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Background: High-sensitivity cardiac troponin (hs-cTn) laboratory assays are used to rule out myocardial infarction (MI) on presentation, but prolonged result turnaround times can delay patient management. Our primary aim was to identify patients at low risk of index MI using a rapid point-of-care (POC) whole-blood hs-cTnI assay at presentation with potential early patient discharge. Methods: Consecutive patients presenting to the emergency department from 2 prospective observational studies with suspected acute coronary syndrome were enrolled. A POC hs-cTnI assay (Atellica VTLi) threshold using whole blood at presentation, which resulted in a negative predictive value of ≥99.5% and sensitivity of >99% for index MI, was derived (SEIGE [Safe Emergency Department Discharge Rate]) and validated with plasma (SAMIE [Suspected Acute Myocardial Infarction in Emergency]). Event adjudications were established with hs-cTnI assay results from routine clinical care. The primary outcome was MI at 30 days. Results: A total of 1086 patients (8.1% with MI) were enrolled in a US derivation cohort (SEIGE) and 1486 (5.5% MI) in an Australian validation cohort (SAMIE). A derivation whole-blood POC hs-cTnI concentration of Conclusions: A POC whole-blood hs-cTnI assay permits accessible, rapid, and safe exclusion of MI and may expedite discharge from the emergency department. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04772157. URL: https://www.australianclinicaltrials.gov.au/anzctr_feed/form ; Unique identifier: 12621000053820.

Introduction: Cardiac complications of COVID-19 include acute cardiac injury, myopericarditis, cardiomyopathy and arrhythmias. This study aimed to describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia. Methods: AUS-COVID is a multicentre observational cohort study across 21 Australian hospitals including all index hospitalisations with laboratory-proven COVID-19 in patients aged 18 years or older. All consecutive patients entered in the AUS-COVID Registry by 28 th January 2021 were included in the present study. Results: Six hundred and forty-four hospitalised patients (62.5 ± 20.1 years old, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (0.5%) patients developed high grade atrioventricular (AV) block. Two (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p Conclusions: Among patients with COVID-19 requiring hospitalisation in Australia, troponin elevation was common but clinical cardiac sequelae were uncommon. The incidence of atrial arrhythmias and troponin elevation was greatest in patients 65 years and older. Trial registration: AUS-COVID. ACTRN12620000486921. http://www.anzctr.org.au/

Background: Complications following catheter ablation of atrial fibrillation (AF) have been extensively examined but little is known about their associated economic burden. Hypothesis: Complications of AF ablations were associated with a significant increase in healthcare resources utilization. Methods: All patients >18 years undergoing AF ablations in the financial years of 2011-2017 in Australia with available cost data from the National Hospital Cost Data Collection were included. The primary outcome was occurrence of any complications up to 30-days post-discharge. All costs were adjusted to 2021 Australian dollars. The increase in length of stay (LOS) and in cost associated with complications, adjusting for patient characteristics, was evaluated using generalized linear models and negative binomial regression. Results: Our study included 19,916 patients (mean age 62.6±11.3 years, 30.2% females). The median length of stay was 1 day (interquartile range [IQR] 1-2 days) and the median cost per hospitalization was $6,646.5 (IQR $5,979.7-$10,210.5). A total of 1,074 patients (5.39%) experienced a complication (4.24% during the hospital stay and 1.37% post-discharge). The most common complications were bleeding (3.18%), pericardial effusion (0.66%), and vascular injury (0.43%). On average, the occurrence of a complication was associated with 2.8 excess bed-days and a $6,119.4 (95%CI $5,491.2-$6,747.7) increase in hospitalization cost (totaling nearly $6.6 millions). Complications that required cardiac surgery were associated with the highest incremental cost per patient ($19,958.5 [95%CI $17,304.5-$22,612.6]) but most of excess cost was attributable to bleeding ($4,808.5 per patient, $3,048,596.1 in total, 44.4% of total excess cost) and pericardial effusion ($6,064.8 per patient, $1,073,094.9 in total, 16.3% of total excess cost). Conclusions: The occurrence of any complication following AF ablation is associated with a significant economic burden, most of which was attributable to bleeding and pericardial effusion. Strategies to improve procedural safety and reduce healthcare cost should focus on these complications.

