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Cardiovascular disease (CVD) is the leading cause of mortality in the world. From 2005 to 2008, the World Health Organization (WHO) planned an initiative to reduce the mortality rate of CVD by 2030 by addressing health, finance, transport, education, and agriculture in these communities. Plans were underway by many countries to meet the goals of the WHO initiative. However, in 2020, the COVID-19 pandemic derailed these goals, and many health systems suffered as the world battled the viral pandemic. The pandemic made health inequities even more prominent and necessitated a different approach to understanding and improving the socioeconomic determinants of health (SDOH). WHO initiated a special initiative to improve SDOH globally. This paper is an update on what other regions across the globe are doing to decrease, more specifically, the impact of socioeconomic determinants of cardiovascular health. Our review highlights how countries and regions such as Canada, the United States, India, Southeast Asia, the Middle East, and Africa are uniquely affected by various socioeconomic factors and how these countries are attempting to counter these obstacles by creating policies and protocols to facilitate an infrastructure that promotes screening and treatment of CVD. Ultimately, interventions directed toward populations that have been economically and socially marginalized may aid in reducing the disease and financial burden associated with CVD., (Copyright © 2024 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Although heart rate response (HRR) to regadenoson stress has been shown to be a strong predictor of outcome, it has not been investigated in a large all-comers cohort. The prognostic utility of systolic blood pressure response (SBPR) has not been investigated in comparison with HRR., Methods and Results: In a retrospective cohort of 10,227 patients undergoing regadenoson stress single-photon emission computed tomography myocardial perfusion imaging (MPI), HRR, and SBPR were calculated as 100×(peak hyperemia value-baseline value)/baseline value. During 35±21 months follow-up, 921 (8.8%) deaths were observed. The median HRR was 35% (interquartile range [IQR], 21% to 51%). The median SBPR was -9% (IQR, -17% to -2%). HRR and SBPR were independently associated with all-cause mortality with adjusted hazard ratio [HR] of .980 per 1% increment in HRR (CI, .977-.984) and .994 per 1% increment in SBPR (CI, .988-.999). Mortality rates increased with decreasing HRR quartile and SBPR tertile. HRR provided incremental prognostic value for all-cause mortality beyond clinical and imaging parameters (area under the curve [AUC] increase, .03; P<.001) and SBPR data (AUC increase, .11; P<0001). SBPR did not provide significant incremental prognostic value beyond clinical and imaging parameters or HRR data. We derived and validated HRR of <20% as a cut-off that can improve risk stratification beyond clinical and MPI findings., Conclusion: Among patients undergoing stress MPI, impaired HRR to regadenoson provided independent and incremental prognostic value for all-cause mortality beyond clinical, imaging, and SBPR data. SBPR positively correlates with HRR, but it does not provide incremental prognostic utility. HRR, but not SBPR, should be routinely reported and considered in assessing patients' overall risk. An abnormal HRR threshold of <20% can improve risk stratification., (Copyright © 2024 American Society of Nuclear Cardiology. Published by Elsevier Inc. All rights reserved.)

Background: Higher rates of CIED implantations have been associated with an increased rate of lead failures and complications resulting in higher rates of transvenous lead extractions (TLE)., Objective: To assess the trends TLE admissions and evaluate the patient related predictors of safety outcomes., Methods: National Readmission Database was queried to identify patients who underwent TLE from January 2016 to December 2019. We conducted a multivariate regression analysis to identify variables associated with in-hospital mortality in patients undergoing TLE. Additionally, we compared trends and outcomes of TLE among patients with prior sternotomy versus those without prior sternotomy and analyzed sex-based differences among patients undergoing TLE., Results: We identified 30,128 hospitalizations for TLE. The index admission in-hospital mortality rate was 3.21% with cardiac tamponade happening in 1.46% of the admissions. Age, infective endocarditis, CKD, congestive heart failure and anemia were associated with higher in-hospital mortality rates. There was a lower rate of in-hospital mortality in patients with history of prior sternotomy versus patients without (OR 0.72, CI: 0.59-0.87, p-value < 0.001). There was no difference in in-hospital mortality rate between males and females. Females had a shorter length and a higher cost of stay when compared to male gender., Conclusion: TLE admissions continue to increase. Overall rates of mortality and complications are relatively low. Patients with prior sternotomy had better outcomes and less complications when compared to those without prior sternotomy. Female gender is associated with higher rates of cardiac tamponade, yet shorter length of stay with lower cost., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In asymptomatic patients with end-stage renal disease (ESRD) wait-listed for kidney transplantation (KT), it is unclear whether a change in ischemic burden on serial surveillance SPECT myocardial perfusion imaging (MPI) impacts outcome., Methods and Results: In a retrospective cohort of 700 asymptomatic KT candidates with ≥ 2 sequential SPECT-MPI studies, we defined a significant change in ischemic burden between MPIs as ΔSDS of ≥ 2 points. Patients were followed for mean 19 ± 12 months after MPI 2 for cardiac death or myocardial infarction. Between MPIs, 29 (4%) subjects received coronary revascularization which was associated with a greater incidence of reduction in ischemic burden on MPI 2 (31% vs. 17%, P = 0.049). Among 514 patients with no ischemia on MPI 1 (SDS ≤ 1), 15% had new ischemia on MPI 2 which was associated with increased MACE (adjusted HR 1.75; CI 1.02-3.01; P = 0.041). Among 186 patients with ischemia on MPI 1 (SDS ≥ 2), 66% had improvement of ischemic burden on MPI 2 which was associated with significantly lower MACE (adjusted HR 0.46; CI 0.25-0.82; P = 0.009). There was no significant interaction between coronary revascularization and improvement in ischemic burden impacting outcome (interaction P = 0.845)., Conclusion: Among KT candidates who underwent serial MPI for CAD surveillance, new ischemia was associated with increased MACE risk. Improvement in ischemic burden was associated with lower MACE risk irrespective of coronary revascularization status., (© 2023. The Author(s) under exclusive licence to American Society of Nuclear Cardiology.)

