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ObjectiveTo identify potential race, sex and age disparities in performance of transthoracic echocardiography (TTE) over several decades.MethodsTTE reports from five academic and community sites within a single integrated healthcare system were linked to 100% Medicare fee-for-service claims from 1 January 2005 to 31 December 2017. Multivariable Poisson regression was used to estimate adjusted rates of TTE utilisation after the index TTE according to baseline age, sex, race and comorbidities among individuals with ≥2 TTEs. Non-white race was defined as black, Asian, North American Native, Hispanic or other categories using Medicare-assigned race categories.ResultsA total of 15 870 individuals (50.1% female, mean 72.2±12.7 years) underwent a total of 63 535 TTEs (range 2–55/person) over a median (IQR) follow-up time of 4.9 (2.4–8.5) years. After the index TTE, the median TTE use was 0.72 TTEs/person/year (IQR 0.43–1.33; range 0.12–26.76). TTE use was lower in older individuals (relative risk (RR) for 10-year increase in age, 0.91, 95% CI 0.89 to 0.92, p<0.001), women (RR 0.97, 95% CI 0.95 to 0.99, p<0.001) and non-white individuals (RR 0.95, 95% CI 0.93 to 0.97, p<0.001). Black women in particular had the lowest relative use of TTE (RR 0.92, 95% CI 0.88 to 0.95, p<0.001). The only clinical conditions associated with increased TTE use after multivariable adjustment were heart failure (RR 1.04, 95% CI 1.00 to 1.08, p=0.04) and chronic obstructive pulmonary disease (RR 1.05, 95% CI 1.00 to 1.10, p=0.04).ConclusionsAmong Medicare beneficiaries with multiple TTEs in a single large healthcare system, the median TTE use after the index TTE was 0.72 TTEs/person/year, although this varied widely. Adjusted for comorbidities, female sex, non-white race and advancing age were associated with decreased TTE utilisation.

Characteristics of tricuspid valve prolapse (TVP) on transthoracic echocardiography are not well defined. As tricuspid valve interventions are increasingly considered, information on the definition and clinical significance of TVP is needed.

Ultrasound enhancing agents (UEAs) are routinely used to improve transthoracic echocardiographic (TTE) image quality, yet anticipation of UEA need is a barrier to their use.

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ObjectiveThe Appropriate Use Criteria (AUC) has been used to identify individuals who are likely to benefit from percutaneous coronary intervention (PCI) for stable ischaemic heart disease. However, whether physicians reliably grade PCI appropriateness and whether AUC categories stratify symptomatic improvement in real-world practice are unclear.MethodsPatient-reported outcomes measures (PROMs) for angina (Seattle Angina Questionnaire (SAQ-7)), dyspnoea (Rose Dyspnea Scale (RDS)) and depression (Patient Health Questionnaire-2 (PHQ-2)) were collected on patients undergoing elective coronary angiography at an academic medical centre. Retrospectively, two physicians independently determined PCI appropriateness by the AUC criteria.ResultsInter-rater agreement on appropriateness was moderate (κ=0.48, 95% CI 0.32 to 0.63). Of PCI procedures evaluated, 57 (47.1%) were appropriate (A-PCI), 62 (51.2%) were maybe appropriate (MA-PCI) and 2 (1.6%) were rarely appropriate. At baseline, A-PCI compared with MA-PCI patients had worse RDS scores (2.0 vs 1.2, p=0.01). At 30 days, the change in SAQ-7 summary score was similar between groups (A-PCI vs MA-PCI, +27.1 vs +20.7, p=0.11). The mean change in RDS score was greater in A-PCI than MA-PCI (−1.0 vs −0.5, p for group by time interaction=0.03). PHQ-2 scores were similar and did not improve at 30 days.ConclusionIn patients undergoing PCI with PROMs collected before and 30 days after PCI, similar improvements in angina were observed regardless of appropriateness. Inter-rater agreement on PCI appropriateness was only moderate. Use of PROMs may improve reliability of physician assessments of PCI appropriateness.

•The value of echocardiography can be demonstrated via impact on patient outcomes.•Large, pooled echocardiographic data present unique challenges and opportunities.•Efforts to link imaging data across sites and to outcomes data are ongoing.

