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Background: Although current guidelines recommend implantable cardioverter-defibrillator (ICD) placement in survivors of out-of-hospital cardiac arrest, contemporary data on secondary-prevention ICDs in survivors of out-of-hospital cardiac arrest remain limited., Methods and Results: Using 2013 to 2019 CARES (Cardiac Arrest Registry to Enhance Survival) linked to Medicare, we identified 3226 patients aged ≥65 years with an initial shockable rhythm who survived to discharge without severe neurological disability. Multivariable hierarchical regression models were used to examine the association between patient variables and ICD placement and quantify hospital variation in ICD implantation. The mean age was 72.2 years, 23.5% were women, 10% were Black individuals, and 4% were Hispanic individuals. Overall, 997 (30.9%) patients received an ICD before discharge, 1266 (39.2%) at 90 days, and 1287 (39.9%) within 6 months. Older age (≥85 years), female sex, history of diabetes, calendar year, and presentation with acute myocardial infarction were associated with lower odds of ICD implantation, but race or ethnicity was not associated with ICD implantation. Among 297 hospitals, the median proportion of survivors receiving ICD at discharge was 28.6% (interquartile range, 20%-50%). The relative odds of ICD implantation varied by 62% across hospitals (median odds ratio, 1.62 [95% CI, 1.38-1.82]) after adjusting for case mix., Conclusions: Fewer than 1 in 3 survivors of out-of-hospital cardiac arrest due to a shockable rhythm received a secondary-prevention ICD before discharge. Although patient variables were associated with ICD implantation, there was no difference by race or ethnicity. Even after adjusting for patient case mix, ICD implantation varied markedly across hospitals.

Background: Cardiac arrest is 1 of the leading causes of morbidity and mortality, with an estimated 340 000 out-of-hospital and 292 000 in-hospital cardiac arrest events per year in the United States. Survival rates are lower in certain racial and socioeconomic groups., Methods and Results: We performed a county-level cross-sectional longitudinal study using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research multiple causes of death data set between 2016 and 2020 among individuals of all ages whose death was attributed to cardiac arrest. The Social Vulnerability Index is a composite measure that includes socioeconomic vulnerability, household composition, disability, individuals from racial and ethnic minority groups status and language, and housing and transportation domains. We examined the impact of social determinants on cardiac arrest mortality stratified by age, race, ethnicity, and sex in the United States. All age-adjusted mortality rate (cardiac arrest AAMRs) are reported as per 100 000. Overall cardiac arrest AAMR during the study period was 95.6. The cardiac arrest AAMR was higher for men compared with women (119.6 versus 89.9) and for the Black population compared with the White population (150.4 versus 92.3). The cardiac arrest AAMR increased from 64.8 in counties in quintile 1 of Social Vulnerability Index to 141 in quintile 5, with an average increase of 13% (95% CI, 9.8%-16.9%) in AAMR per quintile increase., Conclusions: Mortality from cardiac arrest varies widely, with a >2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the United States based on social determinants of health.

Background Disparities in bystander cardiopulmonary resuscitation (CPR) and survival have been reported for Black and Hispanic individuals with out-of-hospital cardiac arrest (OHCA). Whether Asian individuals have lower rates of bystander CPR and survival for OHCA, as compared with White individuals, remains unknown. Methods and Results Within the US-based CARES (Cardiac Arrest Registry to Enhance Survival), we identified 278 989 OHCAs in Asian and White individuals during 2013 to 2021. Using hierarchical Poisson logistic regression with emergency medical service agency modeled as a random effect and patient and OHCA characteristics as fixed effects, we compared rates of bystander CPR, survival to discharge, and favorable neurological survival between Asian and White individuals with OHCA. Overall, 14 835 (5.3%) OHCAs occurred in Asian individuals. Compared with White individuals with OHCA, Asian individuals were older (67.0±17.6 versus 62.8±16.9 years) and were less likely to have drug overdose as the cause of OHCA (1.3% versus 6.6%) and a shockable arrest rhythm (19.2% versus 22.4%). Layperson bystander CPR rates were similar between Asian and White individuals (42.6% versus 42.1%; adjusted relative risk for Asian individuals, 0.99 [95% CI, 0.97-1.02]; P =0.69). However, rates of survival to discharge were lower in Asian individuals with OHCA (8.2% versus 10.3%; adjusted relative risk 0.92 [0.86-0.98] P =0.006). Similarly, the rate of favorable neurological survival was lower for Asian individuals (6.5% versus 8.7%; adjusted relative risk, 0.85 [0.79-0.91]; P <0.001). Conclusions Despite similar rates of bystander CPR, Asian individuals with OHCA have lower survival rates than White individuals with OHCA. The reasons for the lower survival rate deserve further study to determine whether there are disparities in resuscitation care between Asian and White individuals with OHCA.