Purpose: To characterize the recovery of diagnostic cardiovascular procedure volumes in U.S. and non-U.S. facilities in the year following the initial COVID-19 outbreak., Materials and Methods: The International Atomic Energy Agency (IAEA) coordinated a worldwide study called the IAEA Noninvasive Cardiology Protocols Study of COVID-19 2 (INCAPS COVID 2), collecting data from 669 facilities in 107 countries, including 93 facilities in 34 U.S. states, to determine the impact of the pandemic on diagnostic cardiovascular procedure volumes. Participants reported volumes for each diagnostic imaging modality used at their facility for March 2019 (baseline), April 2020, and April 2021. This secondary analysis of INCAPS COVID 2 evaluated differences in changes in procedure volume between U.S. and non-U.S. facilities and among U.S. regions. Factors associated with return to prepandemic volumes in the United States were also analyzed in a multivariable regression analysis., Results: Reduction in procedure volumes in April 2020 compared with baseline was similar for U.S. and non-U.S. facilities (-66% vs -71%, P = .27). U.S. facilities reported greater return to baseline in April 2021 than did all non-U.S. facilities (4% vs -6%, P = .008), but there was no evidence of a difference when comparing U.S. facilities with non-U.S. high-income country (NUHIC) facilities (4% vs 0%, P = .18). U.S. regional differences in return to baseline were observed between the Midwest (11%), Northeast (9%), South (1%), and West (-7%, P = .03), but no studied factors were significant predictors of 2021 change from prepandemic baseline., Conclusion: The reductions in cardiac testing during the early pandemic have recovered within a year to prepandemic baselines in the United States and NUHICs, while procedure volumes remain depressed in lower-income countries. Keywords: SPECT, Cardiac, Epidemiology, Angiography, CT Angiography, CT, Echocardiography, SPECT/CT, MR Imaging, Radionuclide Studies, COVID-19, Cardiovascular Imaging, Diagnostic Cardiovascular Procedure, Cardiovascular Disease, Cardiac Testing Supplemental material is available for this article. © RSNA, 2023., Competing Interests: Disclosures of conflicts of interest: C.B.H. No relevant relationships. S.D. Research grants to author’s institution from Pfizer, GE HealthCare, Attralus, Siemens, and Philips; consulting fees from AstraZeneca and Novo Nordisk; support from Novo Nordisk for travel to an advisory board meeting. L.J.S. No relevant relationships. T.C.V. No relevant relationships. A.D.C. Grant support from GW Heart and Vascular Institute; consultant for Siemens Healthineers; equity in Cleerly. N.B. No relevant relationships. R.J.C. No relevant relationships. G.K. No relevant relationships. J.V.V. No relevant relationships. M.C.W. Support from the British Heart Foundation (FS/ICRF/20/26002); payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or education events from Canon Medical Systems, Siemens Healthineers, and Novartis; member of the Radiology: Cardiothoracic Imaging editorial board. M.A.M. Research support from Siemens; consulting fees from Jubilant and Philips; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Jubilant. D.S.B. Receives software royalties from Cedars-Sinai Medical Center; consultant for General Electric and Bayer. A.B. No relevant relationships. R.W.B. No relevant relationships. P.E.B. No relevant relationships. M.J.B. Grant support from General Electric. R.P.B.P. Women as One grant ($25 000), paid to author’s institution; Knowledge to Practice honoraria ($500) for being a panelist during a virtual educational event; honoraria ($1000, $2500) from American College of Radiology for CME education products; member of American Society of Nuclear Cardiology board of directors, Intersocietal Accreditation Commission CT board of directors, and American College of Cardiology board of governors. M.Y.C. No relevant relationships. M.P.D. Salary support from Genentech for COVID-19 research. R.D. No relevant relationships. M.F. Grants or contracts from the National Institutes of Health (NIH) and the American Heart Association (AHA); consulting fees from Biography, Elucid, HeartFlow, and Siemens Healthineers; vice-president of the Society of Cardiovascular Computed Tomography; stock or stock options in Elucid. J.B.G. No relevant relationships. F.G.H. Grant support from GE HealthCare. R.C.H. No relevant relationships. L.K. Member of the Radiology: Cardiothoracic Imaging editorial board. V.L.M. Grants or contracts from the NIH, AHA, and Siemens; consulting fees from Siemens, INVIA Medical Imaging Solutions, and Ionetix; member of AHA Cardiovascular Radiology and Interventions Council Leadership Committee and the American Society of Nuclear Cardiology Program Committee; stock in General Electric, Ionetix, and Cardinal Health; scientific advisor to Ionetix; received software from INVIA Medical Imaging Solutions. J.N. No relevant relationships. P.F.R.L. Grants or contracts from iTHRIV Scholar, which is supported in part by the National Center for Advancing Translational Sciences of the NIH (award nos. UL1TR003015 and KL2TR003016); patent planned, issued, or pending number 3062/140PCT/US for "Methods, systems, and computer-readable media for utilizing US device to perform MV decalcification." N.R.S. Grant support from Pfizer; stock in General Electric. A.S. No relevant relationships. P.S. Grant funding from Pfizer to author’s institution and from Astellas; royalties from UpToDate; personal consulting fees from Bridgebio (Eidos), Spectrum Dynamics, Pfizer, and Alnylam; member of the American Society of Nuclear Cardiology board of directors. R.C.T. No relevant relationships. D.W. Consultant for Astellas, BridgeBio, Pfizer, and Alnylam advisory boards; payment for speakers bureaus work from Astellas and Pfizer; chair of ASNC Health Policy Committee; member of advisory boards of Bridge Bio and Alynylam, and grant interviewer for Ionis. Y.A.C. No relevant relationships. E.M. No relevant relationships. M.J.R. No relevant relationships. J.L.M. No relevant relationships. P.P. Consulting fees from Medtronic and AstraZeneca. M.S. No relevant relationships. T.N.B.P. No relevant relationships. Y.P. No relevant relationships. M.D. No relevant relationships. D.P. No relevant relationships. A.J.E. Support from the International Atomic Energy Agency to Columbia University; grants from GE HealthCare, Canon Medical Systems, W.L. Gore & Associates, Eidos Therapeutics, Attralus, Pfizer, Roche Medical Systems, and Neovasc to Columbia University; speaker’s fees from Ionetix; consulting fees from W. L. Gore & Associates; support from the Society of Nuclear Medicine and Molecular Imaging for attending meetings and/or travel; patents planned, issued, or pending for Columbia Technology Ventures; leadership or fiduciary role in the American College of Cardiology, American Society of Nuclear Cardiology, and the Society of Nuclear Medicine and Molecular Imaging; and authorship fees from Wolters Kluwer Healthcare–UpToDate., (© 2023 by the Radiological Society of North America, Inc.)

Background: Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks., Methods: We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time., Results: A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4-5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement., Conclusions: TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.

Background: Twiddler's syndrome is a poorly understood clinical phenomenon when patients either consciously or subconsciously rotate their cardiac device resulting in lead dislodgement. We aimed to determine the true prevalence and risk factors associated with Twiddler's syndrome in a real-world population., Methods: A retrospective chart review was performed on all patients who underwent cardiac device implantation from January 1st 2017 until Jan 1st 2022. We specifically searched for the terms "Twiddler" or "Twiddler's" imbedded within the text of the medical chart. Demographic and clinical variables were collected from the electronic medical record system. We utilized multivariable logistic regression analysis as well as Kaplan-Meier prediction models to determine independent clinical predictors of Twiddler's syndrome as well as associated mortality, respectively., Results: Twenty one out of 1793 patients (1.2%) were identified as having Twiddler's syndrome after chart review. Independent variables associated with Twiddler's syndrome were female sex (OR 3.76; 95% CI 1.29-10.95), antidepressant medications (OR 3.58; 95% CI 1.07-11.99), and BMI (OR 1.08; 95% CI 1.03-1.31). There was no increased six-month mortality via Kaplan-Meier analysis., Conclusion: Our study shows that 1.2% of patients in our real-world population had evidence of Twiddler's syndrome. Independent predictors of Twiddler's syndrome include female sex, antidepressant medications as well as BMI., (© 2022 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals LLC.)