IMPORTANCE: The addition of a claims-based frailty metric to traditional comorbidity-based risk-adjustment models for acute myocardial infarction (AMI), heart failure (HF), and pneumonia improves the prediction of 30-day mortality and readmission. This may have important implications for hospitals that tend to care for frail populations and participate in Centers for Medicare & Medicaid Services value-based payment programs, which use these risk-adjusted metrics to determine reimbursement. OBJECTIVE: To determine whether the addition of frailty measures to traditional comorbidity-based risk-adjustment models improved prediction of outcomes for patients with AMI, HF, and pneumonia. DESIGN, SETTING, AND PARTICIPANTS: A nationwide cohort study included Medicare fee-for-service beneficiaries 65 years and older in the United States between January 1 and December 1, 2016. Analysis began August 2018. MAIN OUTCOMES AND MEASURES: Rates of mortality within 30 days of admission and 30 days of discharge, as well as 30-day readmission rates by frailty group. We evaluated the incremental effect of adding the Hospital Frailty Risk Score (HFRS) to current comorbidity-based risk-adjustment models for 30-day outcomes across all conditions. RESULTS: For 785 127 participants, there were 166 200 hospitalizations [21.2%] for AMI, 348 619 [44.4%] for HF, and 270 308 [34.4%] for pneumonia. The mean (SD) age at the time of hospitalization was 79.2 (8.9) years; 656 315 (83.6%) were white and 402 639 (51.3%) were women. The mean (SD) HFRS was 7.3 (7.4) for patients with AMI, 10.8 (8.3) for patients with HF, and 8.2 (5.7) for patients with pneumonia. Among patients hospitalized for AMI, an HFRS more than 15 (compared with an HFRS &lt;5) was associated with a higher risk of 30-day postadmission mortality (adjusted odds ratio [aOR], 3.6; 95% CI, 3.4-3.8), 30-day postdischarge mortality (aOR, 4.0; 95% CI, 3.7-4.3), and 30-day readmission (aOR, 3.0; 95% CI, 2.9-3.1) after multivariable adjustment for age, sex, race, and comorbidities. Similar patterns were observed for patients hospitalized with HF (30-day postadmission mortality: aOR, 3.5; 95% CI, 3.4-3.7; 30-day postdischarge mortality: aOR, 3.5; 95% CI, 3.3-3.6; and 30-day readmission: aOR, 2.9; 95% CI, 2.8-3.0) and among patients with pneumonia (30-day postadmission mortality: aOR, 2.5; 95% CI, 2.3-2.6; 30-day postdischarge mortality: aOR, 3.0; 95% CI, 2.9-3.2; and 30-day readmission: aOR, 2.8; 95% CI, 2.7-2.9). The addition of HFRS to traditional comorbidity-based risk-prediction models improved discrimination to predict outcomes for all 3 conditions. CONCLUSIONS AND RELEVANCE: Among Medicare fee-for-service beneficiaries, frailty as measured by the HFRS was associated with mortality and readmissions among patients hospitalized for AMI, HF, or pneumonia. The addition of HFRS to traditional comorbidity-based risk-prediction models improved the prediction of outcomes for all 3 conditions.

The role of basal septal hypertrophy (BSH) on preprocedural transthoracic echocardiography in transcatheter aortic valve replacement (TAVR) is unknown.