Background Although chronic total occlusions (CTOs) are common in older adults, they are less likely to be offered CTO percutaneous coronary intervention for angina relief than younger adults. The health status impact of CTO percutaneous coronary intervention in adults aged ≥75 years has not been studied. We sought to compare technical success rates and angina-related health status outcomes at 12 months between adults aged ≥75 and <75 years in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion) registry. Methods and Results Angina-related health status was assessed with the Seattle Angina Questionnaire (score range 0-100, higher scores denote less angina). Technical success rates were compared using hierarchical modified Poisson regression, and 12-month health status was compared using hierarchical multivariable linear regression between adults aged ≥75 and <75 years. Among 1000 participants, 19.8% were ≥75 years with a mean age of 79.5±4.1 years. Age ≥75 years was associated with a lower likelihood of technical success (adjusted risk ratio=0.92 [95% CI, 0.86-0.99; P =0.02]) and numerically higher rates of in-hospital major adverse cardiovascular events (9.1% versus 5.9%, P =0.10). There was no difference in Seattle Angina Questionnaire Summary Score at 12 months between adults aged ≥75 and <75 years (adjusted difference=0.9 [95% CI, -1.4 to 3.1; P =0.44]). Conclusions Despite modestly lower success rates and higher complication rates, adults aged ≥75 years experienced angina-related health status benefits after CTO-percutaneous coronary intervention that were similar in magnitude to adults aged <75 years. CTO percutaneous coronary intervention should not be withheld based on age alone in otherwise appropriate candidates.

Background Although many hospitals have resuscitation champions, it is unknown if hospitals with very active physician or nonphysician champions have higher survival rates for in-hospital cardiac arrest (IHCA). Methods and Results We surveyed adult hospitals in Get With The Guidelines-Resuscitation about resuscitation practices, including about their resuscitation champion. Hospitals were categorized as having a very active physician champion, a very active nonphysician champion, or other (no champion or not very active champion). For each hospital, we calculated risk-standardized survival rates for IHCA during the period of 2016 to 2018 and categorized them into quintiles of risk-standardized survival rates. The association between a hospital's resuscitation champion type and their quintile of survival was evaluated using multivariable hierarchical proportional odds logistic regression. Overall, 192 hospitals (total of 44 477 IHCAs) comprised the study cohort. Risk-standardized survival rates for IHCA varied widely between hospitals (median: 24.7%; range: 9.2%-37.5%). Very active physician champions were present in 29 (15.1%) hospitals, 64 (33.3%) had very active nonphysician champions, and 99 (51.6%) did not have a very active champion. Compared with sites without a very active resuscitation champion, hospitals with a very active physician champion were 4 times more likely to be in a higher survival quintile, even after adjusting for resuscitation practices across hospital groups (adjusted odds ratio [OR], 3.90; 95% CI, 1.39-10.95). In contrast, there was no difference in survival between sites without very active champions and those with very active non-physician champions (adjusted OR, 1.28; 95% CI, 0.62-2.65). Conclusions The background and engagement level of a resuscitation champion is a critical factor in a hospital's survival outcomes for IHCA.