Introduction: To assess whether hypertension is an independent risk factor for mortality amongst patients hospitalised with COVID-19 and to evaluate the impact of angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) on mortality in patients with a background of hypertension. Methods: This observational cohort study included all consecutive index hospitalisations with laboratory proven COVID-19 aged 18 years or older across 21 Australian hospitals entered in the AUS-COVID Registry by 22nd January 2021. Patients were excluded if their past medical or medication history was not available or if they were transferred to another hospital in which case mortality outcomes were not available. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs. Results: 546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (aOR 1.09, 95% CI 1.07-1.12, p Conclusions: In patients hospitalised with COVID-19, pre-existing hypertension was the most prevalent comorbidity but was not independently associated with mortality. Similarly, the baseline use of ACE inhibitors or ARBs had no independent association with in-hospital mortality.

Introduction: The subcutaneous (S-) implantable cardioverter defibrillator (ICD) is an alternative to the transvenous (TV-) ICD that is increasingly implanted in younger patients. However, data on the safety and effectiveness of the S-ICD in older patients are lacking. Methods: We compared S-ICD and single chamber TV-ICD implants in Medicare beneficiaries (≥65yrs) using National Cardiovascular Data Registry ICD Registry data from 9/28/2012 through 12/31/2017. We excluded patients with prior pacemaker or ICD, an indication for pacing or resynchronization, and those undergoing implant in an acute setting. Mortality status was determined using the Medicare master summary beneficiary file. Cox regression analyses with overlap weights were used to compare all-cause mortality. Mean cumulative counts of all-cause readmissions were compared among for Fee for Service beneficiaries. Results: A total of 23,717 patients met inclusion criteria [mean age 72.7±5.8 years, 29% female, 69% ischemic heart disease, 33% atrial arrhythmias, 49% NYHA II, 31.7% NYHA III, ejection fraction (EF) 28±9%, 3% dialysis dependent, 20% with prior ventricular tachycardia]. Compared to TV-ICD patients (n=22,264), S-ICD patients (n=1,453, 6% overall) were more often male, black, diabetic, dialysis dependent and were less likely to have atrial or ventricular arrhythmias or ischemic heart disease. There was no difference in age or EF between the 2 groups. In adjusted analyses, during a median follow-up of 2.3 years (IQR: 1.2 - 3.5), there was no difference between the 2 groups in all-cause mortality (HR 1.04, CI 0.91-1.17, Figure A ) or readmissions (based on overlap of confidence intervals, Figure B ). Conclusions: In a large representative cohort of older patients undergoing ICD implant, all-cause mortality and readmission were similar among S-ICD and TV-ICD recipients. These findings support use of the S-ICD for the prevention of sudden cardiac death in appropriately selected older patients.

Background— The extent to which articles are cited is a surrogate of the impact and importance of the research conducted; poorly cited articles may identify research of limited use and potential wasted investments. We assessed trends in the rates of poorly cited articles and journals in the cardiovascular literature from 1997 to 2007. Methods and Results— We identified original articles published in cardiovascular journals and indexed in the Scopus citation database from 1997 to 2007. We defined poorly cited articles as those with ≤5 citations in the 5 years following publication and poorly cited journals as those with >75% of journal content poorly cited. We identified 164 377 articles in 222 cardiovascular journals from 1997 to 2007. From 1997 to 2007, the number of cardiovascular articles and journals increased by 56.9% and 75.2%, respectively. Of all the articles, 75 550 (46.0%) were poorly cited, of which 25 650 (15.6% overall) had no citations. From 1997 to 2007, the proportion of poorly cited articles declined slightly (52.1%–46.2%, trend P P Conclusion— Nearly half of all peer-reviewed articles published in cardiovascular journals are poorly cited 5 years after publication, and many are not cited at all. The cardiovascular literature and the number of poorly cited articles both increased substantially from 1997 to 2007. The high proportion of poorly cited articles and journals suggests inefficiencies in the cardiovascular research enterprise.