IMPORTANCE: Hospital outcomes for transcatheter aortic valve replacement (TAVR) may be dependent on the quality of evaluation, personnel, and procedural and postprocedural care common to patients undergoing cardiac surgery. OBJECTIVES: We sought to assess whether those hospitals with better patient outcomes for surgical aortic valve replacement (SAVR) subsequently achieved better TAVR outcomes after launching TAVR programs. DESIGN, SETTING, AND PARTICIPANTS: This national cohort included US patients 65 years and older. The analysis used the Centers for Medicare and Medicaid Services’ Medicare Provider and Review data collected between January 1, 2010, and September 29, 2015. Only hospitals performing at least 1 SAVR prior to September 1, 2011, and performing at least 1 TAVR after this date were included in the analysis. Data analysis was completed from June 2018 to August 2018. INTERVENTIONS: Isolated aortic valve replacements. MAIN OUTCOMES AND MEASURES: Hospital risk-adjusted 30-day mortality for SAVR in the pre-TAVR period was used as a surrogate for SAVR quality. Thirty-day and 1-year TAVR mortality rates were examined after stratification by quartile of baseline hospital risk-adjusted SAVR mortality. RESULTS: A total of 51 924 TAVR procedures were performed in 519 hospitals, of which 19 798 were performed at hospitals in quartile 1 (the lowest risk-adjusted SAVR mortality rate), 7663 were performed in quartile 2, 10 180 were performed in quartile 3, and 14 283 were performed in quartile 4 (the highest risk-adjusted SAVR mortality rate). Observed mortality rates at 30 days consistently increased with increasing baseline hospital SAVR risk-adjusted mortality (quartile 1, 917 patients [4.6%]; quartile 2, 381 [5.0%]; quartile 3, 521 [5.1%]; quartile 4, 800 [5.6%]; P &lt; .001). The same pattern was observed in 1-year mortality (quartile 1, 3359 [17.0%]; quartile 2, 1337 [17.5%]; quartile 3, 1852 [18.2%]; quartile 4, 2652 [18.6%]; P &lt; .001). After multivariable analysis, compared with the lowest quartile of SAVR mortality, undergoing TAVR at a hospital with higher baseline SAVR mortality continued to be associated with higher 30-day mortality (odds ratios: quartile 2, 1.02 [95% CI, 0.87-1.21]; quartile 3, 1.13 [95% CI, 1.02-1.26]; quartile 4, 1.23 [95% CI, 1.07-1.40]; P = .02) and 1-year mortality (hazard ratios: quartile 2, 1.04 [95% CI, 0.92-1.17]; quartile 3, 1.14 [95% CI, 1.02-1.28]; quartile 4, 1.16 [95% CI, 1.05-1.28]; P = .02). CONCLUSIONS AND RELEVANCE: Hospitals with higher SAVR mortality rates also had higher short-term and long-term TAVR mortality after initiating TAVR programs. Quality of cardiac surgical care may be associated with a hospital’s performance with new structural heart disease programs.

Aortic stenosis (AS) is the most common valvular heart disease in high-income countries. Adjusted for clinical confounders, the risk associated with increasing AS severity across the spectrum of AS severity remains uncertain.

Introduction:Frailty is associated with increased morbidity and mortality in patients undergoing left atrial appendage closure (LAAC). We compared the performance of two claims-based frailty measures in predicting adverse outcomes following LAAC.Methods:We identified patients 65 years and older who underwent LAAC between October 1, 2016 and December 31, 2019 in Medicare fee-for-service claims. Frailty was assessed using the previously validated Hospital Frailty Risk Score (HFRS) and Kim Claims-based Frailty Index (CFI). Patients were identified as frail based on HFRS ≥5 and CFI ≥0.25.Results:Of the 21,787 patients who underwent LAAC, frailty was identified in 45.6% by HFRS and 15.4% by CFI. There was modest agreement between the two frailty measures (kappa 0.25, Pearson’s correlation 0.62). After adjusting for age, sex, and comorbidities, frailty was associated with higher risk of 30-day mortality, 1-year mortality, 30-day readmission, long hospital stay, and short time at home (p<0.01 for all) regardless of the frailty instrument used. Model discrimination was similar between the HFRS and the CFI with fair discrimination of all outcomes (C-statistic 0.686 - 0.759). The addition of frailty to standard comorbidities significantly improved model performance to predict 1-year mortality, long hospital stay, and short time at home (Delong p-value <0.001).Conclusions:Despite significant variation in frailty detection and only modest agreement between the two frailty measures, frailty status was highly predictive of mortality, readmission, long hospital stay, and days at home. Future studies should focus on prospective evaluation of frailty in patients eligible for LAAC, which may further refine the relationship between frailty and adverse outcomes, and help inform shared decision-making in this population.