Background Sustained return of spontaneous circulation (ROSC) is the most proximal and direct assessment of acute resuscitation quality in hospitals. However, validated tools to benchmark hospital rates for ROSC after in-hospital cardiac arrest currently do not exist. Methods and Results Within the national Get With The Guidelines-Resuscitation registry, we identified 83 206 patients admitted from 335 hospitals from 2014 to 2017 with in-hospital cardiac arrest. Using hierarchical logistic regression, we derived and validated a model for ROSC, defined as spontaneous and sustained ROSC for ≥20 consecutive minutes, from 24 pre-arrest variables and calculated rates of risk-standardized ROSC for in-hospital cardiac arrest for each hospital. Overall, rates of ROSC were 72.0% and 72.7% for the derivation and validation cohorts, respectively. The model in the derivation cohort had moderate discrimination (C-statistic 0.643) and excellent calibration ( R 2 of 0.996). Seventeen variables were associated with ROSC, and a parsimonious model retained 10 variables. Before risk-adjustment, the median hospital ROSC rate was 70.5% (interquartile range: 64.7-76.9%; range: 33.3-89.6%). After adjustment, the distribution of risk-standardized ROSC rates was narrower: median of 71.9% (interquartile range: 68.2-76.4%; range: 42.2-84.6%). Overall, 56 (16.7%) of 335 hospitals had at least a 10% absolute change in percentile rank after risk standardization: 27 (8.0%) with a ≥10% negative percentile change and 29 (8.7%) with a ≥10% positive percentile change. Conclusions We have derived and validated a model to risk-standardize hospital rates of ROSC for in-hospital cardiac arrest. Use of this model can support efforts to compare acute resuscitation survival across hospitals to facilitate quality improvement.

Background Women have higher utilization of "do not attempt resuscitation" (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in-hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest from the Get With The Guidelines-Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10-1.20]; P <0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30-1.52]; P <0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26-1.45]; P <0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99-1.02]; P =0.74) was appreciated. Conclusions In patients successfully resuscitated from in-hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.

Background For individuals with an out-of-hospital cardiac arrest (OHCA), survival may be influenced by the neighborhood in which the arrest occurs. Methods and Results Within the national CARES (Cardiac Arrest Registry to Enhance Survival) registry, we identified 169 502 patients with OHCA from 2013 to 2017. On the basis of census tract data, OHCAs were categorized as occurring in predominantly white (>80% white), majority black (>50% black), or integrated (neither of these 2) neighborhoods and in low-income (median household <$40 000), middle-income ($40 000 to $80 000), or high-income (>$80 000) neighborhoods. With hierarchical logistic regression, the association of neighborhood race and income on overall survival was assessed. Overall, 37.5%, 16.6%, and 45.9% of people had an OHCA in predominantly white, majority black, and integrated neighborhoods, and 30.1%, 53.4%, and 16.5% in low-, middle-, and high-income neighborhoods, respectively. Compared with OHCAs occurring in predominantly white neighborhoods, those in majority black neighborhoods were 12% less likely (6.9% versus 10.6%; adjusted odds ratio 0.88; 95% CI 0.82-0.95; P <0.001) to survive to discharge, whereas those in integrated neighborhoods had similar survival (10.3% versus 10.6%; adjusted odds ratio 1.00; 95% CI 0.96-1.04; P =0.93). Compared with high-income neighborhoods, those in middle-income neighborhoods were 11% (10.1% versus 11.3%; adjusted odds ratio 0.89; 95% CI 0.8-0.94; P <0.001) less likely to survive to discharge, whereas those in low-income neighborhoods were 12% (8.6% versus 11.3%; adjusted odds ratio 95% CI 0.83-0.94; P <0.001) less likely to survive. Differential rates of bystander cardiopulmonary resuscitation only modestly attenuated neighborhood differences in survival. Conclusions OHCAs in majority black and non-high-income neighborhoods have lower survival rates, and these differences were not explained by differential bystander cardiopulmonary resuscitation rates.

