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For individuals who have 1 or more of these CVD risk factors and an estimated 10-year CVD risk between 7.5% and less than 10%, the USPSTF provides a C recommendation that clinicians selectively offer statin therapy. Specifically, the task force concluded that statins were effective for decreasing the rates of both overall mortality and cardiovascular disease (CVD) events in adults aged 40 to 75 years at risk for CVD. Editorial In 2016, the US Preventive Services Task Force (USPSTF) issued its first recommendations for statin therapy for the primary prevention of cardiovascular disease based on an evidence review that included 19 randomized clinical trials (RCTs).[1] In this issue of I JAMA i , the USPSTF presents an update[2] of the 2016 recommendations based on an updated evidence report and systematic review[3] using the same 19 RCTs plus a single new RCT (TRACE-RA), as well as additional data from 2 previous RCTs that included patients treated for both primary and secondary prevention (PROSPER and ALLHAT-LLT).[3] Given the overlap in the contributing studies, the USPSTF updated evidence summary and resulting treatment recommendations for statin use in primary prevention remained largely unchanged. [Extracted from the article]

Importance: Randomized clinical trials suggest benefit of endovascular-reperfusion therapy for large vessel occlusion in acute ischemic stroke (AIS) is time dependent, but the extent to which it influences outcome and generalizability to routine clinical practice remains uncertain.Objective: To characterize the association of speed of treatment with outcome among patients with AIS undergoing endovascular-reperfusion therapy.Design, Setting, and Participants: Retrospective cohort study using data prospectively collected from January 2015 to December 2016 in the Get With The Guidelines-Stroke nationwide US quality registry, with final follow-up through April 15, 2017. Participants were 6756 patients with anterior circulation large vessel occlusion AIS treated with endovascular-reperfusion therapy with onset-to-puncture time of 8 hours or less.Exposures: Onset (last-known well time) to arterial puncture, and hospital arrival to arterial puncture (door-to-puncture time).Main Outcomes and Measures: Substantial reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), ambulatory status, global disability (modified Rankin Scale [mRS]) and destination at discharge, symptomatic intracranial hemorrhage (sICH), and in-hospital mortality/hospice discharge.Results: Among 6756 patients, the mean (SD) age was 69.5 (14.8) years, 51.2% (3460/6756) were women, and median pretreatment score on the National Institutes of Health Stroke Scale was 17 (IQR, 12-22). Median onset-to-puncture time was 230 minutes (IQR, 170-305) and median door-to-puncture time was 87 minutes (IQR, 62-116), with substantial reperfusion in 85.9% (5433/6324) of patients. Adverse events were sICH in 6.7% (449/6693) of patients and in-hospital mortality/hospice discharge in 19.6% (1326/6756) of patients. At discharge, 36.9% (2132/5783) ambulated independently and 23.0% (1225/5334) had functional independence (mRS 0-2). In onset-to-puncture adjusted analysis, time-outcome relationships were nonlinear with steeper slopes between 30 to 270 minutes than 271 to 480 minutes. In the 30- to 270-minute time frame, faster onset to puncture in 15-minute increments was associated with higher likelihood of achieving independent ambulation at discharge (absolute increase, 1.14% [95% CI, 0.75%-1.53%]), lower in-hospital mortality/hospice discharge (absolute decrease, -0.77% [95% CI, -1.07% to -0.47%]), and lower risk of sICH (absolute decrease, -0.22% [95% CI, -0.40% to -0.03%]). Faster door-to-puncture times were similarly associated with improved outcomes, including in the 30- to 120-minute window, higher likelihood of achieving discharge to home (absolute increase, 2.13% [95% CI, 0.81%-3.44%]) and lower in-hospital mortality/hospice discharge (absolute decrease, -1.48% [95% CI, -2.60% to -0.36%]) for each 15-minute increment.Conclusions and Relevance: Among patients with AIS due to large vessel occlusion treated in routine clinical practice, shorter time to endovascular-reperfusion therapy was significantly associated with better outcomes. These findings support efforts to reduce time to hospital and endovascular treatment in patients with stroke. [ABSTRACT FROM AUTHOR]

Importance: Despite guideline recommendations, many patients discontinue P2Y12 inhibitor therapy earlier than the recommended 1 year after myocardial infarction (MI), and higher-potency P2Y12 inhibitors are underutilized. Cost is frequently cited as an explanation for both of these observations.Objective: To determine whether removing co-payment barriers increases P2Y12 inhibitor persistence and lowers risk of major adverse cardiovascular events (MACE).Design, Setting, and Participants: Cluster randomized clinical trial among 301 hospitals enrolling adult patients with acute MI (June 5, 2015, through September 30, 2016); patients were followed up for 1 year after discharge (final date of follow-up was October 23, 2017), with blinded adjudication of MACE; choice of P2Y12 inhibitor was per clinician discretion.Interventions: Hospitals randomized to the intervention (n = 131 [6436 patients]) provided patients with co-payment vouchers for clopidogrel or ticagrelor for 1 year (median voucher value for a 30-day supply, $137 [25th-75th percentile, $20-$339]). Hospitals randomized to usual care (n = 156 [4565 patients]) did not provide study vouchers.Main Outcomes and Measures: Independent coprimary outcomes were patient-reported persistence with P2Y12 inhibitor (defined as continued treatment without gap in use ≥30 days) and MACE (death, recurrent MI, or stroke) at 1 year among patients discharged with a prescription for clopidogrel or ticagrelor.Results: Among 11 001 enrolled patients (median age, 62 years; 3459 [31%] women), 10 102 patients were discharged with prescriptions for clopidogrel or ticagrelor (clopidogrel prescribed to 2317 [36.0%] in the intervention group and 2497 [54.7%] in the usual care group), 4393 of 6135 patients (72%) in the intervention group used the voucher, and follow-up data at 1 year were available for 10 802 patients (98.2%). Patient-reported persistence with P2Y12 inhibitors at 1 year was higher in the intervention group than in the control group (unadjusted rates, 5340/6135 [87.0%] vs 3324/3967 [83.8%], respectively; P < .001; adjusted difference, 2.3% [95% CI, 0.4% to 4.1%]; adjusted odds ratio, 1.19 [95% CI, 1.02 to 1.40]). There was no significant difference in MACE at 1 year between intervention and usual care groups (unadjusted cumulative incidence, 10.2% vs 10.6%; P = .65; adjusted difference, 0.66% [95% CI, -0.73% to 2.06%]; adjusted hazard ratio, 1.07 [95% CI, 0.93 to 1.25]).Conclusions and Relevance: Among patients with MI, provision of vouchers to offset medication co-payments for P2Y12 inhibitors, compared with no vouchers, resulted in a 3.3% absolute increase in patient-reported persistence with P2Y12 inhibitors and no significant reduction in 1-year MACE outcomes.Trial Registration: ClinicalTrials.gov Identifier: NCT02406677. [ABSTRACT FROM AUTHOR]

