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Abstract We present a multi-stage neural network approach for 3D reconstruction of coronary artery trees from uncalibrated 2D X-ray angiography images. This method uses several binarized images from different angles to reconstruct a 3D coronary tree without any knowledge of image acquisition parameters. The method consists of a single backbone network and separate stages for vessel centerline and radius reconstruction. The output is an analytical matrix representation of the coronary tree suitable for downstream applications such as hemodynamic modeling of local vessel narrowing (i.e., stenosis). The network was trained using a dataset of synthetic coronary trees from a vessel generator informed by both clinical image data and literature values on coronary anatomy. Our multi-stage network achieved sub-pixel accuracy in reconstructing vessel radius (RMSE = 0.16 ± 0.07 mm) and stenosis radius (MAE = 0.27 ± 0.18 mm), the most important feature used to inform diagnostic decisions. The network also led to 52% and 38% reduction in vessel centerline reconstruction errors compared to a single-stage network and projective geometry-based methods, respectively. Our method demonstrated robustness to overcome challenges such as vessel foreshortening or overlap in the input images. This work is an important step towards automated analysis of anatomic and functional disease severity in the coronary arteries.

Abstract Mobile health (mHealth) interventions may enhance positive health behaviors, but randomized trials evaluating their efficacy are uncommon. Our goal was to determine if a mHealth intervention augmented and extended benefits of center-based cardiac rehabilitation (CR) for physical activity levels at 6-months. We delivered a randomized clinical trial to low and moderate risk patients with a compatible smartphone enrolled in CR at two health systems. All participants received a compatible smartwatch and usual CR care. Intervention participants received a mHealth intervention that included a just-in-time-adaptive intervention (JITAI) as text messages. The primary outcome was change in remote 6-minute walk distance at 6-months stratified by device type. Here we report the results for 220 participants enrolled in the study (mean [SD]: age 59.6 [10.6] years; 67 [30.5%] women). For our primary outcome at 6 months, there is no significant difference in the change in 6 min walk distance across smartwatch types (Intervention versus control: +31.1 meters Apple Watch, −7.4 meters Fitbit; p = 0.28). Secondary outcomes show no difference in mean step counts between the first and final weeks of the study, but a change in 6 min walk distance at 3 months for Fitbit users. Amongst patients enrolled in center-based CR, a mHealth intervention did not improve 6-month outcomes but suggested differences at 3 months in some users.

Background Mobile health (mHealth) interventions have the potential to deliver longitudinal support to users outside of episodic clinical encounters. We performed a qualitative substudy to assess the acceptability of a text message‐based mHealth intervention designed to increase and sustain physical activity in cardiac rehabilitation enrollees. Methods and Results Semistructured interviews were conducted with intervention arm participants of a randomized controlled trial delivered to low‐ and moderate‐risk cardiac rehabilitation enrollees. Interviews explored participants' interaction with the mobile application, reflections on tailored text messages, integration with cardiac rehabilitation, and opportunities for improvement. Transcripts were thematically analyzed using an iteratively developed codebook. Sample size consisted of 17 participants with mean age of 65.7 (SD 8.2) years; 29% were women, 29% had low functional capacity, and 12% were non‐White. Four themes emerged from interviews: engagement, health impact, personalization, and future directions. Participants engaged meaningfully with the mHealth intervention, finding it beneficial in promoting increased physical activity. However, participants desired greater personalization to their individual health goals, fitness levels, and real‐time environment. Generally, those with lower functional capacity and less experience with exercise were more likely to view the intervention positively. Finally, participants identified future directions for the intervention including better incorporation of exercise physiologists and social support systems. Conclusions Cardiac rehabilitation enrollees viewed a text message‐based mHealth intervention favorably, suggesting the potentially high usefulness of mHealth technologies in this population. Addressing participant‐identified needs on increased user customization and inclusion of clinical and social support is crucial to enhancing the effectiveness of future mHealth interventions. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04587882.