Introduction We sought to investigate the association between left-sided prosthetic valve dysfunction and gastrointestinal (GI) bleeding. Methods In a retrospective cohort of patients with left-sided prostheses, we identified those who experienced one or more GI bleeds. The latest or chronologically closest echocardiogram to the GI bleed was analyzed by a blinded investigator for prosthetic valve dysfunction. Results Among 334 unique patients, 166 had aortic prostheses, 127 had mitral prostheses, and 41 had both. A total of 58 (17.4%) subjects had GI bleeding events. Patients in the "GI Bleed" group had higher mean ejection fraction (56±14% vs. 49±15%; P = 0.003) and higher prevalence of hypertension, end-stage renal disease, and liver cirrhosis compared to the "No GI Bleed" group. There was a higher prevalence of moderate or severe prosthetic valve regurgitation in the GI Bleed vs. No GI Bleed group (8.6% vs. 2.2%; P = 0.027). Moderate or severe prosthetic valve regurgitation was independently associated with GI bleeding (odds ratio, 6.18; 95% confidence interval, 1.27-30.05; P = 0.024), after adjusting for ejection fraction, hypertension, end-stage renal disease and liver cirrhosis. Paravalvular regurgitation was associated with a higher incidence of GI bleeding compared to transvalvular regurgitation (35.7% vs. 11.9%; P = 0.044). The prevalence of prosthetic valve stenosis was similar between the GI Bleed and No GI Bleed groups (6.9% vs. 5.8%; P = 0.761). Conclusion In a cohort of patients with predominantly surgically placed prosthetic valves, moderate to severe left-sided prosthetic valve regurgitation was independently associated with GI bleeding., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Hussain et al.)

Background: The utility of serial SPECT myocardial perfusion imaging (MPI) for CAD surveillance in asymptomatic ESRD patients awaiting kidney transplantation (KT) is uncertain., Methods and Results: We retrospectively investigated 700 asymptomatic KT candidates with ≥ 2 pre-transplant SPECT-MPIs (mean interval, 20 ± 13 months). Worsening MPI was defined as total perfusion deficit increase (ΔTPD) > 5%. High clinical risk was defined as ≥ 3 AHA/ACC KT risk factors. The primary outcome was major adverse cardiac events (MACE) of cardiac death or myocardial infarction. The initial MPI was normal in 462 (66%) subjects. On repeat MPI, ΔTPD > 5% was observed in 82 (12%) subjects, and the incidence increased with increasing time gap between MPIs (P = .006). During a mean follow-up of 16 ± 8 months, there were 119 (17%) MACEs. In the entire cohort, ΔTPD > 5% was not significantly associated with MACE (HR = 1.38; P = .210). ΔTPD > 5% was associated with increased MACE rate among patients with normal initial MPI (HR = 2.30; P = .005), but not among those with abnormal initial MPI (P = .260). There was a significant interaction between ΔTPD > 5% and initial MPI normalcy status in predicting MACE (interaction P = .018), such that the predictive value of ΔTPD is dependent on the initial MPI normalcy. Among subjects with normal initial MPI, ΔTPD > 5% was significantly associated with MACE only if the sum of KT risk factors was ≥ 3 (HR = 2.26; P = .016). Among 123 patients who underwent coronary angiography, ΔTPD > 5% was associated with a higher prevalence of obstructive CAD when the initial MPI was normal and the sum of KT risk factors was ≥ 3., Conclusion: Among patients with ESRD waitlisted for KT, new/worsening MPI abnormalities are expected. On serial surveillance, ΔTPD > 5% is associated with MACE and obstructive CAD among those with a normal initial MPI and ≥ 3 AHA/ACC KT risk factors., (© 2022. The Author(s) under exclusive licence to American Society of Nuclear Cardiology.)