Importance: Data are lacking on the effect of a renin-angiotensin system (RAS) inhibitor prescribed after transcatheter aortic valve replacement (TAVR). Treatment with a RAS inhibitor may reverse left ventricular remodeling and improve function.Objective: To investigate the association of prescription of a RAS inhibitor and outcomes after TAVR.Design, Setting, and Participants: Retrospective cohort study of TAVR procedures performed in the United States (using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry) between July 2014 and January 2016 that were linked to Medicare claims data (final date of follow-up: March 31, 2017). To account for differences in demographics, echocardiographic findings, and in-hospital complications, 1:1 propensity matching was performed.Exposures: Initial hospital discharge prescription of a RAS inhibitor after TAVR.Main Outcomes and Measures: Primary outcomes were all-cause death and readmission due to heart failure at 1 year after discharge, which were considered separately. The secondary outcome was health status assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ; score range: 0-100, with a higher score indicating less symptom burden and better quality of life; a small effect size was defined as 5 points) at 1 year.Results: Among 21 312 patients who underwent TAVR at 417 US sites, 8468 patients (39.7%) were prescribed a RAS inhibitor at hospital discharge. After propensity matching, 15 896 patients were included (mean [SD] age, 82.4 [6.8] years; 48.1% were women; mean [SD] left ventricular ejection fraction [LVEF], 51.9% [11.5%]). Patients with a prescription for a RAS inhibitor vs those with no prescription had lower mortality rates at 1 year (12.5% vs 14.9%, respectively; absolute risk difference [ARD], -2.4% [95% CI, -3.5% to -1.4%]; hazard ratio [HR], 0.82 [95% CI, 0.76 to 0.90]) and lower heart failure readmission rates at 1 year (12.0% vs 13.8%; ARD, -1.8% [95% CI, -2.8% to -0.7%]; HR, 0.86 [95% CI, 0.79 to 0.95]). When stratified by LVEF, having a prescription for a RAS inhibitor vs no prescription was associated with lower 1-year mortality among patients with preserved LVEF (11.1% vs 13.9%, respectively; ARD, -2.81% [95% CI, -3.95% to -1.67%]; HR, 0.78 [95% CI, 0.71 to 0.86]), but not among those with reduced LVEF (18.8% vs 19.5%; ARD, -0.68% [95% CI, -3.52% to 2.20%]; HR, 0.95 [95% CI, 0.81 to 1.12]) (P = .04 for interaction). Of 15 896 matched patients, 4837 (30.4%) were included in the KCCQ score analysis and improvements at 1 year were greater in patients with a prescription for a RAS inhibitor vs those with no prescription (median, 33.3 [interquartile range, 14.2 to 51.0] vs 31.3 [interquartile range, 13.5 to 51.1], respectively; difference in improvement, 2.10 [95% CI, 0.10 to 4.06]; P < .001), but the effect size was not clinically meaningful.Conclusions and Relevance: Among patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge compared with no prescription was significantly associated with a lower risk of mortality and heart failure readmission. However, due to potential selection bias, this finding requires further investigation in randomized trials. [ABSTRACT FROM AUTHOR]

Importance: Although non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used to prevent thromboembolic disease, there are limited data on NOAC-related intracerebral hemorrhage (ICH).Objective: To assess the association between preceding oral anticoagulant use (warfarin, NOACs, and no oral anticoagulants [OACs]) and in-hospital mortality among patients with ICH.Design, Setting, and Participants: Retrospective cohort study of 141 311 patients with ICH admitted from October 2013 to December 2016 to 1662 Get With The Guidelines-Stroke hospitals.Exposures: Anticoagulation therapy before ICH, defined as any use of OACs within 7 days prior to hospital arrival.Main Outcomes and Measures: In-hospital mortality.Results: Among 141 311 patients with ICH (mean [SD] age, 68.3 [15.3] years; 48.1% women), 15 036 (10.6%) were taking warfarin and 4918 (3.5%) were taking NOACs preceding ICH, and 39 585 (28.0%) and 5783 (4.1%) were taking concomitant single and dual antiplatelet agents, respectively. Patients with prior use of warfarin or NOACs were older and had higher prevalence of atrial fibrillation and prior stroke. Acute ICH stroke severity (measured by the National Institutes of Health Stroke Scale) was not significantly different across the 3 groups (median, 9 [interquartile range, 2-21] for warfarin, 8 [2-20] for NOACs, and 8 [2-19] for no OACs). The unadjusted in-hospital mortality rates were 32.6% for warfarin, 26.5% for NOACs, and 22.5% for no OACs. Compared with patients without prior use of OACs, the risk of in-hospital mortality was higher among patients with prior use of warfarin (adjusted risk difference [ARD], 9.0% [97.5% CI, 7.9% to 10.1%]; adjusted odds ratio [AOR], 1.62 [97.5% CI, 1.53 to 1.71]) and higher among patients with prior use of NOACs (ARD, 3.3% [97.5% CI, 1.7% to 4.8%]; AOR, 1.21 [97.5% CI, 1.11-1.32]). Compared with patients with prior use of warfarin, patients with prior use of NOACs had a lower risk of in-hospital mortality (ARD, -5.7% [97.5% CI, -7.3% to -4.2%]; AOR, 0.75 [97.5% CI, 0.69 to 0.81]). The difference in mortality between NOAC-treated patients and warfarin-treated patients was numerically greater among patients with prior use of dual antiplatelet agents (32.7% vs 47.1%; ARD, -15.0% [95.5% CI, -26.3% to -3.8%]; AOR, 0.50 [97.5% CI, 0.29 to 0.86]) than among those taking these agents without prior antiplatelet therapy (26.4% vs 31.7%; ARD, -5.0% [97.5% CI, -6.8% to -3.2%]; AOR, 0.77 [97.5% CI, 0.70 to 0.85]), although the interaction P value (.07) was not statistically significant.Conclusions and Relevance: Among patients with ICH, prior use of NOACs or warfarin was associated with higher in-hospital mortality compared with no OACs. Prior use of NOACs, compared with prior use of warfarin, was associated with lower risk of in-hospital mortality. [ABSTRACT FROM AUTHOR]

Importance: The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism.Objective: To evaluate the association of S-LAAO vs no receipt of S-LAAO with the risk of thromboembolism among older patients undergoing cardiac surgery.Design, Setting, and Participants: Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged 65 years and older with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014.Exposures: S-LAAO vs no S-LAAO.Main Outcomes and Measures: The primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years of follow-up, as defined by Medicare claims data. Secondary end points included hemorrhagic stroke, all-cause mortality, and a composite end point (thromboembolism, hemorrhagic stroke, or all-cause mortality).Results: Among 10 524 patients undergoing surgery (median age, 76 years; 39% female; median CHA2DS2-VASc score, 4), 3892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, all-cause mortality in 21.5%, and the composite end point in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs 6.2%), all-cause mortality (17.3% vs 23.9%), and the composite end point (20.5% vs 28.7%) but no significant difference in rates of hemorrhagic stroke (0.9% vs 0.9%). After inverse probability-weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95% CI, 0.56-0.81; P < .001), all-cause mortality (HR, 0.88; 95% CI, 0.79-0.97; P = .001), and the composite end point (HR, 0.83; 95% CI, 0.76-0.91; P < .001) but not hemorrhagic stroke (subdistribution HR, 0.84; 95% CI, 0.53-1.32; P = .44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2% vs 6.0%; adjusted subdistribution HR, 0.26; 95% CI, 0.17-0.40; P < .001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1% vs 6.3%; adjusted subdistribution HR, 0.88; 95% CI, 0.56-1.39; P = .59).Conclusions and Relevance: Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years. These findings support the use of S-LAAO, but randomized trials are necessary to provide definitive evidence. [ABSTRACT FROM AUTHOR]