Background Smartphone applications and wearable devices are promising mobile health interventions for hypertension self‐management. However, most mobile health interventions fail to use contextual data, potentially diminishing their impact. The myBPmyLife Study is a just‐in‐time adaptive intervention designed to promote personalized self‐management for patients with hypertension. Methods and Results The study is a 6‐month prospective, randomized‐controlled, remotely administered trial. Participants were recruited from the University of Michigan Health in Ann Arbor, Michigan or the Hamilton Community Health Network, a federally qualified health center network in Flint, Michigan. Participants were randomized to a mobile application with a just‐in‐time adaptive intervention promoting physical activity and lower‐sodium food choices as well as weekly goal setting or usual care. The mobile study application encourages goal attainment through a central visualization displaying participants' progress toward their goals for physical activity and lower‐sodium food choices. Participants in both groups are followed for up for 6 months with a primary end point of change in systolic blood pressure. Exploratory analyses will examine the impact of notifications on step count and self‐reported lower‐sodium food choices. The study launched on December 9, 2021, with 484 participants enrolled as of March 31, 2023. Enrollment of participants was completed on July 3, 2023. After 6 months of follow‐up, it is expected that results will be available in the spring of 2024. Conclusions The myBPmyLife study is an innovative mobile health trial designed to evaluate the effects of a just‐in‐time adaptive intervention focused on improving physical activity and dietary sodium intake on blood pressure in diverse patients with hypertension. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05154929.

BackgroundThe rising adoption of wearable technology increases the potential to identify arrhythmias. However, specificity of these notifications is poorly defined and may cause anxiety and unnecessary resource utilization. Herein, we report results of a follow-up screening protocol for incident atrial fibrillation/flutter (AF) within a large observational digital health study.MethodsThe MIPACT Study enrolled 6,765 adult patients who were provided an Apple Watch and blood pressure (BP) monitors. From March to July 2019, participants were asked to contact the study team for any irregular heart rate (HR) notification. They were assessed using structured questionnaires and asked to provide 6 Apple Watch EKGs. Those with arrhythmias or non-diagnostic EKGs were sent 7-day monitors. The EHR was reviewed after 3 years to determine if participants developed arrhythmias.Results86 participants received notifications and met inclusion criteria. Mean age was 50.5 (SD 16.9) years, and 46 (53.3%) were female. Of 76 participants assessed by the study team, 32 (42.1%) reported anxiety surrounding notifications. Of 59 participants who sent at least 1 EKG, 52 (88.1%) were in sinus rhythm, 3 (5.1%) AF, 2 (3.4%) indeterminate, and 2 (3.4%) sinus bradycardia. Cardiac monitor demonstrated AF in 2 of 3 participants with AF on Apple Watch EKGs. 2 contacted their PCPs and were diagnosed with AF. In total, 5 cases of AF were diagnosed with 1 additional case identified during EHR review.ConclusionWearable devices produce alarms that can frequently be anxiety provoking. Research is needed to determine the implications of these alarms and appropriate follow-up.

Background Survivors of in‐hospital cardiac arrest (IHCA) experience ongoing physical and cognitive impairments, often requiring support from a caregiver at home afterwards. Caregivers are important in the survivor's recovery, yet there is little research specifically focused on their experiences once the survivor is discharged home. In this study, we highlight how caregivers for veteran IHCA survivors described and experienced their caregiver role, the strategies they used to fulfill their role, and the additional needs they still have years after the IHCA event. Methods and Results Between March and July 2019, semistructured telephone interviews were conducted with 12 caregivers for veteran IHCA survivors. Interviews were transcribed, and content analysis was performed. Patterns within the data were further analyzed and grouped into themes. A predominant theme of “disruption” was identified across 3 different domains including the following: (1) disruption in caregiver's life, (2) disruption in caregiver–patient relationship, and (3) disruption in caregiver's well‐being. Disruption was associated with both positive and negative caregiver experiences. Strategies caregivers used and resources they felt would have helped them adjust to their caregiver role were also identified. Conclusions Caregivers for veteran IHCA survivors experienced a disruption in many facets of their lives. Caregivers felt the veterans' IHCA impacted various aspects of their lives, and they continued to need additional support in order to care for the IHCA survivor and themselves. Although some were able to procure coping strategies, such as counseling and engaging in stress‐relieving activities, most indicated additional help and resources were still needed.

