architecture and (2) an unsupervised autoencoder, alongside two traditional methods: logistic regression and a spline-based method in estimating propensity scores for matching. Performance metrics included bias, standard errors, and coverage probability. The analysis was also extended to real-world data, with estimates compared to those obtained via a double robust approach. Results The analysis revealed that supervised deep learning models outperformed unsupervised autoencoders in variance estimation while maintaining comparable levels of bias. These results were supported by analyses of real-world data, where the supervised model’s estimates closely matched those derived from conventional methods. Additionally, deep learning models performed well compared to traditional methods in settings where exposure was rare. Conclusion Supervised deep learning models hold promise in refining propensity score estimations in epidemiological research, offering nuanced confounder adjustment, especially in complex datasets. We endorse integrating supervised deep learning into epidemiological research and share reproducible codes for widespread use and methodological transparency.