Importance: There are important differences among guideline recommendations for using statin therapy in primary prevention. New recommendations from the US Preventive Services Task Force (USPSTF) emphasize therapy based on the presence of 1 or more cardiovascular disease (CVD) risk factors and a 10-year global CVD risk of 10% or greater.Objective: To determine the difference in eligibility for primary prevention statin treatment among US adults, assuming full application of USPSTF recommendations compared with the American College of Cardiology/American Heart Association (ACC/AHA) guidelines.Design, Setting, and Participants: National Health and Nutrition Examination Survey (NHANES) data (2009-2014) were used to assess statin eligibility under the 2016 USPSTF recommendations vs the 2013 ACC/AHA cholesterol guidelines among a nationally representative sample of 3416 US adults aged 40 to 75 years with fasting lipid data and triglyceride levels of 400 mg/dL or less, without prior CVD.Exposures: The 2016 USPSTF recommendations vs 2013 ACC/AHA guidelines.Main Outcomes and Measures: Eligibility for primary prevention statin therapy.Results: Among the US primary prevention population represented by 3416 individuals in NHANES, the median weighted age was 53 years (interquartile range, 46-61), and 53% (95% CI, 52%-55%) were women. Along with the 21.5% (95% CI, 19.3%-23.7%) of patients who reported currently taking lipid-lowering medication, full implementation of the USPSTF recommendations would be associated with initiation of statin therapy in an additional 15.8% (95% CI, 14.0%-17.5%) of patients, compared with an additional 24.3% (95% CI, 22.3%-26.3%) of patients who would be recommended for statin initiation under full implementation of the 2013 ACC/AHA guidelines. Among the 8.9% of individuals in the primary prevention population who would be recommended for statins by ACC/AHA guidelines but not by USPSTF recommendations, 55% would be adults aged 40 to 59 years with a mean 30-year cardiovascular risk greater than 30%, and 28% would have diabetes.Conclusions And Relevance: In this sample of US adults from 2009-2014, adherence to the 2016 USPSTF recommendations for statin therapy, compared with the 2013 ACC/AHA guidelines, could lead to a lower number of individuals recommended for primary prevention statin therapy, including many younger adults with high mean long-term CVD risk. [ABSTRACT FROM AUTHOR]

Importance: Antithrombotic therapies are known to prevent stroke for patients with atrial fibrillation (AF) but are often underused in community practice.Objectives: To examine the prevalence of patients with acute ischemic stroke with known history of AF who were not receiving guideline-recommended antithrombotic treatment before stroke and to determine the association of preceding antithrombotic therapy with stroke severity and in-hospital outcomes.Design, Setting, and Participants: Retrospective observational study of 94 474 patients with acute ischemic stroke and known history of AF admitted from October 2012 through March 2015 to 1622 hospitals participating in the Get With the Guidelines-Stroke program.Exposures: Antithrombotic therapy before stroke.Main Outcomes and Measures: Stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS; range of 0-42, with a higher score indicating greater stroke severity and a score ≥16 indicating moderate or severe stroke), and in-hospital mortality.Results: Of 94 474 patients (mean [SD] age, 79.9 [11.0] years; 57.0% women), 7176 (7.6%) were receiving therapeutic warfarin (international normalized ratio [INR] ≥2) and 8290 (8.8%) were receiving non-vitamin K antagonist oral anticoagulants (NOACs) preceding the stroke. A total of 79 008 patients (83.6%) were not receiving therapeutic anticoagulation; 12 751 (13.5%) had subtherapeutic warfarin anticoagulation (INR <2) at the time of stroke, 37 674 (39.9%) were receiving antiplatelet therapy only, and 28 583 (30.3%) were not receiving any antithrombotic treatment. Among 91 155 high-risk patients (prestroke CHA2DS2-VASc score ≥2), 76 071 (83.5%) were not receiving therapeutic warfarin or NOACs before stroke. The unadjusted rates of moderate or severe stroke were lower among patients receiving therapeutic warfarin (15.8% [95% CI, 14.8%-16.7%]) and NOACs (17.5% [95% CI, 16.6%-18.4%]) than among those receiving no antithrombotic therapy (27.1% [95% CI, 26.6%-27.7%]), antiplatelet therapy only (24.8% [95% CI, 24.3%-25.3%]), or subtherapeutic warfarin (25.8% [95% CI, 25.0%-26.6%]); unadjusted rates of in-hospital mortality also were lower for those receiving therapeutic warfarin (6.4% [95% CI, 5.8%-7.0%]) and NOACs (6.3% [95% CI, 5.7%-6.8%]) compared with those receiving no antithrombotic therapy (9.3% [95% CI, 8.9%-9.6%]), antiplatelet therapy only (8.1% [95% CI, 7.8%-8.3%]), or subtherapeutic warfarin (8.8% [95% CI, 8.3%-9.3%]). After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeutic warfarin, NOACs, or antiplatelet therapy was associated with lower odds of moderate or severe stroke (adjusted odds ratio [95% CI], 0.56 [0.51-0.60], 0.65 [0.61-0.71], and 0.88 [0.84-0.92], respectively) and in-hospital mortality (adjusted odds ratio [95% CI], 0.75 [0.67-0.85], 0.79 [0.72-0.88], and 0.83 [0.78-0.88], respectively).Conclusions and Relevance: Among patients with atrial fibrillation who had experienced an acute ischemic stroke, inadequate therapeutic anticoagulation preceding the stroke was prevalent. Therapeutic anticoagulation was associated with lower odds of moderate or severe stroke and lower odds of in-hospital mortality. [ABSTRACT FROM AUTHOR]

The authors comment on a study which hypothesized that the lack of a mortality benefit in more recent lipid-lowering trials may reflect that those trials had enrolled patients with low baseline low-density lipoprotein cholesterol (LDL-C) levels. They discuss the clinical care implications of the results of the meta-analysis of 34 randomized clinical trials that determined whether baseline LDL-C levels were related to the benefits of more intensive versus less intensive lipid-lowering therapy.