Objective: To assess whether survival rates for in-hospital cardiac arrest (IHCA) vary across hospitals depending on whether resuscitations are typically led by an attending physician, a physician trainee, or a nonphysician. Patients and Methods: In 2018, we conducted a survey of hospitals participating in the national Get with the Guidelines – Resuscitation registry for IHCA. Using responses from the question “Who typically leads codes at your institution?” we categorized hospitals on the basis of who typically leads their resuscitations: attending physician, physician trainee, or nonphysician. We then compared risk-adjusted hospital rates of return of spontaneous circulation, survival to discharge, and favorable neurological survival from 2015 to 2017 between these 3 hospital groups by using multivariable hierarchical regression. Results: Overall, 193 hospitals completed the study survey, representing a total of 44,477 IHCAs (mean age, 65.0±15.5 years; 40.8% were women). Most hospitals had resuscitations led by physicians, with 121 (62.7%) led by an attending physician, 58 (30.0%) by a physician trainee, and 14 (7.3%) by a nonphysician. The risk-standardized rates of survival to discharge were similar across hospitals, regardless of whether resuscitations were typically led by an attending physician, a physician trainee, or a nonphysician (25.6%±4.8%, 25.9%±4.7%, and 25.7%±3.6%, respectively; P=.88). Similarly, there were no differences between the 3 groups in risk-adjusted rates of return of spontaneous circulation (71.7%±6.3%, 73%±6.3%, and 73.4%±6.4%; P=.30) and favorable neurological survival (21.6%±7.1%, 22.7%±6.1%, and 20.9%±6.5%; P=.50). Conclusion: In hospitals in a national IHCA registry, IHCA resuscitations were usually led by physicians. However, there was no association between a hospital’s typical resuscitation team leader credentials and IHCA survival outcomes.

Abstract Background Rapid and irregular ventricular rates (RVR) are an important consequence of atrial fibrillation (AF). Raw accelerometry data in combination with electrocardiogram (ECG) data have the potential to distinguish inappropriate from appropriate tachycardia in AF. This can allow for the development of a just-in-time intervention for clinical treatments of AF events. The objective of this study is to develop a machine learning algorithm that can distinguish episodes of AF with RVR that are associated with low levels of activity. Methods This study involves 45 patients with persistent or paroxysmal AF. The ECG and accelerometer data were recorded continuously for up to 3 weeks. The prediction of AF episodes with RVR and low activity was achieved using a deterministic probabilistic finite-state automata (DPFA)-based approach. Rapid and irregular ventricular rate (RVR) is defined as having heart rates (HR) greater than 110 beats per minute (BPM) and high activity is defined as greater than 0.75 quantile of the activity level. The AF events were annotated using the FDA-cleared BeatLogic algorithm. Various time intervals prior to the events were used to determine the longest prediction intervals for predicting AF with RVR episodes associated with low levels of activity. Results Among the 961 annotated AF events, 292 met the criterion for RVR episode. There were 176 and 116 episodes with low and high activity levels respectively. Out of the 961 AF episodes, 770 (80.1%) were used in the training data set and the remaining 191 intervals were held out for testing. The model was able to predict AF with RVR and low activity up to 4.5 min before the events. The mean prediction performance gradually decreased as the time to events increased. The overall Area under the ROC Curve (AUC) for the model lies within the range of 0.67–0.78. Conclusion The DPFA algorithm can predict AF with RVR associated with low levels of activity up to 4.5 min before the onset of the event. This would enable the development of just-in-time interventions that could reduce the morbidity and mortality associated with AF and other similar arrhythmias.

Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site‐level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end‐of‐life care.

Background: Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses. Methods: We performed an observational cohort study of adults undergoing major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of heart failure was defined using keywords from the history and clinical examination or administrative documentation. Across stratified subsamples of cases with and without clinically diagnosed heart failure, health records were intensively reviewed by an expert panel to develop an adjudicated heart failure reference standard using diagnostic criteria congruent with consensus guidelines. We calculated agreement among experts, and analysed performance of clinically diagnosed heart failure compared with the adjudicated reference standard. Results: Across 40 555 major noncardiac procedures, a stratified subsample of 511 patients was reviewed by the expert panel. The prevalence of heart failure was 9.1% based on clinically diagnosed compared with 13.3% (95% confidence interval [CI], 10.3–16.2%) estimated by the expert panel. Overall agreement and inter-rater reliability (kappa) among heart failure experts were 95% and 0.79, respectively. Based upon expert adjudication, heart failure was clinically diagnosed with an accuracy of 92.8% (90.6–95.1%), sensitivity 57.4% (53.1–61.7%), specificity 98.3% (97.1–99.4%), positive predictive value 83.5% (80.3–86.8%), and negative predictive value 93.8% (91.7–95.9%). Conclusions: Limitations exist to the preoperative clinical diagnosis of heart failure, with nearly half of cases undiagnosed preoperatively. Considering the risks of undiagnosed heart failure, efforts to improve preoperative heart failure diagnoses are warranted.

Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in many disruptions in care for patients experiencing in-hospital cardiac arrest (IHCA). We sought to identify changes made in hospital resuscitation practices during progression of the COVID-19 pandemic. Methods: We conducted a descriptive qualitative study using in-depth interviews of clinical staff leadership involved with resuscitation care at a select group of U.S. acute care hospitals in the national American Heart Association Get With The Guidelines-Resuscitation registry for IHCA. We focused interviews on resuscitation practice changes for IHCA since the initiation of the COVID-19 pandemic. We used rapid analysis techniques for qualitative data summarization and analysis. Results: A total of 6 hospitals were included with interviews conducted with both physicians and nurses between November 2020 and April 2021. Three topical themes related to shifts in resuscitation practice through the COVID-19 pandemic were identified: 1) ensuring patient and provider safety and wellness (e.g., use of personal protective equipment); 2) changing protocols and training for routine educational practices (e.g., alterations in mock codes and team member roles); and 3) goals of care and end of life discussions (e.g., challenges with visitor and family policies). We found advances in leveraging technology use as an important topic that helped institutions address challenges across all 3 themes. Conclusions: Early on, the COVID-19 pandemic resulted in many changes to resuscitation practices at hospitals placing an emphasis on enhanced safety, training, and end of life planning. These lessons have implications for understanding how systems may be better designed for resuscitation efforts.

Abstract Coronary Artery Disease (CAD) is commonly diagnosed using X-ray angiography, in which images are taken as radio-opaque dye is flushed through the coronary vessels to visualize the severity of vessel narrowing, or stenosis. Cardiologists typically use visual estimation to approximate the percent diameter reduction of the stenosis, and this directs therapies like stent placement. A fully automatic method to segment the vessels would eliminate potential subjectivity and provide a quantitative and systematic measurement of diameter reduction. Here, we have designed a convolutional neural network, AngioNet, for vessel segmentation in X-ray angiography images. The main innovation in this network is the introduction of an Angiographic Processing Network (APN) which significantly improves segmentation performance on multiple network backbones, with the best performance using Deeplabv3+ (Dice score 0.864, pixel accuracy 0.983, sensitivity 0.918, specificity 0.987). The purpose of the APN is to create an end-to-end pipeline for image pre-processing and segmentation, learning the best possible pre-processing filters to improve segmentation. We have also demonstrated the interchangeability of our network in measuring vessel diameter with Quantitative Coronary Angiography. Our results indicate that AngioNet is a powerful tool for automatic angiographic vessel segmentation that could facilitate systematic anatomical assessment of coronary stenosis in the clinical workflow.

Background Current guidelines recommend use of sacubitril‐valsartan in patients with heart failure with reduced ejection fraction (HFrEF). Early data suggested low uptake of sacubitril‐valsartan, but contemporary data on real‐world use and their associated cost are limited. Methods and Results This was a retrospective study of individuals enrolled in Optum Clinformatics, a national insurance claims data set from 2016 to 2018. We included all adult patients with HFrEF with 2 outpatient encounters or 1 inpatient encounter with an International Classification of Diseases, Tenth Revision (ICD‐10), diagnosis of HFrEF and 6 months of continuous enrollment, also receiving β‐blockers and angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers within 6 months of HFrEF diagnosis. We included 70 245 patients with HFrEF, and 5217 patients (7.4%) received sacubitril‐valsartan prescriptions. Patients receiving care through a cardiologist compared with a primary care physician alone were more likely to receive sacubitril‐valsartan (odds ratio, 1.61 [95% CI, 1.52–1.71]). Monthly out‐of‐pocket (OOP) cost for sacubitril‐valsartan, compared with angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers, was higher for both commercially insured patients (mean, $69 versus $6.74) and Medicare Advantage (mean, $62 versus $2.52). For patients with commercial insurance, OOP cost was lower in 2016 than in 2018. For patients with Medicare Advantage, there was a significant geographic variation in the OOP costs across the country, ranging from $31 to $68 per month across different regions, holding all other patient‐related factors constant. Conclusions Sacubitril‐valsartan use was infrequent among patients with HFrEF. Patients receiving care with a cardiologist were more likely to receive sacubitril‐valsartan. OOP costs remain high, potentially limiting use. Significant geographic variation in OOP costs, unexplained by patient factors, was noted.