Background Although admission heart rate predicts higher mortality after acute myocardial infarction ( AMI ), less is known about discharge heart rate. We tested the hypothesis that higher discharge heart rate after AMI is related to increased long-term mortality independent of admission heart rate, and assessed whether β blockers modify this relationship. Methods and Results In 2 prospective US multicenter registries of AMI , we evaluated the associations of discharge and admission heart rate with 3-year mortality using Cox models. Among 6576 patients with AMI , discharge heart rate was modestly associated with initial heart rate ( r=0.28), comorbidities, and infarct severity. In this cohort, 10.7% did not receive β blockers at discharge. After full adjustment for demographic, psychosocial, and clinical covariates, discharge heart rate (hazard ratio [HR]=1.14 per 10 beats per minute [bpm]; 95% CI =1.07-1.21 per 10 bpm) was more strongly associated with risk of death than admission heart rate (HR=1.05 per 10 bpm; 95% CI=1.02-1.09 per 10 bpm) when both were entered in the same model ( P=0.043 for comparison). There was a significant interaction between discharge heart rate and β-blocker use ( P=0.004) on mortality, wherein risk of death was markedly higher among those with high discharge heart rate and not on β blockers (HR=1.35 per 10 bpm; 95% CI=1.19-1.53 per 10 bpm) versus those with a high discharge heart rate and on β blockers at discharge (HR=1.10 per 10 bpm; 95% CI=1.03-1.17 per 10 bpm). Conclusions Higher discharge heart rate after AMI was more strongly associated with 3-year mortality than admission heart rate, and the risk associated with higher discharge heart rate was modified by β blockers at discharge. These findings highlight opportunities for risk stratification and intervention that will require further investigation.

Background Smoking is the most important risk factor for peripheral artery disease ( PAD ). Smoking cessation is key in PAD management. We aimed to examine smoking rates and smoking cessation interventions offered to patients with PAD consulting a vascular specialty clinic; and assess changes in smoking behavior over the year following initial visit. Methods and Results A total of 1272 patients with PAD and new or worsening claudication were enrolled at 16 vascular specialty clinics (2011-2015, PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry). Interviews collected smoking status and cessation interventions at baseline, 3, 6, and 12 months. Among smokers, transition state models analyzed smoking transitions at each time point and identified factors associated with quitting and relapse. On presentation, 474 (37.3%) patients were active, 660 (51.9%) former, and 138 (10.8%) never smokers. Among active smokers, only 16% were referred to cessation counseling and 11% were prescribed pharmacologic treatment. At 3 months, the probability of quitting smoking was 21%; among those continuing to smoke at 3 months, the probability of quitting during the next 9 months varied between 11% and 12% ( P<0.001). The probability of relapse among initial quitters was 36%. At 12 months, 72% of all smokers continued to smoke. Conclusions More than one third of patients with claudication consulting a PAD provider are active smokers and few received evidence-based cessation interventions. Patients appear to be most likely to quit early in their treatment course, but many quickly relapse and 72% of all patients smoking at baseline are still smoking at 12 months. Better strategies are needed to provide continuous cessation support. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 01419080.