Importance: Implantable cardioverter-defibrillators (ICDs) are not recommended within 40 days of myocardial infarction (MI); thus, ICD implantation might not be considered during the post-MI care transition. Objective: To examine ICD implantation rates and associated mortality among older MI patients with low ejection fraction (EF). Design, Setting, and Participants: Retrospective observational study of Medicare beneficiaries with an EF of 35% or less after MI, treated at 441 US hospitals between 2007 and 2010, excluding patients with prior ICD implantation. Follow-up data were available through December 2010. Exposures: ICD implantation within 1 year of MI vs no ICD implantation within 1 year of MI. Main Outcomes and Measures: Patient characteristics associated with receiving an ICD within 1 year after discharge and 2-year mortality associated with ICD implantation. Results: Among 10,318 MI patients with EF of 35%or lower, the cumulative 1-year ICD implantation rate was 8.1% (95%CI, 7.6%-8.7%). Patients with ICD implantation were more likely to have prior coronary artery bypass graft procedures, higher peak troponin levels, in-hospital cardiogenic shock, and cardiology follow-up within 2 weeks after discharge relative to patients who did not receive an ICD within 1 year. Implantation of ICD was associated with lower 2-year mortality (15.3 events per 100 patient-years [128 deaths in 838 patient-years] vs 26.4 events per 100 patient-years [3033 deaths in 11 479 patient-years]; adjusted HR, 0.64; 95%CI, 0.53-0.78). [table: see text] Conclusions and Relevance: In this large registry study of older patients who experienced MI from 2007-2010, fewer than 1 in 10 eligible patients with low EF received an ICD within 1 year after MI, although ICD implantation was associated with lower risk-adjusted mortality at 2 years. Additional research is needed to determine evidence-based approaches to increase ICD implantation among eligible patients. [ABSTRACT FROM AUTHOR]

IMPORTANCE. Introducing new medical devices into routine practice raises concerns because patients and outcomes may differ from those in randomized trials. OBJECTIVE. To update the previous report of 30-day outcomes and present 1-year outcomes following transcatheter aortic valve replacement (TAVR) in the United States. DESIGN, SETTING, AND PARTICIPANTS Data from the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve Therapies Registry were linked with patient-specific Centers for Medicare & Medicaid Services (CMS) administrative claims data. At 299 US hospitals, 12182 patients linked with CMS data underwent TAVR procedures performed from November 2011 through June 30,2013, and the end of the follow-up period was June 30,2014. EXPOSURE. Transcatheter aortic valve replacement. MAIN OUTCOMES AND MEASURES. One-year outcomes including mortality, stroke, and rehospitalization were evaluated using multivariate modeling. RESULTS. The median age of patients was 84 years and 52% were women, with a median STS Predicted Risk of Operative Mortality (STS PROM) score of 7.1%. Following the TAVR procedure, 59.8% were discharged to home and the 30-day mortality was 7.0% (95% Cl, 6.5%-7.4%) (n = 847 deaths). In the first year after TAVR, patients were alive and out of the hospital for a median of 353 days (interquartile range, 312-359 days); 24.4% (n = 2074) of survivors were rehospitalized once and 12.5% (n = 1525) were rehospitalized twice. By 1 year, the overall mortality rate was 23.7% (95% Cl, 22.8%-24.5%) (n = 2450 deaths), the stroke rate was 4.1% (95% Cl, 3.7%-4.5%) (n = 455 stroke events), and the rate of the composite outcome of mortality and stroke was 26.0% (25.1%-26.8%) (n = 2719 events). Characteristics significantly associated with 1-year mortality included advanced age (hazard ratio [HR] for a 95 vs <75 years, 1.61 [95% Cl, 1.24-2.09]; HR for 85-94 years vs <75 years, 1.35 [95% Cl, 1.18-1.55]; and HR for 75-84 years vs <75 years, 1.23 [95% Cl, 1.08-1.41]), male sex (HR, 1.21; 95% Cl, 1.12-1.31), end-stage renal disease (HR, 1.66; 95% Cl, 1.41-1.95), severe chronic obstructive pulmonary disease (HR, 1.39; 95% Cl, 1.25-1.55), nontransfemoral access (HR, 1.37; 95% Cl, 1.27-1.48), STS PROM score greater than 15% vs less than 8% (HR, 1.82; 95% Cl, 1.60-2.06), and preoperative atrial fibrillation/flutter (HR, 1.37; 95% Cl, 1.27-1.48). Compared with men, women had a higher risk of stroke (HR, 1.40; 95% Cl, 1.15-1.71). CONCLUSIONS. AND RELEVANCE Among patients undergoing TAVR in US clinical practice, at 1-year follow-up, overall mortality was 23.7%, the stroke rate was 4.1%, and the rate of the composite outcome of death and stroke was 26.0%. These findings should be helpful in discussions with patients undergoing TAVR. [ABSTRACT FROM AUTHOR]

The authors comment on the Recommendation Statement on blood pressure screening in adults released by the U.S. Preventive Services Task Force (USPSTF) in 2021. Topics discussed include the call of the USPSTF for hypertension screening in adults 18 years or older, need for innovation in the application of the recommendations based on the National Health and Nutrition Examination survey, and failure of screening to improve blood pressure control.

An editorial is presented which addresses the author's claim that genetic studies can be used to clarify the complexities that are associated with lipid biology and treatment, and it mentions clinical trials involving lowdensity lipoproteins (LDLs), cardiovascular disease (CVD) risks, and high-density lipoproteins (HDLs). An article in the journal which deals with coronary heart disease patients and statin-cholesteryl ester transfer protein (CETP) inhibitor therapy is assessed.

The article provides information on research which examined how the associations between modifiable risk factors and coronary heart disease (CHD) events changed from 1983 through 1995 and from 1996 through 2011. Topics addressed include model used to estimate the hazard ratios (HRs) of CHD due to systolic blood pressure (SBP), diabetes, smoking and total to high-density lipoprotein cholesterol, and findings of the study.

IMPORTANCE Clinical trials of prophylactic implantable cardioverter-defibrillators (ICDs) have included a minority of patients with a left ventricular ejection fraction (LVEF) between 30% and 35%. Because a large number of ICDs In the United States are implanted in such patients, it is important to study survival associated with this therapy. OBJECTIVE To characterize patients with LVEF between 30% and 35% and compare the survival of those with and without ICDs. DESIGN. SETTING. AND PARTICIPANTS Retrospective cohort study of Medicare beneficiaries in the National Cardiovascular Data Registry ICD registry (January 1.2006, through December 31,2007) with an LVEF between 30% and 35% who received an ICD during a heart failure hospitalization and similar patients in the Get With The Guidelines-Heart Failure (GWTG-HF) database (January 1,2005, through December 31,2009) with no ICD. The analysis was repeated in patients with an LVEF less than 30%. There were 3120 patients with an LVEF between 30% and 35% (816 In matched cohorts) and 4578 with an LVEF less than 30% (2176 in matched cohorts). Propensity score matching and Cox models were applied. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality; data were obtained from Medicare claims through December 31,2011. RESULTS There were no significant differences in the baseline characteristics of the matched groups (n = 408 for both groups). Among patients with an LVEF between 30% and 35%. there were 248 deaths in the ICD Registry group, within a median follow-up of 4.4 years (interquartile range, 2.7-4.9) and 249 deaths in the GWTG HF group, within a median follow-up of 2.9 years (interquartile range, 2.1-4.4). The risk of all-cause mortality in patients with an LVEF between 30% and 35% and an ICD was significantly lower than that in matched patients without an ICD (3-year mortality rates: 51.4% vs 55.0%; hazard ratio. 0.83 [95% CI. 0.69-0.99]; P = .04). Presence of an ICD also was associated with better survival in patients with an LVEF less than 30% (3-year mortality rates: 45.0% vs 57.6%; 634 and 660 total deaths; hazard ratio. 0.72 [95% CI. 0.65-0.81]; P < .001) (P = .20 for interaction). CONCLUSIONS AND relevance Among Medicare beneficiaries hospitalized for heart failure and with an LVEF between 30% and 35% and less than 30%. survival at 3 years was better in patients who received a prophylactic ICD than in comparable patients with no ICD. These findings support guideline recommendations to implant prophylactic ICDs in eligible patients with an LVEF of 35% or less. [ABSTRACT FROM AUTHOR]