Background: The incidence of coronavirus disease 2019 (COVID-19) in patients with ST-segment elevation myocardial infarction (STEMI) has not been fully described. Methods: All patients with STEMI undergoing primary percutaneous coronary intervention (PCI) in Ontario, Canada between March 1 and September 30, 2020 were included. Rates of positive COVID-19 tests from January 1, 2020 to the date of STEMI presentation were ascertained. For comparison, COVID-19 results were also evaluated in the adult Ontario population between January 1, 2020 and September 30, 2020, using provincial laboratory testing data. Results: There were 3606 unique patients presenting with STEMI and receiving PCI in Ontario, Canada during the study period. Sixteen patients (0.44%) tested positive for COVID-19. The background infection rate among all 12,448,541 Ontario residents was similar, at 0.34%. Conclusions: The results of this population-based analysis suggest that proceeding with primary PCI with appropriate infection control practices is reasonable when community infection rates are low. Résumé: Contexte: L'incidence de la maladie à coronavirus 2019 (COVID-19) chez les patients présentant un infarctus du myocarde avec élévation du segment ST (STEMI) n'a pas été entièrement décrite. Méthodologie: Tous les patients atteints de STEMI ayant subi une intervention coronarienne percutanée (ICP) primaire en Ontario (Canada) entre le 1er mars et le 30 septembre 2020 ont été inclus. Les taux de tests positifs à la COVID entre le 1er janvier 2020 et le moment de la présentation du STEMI ont été vérifiés. Aux fins de comparaison, les résultats des tests de dépistage de la COVID-19 ont également été évalués au sein de la population adulte de l'Ontario entre le 1er janvier 2020 et le 30 septembre 2020 au moyen des données des laboratoires provinciaux. Résultats: Pendant la période d’étude, 3 606 patients présentant un STEMI et ayant subi une ICP en Ontario (Canada) ont été recensés. Seize patients (0,44 %) ont reçu un résultat positif au test de dépistage de la COVID-19. Le taux d'infection parmi les 12 448 541 résidents de l'Ontario était similaire, soit 0,34 %. Conclusions: Les résultats de cette analyse populationnelle portent à penser qu'il est raisonnable de procéder à une ICP primaire avec des mesures appropriées de contrôle des infections lorsque les taux d'infection dans la collectivité sont faibles.

Abstract Background In response to the development of highly effective but expensive new medications, policymakers, payors, and health systems are considering novel and pragmatic ways to provide these medications to patients. One approach is to target these treatments to those most likely to benefit. However, to maximize the fairness of these policies, and the acceptance of their implementation, the values and beliefs of patients should be considered. The provision of treatments for chronic hepatitis C (CHC) in the resource-constrained context of the Veterans Health Administration (VHA) offered a real-world example of this situation, providing the opportunity to test the value of using Democratic Deliberation (DD) methods to solicit the informed opinions of laypeople on this complex issue. Methods We recruited Veterans (n = 30) from the VHA to attend a DD session. Following educational presentations from content experts, participants engaged in facilitated small group discussions to: 1) identify strategies to overcome CHC treatment barriers and 2) evaluate, vote on, and modify/improve two CHC treatment policies – “first come, first served” (FCFS) and “sickest first” (SF). We used transcripts and facilitators’ notes to identify key themes from the small group discussions. Additionally, participants completed pre- and post-DD surveys. Results Most participants endorsed the SF policy over the FCFS policy, emphasizing the ethical and medical appropriateness of treating the sickest first. Concerns about SF centered on the difficulty of implementation (e.g., how is “sickest” determined?) and unfairness to other Veterans. Proposed modifications focused on: 1) the need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support, 4) improving access, and 5) facilitating better decision-making. Conclusions DD offered a robust and useful method for addressing the allocation of the scarce resource of CHC treatment. Participants were able to develop a modified version of the SF policy and offered diverse recommendations to promote fairness and improve quality of care for Veterans. DD is an effective approach for incorporating patient preferences and gaining valuable insights for critical healthcare policy decisions in resource-limited environments.

