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Background: Although high rates of P2Y 12 inhibitor pretreatment (defined as the administration before coronary angiography) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) have been reported, contemporary U.S. practice patterns are not well studied., Objectives: The goal of this study was to investigate the temporal U.S. trends, variability, and clinical outcomes of P2Y 12 inhibitor pretreatment in NSTE-ACS., Methods: Consecutive patients who underwent early invasive strategy for NSTE-ACS (coronary angiography ≤24 hours of arrival) in the National Cardiovascular Data Registry Chest Pain-Myocardial Infarction (MI) Registry were analyzed. A time-trend analysis was conducted on a complete cohort between January 1, 2013, and March 31, 2023. Subsequently, a more recent cohort (January 1, 2019, to March 31, 2023) with a complete set of variables was used to construct hierarchical regression models to quantify the variability in the use of pretreatment among operators and institutions. For this contemporary cohort, instrumental variable analysis, with operator preference as the instrument, was performed to compare the in-hospital outcomes between patients who received pretreatment and those who did not., Results: Use of P2Y 12 inhibitor pretreatment decreased from 24.8% in 2013Q1 to 12.4% in 2023Q1. Among the contemporary cohort of 110,148 patients (2019-2023; mean age 63.9 ± 12.5 years; 33.0% female), 17,509 (15.9%) received pretreatment. Significant variability in P2Y 12 inhibitor pretreatment was observed (range: 0%-100%): hierarchical regression model demonstrated that 2 similar patients would have a >3-fold difference in the odds of pretreatment from 1 random operator or institution as compared with another (median OR: 3.74 [95% CI: 3.57-3.91] and 3.63 [95% CI: 3.51-3.74], respectively). Instrumental variable analysis demonstrated no significant differences in in-hospital all-cause death (1.5% vs 1.7%; P = 0.07), recurrent MI (0.6% vs 0.6%; P = 0.98), or major bleeding (2.7% vs 2.8%; P = 0.98) with pretreatment. However, in patients who underwent coronary artery bypass surgery, pretreatment was associated with a longer length of stay (11.2 ± 5.1 days vs 9.8 ± 5.0 days; P < 0.01)., Conclusions: In a national U.S. registry, we observed significant variability in the use of P2Y 12 inhibitor pretreatment among NSTE-ACS patients. Given the lack of clear advantages and the potential for prolonged hospital stays, our findings highlight the importance of efforts to improve standardization., Competing Interests: Funding Support and Author Disclosures This analysis was funded by the National Cardiovascular Data Registry. Dr Rymer has received research funding from the National Heart, Lung, and Blood Institute, Novo Nordisk, Chiesi, Abiomed, and Pfizer. Dr Sandhu has received prior consulting fees from Lexicon Pharmaceuticals; and has received research funding from the American Heart Association, National Institutes of Health, Novartis Pharmaceuticals, and Reprieve Cardiovascular outside of the submitted work. Dr Masoudi serves on a steering committee for a registry sponsored by Bristol Myers Squibb. Dr Spertus owns the copyright to the Seattle Angina Questionnaire; has received consulting income from Janssen, Bayer, AstraZeneca, Novartis, and Merck; serves on the cardiovascular scientific advisory board of United Healthcare; is on the board of directors for Blue Cross Blue Shield of Kansas City; and holds equity interest in Health Outcomes Sciences. Dr Kohsaka has received research funding from the Japan Society for the Promotion of Science and Pfizer; and has received consulting fees from Novartis and Bristol Myers Squibb, outside of the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures Dr Sandhu is supported by National Heart, Lung, and Blood Institute grant 1K23HL151672. Dr Rodriguez was funded by NIH National Heart, Lung, and Blood Institute grants 1K01HL144607, R01HL168188, and R01HL167974, the American Heart Association/Harold Amos Medical Faculty Development program, and Doris Duke Foundation Grant #2022051. Dr Jain has received consulting fees from Bristol Myers Squibb, ARTIS Ventures, and Broadview Ventures outside of the submitted work. Dr Bhatt has received research grant support to his institution from National Institutes of Health/National Heart, Lung, and Blood Institute, National Institutes of Health/National