IMPORTANCE The benefits of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) are time dependent and guidelines recommend a door-to-needle (DTN) time of 60 minutes or less. However. studies have found that less than 30% of US patients are treated within this time window. Target: Stroke was designed as a national quality improvement initiative to improve DTN times for tPA administration in patients with AIS. OBJECTIVES To evaluate DTN times for tPA administration and the proportion of patients with times of 60 minutes or less before and after initiation of a quality improvement initiative and to determine whether potential improvements in DTN times were associated with improvements in clinical outcomes. DESIGN, SETTING, AND PATIENTS The Target: Stroke initiative disseminated 10 care strategies to achieve faster DTN times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. This study included 71 169 patients with AIS treated with tPA (27 319 during the preintervention period from April 2003-December 2009 and 43 850 during the postintervention period from January 2010-September 2013) from 1030 Get With The Guidelines-Stroke participating hospitals (52.8% of total). MAIN OUTCOMES AND MEASURES The DTN times for tPA administration of 60 minutes or less and in-hospital risk-adjusted mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination. RESULTS Measures of DTN time for tPA administration improved significantly during the postintervention period compared with the preintervention period as did clinical outcomes. Study Period Preintervention (n = 27 319) Postintervention (n = 43 850) Adjusted Odds Ratio (95% CI) P Value tPA DTN time, median (IQR), min 77 (60-98) 67 (51-87) < .001 tPA DTN time < 60 min, % (95% CI) 26.5 (26.0-27.1) 41.3 (40.8-41.7) < .001 End of each period 29.6 (27.8-31.5) 53.3 (51.5-55.2) < .001 Improvement in tPA DTN time ≤ 60 1.36 (1.04-1.67) 6.20 (5.58-6.78) < .001 min, % per year (95% Cl) In-hospital all-cause mortality, % 9.93 8.25 0.89 (0.83-0.94) < .001 Discharge to home, % 37.6 42.7 1.14 (1.09-1.19) < .001 Independent ambulatory status, % 42.2 45.4 1.03 (0.97-1.10) .31 Symptomatic intracranial 5.68 4.68 0.83 (0.76-0.91) < .001 hemorrhage within 36 h, % CONCLUSIONS AND RELEVANCE Implementation of a national quality improvement initiative was associated with improved timeliness of tPA administration following AIS on a national scale, and this improvement was associated with lower in-hospital mortality and intracranial hemorrhage, along with an increase in the percentage of patients discharged home. [ABSTRACT FROM AUTHOR]

IMPORTANCE The new 2014 blood pressure (BP) guideline released by the panel members appointed to the Eighth Joint National Committee (JNC 8; 2014 BP guideline) proposed less restrictive BP targets for adults aged 60 years or older and for those with diabetes and chronic kidney disease. OBJECTIVE To estimate the proportion of US adults potentially affected by recent changes in recommendations for management of hypertension. DESIGN Cross-sectional, nationally representative survey. PARTICIPANTS Using data from the National Health and Nutrition Examination Survey between 2005 and 2010 (n = 16 372), we evaluated hypertension control and treatment recommendations for US adults. MAIN OUTCOMES AND MEASURES Proportion of adults estimated to meet guideline-based BP targets under the 2014 BP guideline and under the previous seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guideline. RESULTS The proportion of younger adults (18-59 years) with treatment-eligible hypertension under the JNC 7 guideline was 20.3% (95% CI, 19.1%-21.4%) and decreased to 19.2% (95% CI, 18.1%-20.4%) under the 2014 BP guideline. Larger declines were observed among older adults (≥60 years), decreasing from 68.9% (95% CI, 66.9%-70.8%) under JNC 7 to 61.2% (95% CI, 59.3%-63.0%) under the 2014 BP guideline. The proportion of adults with treatment-eligible hypertension who met BP goals increased slightly for younger adults, from 41.2% (95% CI, 38.1%-44.3%) under JNC 7 to 47.5% (95% CI, 44.4%-50.6%) under the 2014 BP guideline, and more substantially for older adults, from 40.0% (95% CI, 37.8%-42.3%) under JNC 7 to 65.8% (95% CI, 63.7%-67.9%) under the 2014 BP guideline. Overall, 1.6% (95% CI, 1.3%-1.9%) of US adults aged 18-59 years and 27.6% (95% CI, 25.9%-29.3%) of adults aged 60 years or older were receiving BP-lowering medication and meeting more stringent JNC 7 targets. These patients may be eligible for less stringent or no BP therapy with the 2014 BP guideline. CONCLUSIONS AND RELEVANCE Compared with the JNC 7 guideline, the 2014 BP guideline from the panel members appointed to the JNC 8 was associated with a reduction in the proportion of US adults recommended for hypertension treatment and a substantial increase in the proportion of adults considered to have achieved goal BP, primarily in older adults. [ABSTRACT FROM AUTHOR]

IMPORTANCE Studies have shown variation in the use of red blood cell transfusion among patients with acute coronary syndromes. There are no definitive data for the efficacy of transfusion in improving outcomes, and concerning data exist about possible association with harm. Current transfusion practices in patients undergoing percutaneous coronary intervention (PCI) are not well understood. OBJECTIVE To determine the current patterns of blood transfusion among patients undergoing PCI and the association of transfusion with adverse cardiac outcomes across hospitals in the United States. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of all patient visits from the CathPCI Registry from July 2009 to March 2013 that included PCI, excluding those with missing data on bleeding complications or who underwent in-hospital coronary artery bypass graft surgery (N = 2 258 711 visits). MAIN OUTCOMES AND MEASURES Transfusion rates in the overall population and by hospital (N = 1431) were the primary outcomes. The association of transfusion with myocardial infarction, stroke, and death after accounting for a patient's propensity for transfusion was also measured. RESULTS The overall rate of transfusion was 2.14% (95% CI, 2.13%-2.16%) and quarterly transfusion rates slightly declined from July 2009 to March 2013 (from 2.11% [95% CI, 2.03%-2.19%] to 2.04% [95% CI, 1.97%-2.12%]; P < .001). Patients who were more likely to receive transfusion were older (mean, 70.5 vs 64.6 years), were women (56.3% vs 32.5%), and had hypertension (86.4% vs 82.0%), diabetes (44.8% vs 34.6%), advanced renal dysfunction (8.7% vs 2.3%), prior myocardial infarction (33.0% vs 30.2%), or prior heart failure (27.0% vs 11.8%). Overall, 96.3% of sites gave a transfusion to less than 5% of patients and 3.7% of sites gave a transfusion to 5% of patients or more. Variation in hospital risk-standardized rates of transfusion persisted after adjustment, and hospitals showed variability in their transfusion thresholds. Receipt of transfusion was associated with myocardial infarction (42 803 events; 4.5% vs 1.8%; odds ratio [OR], 2.60; 95% CI, 2.57-2.63), stroke (5011 events; 2.0% vs 0.2%; OR, 7.72; 95% CI, 7.47-7.98), and in-hospital death (31 885 events; 12.5% vs 1.2%; OR, 4.63; 95% CI, 4.57-4.69), irrespective of bleeding complications. CONCLUSIONS AND RELEVANCE Among patients undergoing PCI at US hospitals, there was considerable variation in blood transfusion practices, and receipt of transfusion was associated with increased risk of in-hospital adverse cardiac events. These observational findings may warrant a randomized trial of transfusion strategies for patients undergoing PCI. [ABSTRACT FROM AUTHOR]