Introduction:Lower rates of transcatheter aortic valve implantation (TAVI) among Black individuals have been observed, the drivers of this disparity remain poorly understood. We studied the association between county-level racial segregation and rates of aortic stenosis (AS) diagnosis and management.Methods:We identified Black and white Medicare fee-for-service beneficiaries living in metropolitan areas between 2016 and 2019. Using the American Community Survey’s residential segregation index (SI), a measure of geographic distribution of Black and white residents ranging from 0 (complete integration) to 100 (complete segregation), we determined segregation in each beneficiaries’ county of residence. We calculated population-level rates of AS diagnosis and TAVI using validated ICD-10 codes. Using hierarchical modeling, we determined the association between racial segregation and rates of AS diagnosis, TAVI receipt, and 30-day mortality.Results:A total of 29,264,075 beneficiaries were included in the analysis. Living in a high-segregation county (SI>60) was associated with increased rates of AS diagnosis overall (adjusted OR 1.03 95%CI 1.02-1.03) but no difference in TAVI. However, among Black beneficiaries, increasing county-level segregation was associated with decreased rates of AS diagnosis and TAVI; the opposite association was observed among white beneficiaries (Figure 1). Among those with an AS diagnosis, the interaction between Black race and segregation, and lower rates of TAVI persisted (interaction p-value 0.003). Segregation and race were not independently associated with 30-day mortality.Conclusions:Living in a high-segregation county is independently associated with decreased population-level rates of AS diagnosis and receipt of TAVI for Black, but not white, individuals. Among Black people living in high-segregation counties, disparities in TAVI rates are associated with decreased AS diagnosis and access to TAVI.

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The growth of centers capable of performing percutaneous coronary intervention (PCI) has outpaced population growth despite declining incidence of myocardial infarction and prevalence of coronary artery disease, potentially increasing the proportion of operators falling below minimal yearly volume standards set by professional societies.

Background:Indexing mitral regurgitation (MR) regurgitation volume (RVol) for left ventricular (LV) cavity size accounts for concomitant LV remodeling, but whether it improves prognostication of mortality is uncertain.Methods:The ratio of RVol to LV end-diastolic diameter (LVDD) was measured in 399 individuals (mean age 70.1 ±16.4 years, 51.1% female) with any MR (mean RVol 49.2 ± 27.7 mL) undergoing echocardiography (TTE). Individuals with prior mitral valve interventions were excluded. The relationship between RVol/LVDD and all-cause mortality was examined. The incremental predictive value of RVol/LVDD was compared to RVol alone.Results:Over a median (interquartile range) of 8.8 (3.4-10.5) years follow-up, there were 101 deaths (25.3%). Amongst those treated medically (N = 348), a lower ratio was associated with higher mortality (HR per 1-mL/cm decrease, 1.04, 95% CI 1.01-1.10, p = 0.04), despite a lesser degree of MR (low vs. high RVol/LVDD group, mean RVol, 30.3 ± 11.7 mL vs. 68.1 ± 26.3 mL, p < 0.001), with an inflection for increased risk < 8.4 mL/cm (Figure). By contrast, amongst those treated surgically (N = 41), no association was observed (p = 0.69) between RVol/LVDD and mortality, though death was less frequent. This association with risk was observed only amongst individuals with a reduced LVEF and was independent of etiology of MR (e.g. secondary vs. primary). Compared to RVol alone, indexing for LV cavity size improved the prognostication of death (p < 0.001).Conclusions:Amongst patients with MR with a reduced LVEF, treated medically, survival was significantly worse amongst individuals with lower RVol/LVDD ratios. Furthermore, indexing for LV cavity size improved prediction of mortality compared to RVol alone. These results overall suggest that RVol should be routinely indexed for LV size to improve prognostication of risk. Moreover, they suggest a threshold may exist where LV size predominates risk in individuals with MR, treated medically.

Introduction and Hypothesis:Female sex has long been considered a risk factor for anthracycline-associated cardiotoxicity, based largely on data in childhood cancer survivors. However, preclinical experiments suggest that female sex hormones present in adulthood may protect against doxorubicin cardiotoxicity. We therefore hypothesized that female sex would be associated with a decreased odds of heart failure in adult patients treated with anthracyclines.Methods:We conducted a retrospective cohort study of 871 adult patients (44% women and 56% men) at our medical center with no prior history of heart failure who were treated with anthracyclines for non-hormone-dependent malignancies including lymphoma, leukemia, and sarcoma. Patients who expired during the study period were excluded. The presence or absence of heart failure within five years of initiation of anthracyclines was assessed using ICD-9/10 codes. Logistic regression models were used to assess odds ratios based on self-reported sex and other covariates, adjusting for age.Results:Baseline characteristics were similar in men and women, including age, total cumulative anthracycline dose, and prevalence of cardiovascular comorbidities such as hypertension, diabetes, and coronary artery disease. The odds of heart failure increased modestly with age (OR: 1.02; 95% CI: 1.01 to 1.03, p = 0.001). In an age-adjusted model, female sex was not associated with subsequent heart failure (OR: 1.03, 95% CI 0.72 to 1.47, p = 0.88), including after stratification by age ≤ 50 years or > 50 years as a surrogate for menopausal status.Conclusions:In this retrospective cohort study, female sex was not associated with heart failure in adult patients treated with anthracyclines for non-hormone-dependent tumors. These findings diverge from prior reports suggesting an increased risk of cardiotoxicity in women. Future studies will assess the competing risks of cancer and cardiovascular disease/death in men versus women treated with anthracyclines.