Background— Young women ( Methods and Results— We included patients aged 18 to 64 years with a principal diagnosis of acute myocardial infarction. Data were used from the Healthcare Cost and Utilization Project-State Inpatient Database for California (07–09). Readmission diagnoses were categorized by using an aggregated version of the Centers for Medicare and Medicaid Services’ Condition Categories, and readmission timing was determined from the day after discharge. Of 42 518 younger patients with acute myocardial infarction (26.4% female), 4775 (11.2%) had at least 1 readmission. The 30-day all-cause readmission rate was higher for women (15.5% versus 9.7%, P P =0.01). Female sex was associated with a higher rate of 30-day readmission, which persisted after adjustment (hazard ratio, 1.22; 95% confidence interval, 1.15–1.30). There was no significant interaction between age and sex on readmission. Conclusions— In comparison with men, younger women have a higher risk for readmission, even after the adjustment for confounders. The timing of 30-day readmission was similar in women and men, and both sexes were susceptible to a wide range of causes for readmission.

Background: Hospital data on cardiac services provided is restricted to a limited number of services collected by the American Hospital Association (AHA) Survey. We developed an alternative method to identify hospital services using individual patient administrative claims data for acute myocardial infarction (AMI) in the Premier Database. Methods: We first determined inpatient cardiac services relevant for AMI care from guidelines. Then, we identified these services from patient claims using ICD-9, CPT, Medicare Revenue and provider specialty codes. Additionally, Premier Chargemaster and Physician Specialty Codes were used. A hospital was classified as providing a service if they had >5 AMI patient claims for the service in the Premier database from 2009-2011. To measure the accuracy of the claims based method, we compared the percentage of hospitals that were shown to provide a service identified through the AHA survey for a subset of services identifiable from both sources. Results: We identified 32 services relevant for AMI care that could be defined using data with inpatient claims among 476 hospitals in the Premier database (Figure). The availability of these services ranged from 100% (for services such as chest x-ray) to 1% for heart transplant service. When compared to the subset of 12 services also collected in the AHA survey, a high percentage of agreement (≥80%) was noted for 10/16 (63%) services (such as a dedicated ED, general CT, coronary angiography, PCI, ICU, pharmacist and physio/OT services). Moderate agreement was seen for one service (coronary care unit), and 5/16 (31%) services showed low agreement (≤50%) (EP testing, inpatient cardiac surgical services, inpatient cardiac rehabilitation, transplant unit, and social worker). Conclusion: It is feasible to use claims data to determine in-hospital AMI services, but the accuracy of the method needs to be investigated further for certain services that have a low degree of agreement in our analysis.

Background: Long-term implantable cardioverter-defibrillator (ICD) adverse events are poorly documented. In the NCDR ICD Registry™, a nationally representative cohort, we calculated the rate of long-term post-discharge device related adverse events. Methods: We included first-time ICD implants from 2006-2010 that could be matched with Medicare fee-for-service claims data to identify outcomes. We excluded patients if they had a previous ICD or pacemaker, CABG during their procedure, or were not discharged alive. The primary outcome was device reoperation (involving the generator, leads, pocket, or a combination) for device malfunction, infection, other complications (wound disruption, cardiac perforation, etc.), or reoperation for battery end-of-life and/or device upgrade. Analysis was performed using unadjusted cumulative incidence functions taking into consideration the competing risk of death. Results: We identified 185,263 ICD implants of which 114,649 (19.7% single-chamber, 41.3% dual-chamber, 38.8% CRT-D) could be matched to Medicare data (mean age 74.8±6.2 years, 72.5% male).Of these, 83.5% were for primary prevention of sudden cardiac death. The median follow up was 2.7 yrs (max follow-up 6 yrs). At least 1 reoperation occurred in 15.5% of patients by 6 yrs and more than 80% of these reoperations occurred after the early (>90 days) post-implantation period (Figure). Reoperation rates for specific complications (per 1000 patient yrs) were device malfunction (14.3), infection (5.1), other device related complications (18.4) and reoperation for generator battery end-of-life and/or device upgrade (12.9). The crude reoperation rate (for any cause) was similar among device types (P=0.19). Conclusion: Patients continue to have adverse outcomes in the years post ICD implantation, predominately from device malfunction. Our next steps are to identify patient, device, and provider factors associated with these long-term adverse events.