IMPORTANCE Transcatheter aortic valve replacement (TAVR)was approved by the US Food and Drug Administration for the treatment of severe, symptomatic aortic stenosis and inoperable status (in 2011) and high-risk but operable status (starting in 2012). A national registry (the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy [STS/ACC TVT] Registry)was initiated to meet a condition for Medicare coverage and also facilitates outcome assessment and comparison with other trials and international registries. OBJECTIVE To report the initial US commercial experience with TAVR. DESIGN, SETTING, AND PARTICIPANTS We obtained results from all eligible US TAVR cases (n=7710) from 224 participating registry hospitals following the Edwards Sapien XT device commercialization (November 2011-May 2013). MAIN OUTCOMES AND MEASURES Primary outcomes included all-cause in-hospital mortality and stroke following TAVR. Secondary analyses included procedural complications and outcomes by clinical indication and access site. Device implantation success was defined as successful vascular access, deployment of a single device in the proper anatomic position, appropriate valve function without either moderate or severe AR, and successful retrieval of the delivery system. Thirty-day outcomes are presented for a representative 3133 cases (40.6%) at 114 centers with at least 80% complete follow-up reporting. RESULTS The 7710 patients who underwent TAVR included 1559 (20%) cases that were inoperable and 6151 (80%) cases that were high-risk but operable. The median agewas 84 years (interquartile range [IQR], 78-88 years); 3783 patients (49%) were women and the median STS predicted risk of mortalitywas 7%(IQR, 5%-11%). At baseline, 2176 patients (75%)were either not at all satisfied (1297 patients [45%]) or mostly dissatisfied (879 patients [30%]) with their symptom status; 2198 (72%) had a 5-mwalk time longer than 6 seconds (slow gait speed). The most common vascular access approachwas transfemoral (4972 patients [64%]), followed by transapical (2197 patients [29%]) and other alternative approaches (536 patients [7%]); successful device implantation occurred in 7069 patients (92%; 95%CI, 91%-92%). The observed incidence of in-hospital mortalitywas 5.5%(95%CI, 5.0%-6.1%). Other major complications included stroke (2.0%; 95%CI, 1.7%-2.4%), dialysis-dependent renal failure (1.9%; 95%CI, 1.6%-2.2%), and major vascular injury (6.4%; 95%CI, 5.8%-6.9%). Median hospital stay was 6 days (IQR, 4-10 days), with 4613 (63%) discharged home. Among patients with available follow-up at 30 days (n=3133), the incidence of mortalitywas 7.6%(95%CI, 6.7%-8.6%) (noncardiovascular cause, 52%); a stroke had occurred in 2.8%(95%CI, 2.3%-3.5%), new dialysis in 2.5%(95%CI, 2.0%-3.1%), and reintervention in 0.5%(95%CI, 0.3%-0.8%). CONCLUSIONS AND RELEVANCE Among patients undergoing TAVR at US centers in the STS/ACC TVT Registry, device implantation successwas achieved in 92%of cases, the overall in-hospital mortality rate was 5.5%, and the stroke ratewas 2.0%. Although these postmarket US approval findings are comparable with prior published trial data and international experience, long-term follow-up is essential to assess continued efficacy and safety. [ABSTRACT FROM AUTHOR]

Importance Randomized clinical trials suggest the benefit of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke is time dependent. However, modest sample sizes have limited characterization of the extent to which onset to treatment (OTT) time influences outcome; and the generalizability of findings to clinical practice is uncertain. Objective To evaluate the degree to which OTT time is associated with outcome among patients with acute ischemic stroke treated with intraveneous tPA. Design, Setting, and Patients Data were analyzed from 58 353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset in 1395 hospitals participating in the Get With The Guidelines-Stroke Program, April 2003 to March 2012. Main Outcomes and Measures Relationship between OTT time and in-hospital mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination. Results Among the 58353 tPA-treated patients, median age was 72 years, 50.3% were women, median OTT time was 144 minutes (interquartile range, 115-170), 9.3% (5404) had OTT time of 0 to 90 minutes, 77.2 % (45 029) had OTT time of 91 to 180 minutes, and 13.6% (7920) had OTT time of 181 to 270 minutes. Median pretreatment National Institutes of Health Stroke Scale documented in 87.7% of patients was 11 (interquartile range, 6-17). Patient factors most strongly associated with shorter OTT Included greater stroke severity (odds ratio [OR], 2.8; 95% CI, 2.5-3.1 per5-point increase), arrival by ambulance (OR, 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR, 4.6; 95% CI, 3.8-5.4). Overall, there were 5142 (8.8%) in-hospital deaths, 2873 (4.9%) patients had intracranial hemorrhage, 19491 (33.4%) patients achieved independent ambulation at hospital discharge, and 22 541 (38.6%) patients were discharged to home. Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR, 0.96; 95% CI, 0.95-0.98; P<.001), reduced symptomatic intracranial hemorrhage (OR, 0.96; 95% CI, 0.95-0.98; P<.001), increased achievement of independent ambulation at discharge (OR, 1.04; 95% CI, 1.03-1.05; PC. 001), and increased discharge to home (OR, 1.03; 95% CI, 1.02-1.04; P<.001). Conclusions and Relevance In a registry representing US clinical practice, earlier thrombolytic treatment was associated with reduced mortality and symptomatic intracranial hemorrhage, and higher rates of independent ambulation at discharge and discharge to home following acute ischemic stroke. These findings support intensive efforts to accelerate hospital presentation and thrombolytic treatment in patients with stroke. [ABSTRACT FROM AUTHOR]

The article focuses on a study conducted to analyze the survival rate of patients receiving treatment through a primary prevention implantable cardioverter-defibrillator (ICD) in clinical practice and a comparison with clinical trials. The study was conducted through retrospective analysis of medical databases for patients suffering with cardiovascular diseases and informs that data was collected for January 1, 2006 to December 31, 2007. According to the results, no difference was found between patient survival during clinical trials and clinical practices.