Abstract Background In-hospital cardiac arrests (IHCA) occur commonly and are associated with poor survival and variable outcomes. This study aimed to directly survey IHCA responders to understand their perceptions of resuscitation care. Methods As part of a quality improvement initiative, we surveyed participating providers of IHCAs at our institution from Jan 2014 to May 2016. The survey included unstructured free text feedback, which was the focus of this study. We systematically coded the free text and organized identifiable latent themes using thematic analysis. We used the natural timeline of an IHCA – pre-arrest, arrest, and post-arrest – for organization of the identifiable latent themes, and created a separate category for holistic remarks that arched across the timeline. Results We identified 172 IHCAs with a mean of 1.7 responses per arrest (range: 1–8 responses). The mean age of this patient population was 59 years at the time of arrest, and 107 (62%) were men. We identified several themes - [1] issues around code activation and code status characterized the pre-arrest period [2] ,team interactions and issues around supplies/equipment dominated the intra-arrest period, and [3] code cessation and transitions of care typified the post-arrest period. Holistic remarks focused on attentiveness paid by the arrest team to patient comfort and family. Some comments reflected positive experiences but most focused on areas of improvement consistent with the initiative’s purpose. In certain cases, we identified a tension between the need to balance established resuscitation protocols with flexibility required by real-life circumstances. Conclusions Directly surveying those who participated in IHCAs led to novel insights about their experiences. Our findings suggest that parsing through such qualitative feedback can help hospitals identify areas of improvement, modulate expectations, temper emotions, and refine protocols.

In the United States, approximately 292,000 adults (>18 years old) per year suffer an in-hospital cardiac arrest (IHCA). Survival rates have increased over the last decade and many survivors return to their communities. IHCA has been recognized as a unique disease entity because the arrest happens in a medical care setting and survivors often have more medical co-morbidities. Although more individuals are surviving IHCA, very little is known about their long-term recovery experiences. Semi-structured interviews with 19 IHCA survivors were conducted to better understand their recovery experiences and identify strategies of adaptation that they felt aided their recovery. Thematic analysis indicated that IHCA survivors experience ongoing challenges to recovery. Reconceptualization of independence was necessary for some participants to re-engage in social and physical activities and a few were able to engage in new activities. Our findings suggest that IHCA survivors often develop their own strategies for adaptation in order to continue participation in their social lives and that their recovery experiences are ongoing. Intervention programs and follow-up care should continuously ask survivors what is important to them and identify resources that will support their goals. Questions should include physical, cognitive, psychological and social goals that extend beyond those specifically related to IHCA since our findings indicate that the effects of IHCA are long-lasting and encompass all aspects of survivors’ lives.

Background Limited information is available regarding in‐hospital cardiac arrest (IHCA) in patients with COVID‐19. Methods and Results We leveraged the American Heart Association COVID‐19 Cardiovascular Disease (AHA COVID‐19 CVD) Registry to conduct a cohort study of adults hospitalized for COVID‐19. IHCA was defined as those with documentation of cardiac arrest requiring medication or electrical shock for resuscitation. Mixed effects models with random intercepts were used to identify independent predictors of IHCA and mortality while accounting for clustering at the hospital level. The study cohort included 8518 patients (6080 not in the intensive care unit [ICU]) with mean age of 61.5 years (SD 17.5). IHCA occurred in 509 (5.9%) patients overall with 375 (73.7%) in the ICU and 134 (26.3%) patients not in the ICU. The majority of patients at the time of ICHA were not in a shockable rhythm (76.5%). Independent predictors of IHCA included older age, Hispanic ethnicity (odds ratio [OR], 1.9; CI, 1.4–2.4; P

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: Community-engaged research engages the community in a collaborative manner to improve the local setting and has been increasingly applied to health services research. These complex studies require collaboration and team building among clinical experts, methodologists, and community stakeholders, yet few examples of this process have been published. Aim: Through a study of community emergency medical services, our aim was to understand team building among content experts and methodologists to advance the framework for adaptive community-engaged research. Methods: We collected process field notes and transcripts from the project kick-off meetings and analyzed the data using an immersion/crystallization process, which is an exploratory qualitative analysis characterized by continual review of the data collected. All 25 members of the study’s research team, who are both local to Michigan and reside out-of-state, were invited to attend. Results: We describe the process of the kick-off event for this community-engaged study and report major themes: collaborating throughout each stage of the kick-off meeting, building trusting relationships by challenging each other’s perspectives and sharing expertise, and gaining shared experiences of learning and understanding of study content and goals. Conclusion: Team-building in community engaged health research requires thoughtful effort, and planned kick-off meeting can be a useful strategy to build a shared vision among content experts and methodologists.