Institute on Aging, American College of Cardiology Foundation, and the Centers for Disease Control and Prevention; and has received consulting fees from Sanofi Pasteur, Merck, and Novo Nordisk. Dr Sandhu has received consulting fees from Lexicon Pharmaceuticals; and has received research funding from the American Heart Association, Novartis Pharmaceuticals, and Reprieve Cardiovascular outside of the submitted work. Dr Rodriguez has received equity from Carta Healthcare and HealthPals; and has received consulting fees from HealthPals, Novartis, NovoNordisk, Esperion Therapeutics, Movano Health, Kento Health, Inclusive Health, Edwards, Arrowhead Pharmaceuticals, HeartFlow, and iRhythm outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Coronary artery calcium (CAC) is a strong predictor of cardiovascular events across all racial and ethnic groups. CAC can be quantified on nonelectrocardiography (ECG)-gated computed tomography (CT) performed for other reasons, allowing for opportunistic screening for subclinical atherosclerosis., Objectives: The authors investigated whether incidental CAC quantified on routine non-ECG-gated CTs using a deep-learning (DL) algorithm provided cardiovascular risk stratification beyond traditional risk prediction methods., Methods: Incidental CAC was quantified using a DL algorithm (DL-CAC) on non-ECG-gated chest CTs performed for routine care in all settings at a large academic medical center from 2014 to 2019. We measured the association between DL-CAC (0, 1-99, or ≥100) with all-cause death (primary outcome), and the secondary composite outcomes of death/myocardial infarction (MI)/stroke and death/MI/stroke/revascularization using Cox regression. We adjusted for age, sex, race, ethnicity, comorbidities, systolic blood pressure, lipid levels, smoking status, and antihypertensive use. Ten-year atherosclerotic cardiovascular disease risk was calculated using the pooled cohort equations., Results: Of 5,678 adults without ASCVD (51% women, 18% Asian, 13% Hispanic/Latinx), 52% had DL-CAC >0. Those with DL-CAC ≥100 had an average 10-year ASCVD risk of 24%; yet, only 26% were on statins. After adjustment, patients with DL-CAC ≥100 had increased risk of death (HR: 1.51; 95% CI: 1.28-1.79), death/MI/stroke (HR: 1.57; 95% CI: 1.33-1.84), and death/MI/stroke/revascularization (HR: 1.69; 95% CI: 1.45-1.98) compared with DL-CAC = 0., Conclusions: Incidental CAC ≥100 was associated with an increased risk of all-cause death and adverse cardiovascular outcomes, beyond traditional risk factors. DL-CAC from routine non-ECG-gated CTs identifies patients at increased cardiovascular risk and holds promise as a tool for opportunistic screening to facilitate earlier intervention., Competing Interests: Funding Support and Author Disclosures This work was supported by the Stanford University Human-Centered Artificial Intelligence Seed Grant. Mr Khandwala and Mr Eng are employees and shareholders of Bunkerhill Health. Dr Chaudhari has received research support from the Stanford University Precision Health and Integrated Diagnostics Seed Grant and the Stanford University Human-Centered Artificial Intelligence–Artificial Intelligence in Medicine and Imaging Seed Grant; has provided consulting services to Subtle Medical, Chondrometrics GmbH, Image Analysis Group, Edge Analytics, ICM, and Culvert Engineering; is a shareholder of Subtle Medical, LVIS Corporation, and Brain Key; and receives research support from GE Healthcare and Philips, all outside of the submitted work. Dr Sandhu has received research support from the National Heart, Lung, and Blood Institute (1K23HL151672-01). Dr Rodriguez was funded by grants from the National Institutes of Health National Heart, Lung, and Blood Institute (1K01HL144607), the American Heart Association/Harold Amos Faculty Development program, and the Doris Duke Foundation (Grant #2022051); and has consulting relationships with Healthpals, Novartis, Novo Nordisk, Esperion, and AstraZeneca outside of the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aim: The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure., Methods: A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021., Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses., (Copyright © 2022 American Heart Association, Inc., the American College of Cardiology Foundation, and the Heart Failure Society of America. Published by Elsevier Inc. All rights reserved.)