Introduction:Differences in patient characteristics, changes in treatment algorithms, and advances in medical technology could each influence the applicability of older randomized trial results to contemporary clinical practice.Objectives:To evaluate whether the Dual Antiplatelet Therapy (DAPT) Study population is different from a contemporary population of US patients receiving percutaneous coronary intervention (PCI), and to estimate the treatment effect of extended duration antiplatelet therapy after PCI in this more contemporary cohort.Methods:We compared characteristics of drug-eluting stent (DES)-treated patients randomized in the DAPT Study to a sample of more contemporary DES-treated patients in the NCDR CathPCI Registry from July 2016-June 2017. After linking trial and registry data, we employed inverse-odds of trial participation weighting to account for patient and procedural characteristics and estimated a contemporary “real-world” treatment effect of 30 vs. 12 months of DAPT after coronary stent procedures.Results:The US DES-treated trial cohort included 8864 DAPT Study patients and the registry cohort included 568,540 patients. Compared to the trial population, registry patients had more comorbidities and were more likely to present with myocardial infarction and receive 2nd generation DES. After reweighting trial results to represent the registry population, there was no longer a significant effect of prolonged DAPT on reducing stent thrombosis (reweighted treatment effect: -0.40, 95% CI: -0.99%, 0.15%), MACCE ( reweighted treatment effect: -0.52, 95% CI: -2.62%, 1.03%), or MI (reweighted treatment effect: -0.97%, 95% CI: -2.75%, 0.18%), but the increase in bleeding with prolonged DAPT persisted (reweighted treatment effect: 2.42%, 95% CI: 0.79%, 3.91%).Conclusions:Differences between patients and devices used in contemporary clinical practice compared with the DAPT Study may be associated with attenuation of benefits and relatively greater harms attributable to prolonged DAPT duration. These findings may limit applicability of average treatment effects from the DAPT Study in modern clinical practice.

Background:Frailty is associated with a higher risk for adverse outcomes after aortic valve replacement (AVR) for severe aortic valve stenosis, but whether or not frail patients have differential benefit from transcatheter (TAVR) vs. surgical (SAVR) AVR is uncertain.Methods:We linked adults ≥ 65 years old in the US CoreValve High Risk (HiR) or Surgical or Transcatheter Aortic-Valve Replacement in Intermediate Risk Patients (SURTAVI) trial to 100% Medicare claims 2/2/2011-9/30/2015. Two frailty measures, a deficit-based (DFI) and phenotype-based (PFI) frailty index, based on the Rockwood and Fried definitions of frailty respectively, were generated for linked individuals. The absolute and relative treatment effect of TAVR vs. SAVR were evaluated within frailty index (FI) tertiles for the primary endpoint of death and non-death secondary outcomes, as defined by the trials, using multivariable Cox regression. Functional status decline was additionally in TAVR vs. SAVR by FI tertile using multivariable logistic regression.Results:Of 1,442 (linkage rate = 60.0%) individuals in the linked HiR and SURTAVI trials, 741 (51.4%) individuals received TAVR and 701 (48.6%) received SAVR (mean age 81.8 ± 6.1 years, 44.0% female, mean Society of Thoracic Surgeons risk score 5.9 ± 2.7). Those in higher FI tertiles had a greater burden of comorbidities. Though the rates of death in the highest FI tertiles (DFI 38.6%, PFI 33.8%) were 2-3-fold higher than the lowest tertile (DFI 14.8%, HR 2.86, 95% CI 2.15-3.79, p < 0.001; PFI 17.9%; HR 2.05, 95% CI 1.58-2.67, p < 0.001), there were no significant differences in the relative or absolute treatment effect of SAVR vs. TAVR across FI tertiles for all death, non-death, and functional outcomes (all interaction p-values > 0.05). Results were overall consistent across individual trials and frailty definitions (Figure).Conclusions:Among CoreValve trial participants linked to Medicare claims, two different frailty indices based on Fried and Rockwood definitions identified individuals at higher risk of death and functional decline but no differential benefit from TAVR vs. SAVR.