Background We systematically reviewed trials comparing different reperfusion strategies for ST‐segment–elevation myocardial infarction and used multivariate network meta‐analysis to compare outcomes across these strategies. Methods and Results We identified 31 contemporary trials in which patients with ST‐segment–elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as “facilitated PCI” when the median time interval between fibrinolysis to PCI was

Fractional flow reserve (FFR) is a physiologic measurement of coronary artery perfusion. Studies have demonstrated its benefit in lowering cost and improving outcomes in patients undergoing elective coronary angiography, though follow-up surveys have demonstrated low usage nationwide. We sought to investigate the actual usage in elderly patients undergoing elective coronary angiography. Overall utilization of FFR for elective coronary angiography was 6.3%. Age, sex, race, prior stress testing and region of the country were all statistically significant predictors for FFR use. There still exist many barriers to widespread adoption of this modality, which require further exploration.

Objectives: We evaluated the impact of implementation of the TN-STEMI programme on various characteristics of the pharmacoinvasive group by comparing clinical as well as angiographic outcomes between the pre- and post-implementation groups. Methods: The TN-STEMI programme involved 2420 patients of which 423 patients had undergone a pharmacoinvasive strategy of reperfusion. Of these, 407 patients had a comprehensive blinded core-lab evaluation of their angiograms post-lysis and clinical evaluation of various parameters including time-delays and adverse cardio- and cerebro-vascular events at 1 year. Streptokinase was used as the thrombolytic agent in 94.6% of the patients. Results: In the post-implementation phase, there was a significant improvement in ‘First medical contact (FMC)-to-ECG’ (11 vs. 5 min, p

The TN STEMI Program was a multicenter, prospective, observational study conducted in Tamil Nadu, India, that assessed the effects of implementing the STEMI India Model for the management of STEMI. We discuss the economic and societal impact in this article. Given that the intervention resulted in an absolute mortality reduction of 3.4%, we calculated a number needed to treat of 30 patients. At an annualized project cost of INR 15.11 million, this approximately calculates to INR 193,749 (USD 3,311) per life saved. The utility of the TN-STEMI Program can be estimated to be 1,108 life-years. This calculates to approximately INR 13,643 (USD 233) per life-year saved. Our estimates will likely be of particular interest to policy makers in low and middle-income countries, where financial and resource constraints pose a perennial public health challenge.

BackgroundThe Physician Consortium for Performance Improvement recently proposed percutaneous coronary intervention (PCI)‐specific process measures. However, information about hospital performance on these measures and the association of PCI process and outcomes measures are not available. Methods and ResultsWe linked the National Cardiovascular Data Registry (NCDR) CathPCI Registry with Medicare claims data to assess hospital performance on established PCI process measures (aspirin, thienopyridines, and statins on discharge; door‐to‐balloon time; and referral to cardiac rehabilitation), newly proposed PCI process measures (documentation of contrast dose, glomerular filtration rate, and PCI indication; appropriate indication for elective PCI; and use of embolic protection device), and a composite of all process measures. We calculated weighted pair‐wise correlations between each set of process metrics and performed weighted correlation analyses to assess the association between composite measure performance with corresponding 30‐day risk‐standardized mortality and readmission rates. We reported the variance in risk‐standardized 30‐day outcome rates explained by process measures. We analyzed 1 268 860 PCIs from 1331 hospitals. For many process measures, median hospital performance exceeded 90%. We found strong correlations between medication‐specific process measures (P

BackgroundPatients with chronic kidney disease (CKD) are at increased risk for bleeding, transfusion, and dialysis after cardiac catheterization. Whether rates of these complications are increased in this high‐risk population undergoing transradial access compared with transfemoral access is unknown. Methods and ResultsFrom the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking program, we identified 229 108 patients undergoing cardiac catheterization between 2007 and 2014, of which 48 155 (21.0%) had baseline glomerular filtration rate (GFR) between 15 and 59 mL/min. We used multivariable Cox modeling to determine the independent association between transradial access and postprocedure transfusion as well as progression to new dialysis by degree of renal dysfunction. Overall, 35 979 (15.7%) of patients underwent Transradial access. Transradial patients tended to be slightly younger, but, overall, had similar rates of CKD compared to transfemoral patients (24.3% vs 27.1%). Transradial patients had longer fluoroscopy times (7.2 vs 6.0 minutes; P

BackgroundMost 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 ResultsWithin 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