The article offers information on a study based on the heart failure treatment by the help of Aldosterone antagonist therapy. It also focuses on the effectiveness and safety of the Aldosterone antagonist therapy in clinical practice patterns. As mentioned, the study used older patients hospitalized with heart failure and reduced ejection fraction. It says that the therapy improved heart failure readmission among eligible older patients. It also mentions of the developement of Comparative Effectiveness of Therapies for Heart Failure (COMPARE-HE) program using a national clinical registry for dealing with issues related to effectiveness and safety of the therapy.

The article provides information on a research study which examined 3000 patients undergoing coronary artery bypass graft (CABG) surgery enrolled in the PREVENT IV trial. The study compared the long-term outcomes of endoscopy against open vein-graft harvesting for Medicare patients undergoing CABG surgery in the U.S. The primary outcome measures of the study was all-cause mortality and the secondary outcome measures included wound complications and the composite of death, myocardial infarction, and revascularization. The results of the study showed that there were no significant differences between long-term mortality rates and the composite of death, myocardial infarction, and revascularization.

The article discuses the change in hospital outcome ratings and the eligibility to gain financial benefits in the U.S. after the inclusion of initial stroke severity in a 30 day mortality model for acute ischemic stroke. It states that a significant improvement in model discrimination and changes in mortality performance ranking were observed after inclusion of stroke severity with the National Institutes of Health Stroke Scale (or NIHSS) score to a 30 day mortality model based on claims data with acute ischemic stroke. It further highlights that it is essential to include stroke severity for availing medical beneficiaries with acute ischemic stroke.

The article presents information research conducted on the risk of intracranial hemorrhage in patients suffering from acute ischemic stroke who receive warfarin and are treated with intravenous tissue plasminogen activator. The data from the American Heart Association of the U.S. determines the risk as the function of the international normalized ratio (INR) wherein if the INR is low the patients receive warfarin. Information on the patients who received warfarin was in a more comorbid condition and also had an unadjusted rate of symptomatic intracranial hemorrhage is also presented.

The article discusses the results of a study that evaluates whether evidence-based therapies can be improved by a multifaceted quality improvement (QI) intervention and reduce cases of acute coronary syndromes (ACS) in Brazil. The study shows that those in the intervention group registered in-hospital cardiovascular event rates of 5.5 percent while the control group posted 7.0 percent event rates. It concludes that a multifaceted educational intervention resulted in improvement in the use of evidence-based therapies among patients with ACS.

The article discusses a study of the relationship between sex and symptom presentation and sex, symptom presentation and hospital mortality after accounting for age among hospitalized patients with myocardial infarction (MI) in the U.S. The study used data from the National Registry of Myocardial Infarction (NRMI). Results show that 35.4% of the overall proportion of MI patients were presented without chest pain/discomfort. Also noted is the higher percentage of men with MI to present chest pain/discomfort over women. The key role of sex-based differences in MI presentation is mentioned.

The article discusses a study on the link between the number of risk factors for coronary heart disease (CHD) and hospital mortality in patients with first myocardial infarction (MI). Data from the National Registry of Myocardial Infarction (NRMI) in the U.S. from 1994 to 2006 were used in the study. A total of 542,008 patients with first MI and with no prior cardiovascular disease were evaluated for five major CHD risk factors including hypertension, smoking, dyslipidemia, diabetes and family history of CHD. The study found that at least one of the five risk factors was present in 85.6% of the patients. The authors conclude that in-hospital mortality among patients with first MI was inversely related to the number of risk factors.

The article investigates the relation of physician billing with nuclear stress and stress echocardiography testing after coronary revascularization. Results reveal that the overall cumulative incidence of nuclear or echocardiography stress testing within 30 days of the index cardiac-related outpatient visit following revascularization was 12.2%. The cumulative incidence of nuclear stress testing was 12.6%, 8.8%, and 5.0% among physicians who billed for technical and professional fees, professional fees only, or neither, respectively. The findings indicate that nuclear stress testing and stress echocardiography testing after revascularization were more common among patients treated by doctors who billed for technical fees, professional fees, or both.

The article discusses a study of the prevalence and outcomes of same-day discharge among older patients undergoing elective percutaneous coronary intervention (PCI) in the U.S. between November 2004 and December 2008. The Duke University Medical Center institutional review board in North Carolina has approved the study. Death and rehospitalization were included in the primary end points assessed for the analysis. Results stress the variability of same-day discharge among older patients undergoing elective PCI across PCI facilities. Also noted is the lack of association between a same-day discharge strategy and increased risk for death or readmission.

The article discusses a study which examined the proportion of ST-elevation myocardial infarction (STEMI) patients who are transferred with a door-in to door-out (DIDO) time of 30 minutes or less and assessed patient factors linked with delays in DIDO time. It notes that the preferred method of reperfusion for STEMI patients is primary percutaneous coronary intervention (PCI). Results showed that median DIDO time was 68 minutes. Older age, female sex and off-hours presentation were some of the factors associated with a DIDO time greater than 30 minutes. The study also found that only .6% of patients with DIDO times greater than 30 minutes had an absolute contraindication to fibrinolysis.

The article focuses on a study that investigated the association between admission to stroke centers for acute ischemic stroke and mortality. Using data from the New York Statewide Planning and Research Cooperative System, the researchers compared mortality for patients admitted with ischemic stroke between 2005 and 2006 at designated stroke centers and at nondesignated hospitals, using differential distance to hospitals as a variable in adjusting for potential pre-hospital selection bias. Results indicated modestly lower mortality among patients with acute ischemic stroke admitted to a designated stroke center, as well as more frequent use of thrombolytic therapy.

The article focuses on an observational cohort study which assessed hospital-level variation use of allogeneic red blood cells (RBC) fresh-frozen plasma, and platelet transfusions in patients undergoing coronary artery bypass graft (CABG) surgery. The study examined patients undergoing primary isolated CABG surgery with cardiopulmonary bypass during calendar year 2008 at 798 sites in the U.S. Study findings revealed wide variability in the rates of transfusion of RBCs and other blood products, independent of case mix, among patients undergoing CABG surgery with cardiopulmonary bypass in U.S. hospitals in an adult cardiac surgical database.

The article discusses a study which investigated the associations between outpatient follow-up within 7 days after discharge from a heart failure hospitalization and readmission within 30 days. The researchers analyzed patients 65 years or older with heart failure and discharged to home from hospitals participating in health programs from January 1, 2003 through December 31, 2006. It was suggested by the researchers that patients with higher early follow-up rates have a lower risk of 30-day readmission.

The article discusses research regarding the stability of international normalized ratios (INRs) in patients taking long-term warfarin therapy, and it mentions how the drug warfarin is used to decrease the risk of stroke among patients with atrial fibrillation. The therapeutic aspects of non-vitamin K oral anticoagulants are examined, along with drug monitoring and safety measures. The claim that warfarin stability is difficult to predict is also assessed.