The superiority of angiotensin receptor-neprilysin inhibitor (ARNI) over angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ARB) has not been reassessed after the publication of recent trials that did not find clinical benefits. Therefore, we performed an updated network meta-analysis comparing the efficacy and safety of ARNI, ACE-I, ARB, and placebo in heart failure with reduced ejection fraction. We included randomized clinical trials that compared ARNI, ARB, ACE-I, and placebo in heart failure with reduced ejection fraction. We extracted prespecified efficacy end points and produced network estimates, p scores, and surface under the cumulative ranking curve scores using frequentist and Bayesian network meta-analysis approaches. A total of 28 randomized controlled trials including 47,407 patients were included. ARNI was associated with lower risk of all-cause mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68 to 0.96), cardiac death (RR 0.79, 95% CI 0.64 to 0.99), and major adverse cardiac events (MACEs; RR 0.83, 95% CI 0.72 to 0.97) but higher risk of hypotension (RR 1.46, 95% CI 1.02 to 2.10) than ARB. ARNI was associated with lower risk of MACE (RR 0.85, 95% CI 0.74 to 0.97), but higher risk of hypotension (RR 1.69, 95% CI 1.27 to 2.24) compared with ACE-I. P scores and surface under the cumulative ranking curve scores demonstrated superiority of ARNI over ARB and ACE-I in all-cause mortality, cardiac death, MACE, and hospitalization for heart failure. In conclusion, ARNI was associated with improved clinical outcomes, except for higher risk of hypotension, compared with ARB and ACE-I., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) or positron emission tomography (PET) is a widely used technique for the evaluation of coronary artery disease (CAD). Interpreting physicians rely on regional variations in myocardial radiotracer uptake between rest and stress images to identify hemodynamically significant epicardial coronary artery stenosis. However, interpretation of MPI is very difficult in patients with large infarcts where there is no scintigraphically normal reference myocardium for comparison. In these patients, the stress and rest images appear similar due to balanced ischemia in the non-infarct territory. There are no clear guidelines on how to approach these cases. We present a case of MPI with a large right coronary artery territory (RCA) infarct where the left main (LM) coronary artery territory has no relative comparator and the images looked the same on stress and rest. However, the patient had multiple high-risk ancillary findings including electrocardiographic (ECG) changes with regadenoson, transient ischemic dilatation (TID), large severe inferior infarct, low myocardial blood flow (MBF) and myocardial flow reserve (MFR), but most notably increased right ventricular (RV) uptake on the stress images that was a subtle clue that we were dealing with LM equivalent in non-infarct zone. The coronary angiogram confirmed our findings. Through our case, we provide a comprehensive approach and review of literature on how to approach such challenging encounters., (© 2022 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Background: Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) is typically continued for 6-12 months depending on clinical presentation. Recent studies have evaluated the safety of shorter durations of DAPT across stable and unstable coronary syndrome but are limited by smaller patient pools and varying indications., Methods: The present study performed a systematic review and network meta-analysis comparing abbreviated (1-3 months) with standard (6-12 months) duration of DAPT. Both conventional and frequentist network meta-analyses with a random-effects model were conducted., Results: Seventeen randomized controlled trials, nine of which included 1-3 months of DAPT, were selected. The risks of any bleeding (RR 0.68, 95% CI 0.54-0.85), major bleeding (RR 0.66, 95% CI 0.50-0.86), and net adverse clinical events (NACE) (RR 0.87, 95% CI 0.76-0.99) were lower with abbreviated (1-3 months) than standard-term (6-12 months) DAPT. No significant differences in the risk of myocardial infarction (RR 1.02, 95% CI 0.87-1.18), definite or probable stent thrombosis (RR 1.11, 95% CI 0.83-1.50), and major adverse cardiac events (MACE) (RR 0.96, 95% CI 0.86-1.06) were observed. Network meta-analysis demonstrated lower risk of any bleeding, major bleeding, and NACE with shorter durations of DAPT compared with 12 months. Risks of definite or probable stent thrombosis, myocardial infarction, and MACE were not significantly different., Conclusion: The results support the growing body of evidence that abbreviated duration (1-3 months) of DAPT may be considered to reduce the risk of bleeding without any differences in myocardial infarction, stent thrombosis, or MACE., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Introduction: With the increasing adoption of left atrial appendage occlusion (LAAO) procedures and the eligibility of patients for pulmonary vein isolation (PVI) post device placement, we examined the feasibility and safety of laser balloon (LB) for PVI in patients with prior LAAO., Methods: We retrospectively examined consecutive patients with paroxysmal or persistent, drug-resistant atrial fibrillation (AF) who underwent LB PVI, after Watchman FLX device implantation at Rush University Medical Center between January 2020 and December 2021., Results: Seven patients (four persistent and three paroxysmal) with a mean age of 64 ± 11 years, predominantly male sex (86%), were included in the study. Two (29%) patients had prior cryoablation PVI with recurrence of AF. The mean CHA 2 DS 2 VASc is 2.6 ± 0.5 and the mean HAS-BLED score is 3.4 ± 0.8. The mean follow-up duration was 10 ± 7 months. The mean duration between Watchman FLX device implantation and LB PVI was 592 days. Acute first pass left pulmonary vein (PV) isolation was achieved in 100% of the procedures. There were no periprocedural complications such as death, pericardial tamponade or effusion, phrenic nerve injury, PV stenosis, device perforation or embolization, or worsening peri-device leak in any of the patients. None of the patients had AF recurrence after the blanking period., Conclusion: LB PVI was safe and effective with 100% acute isolation of left-sided veins in patients with prior LAAO device., (© 2022 Wiley Periodicals LLC.)

Cardiac risk assessment prior to liver transplantation has become widely accepted. With the emergence of nonalcoholic steatohepatitis among the leading causes of end-stage liver disease and the steady rise of the age of liver transplant recipients, the burden of cardiovascular diseases has markedly increased in this population. Selecting appropriate liver transplant candidates is crucial due to the increasing demand for scarce donor organs. The use of noninvasive cardiac imaging for pre-operative assessment of the cardiovascular status of liver transplant recipients has been on the rise, yet the optimal assessment strategy remains an area of active debate. In this review, we examine the relevant literature pertaining to the diagnostic and prognostic applications of noninvasive cardiac imaging in this population. We also propose a simple literature-based evaluation algorithm for CAD surveillance in liver transplant candidates., (© 2021. American Society of Nuclear Cardiology.)

Background: The efficacy and safety of novel oral anticoagulants (NOACs) compared to the current guideline-recommended vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients undergoing transcatheter aortic valve replacement (TAVR) has not been well established. We pooled evidence from all available studies to assess the risks and benefits of this drug class., Methods: We queried electronic databases (MEDLINE, Scopus, and Cochrane central) up until January 28th, 2022 for studies comparing NOACs to VKAs in AF patients undergoing TAVR. Results from studies were presented as risk ratios (RR) and pooled using a random-effects model. Subgroup analysis by study design and meta-regression analysis were performed to explore heterogeneity., Results: A total of 12 studies (3 RCTs and 9 observational) containing 12,203 patients (mean age 81.2 years; 50.5% men) were identified and included in the analysis. Pooled analysis revealed no significant difference between NOACs and VKAs in terms of stroke or systemic embolism (RR: 0.78; p = 0.18), major bleeding (RR: 0.84; p = 0.32), intracranial hemorrhage (RR 0.61; p = 0.06), all-cause mortality (RR: 0.69; p = 0.07), and myocardial infarction (RR: 1.60; p = 0.24) at a mean length of follow-up of 15.1 months. RCTs and observational studies did not significantly differ across outcomes on subgroup analysis. Meta-regression analysis found heterogeneity in all-cause mortality to be significantly explained by percentage of males (coefficient: 0.049, p = 0.007), mean age (coefficient: 0.221, p < 0.001), and CHA2DS2-VASc score (coefficient: -1.657, p < 0.001)., Conclusions: This meta-analysis suggests that outcomes with NOACs do not significantly differ compared to VKAs following TAVR in patients with AF., (© 2022 Wiley Periodicals LLC.)

Background: Data on the diagnostic and prognostic value of subtle abnormalities on myocardial perfusion imaging (MPI) are limited., Methods and Results: In a retrospective single-center cohort of patients who underwent regadenoson SPECT-MPI, near-normal MPI was defined as normal left ventricular ejection fraction (LVEF ≥ 50%) and a summed stress score (SSS) of 1-3 vs SSS = 0 in normal MPI. Borderline ischemia was defined as normal LVEF, SSS = 1-3, and a summed difference score (SDS) of 1 vs SDS = 0 in the absence of ischemia. Coronary angiography data within 6 months from MPI were tabulated. Patients were followed for cardiac death (CD), myocardial infarction (MI), coronary revascularization (CR), and Late CR (LCR) [> 90 days post MPI]. Among 6,802 patients (mean age, 62 ± 13 years; 42% men), followed for a mean of 2.5 ± 2.1 years, 4,398 had normal MPI, 2,404 had near-normal MPI, and 972 had borderline ischemia. Among patients who underwent angiography within 6 months, obstructive (≥ 70% or left main ≥ 50%) CAD was observed at higher rates among subjects with near-normal MPI (33.5% vs 25.5%; P = .049) and those with borderline ischemia (40.5% vs 25.8%; P = .004). During follow-up, 158 (2.3%) CD/MI, 246 (3.6%) CR, and 150 (2.2%) LCR were observed. Near-normal MPI (SSS = 1-3), compared to normal MPI (SSS = 0), was not associated with a significant difference in the risk of the composite endpoint of CD/MI (Hazard ratio [HR], 1.21; 95% confidence interval [CI], .88-1.66; P = .243) or LCR (HR 1.28; CI .93-1.78; P = .130), but was associated with a significant increase in the risk of CR (HR 1.91; CI 1.49-2.46; P < .001). Borderline ischemia (SDS = 1), compared to no ischemia (SDS = 0), was not associated with a significant difference in the risk of CD/MI [HR 1.09; CI .70-1.69; P = .693], but was associated with a significant increase in the risk of CR (HR 5.62; CI 3.08-10.25; P < .001) and LCR (HR 2.98; CI 1.36-6.53; P = .006)., Conclusion: Near-normal MPI and borderline ischemia on SPECT-MPI provide no significant prognostic information in predicting hard cardiac events but are associated with higher rates of obstructive angiographic CAD and coronary revascularizations., (© 2020. American Society of Nuclear Cardiology.)