Background: Non-vitamin K antagonist oral anticoagulants (NOACs) are indicated for stroke prevention in atrial fibrillation (AF) but require lower doses in certain patients. We sought to describe the frequency, appropriateness (according to Food and Drug Administration labeling), and outcomes of patients prescribed reduced doses of NOACs in community practice., Methods and Results: We analyzed data from the ORBIT-AF II (The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II) registry, a prospective, national, observational registry of AF patients. Among 7925 AF patients receiving NOACs, we assessed patterns of use of reduced NOAC doses and associated cardiovascular and bleeding outcomes at median follow-up of 1 year. Overall, 6636 patients (84%) received a NOAC at standard dose, which was consistent with US Food and Drug Administration labeling in 6376 (96%). Reduced NOAC dose was prescribed to 1289 (16% overall), which was consistent with Food and Drug Administration labeling in only 555 patients (43%). Compared with those whose NOAC dose was appropriately reduced, patients receiving inappropriate dose reductions were younger (median age 79 versus 84, P <0.0001) and had lower ORBIT bleeding risk scores (26% ≥4 versus 45%, P <0.0001). Compared with those appropriately receiving standard dosing, patients receiving inappropriately reduced-dose NOACs had higher unadjusted rates of thromboembolic events (2.11 versus 1.35 events per 100 patient years, hazard ratio 1.56, 95% confidence interval 0.92-2.67) and death (6.77 versus 2.60, hazard ratio 2.61, 95% confidence interval 1.86-3.67). After adjustment, outcomes were not significantly different but tended to favor patients dosed appropriately., Conclusions: The majority of dose reductions of NOACs in AF are inconsistent with US Food and Drug Administration recommendations. There appear to be opportunities to improve current NOAC dosing in community practice., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01701817., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: The HeartRescue Project is a multistate public health initiative focused on establishing statewide out-of-hospital cardiac arrest (OHCA) systems of care to improve case capture and OHCA care in the community, by emergency medical services (EMS), and at hospital level., Methods and Results: From 2011 to 2015 in the 5 original HeartRescue states, all adults with EMS-treated OHCA due to a presumed cardiac cause were included. In an adult population of 32.8 million, a total of 64 988 OHCAs-including 10 046 patients with a bystander-witnessed OHCA with a shockable rhythm-were treated by 330 EMS agencies. From 2011 to 2015, the case-capture rate for all-rhythm OHCA increased from an estimated 39.0% (n=6762) to 89.2% (n=16 103; P <0.001 for trend). Overall survival to hospital discharge was 11.4% for all rhythms and 34.0% in the subgroup with bystander-witnessed OHCA with a shockable rhythm. We observed modest temporal increases in bystander cardiopulmonary resuscitation (41.8-43.5%, P <0.001 for trend) and bystander automated external defibrillator application (3.2-5.6%, P <0.001 for trend) in the all-rhythm group, although there were no temporal changes in survival. There were marked all-rhythm survival differences across the 5 states (8.0-16.1%, P <0.001) and across participating EMS agencies (2.7-26.5%, P <0.001)., Conclusions: In the initial 5 years, the HeartRescue Project developed a population-based OHCA registry and improved statewide case-capture rates and some processes of care, although there were no early temporal changes in survival. The observed survival variation across states and EMS systems presents a future challenge to elucidate the characteristics of high-performing systems with the goal of improving OHCA care and survival., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Most studies on out-of-hospital cardiac arrest have focused on immediate survival. However, little is known about long-term outcomes and resource use among survivors., Methods and Results: Within the national CARES registry, we identified 16 206 adults 65 years or older with an out-of-hospital cardiac arrest between 2005 and 2010. Among 1127 patients who were discharged alive, we evaluated whether 1-year mortality, cumulative readmission incidence, and follow-up inpatient costs differed according to patients' race, sex, initial cardiac arrest rhythm, bystander delivery of cardiopulmonary resuscitation, discharge neurological status, and functional status (hospital discharge disposition). Overall 1-year mortality after hospital discharge was 31.8%. Among survivors, there were no long-term mortality differences by sex, race, or initial cardiac arrest rhythm, but worse functional status and severe neurological disability at discharge were associated with