The article focuses on a study which examined the administration of contraindicated drugs enoxaparin and eptifibatide among dialysis patients who are undergoing percutaneous coronary intervention (PCI). The study included 22,778 dialysis patients who underwent PCI between January 1, 2004 and August 31, 2008 in the U.S. Study population was randomized to either receive enoxaparin, eptifibatide or both. Study authors found that patients who received contraindicated antithrombotics had higher risks of in-hospital bleeding and mortality.

The article discusses a study which assessed the relationship between hospital primary angioplasty volume and outcomes and quality of care measures in patients presenting with ST-segment elevation myocardial infarction (STEMI). The study involved 29,513 patients presenting with STEMI and undergoing primary angioplasty in the Get with the Guidelines registry of the American Heart Association. The researchers found that there has been an association between higher-volume primary angioplasty centers versus lower-volume centers and shorter door-to-balloon (DTB) times.

The article presents a study which examined aldosterone antagonist prescription among hospitalized patients with heart failure (HF), temporal trends in use, and appropriateness of use. The study found that only one-third of patients eligible for aldosterone antagonist therapy were given with such therapy. It was also found that aldosterone antagonist use for appropriate indications is less common in certain groups including elderly patients, white, and those with lower systolic blood pressure. Factors that may have slowed adoption of guideline criteria are also mentioned.

The article focuses on a study which estimated the racial differences in survival for patients with in-hospital cardiac arrests. The study also examined the link between sociodemographic and clinical factors, and admitting hospital. It included 10,011 patients diagnosed with cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia. Such patients were from 274 hospitals within the National Registry of Cardiopulmonary Resuscitation. Study authors found that rates of survival to discharge are lower in black patients compared to white patients. They concluded that the racial difference in survival rates was associated with hospital center.

The article presents a retrospective cohort study which assessed the outcomes of patients taking clopidogrel with or without a proton pump inhibitor (PPI) after hospitalization for acute coronary syndrome (ACS). 8205 patients with ACS taking clopidogrel after discharge from 127 Veterans Affairs hospitals between October 1, 2003 and January 31, 2006 were included in the study. The main outcome was all-cause mortality or rehospitalization for ACS. Researchers found that concomitant use of clopidogrel and PPI was associated with an increased risk of adverse outcomes compared with clopidogrel without PPI.

A letter to the editor is presented on laboratory monitoring of renal function and electrolyte levels during the mineralocorticoid receptor antagonist therapy in patients with heart failure.

The article presents an analysis of acute and long-term outcomes of Medicare beneficiaries who have received ventricular assist devices alone or after open-heart surgery. Inpatient claims from the U.S. Centers for Medicare & Medicaid Services were used for the analysis. Incidences of device replacement, device removal, heart transplantation, death, and readmission were main outcome measures. Researchers found that early mortality, morbidity, and costs remain high among Medicare beneficiaries receiving a ventricular assist device.

The article presents a study which examines the effect that accounting for patient demographics, clinical characteristics and mix of treatment opportunities has on hospital performance ratings and eligibility for financial incentives. The study included an analysis of hospital process performance based on core measures for acute myocardial infarction defined by the Centers for Medicare & Medicaid Services. Data from the American Heart Association's Get With the Guidelines program was used. Information related to the patient population is included. The results of the study indicated that accounting for hospital differences in patient characteristics contributed to modest changes in a hospital's performance ranking and eligibility for financial benefits.

The article describes a study performed to examine whether persons with acute coronary syndrome (ACS) who stop using clopidogrel are exposed to a heightened short-term risk for death or acute myocardial infarction. Records were analyzed for 3137 ACS sufferers who were discharged from 127 U.S. Veterans Affairs hospitals between October, 2003 and March, 2005. Clusters of adverse events were observed during the 90-day period immediately subsequent to stopping clopidogrel treatment, although further study is required.

This article presents the results of an observational analysis of sex and racial differences in the use of implantable cardioverter-defibrillators (ICDs) among patients hospitalized with heart failure. Research has shown that patients with heart failure with left ventricular systolic dysfunction should be evaluated for the ICD. Studies have shown that treatment with the device is not evenly handed out to all patients. Since practice guidelines recommend the ICD for patients with a left ventricular ejection fraction of 30 percent or less, this study wanted to see if that was happening. It found that less than 40 percent of eligible patients got the therapy and the rates were lower in women and black patients.

This article reports on a pilot pay-for-performance" program measuring information on treatment for 5 clinical conditions including acute myocardial infarction. 260 hospitals participated in the pilot program. Hospitals with the highest performance in treating a condition received a reimbursement bonus while the worst performers risked future financial penalty. The purpose of the study was to see if pay-for-performance was associated with improved or unintended consequences for heart attack patients. The study concluded that the pay-for-performance program was not associated with a significant improvement in the quality of care and neither did it have a negative effect.

The article discusses a clinical study that was conducted to examine the association between the use of the drug clopidogrel after patients received either a drug-eluting stent or a bare-metal stent for the treatment of coronary artery disease. Clopidogrel is a drug used in thienopyridine antiplatelet therapy to prevent late stent thrombosis. The authors were interested in the long-term outcomes of patients and found that the use of clopidogrel in patients with drug-eluting stents may be associated with a lower risk of death or myocardial infarction.

ontext Selected care processes are increasingly being used to measure hospital quality; however, data regarding the association between hospital process performance and outcomes are limited. Objectives To evaluate contemporary care practices consistent with the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations, to examine how hospital performance varied among centers, to identify characteristics predictive of higher guideline adherence, and to assess whether hospitals' overall composite guideline adherence was associated with observed and risk-adjusted in-hospital mortality rates. Design, Setting, and Participants An observational analysis of hospital care in 350 academic and nonacademic US centers of 64 775 patients enrolled in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) National Quality Improvement Initiative between January 1, 2001, and September 30, 2003, presenting with chest pain and positive electrocardiographic changes or cardiac biomarkers consistent with non-ST-segment elevation acute coronary syndrome (ACS). Main Outcome Measures Use of 9 ACC/AHA class I guideline-recommended treatments and the correlation among hospitals' use of individual care processes as well as overall composite adherence rates. Results Overall, the 9 ACC/AHA guideline-recommended treatments were adhered to in 74% of eligible instances. There was modest correlation in hospital performance among the individual ACS process metrics. However, composite adherence performance varied widely (median [interquartile range] composite adherence scores from lowest to highest hospital quartiles, 63% [59%-66%] vs 82% [80%-84%]). Composite guideline adherence rate was significantly associated with in-hospital mortality, with observed mortality rates decreasing from 6.31% for the lowest adherence quartile to 4.15% for the highest adherence quartile (P<.001). After risk adjustment, every 10% increase in composite adherence at a hospital was associated with an analogous 10% decrease in its patients' likelihood of in-hospital mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.84-0.97; P<.001). Conclusion A significant association between care process and outcomes was found, supporting the use of broad, guideline-based performance metrics as a means of assessing and helping improve hospital quality. [ABSTRACT FROM AUTHOR]