Cardiac risk assessment before kidney transplantation has become widely accepted. However, the optimal patient selection and screening tool for cardiac assessment remain controversial. Clinicians face several challenges in this process, including the ever-growing pre-transplant population, aging transplant candidates, increasing prevalence of coronary artery disease, and scarcity of donor organs. Optimizing the cardiovascular risk profile in kidney transplant candidates is necessary to better appropriate limited donor organs and improve patient outcomes. Increasing waiting times from the initial evaluation for transplant candidacy to the actual transplant raises questions regarding re-testing and re-stratification of risk. In this review, we summarize and discuss the current literature on cardiac evaluation prior to kidney transplantation. We also propose simple evidence-based evaluation algorithms for initial and follow-up CAD surveillance in patients being wait-listed for kidney transplantation., (© 2021. American Society of Nuclear Cardiology.)

Background: The prognostic implications of ST-segment and T-wave (ST/T) abnormalities in patients undergoing stress SPECT-myocardial perfusion imaging (MPI) are not well defined., Methods and Results: This was a single-center, retrospective cohort study of consecutive patients who underwent regadenoson stress SPECT-MPI. Patients with baseline electrocardiogram (ECG) abnormalities that impede ST/T analysis or those with known coronary artery disease were excluded. Patients were categorized as having primary ST abnormalities, secondary ST/T abnormalities due to ventricular hypertrophy or right bundle branch block, T-wave abnormalities, or normal ECG. The primary outcome was major adverse cardiovascular events (MACE) defined as the composite of cardiac death or myocardial infarction. Among 6,059 subjects, 1912 (32%) had baseline ST/T abnormalities. During a mean follow-up of 2.3 ± 1.9 years, the incidence of MACE was significantly higher among patients with secondary ST/T abnormalities compared to those with normal ECG (HR 2.05; 95% confidence interval [CI], 1.04-4.05; P = 0.039). No significant difference in MACE was observed among patients with primary ST abnormalities (HR 1.64; CI 0.87-3.06; P = 0.124) or T-wave abnormalities (HR 1.15; CI 0.62-2.16; P = 0.658) compared with patients who had normal ECG. Among patients with secondary ST/T changes, abnormal MPI was not associated with a significant increase in MACE rates compared to normal MPI (HR 1.18; CI 0.31-4.58; P = 0.808). However, abnormal MPI was associated with higher MACE rates among patients with primary ST abnormalities (HR 4.50; CI 1.44-14.10; P = 0.005) and T-wave abnormalities (HR 3.74; CI 1.20-11.68; P = 0.015). Similarly, myocardial ischemia on regadenoson stress SPECT-MPI was not associated with a significant increase in MACE rates in patients with secondary ST/T abnormalities (HR 1.45; CI 0.38-5.61; P = 0.588), while it was associated with a higher incidence of MACE in patients with primary ST abnormalities (HR 3.012; CI 0.95-9.53; P = 0.049) and T-wave abnormalities (HR 5.06; CI 1.60-15.96; P = 0.002)., Conclusion: While patients with secondary ST/T abnormalities had significantly higher MACE risk, abnormal MPI or presence of myocardial ischemia on regadenoson SPECT-MPI in this group does not add prognostic information. Patients with primary ST abnormalities and T-wave abnormalities do not seem to have a significantly higher MACE risk compared to those with normal ECG; however, abnormal MPI or presence of myocardial ischemia, in these groups, correlates with higher MACE rates., (© 2020. American Society of Nuclear Cardiology.)

Background: There are limited data on the prognostic utility of regadenoson SPECT myocardial perfusion imaging (MPI) in patients with end-stage renal disease (ESRD)., Methods and Results: In a single-center, retrospective study, we analyzed consecutive ESRD patients who underwent regadenoson SPECT-MPI. The severity of MPI abnormalities and ischemic burden were determined quantitatively. The primary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiac death or myocardial infarction. Among 1,227 subjects (mean age 54 ± 13 years, 47% men), 60 (5%) MACE were observed during a mean follow-up of 2.5 ± 1.8 years. The presence and severity of MPI abnormalities and ischemic burden were associated with a stepwise increase in MACE risk. Abnormal MPI (SSS ≥ 4) was associated with increased MACE risk, independent and incremental to relevant clinical covariates; adjusted hazard ratio, 1.95; 95% confidence interval, 1.15-3.32; Δχ 2 = 5.97; P = .013. Myocardial ischemia (SDS ≥ 2) was associated with a trend towards increased MACE risk; adjusted hazard ratio, 1.63; 95% confidence interval, 0.96-2.77; Δχ 2 = 3.12; P = .072., Conclusion: In the largest cohort to date, we demonstrated the incremental prognostic value of abnormal MPI in predicting MACE risk in ESRD patients. Given its size, our study provides improved risk estimates in this population compared to previous reports., (© 2020. American Society of Nuclear Cardiology.)