higher mortality. Moreover, compared with first responders, cardiopulmonary resuscitation delivered by bystanders was associated with 23% lower mortality (hazard ratio 0.77 [confidence interval 0.58-1.02]). Besides mortality, 638 (56.6%) patients were readmitted within the first year, and the cumulative readmission incidence was 197 per 100 patient-years. Mean 1-year inpatient costs were $23 765±41 002. Younger age, black race, severe neurological disability at discharge, and hospital disposition to a skilled nursing or rehabilitation facility were each associated with higher 1-year inpatient costs (P for all <0.05)., Conclusion: Among elderly survivors of out-of-hospital cardiac arrest, nearly 1 in 3 patients die within the first year. Long-term mortality and inpatient costs differed substantially by certain demographic factors, whether cardiopulmonary resuscitation was initiated by a bystander, discharge neurological status, and hospital disposition., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Little is known about survival after out-of-hospital cardiac arrest (OHCA) in children. We examined whether OHCA survival in children differs by age, sex, and race, as well as recent survival trends., Methods and Results: Within the prospective Cardiac Arrest Registry to Enhance Survival (CARES), we identified children (age <18 years) with an OHCA from October 2005 to December 2013. Survival to hospital discharge by age (categorized as infants [0 to 1 year], younger children [2 to 7 years], older children [8 to 12 years], and teenagers [13 to 17 years]), sex, and race was assessed using modified Poisson regression. Additionally, we assessed whether survival has improved over 3 time periods: 2005-2007, 2008-2010, and 2011-2013. Of 1980 children with an OHCA, 429 (21.7%) were infants, 952 (48.1%) younger children, 276 (13.9%) older children, and 323 (16.3%) teenagers. Fifty-nine percent of the study population was male and 31.8% of black race. Overall, 162 (8.2%) children survived to hospital discharge. After multivariable adjustment, infants (rate ratio: 0.56; 95% CI: 0.35, 0.90) and younger children (rate ratio: 0.42; 95% CI: 0.27, 0.65) were less likely to survive compared with teenagers. In contrast, there were no differences in survival by sex or race. Finally, there were no temporal trends in survival across the study periods (P=0.21)., Conclusions: In a large, national registry, we found no evidence for racial or sex differences in survival among children with OHCA, but survival was lower in younger age groups. Unlike in adults with OHCA, survival rates in children have not improved in recent years., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: The volume-outcome relationship associated with intensive care unit (ICU) experience with managing acute myocardial infarction (AMI) remains inadequately understood., Methods and Results: Within a multicenter clinical ICU database, we identified patients with a primary ICU admission diagnosis of AMI between 2008 and 2010 to evaluate whether annual AMI volume of an individual ICU is associated with mortality, length-of-stay, or quality indicators. Patients were categorized into those treated in ICUs with low-annual-AMI volume (≤50th percentile, <2 AMI patients/month, n=569 patients) versus high-annual-AMI volume (≥90th percentile, ≥8 AMI patients/month, n=17 553 patients). Poisson regression and generalized estimating equation with negative binomial regression were used to calculate the relative risk (95% CI) for mortality and length-of-stay, respectively, associated with admission to a low-AMI-volume ICU. When compared with high-AMI-volume, patients admitted to low-AMI-volume ICUs had substantially more medical comorbidities, higher in-hospital mortality (11% versus 4%, P<0.001), longer hospitalizations (6.9±7.0 versus 5.0±5.0 days, P<0.001), and fewer evidence-based therapies for AMI (reperfusion therapy, antiplatelets, β-blockers, and statins). However, after adjustment for baseline patient characteristics, low-AMI-volume ICU was no longer an independent predictor of in-hospital mortality (relative risk 1.17 [0.87 to 1.56]) or hospital length-of-stay (relative risk 1.01 [0.94 to 1.08]). Similar findings were noted in secondary analyses of ICU mortality and ICU length-of-stay., Conclusions: Admission to an ICU with lower annual AMI volume is associated with higher in-hospital mortality, longer hospitalization, and lower use of evidence-based therapies for AMI. However, the relationship between low-AMI-volume and outcomes is no longer present after accounting for the higher-risk medical comorbidities and clinical characteristics of patients admitted to these ICUs., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: During the past decade, survival after in-hospital cardiac arrest has improved markedly. It