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Introduction:Rates and predictors of long-term progression of mitral (MR) and tricuspid regurgitation (TR) are uncertain, despite extensive use of surveillance transthoracic echocardiography (TTE).Methods:We created a database of structured reports from 220,135 consecutive TTEs performed on 118,647 patients at Beth Israel Deaconess Medical Center, Boston, MA between 2000 and 2018. MR and TR were semiquantatively graded (0+, 1+, 2+, 3 +, 4+). We excluded patients with prior mitral or tricuspid valve intervention, endocarditis, or 4+ MR/TR on their first echo, as well as those with only one TTE. We used specialized Proportional Hazards models (to adjust for interval- and left-censored data) to estimate time to MR or TR progression (?+1 increase in severity grade), adjusted for the competing risk of death.Results:Of 38,908 individuals with ?2 TTEs, 34,933 individuals (89.8%) had ?1+ MR and 27,526 individuals (70.7%) had ?1+ TR at baseline. Of these, 5,379 (15.4%) individuals with MR and 3,630 (13.2%) with TR had disease progression during follow-up. The median (IQR) time to progression was 909 (240-2,226) days for MR and 917 (224-2,160) days for TR (Figure). For both MR and TR, age, diastolic blood pressure, left atrial size, LV cavity size, LV ejection fraction, peak aortic velocity, and pulmonary artery systolic pressure predicted progression during follow-up (p <0.001 for all).Conclusions:Both MR and TR are common observed on TTE. Of those with MR or TR, 15.4% and 13.2% respectively have an increase in severity grade of 1+ or more over 18 years. Progression rates demonstrate wide inter-individual variability but increase with disease severity. Accurate prediction of individualized risk of progression is needed to determine prognosis as well as optimal frequency of follow-up imaging.

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ObjectiveTo determine if using a parachute prevents death or major traumatic injury when jumping from an aircraft.DesignRandomized controlled trial.SettingPrivate or commercial aircraft between September 2017 and August 2018.Participants92 aircraft passengers aged 18 and over were screened for participation. 23 agreed to be enrolled and were randomized.InterventionJumping from an aircraft (airplane or helicopter) with a parachute versus an empty backpack (unblinded).Main outcome measuresComposite of death or major traumatic injury (defined by an Injury Severity Score over 15) upon impact with the ground measured immediately after landing.ResultsParachute use did not significantly reduce death or major injury (0% for parachute v0% for control; P>0.9). This finding was consistent across multiple subgroups. Compared with individuals screened but not enrolled, participants included in the study were on aircraft at significantly lower altitude (mean of 0.6 m for participants vmean of 9146 m for non-participants; P<0.001) and lower velocity (mean of 0 km/h vmean of 800 km/h; P<0.001).ConclusionsParachute use did not reduce death or major traumatic injury when jumping from aircraft in the first randomized evaluation of this intervention. However, the trial was only able to enroll participants on small stationary aircraft on the ground, suggesting cautious extrapolation to high altitude jumps. When beliefs regarding the effectiveness of an intervention exist in the community, randomized trials might selectively enroll individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.

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Background:To improve care coordination, Medicare is reporting 30-day readmissions after percutaneous coronary interventions (PCI) as a quality metric. Chest pain or other symptoms concerning for angina is the most common reason for early hospital readmission after PCI. To reduce hospital readmission in ways that improve value and ensure patient safety, clinicians need to understand which patients returning with symptoms are at high risk and merit admission.

Introduction:Early readmission after PCI can be a useful performance measure, particularly if the reasons for readmission are related to patient management (e.g. angina, stent thrombosis or bleeding). Prior studies on readmission have used principal billing discharge diagnosis, but the validity of billing codes for this purpose is unclear.

Background:Policymakers have designated 30-day readmission after percutaneous coronary intervention (PCI) as an important quality metric. Nevertheless, detailed descriptions of the causes and preventability of readmissions after PCI are lacking, leading some to question the usefulness of readmission as a quality metric. Determination of the causes of 30-day readmissions can help clarify the clinical validity of this measure and enable hospitals to develop strategies to reduce readmission rates.