Introduction: The "July effect" refers to the potential of adverse clinical outcomes related to the annual turnover of trainees. We investigated whether this impacts inpatient heart failure (HF) outcomes., Methods: Data from all adults (≥18 years) admitted with a primary diagnosis of HF at US teaching hospitals from the 2012-2014 National Inpatient Sample were analyzed. Non-teaching hospital admissions were excluded. The primary outcome was in-hospital mortality. Secondary metrics included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic and linear regression models were used to adjust for confounders. Admissions were classified into 4 quarters (Q1-Q4), based on the academic calendar. Q1 and Q4 were designated to assess the effect of novice (July effect) versus experienced trainees, respectively., Results: There were 699,675 HF admissions during Q1 and Q4 in the study period. Mean age was 71 ± 15 years and 48% were females. There were 20,270 in-hospital deaths, with no difference between Q1 and Q4; crude odds ratio (OR) 1.00, 95% confidence interval (CI) 0.94-1.07, p = 0.95. After risk adjustment, there was no in-hospital mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, 95% CI 0.89-1.03, p = 0.23. There was no difference in hospital LOS or total cost; 5.8 versus 5.8 days, p = 0.66 and $13,755 versus $13,586, p = 0.46, in Q1 and Q4, respectively., Conclusions: In this nationally representative sample, there was no evidence of a "July effect" on inpatient HF outcomes in the US. This suggests that HF patients should not delay seeking care during trainee transitions at teaching hospitals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Data on the prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) is limited and based on small cohorts., Methods and Results: We conducted a single-center, retrospective cohort study of 10,275 consecutive patients who underwent regadenoson SPECT-MPI. Among the study subjects, 28.7% had abnormal MPI and 25.5% had myocardial ischemia. Patients were followed for a mean of 2.4 ± 2.2 years for major adverse cardiac events (MACE), defined as cardiac death or myocardial infarction. There was a significant stepwise increase in MACE with an increasing burden of perfusion abnormality (P < .001) and myocardial ischemia (P < .001). Abnormal MPI (adjusted HR 1.52; 95% CI 1.21 to 1.91) and myocardial ischemia (adjusted HR 1.53; 95% CI 1.25 to 1.89) were associated with MACE, independent of and incremental to clinical covariates and left ventricular ejection fraction (LVEF). Moreover, post-stress LVEF, LVEF reserve, and left ventricular end-diastolic volume added significant prognostic information. Transient ischemic dilation ≥ 1.31 did not provide incremental prognostic value (adjusted HR 1.02; P = .906)., Conclusion: In the largest cohort to date, we demonstrated that the presence and severity of perfusion abnormality and myocardial ischemia on regadenoson stress SPECT-MPI are associated with an independent increase in MACE., (© 2020. American Society of Nuclear Cardiology.)

Aims: Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone., Methods and Results: Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74)., Conclusion: RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: Vasodilator stress myocardial perfusion imaging (MPI) is the provocative test of choice in patients with left bundle branch block (LBBB) or ventricular paced (V-paced) rhythm. The prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) in these patients has not been studied., Methods and Results: We conducted a retrospective cohort study of 562 patients [mean age, 69 ± 11 years; men, 53.3%] with LBBB (50.7%) or V-paced rhythm (49.3%) who underwent regadenoson stress SPECT-MPI. There were 321 (57.1%) subjects with abnormal MPI and 192 (34.2%) with myocardial ischemia. During a mean follow-up of 2.5 ± 1.9 years, 39 (6.9%) patients had a major adverse cardiac event (MACE), defined as cardiac death or myocardial infarction. The annualized MACE rate in patients with normal MPI was 0.9% (LBBB, 0.8%; V-paced, 1.0%). There was a significant stepwise increase in MACE rates with increasing burdens of perfusion abnormality (P < 0.001) and myocardial ischemia (P = 0.001). Increased risk with abnormal MPI [adjusted hazard ratio, 4.26; P = 0.001] and myocardial ischemia [adjusted hazard ratio, 2.70; P = 0.003] was independent of and incremental to important clinical covariates. Abnormal MPI and myocardial ischemia predicted MACE similarly in both LBBB and V-paced subgroups (interaction P values > 0.05)., Conclusion: In patients with LBBB and V-paced rhythm, regadenoson stress SPECT-MPI provides independent and incremental prognostic value in predicting adverse cardiac events.

Background: To investigate sex differences in coronavirus disease 2019 (COVID-19) outcomes in a large Illinois-based cohort. Methods: A multicenter retrospective cohort study compared males versus females with COVID-19 infections from March 1, 2020, to June 21, 2020, in the Rush University System. We analyzed sex differences in rates of hospitalization, intensive care unit (ICU) admission, vasopressor use, endotracheal intubation, and death in this cohort. A multivariable model correcting for age and sum of comorbidities was used to explore associations between sex and COVID-19-related outcomes. Results: There were 8108 positive COVID-19 patients-4300 (53.0%) females and 3808 (47.0%) males. Males had higher rates of hospitalization (19% vs. 13%; p  < 0.001), ICU transfer (8% vs. 4%; p  < 0.001), vasopressor support (4% vs. 2%; p  < 0.001), and endotracheal intubation (5% vs. 2%; p  < 0.001). Of those who died, 92 were males and 64 were females (2% vs. 1%; p  = 0.003). A multivariable model correcting for age and sum of comorbidities showed a significant association between male sex and mortality in the total cohort (odds ratio, 1.96; 95% confidence interval, 1.34-2.90; p  = 0.001). Conclusion: Male sex was independently associated with death, hospitalization, ICU admissions, and need for vasopressors or endotracheal intubation, after correction for important covariates.

Background: Heart disease remains the leading cause of death in the United States. Although there are clear indications for revascularization in patients with acute coronary syndromes, there is debate regarding the benefits of revascularization in stable ischemic heart disease. We sought to perform a comprehensive meta-analysis to assess the role of revascularization compared to conservative medical therapy alone in patients with stable ischemic heart disease., Hypothesis: There is no significant difference in all-cause mortality or cardiovascular mortality between invasive and medical arms., Methods: We performed a systematic literature search from January 2000 to June 2020. Our literature search yielded seven randomized controlled trials. We analyzed a total of 12 013 patients (6109 in revascularization arm and 5904 in conservative medical therapy arm). Primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac events (MACE) (death, myocardial infarction [MI], or stroke), cardiovascular mortality, MI, and stroke. Additional subgroup analysis for all-cause mortality was performed comparing percutaneous coronary intervention (PCI) with bare metal stent versus conservative therapy; and PCI with drug eluting stent versus conservative therapy., Results: There was no statistically significant difference in primary outcome of all-cause mortality between either arm (odds ratio [OR] = 0.95; 95% CI [confidence interval], 0.83 to 1.08; p = .84). There were statistically significant lower rates of MACE (death, MI or stroke) in the revascularization arm when compared to conservative arm., Conclusions: Our analysis did not show any survival advantage of an initial invasive strategy over conservative medical therapy in patients with stable coronary artery disease (CAD)., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: Tc-99m pyrophosphate (PYP) SPECT is recommended for indeterminate findings on planar imaging. We aimed to compare the findings on planar PYP scintigraphy alone to that of routinely performed PYP SPECT., Methods: PYP scintigraphy data of 133 patients (53% men; mean age 76 years) were evaluated. SPECT was routinely performed following 1-hour planar imaging, in all cases. Semiquantitative visual score and heart-to-contralateral (H/CL) ratio were determined in all patients as recommended., Results: PYP images from 35 patients (26%) were considered to be positive based on SPECT myocardial uptake. Among them, 20 (57%) had a H/CL ratio ≥1.5 and 34 had a visual score ≥ 2. SPECT identified myocardial uptake in one patient with a visual score < 2 and refuted the presence of myocardial uptake in two patients with a visual score ≥ 2. Visual score correlated well with SPECT (r = 0.94; P < .0001) and had an accuracy of 98% for tomographic myocardial uptake. Addition of H/CL ratio reduced the diagnostic performance of visual score., Conclusions: Planar-derived visual score has an excellent accuracy for tomographic myocardial uptake, though it misclassifies a small proportion of patients. H/CL ratio decreases the diagnostic certainty of planar imaging. Tomographic imaging prevents misdiagnoses and should always be performed.