remains unknown whether the improvement in survival has occurred uniformly at all hospitals or was driven by large improvements at only a few hospitals., Methods and Results: We identified 93 342 adults with an in-hospital cardiac arrest at 231 hospitals in the Get With The Guidelines(®)-Resuscitation registry during 2000-2010. Using hierarchical regression models, we evaluated hospital-level trends in survival to discharge. Mean age was 66 years, 59% were men, and 21% were black. Between 2000 and 2010, there was a significant decrease in age, prevalence of heart failure and myocardial infarction, and cardiac arrests due to shockable rhythms (P<0.001 for all) and an increase in prevalence of sepsis, respiratory insufficiency, renal insufficiency, intensive care unit location, and mechanical ventilation before arrest (P<0.001 for all). After adjustment for temporal trends in baseline characteristics, hospital rates of in-hospital cardiac arrest survival improved by 7% per year (odds ratio [OR] 1.07, 95% CI 1.06 to 1.08, P<0.001). Improvement in survival varied markedly and ranged from 3% in the bottom hospital quartile to 11% in the top hospital quartile. Compared with minor teaching hospitals (OR 1.04, 95% CI 1.02 to 1.06), hospital rate of survival improvement was greater at major teaching (OR 1.08, 95% CI 1.06 to 1.10) and nonteaching hospitals (OR 1.07, 95% CI 1.05 to 1.09, P value for interaction=0.03)., Conclusion: Although in-hospital cardiac arrest survival has improved during the past decade, the magnitude of improvement varied across hospitals. Future studies are needed to identify hospital processes that have led to the largest improvement in survival., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: In-hospital cardiac arrest (IHCA) is common and often fatal. However, the extent to which hospitals vary in survival outcomes and the degree to which this variation is explained by patient and hospital factors is unknown., Methods and Results: Within Get with the Guidelines-Resuscitation, we identified 135 896 index IHCA events at 468 hospitals. Using hierarchical models, we adjusted for demographics comorbidities and arrest characteristics (eg, initial rhythm, etiology, arrest location) to generate risk-adjusted rates of in-hospital survival. To quantify the extent of hospital-level variation in risk-adjusted rates, we calculated the median odds ratio (OR). Among study hospitals, there was significant variation in unadjusted survival rates. The median unadjusted rate for the bottom decile was 8.3% (range: 0% to 10.7%) and for the top decile was 31.4% (28.6% to 51.7%). After adjusting for 36 predictors of in-hospital survival, there remained substantial variation in rates of in-hospital survival across sites: bottom decile (median rate, 12.4% [0% to 15.6%]) versus top decile (median rate, 22.7% [21.0% to 36.2%]). The median OR for risk-adjusted survival was 1.42 (95% CI: 1.37 to 1.46), which suggests a substantial 42% difference in the odds of survival for patients with similar case-mix at similar hospitals. Further, significant variation persisted within hospital subgroups (eg, bed size, academic)., Conclusion: Significant variability in IHCA survival exists across hospitals, and this variation persists despite adjustment for measured patient factors and within hospital subgroups. These findings suggest that other hospital factors may account for the observed site-level variations in IHCA survival.

Photodynamic therapy (PDT) with a recently developed photosensitizer Zn-BC-AM was found to effectively induce apoptosis in a well-differentiated nasopharyngeal carcinoma (NPC) HK-1 cell line. Sustained activation of p38 mitogen-activated protein kinase (MAPK) and c-jun N-terminal kinase (JNK) as well as a transient increase in activation of extracellular signal-regulated kinase (ERK) were observed immediately after Zn-BC-AM PDT. A commonly used p38 MAPK/JNK pharmacological inhibitor PD169316 was found to reduce PDT-induced apoptosis of HK-1 cells. PD169316 also prevented the loss of Bcl-2 and Bcl-xL in PDT-treated HK-1 cells. However, inhibition of JNK with SP600125 had no effect on Zn-BC-AM PDT-induced apoptosis while inhibition of ERK with PD98059 or p38 MAPK with SB203580 significantly increased Zn-BC-AM PDT-induced apoptosis. Further study showed that knockdown of the p38beta isoform with siRNA also increased Zn-BC-AM PDT-induced apoptosis, indicating that the anti-apoptotic effect of PD169316 in PDT-treated HK-1 cells was probably independent of p38 MAPK or JNK activation. Taken together, the results suggest that inhibition of p38beta and ERK may enhance the therapeutic efficacy of Zn-BC-AM PDT on NPC cells. It should be noted that data only based on the use of PD169316 should be interpreted in caution., (Copyright (c) 2010 John Wiley & Sons, Ltd.)