Aims: Discontinuation or non-publication of trials may hinder scientific progress and violates the commitment made to research participants. We sought to identify the prevalence of discontinuation and non-publication of heart failure (HF) clinical trials., Methods and Results: We conducted a cross-sectional search of ClinicalTrials.gov to identify all completed and discontinued HF clinical trials. We limited our search to only include trials that were completed by 31 December 2017. Trials were investigated to identify reasons for discontinuation. Informative termination was defined as trial termination due to safety or efficacy concerns. Data pertaining to the trial phase, funding, intervention, enrolment, and trial completion date were extracted for each trial. A total of 572 trials were included. Of these, 21% (n = 118) were discontinued before completion. Patient accrual was the most frequently cited reason (n = 42; 36%) for trial discontinuation, followed by informative termination (n = 16; 14%) and funding (n = 14; 12%). Overall, 24 780 patients were enrolled in trials that were terminated. Of trials that were completed and not terminated, nearly one-third (n = 131/454; 29%) were not published. Seventy-nine (24%) trials were published within 12 months, 192 (59%) within 24 months, and 252 (78%) trials within 36 months., Conclusions: Discontinuation and non-publication of HF trials is common. This raises ethical concerns towards participants who volunteer for research and are exposed to potential risks, inconvenience, and discomfort without furthering scientific progress., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Cardiovascular randomized controlled trials (RCTs) typically set composite end points as the primary outcome to enhance statistical power. However, influence of individual component end points on overall composite outcomes remains understudied., Methods: We searched MEDLINE for RCTs published in 6 high-impact journals (The Lancet, the New England Journal of Medicine, Journal of the American Medical Association, Circulation, Journal of the American College of Cardiology and the European Heart Journal) from 2011 to 2017. Two-armed, parallel-design cardiovascular RCTs which reported composite outcomes were included. All-cause or cardiovascular mortality, myocardial infarction, heart failure, and stroke were deemed "hard" end points, whereas hospitalization, angina, and revascularization were identified as "soft" end points. Type of outcome (primary or secondary), event rates in treatment and control groups for the composite outcome and of its components according to predefined criteria., Results: Of the 45.8% (316/689) cardiovascular RCTs which used a composite outcome, 79.4% set the composite as the primary outcome. Death was the most common component (89.8%) followed by myocardial infarction (66.1%). About 80% of the trials reported complete data for each component. One hundred forty-seven trials (46.5%) incorporated a "soft" end point as part of their composite. Death contributed the least to the estimate of effects (R 2 change = 0.005) of the composite, whereas revascularization contributed the most (R 2 change = 0.423)., Conclusions: Cardiovascular RCTs frequently use composite end points, which include "soft" end points, as components in nearly 50% of studies. Higher event rates in composite end points may create a misleading interpretation of treatment impact due to large contributions from end points with less clinical significance., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: In patients undergoing regadenoson SPECT myocardial perfusion imaging (MPI), the prognostic value of ischemic ST-segment depression (ST↓) and the optimal ST↓ threshold have not been studied., Methods: A retrospective cohort study of consecutive patients referred for regadenoson stress MPI was conducted. Patients with uninterpretable ECG were excluded. Two diagnostic thresholds of horizontal or downsloping ST↓ were studied, ≥ 0.5 mm and ≥ 1.0 mm. The primary endpoint was the composite major adverse cardiac events (MACE) of cardiac death, myocardial infarction, or coronary revascularization., Results: Among 8615 subjects (mean age 62 ± 13 years; 55% women), 89 (1.0%) had ST↓ ≥ 1.0 mm and 133 (1.5%) had ST↓ ≥ 0.5 mm. Regadenoson-induced ST↓ was more common in women (P < .001). Mean follow-up was 2.5 ± 2.2 years. After multivariate adjustment, ST↓ ≥ 1.0 mm was associated with a non-significant increase in MACE risk (P = .069), irrespective to whether MPI was abnormal (P = .162) or normal (P = .214). Ischemic ST↓ ≥ 0.5 mm was independently associated with MACE in the entire cohort (HR 2.14; CI 1.38-3.32; P = .001), whether MPI is normal (HR 2.07; CI 1.07-4.04; P = .032) or abnormal (HR 2.24; CI 1.23-4.00; P = .007), after adjusting for clinical and imaging covariates. An ST↓ threshold of ≥ 0.5 mm provided greater incremental prognostic value beyond clinical and imaging parameters (Δχ 2  = 12.78; P < .001) than ≥ 1.0 mm threshold (Δχ 2  = 3.72; P = .093)., Conclusion: Regadenoson-induced ischemic ST↓ is more common in women and it provides a modest independent prognostic value beyond MPI and clinical parameters. ST↓ ≥ 0.5 mm is a better threshold than ≥ 1.0 mm to define ECG evidence for regadenoson-induced myocardial ischemia.

Background: There is little data on the impact of chronic thrombocytopenia (CTP) on outcomes after transcatheter aortic valve repair (TAVR). Most studies are from single centers and mostly focused on postprocedure thrombocytopenia., Objectives: This study sought to report on the impact of CTP (>1 year) on in-hospital outcomes and healthcare resource utilization after TAVR., Methods: From the National Inpatient Sample (NIS) between 2012 and 2015, we identified patients with CTP who underwent TAVR. A 1:1 propensity-matched cohort was created to examine in-hospital outcomes in patients with and without CTP. The primary outcome was in-hospital mortality. Secondary outcomes included postprocedure complications, length of stay, total cost, and discharge disposition., Results: A matched pair of 4,300 patients with and without CTP were identified. Patients with CTP had higher in-hospital mortality as compared to no CTP patients (6.0 vs. 3.3%, p-value .007), increased postprocedure hemorrhage, platelet and blood transfusion, vascular complications, postop sepsis, and acute kidney injury. With regards to resource utilization, CTP patients had a longer length of stay, higher total cost and were more likely to be discharged to a facility (34.1 vs. 27.6%) other than home (All, p-value <.001). Subanalysis, however, revealed this difference in resource utilization was seen when patients developed postprocedure complications., Conclusion: This study demonstrated higher risk of in-hospital mortality, perioperative complications, and healthcare resource utilization in patients with baseline CTP undergoing TAVR. Further studies are required to investigate ways to improve the management of these patients., (© 2019 Wiley Periodicals, Inc.)

Purpose of Review: To examine the utility and methods of coronary artery disease (CAD) assessment in patients with new-onset heart failure with reduced ejection fraction (HFrEF) of unclear etiology. Moreover, we sought to review the role and techniques of assessing myocardial viability to guide coronary revascularization in patients with established ischemic cardiomyopathy., Recent Findings: Data indicates that surgical coronary revascularization in patients with HFrEF due to ischemic cardiomyopathy leads to lower long-term all-cause mortality and cardiovascular hospitalizations. Thus, identifying ischemic heart disease in patients with new-onset HFrEF is essential. In addition to invasive coronary angiography (ICA), radionuclide myocardial perfusion imaging, coronary CT angiography (CCTA), and cardiac magnetic resonance (CMR) imaging have emerged as effective non-invasive tools in the assessment of CAD in this population. Viability testing remains an area of particular interest and debate and its full potential has not been fully addressed. We propose stepwise algorithms for CAD and viability assessment in this patient population. Non-invasive testing with radionuclide myocardial perfusion imaging, CCTA, and CMR is an alternative to ICA for CAD assessment in patients with new-onset HFrEF of unclear etiology. Several non-invasive imaging modalities have proved to be effective in detecting viable myocardium in patients with ischemic cardiomyopathy. The use of viability imaging to guide coronary revascularization should be individualized.

Competing Interests: Competing interests: MPP does consultancy work for Abbott Medical and LivaNova and received funds to attend a Cryolife Investigators Meeting. TK is a speaker bureau/proctor for Edwards Lifesciences, Medtronic and Abbott Vascular.

Background: The Internet is the primary source of information for prospective cardiology fellowship aspirants. The objective of this study was to evaluate cardiology fellowship programs' online profile. Materials & methods: Two independent reviewers accessed 221 US based cardiology fellowship program websites obtained through Fellowship and Residency Electronic Interactive Database for pre-selected 20 criteria. The update status of websites was assessed using 6-point criteria. Results: Only 25 (11.3%) websites were fully up-to-date; 23 (10.4%) fulfilled 80% of the 20-point criteria and 85 (38.5%) program websites had fewer than 50% of the criteria listed. Conclusion: Most cardiology fellowship program websites lack crucial details. In this technology driven age, efforts should be made to ensure updated websites.

BRASH syndrome is characterized by bradycardia, renal failure, use of an atrioventricular nodal blocker (AVNB), shock, and hyperkalemia. These symptoms represent an ongoing vicious cycle in a patient with a low glomerular filtration rate taking an AVNB. Decreased clearance of the medication and hyperkalemia associated with renal failure synergize to cause bradycardia and hypoperfusion. This reaction causes renal function to worsen, thereby perpetuating the cycle of BRASH syndrome., Competing Interests: Conflict of Interest Disclosure: The authors have completed and submitted the Methodist DeBakey Cardiovascular Journal Conflict of Interest Statement and none were reported., (© 2020 Houston Methodist Hospital Houston, Texas.)

Background: A lifesaving treatment for myocardial infarction is the placement of a stent in a closed or obstructed coronary artery. The largest modifiable risk factor after receiving a stent is medication adherence to Dual AntiPlatelet Therapy, a combination of P2Y12 inhibitors and aspirin., Objective: This study aimed to determine the acceptability of a protocol and an intervention using the My Interventional Drug-Eluting Stent Educational App (MyIDEA) and to evaluate medication adherence using the proportion of days covered (PDC) and platelet activation tests in a multisite randomized controlled trial., Methods: Potential participants who received a post percutaneous coronary intervention (PCI) procedure with a drug-eluting stent were approached. All patients older than 50 years and who spoke English were recruited. Participants were recruited, baseline demographics were collected, and the Hospital Anxiety and Depression Scale (HADS), Rapid Estimate of Adult Literacy in Medicine-Short Form, Burden-Benefit questionnaire, 36-Item Short Form Health Survey, and PCI knowledge questionnaire were administered. Block randomization was used to randomize participants to either usual care or MyIDEA supplementation. MyIDEA is a personalized educational intervention based on the Kolb experiential learning theory using patient narratives for education. During the visits, participants' blood was collected to measure platelet suppression from medication. During the second and third encounters, the Morisky medication adherence score and cardiology outcomes were measured. The study was conducted at the University of Illinois Hospital and John H Stroger Jr Cook County Hospital with appropriate ethical approvals. Platelet suppression was measured through aspirin reactive units and P2Y12 reactive units. Medication adherence was measured using the PDC. The analysis team was blinded to the participants' group membership. The primary outcome was a feasibility analysis of recruitment and retention., Results: The mean age of participants was 60.4 years (SD 7.1); the majority of patients were black and non-Hispanic. The majority of patients' reading levels were seventh grade or above, and they were not very familiar with other electronic devices for information and communication. The number of control subjects was 21, and the number of participants in the interventional arm was 24. The interventional group was able to use MyIDEA in both the hospital and outpatient setting. However, there was no significant difference in platelet suppression or medication adherence between groups. There were also differences between the groups in terms of depression and anxiety, initially, as measured by HADS. No documented adverse event associated with the intervention was found., Conclusions: Elderly patients are willing to use tablet devices to be educated about health conditions. Additional studies are required to measure the effectiveness and determine the most suitable timing and location for patient education., Trial Registration: ClinicalTrials.gov NCT04439864; https://clinicaltrials.gov/ct2/show/NCT04439864., (©Andrew Dallas Boyd, Chioma Iheanyi Ndukwe, Anandu Dileep, Olivia Frances Everin, Yingwei Yao, Betty Welland, Jerry Field, Matt Baumann, Jose D Flores Jr, Adhir Shroff, Vicki Groo, Carolyn Dickens, Rami Doukky, Regeena Francis, Geraldine Peacock, Diana J Wilkie. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 24.06.2020.)

Aims: The aim of this study was to evaluate the performance of risk stratification models (RSMs) in predicting short-term mortality after transcatheter aortic valve replacement (TAVR)., Methods and Results: MEDLINE and Scopus were queried to identify studies which validated RSMs designed to assess 30-day or in-hospital mortality after TAVR. Discrimination and calibration were assessed using C-statistics and observed/expected ratios (OERs), respectively. C-statistics were pooled using a random-effects inverse-variance method, while OERs were pooled using the Peto odds ratio. A good RSM is defined as one with a C-statistic >0.7 and an OER close to 1.0. Twenty-four studies (n=68,215 patients) testing 11 different RSMs were identified. Discrimination of all RSMs was poor (C-statistic <0.7); however, certain TAVR-specific RSMs such as the in-hospital STS/ACC TVT (C-statistic=0.65) and STT (C-statistic=0.66) predicted individual mortality more reliably than surgical models (C-statistic range=0.59-0.61). A good calibration was demonstrated by the in-hospital STS/ACC TVT (OER=0.99), 30-day STS/ACC TVT (OER=1.08) and STS (OER=1.01) models. Baseline dialysis (OER: 2.64 [1.88, 3.70]; p<0.001) was the strongest predictor of mortality., Conclusions: This study demonstrates that the STS/ACC TVT model (in-hospital and 30-day) and the STS model have accurate calibration, making them useful for comparison of centre-level risk-adjusted mortality. In contrast, the discriminative ability of currently available models is limited.