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This study sought to determine the feasibility of performing an extensive randomized outcomes trial comparing a coronary artery calcium (CAC)- versus a pooled cohort equations (PCE) risk score-based strategy for initiating statin therapy for primary atherosclerotic cardiovascular disease (ASCVD) prevention.Statin therapy is standard for the primary prevention of ASCVD in subjects at increased risk. National guidelines recommend using the American College of Cardiology/American Heart Association PCE risk score to guide a statin recommendation. Whether guidance by a CAC score is equivalent or superior is unknown.CorCal (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events) was a randomized trial consenting 601 patients without known ASCVD, diabetes, or prior statin therapy recruited from primary care clinics and randomized to CAC- (n = 302) or PCE guidance (n = 299) of statin initiation for primary prevention. Enrolled subjects and their physicians made final treatment decisions. Primary outcomes compared the proportion of statin recommendations received and subject adherence over 1 year between CAC- and PCE-arm subjects. Modeled medical costs, adverse effects, and low-density lipoprotein-cholesterol (LDL-C) were additional measures of interest.Subjects were well matched, and 540 (89.9%) completed entry testing and received a protocol-based recommendation. A statin was recommended in 101 (35.9%) CAC-arm and 124 (47.9%) PCE-arm subjects (P = 0.005). Compared to PCE-based recommendations, CAC-arm subjects were reclassified from statin to no statin in 36.0% and from no statin to statin in 5.6% of cases, resulting in a total reclassification of 20.6%. Physicians accepted the study-dictated recommendation to start a statin in 88.1% of CAC-arm vs 75.0% of PCE-arm subjects (P = 0.01). Patient-reported adherence to this recommendation at 3 months was 62.2% vs 42.2%, respectively (P = 0.009). At 1 year, statin adherence remained superior, LDL-C levels were lower, estimated costs were similar or reduced in CAC subjects, and few events occurred.CAC guidance may be a more efficient, personalized, cost-effective, and motivating approach to statin initiation and maintenance in primary prevention. This feasibility phase of CorCal should be regarded as hypothesis-generating with respect to cardiovascular outcomes, which is being addressed in a large, longer-term outcomes trial. (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events [CorCal]; NCT03439267).

Low vitamin D (serum or plasma 25‐hydroxyvitamin D (25(OH)D)) is a global pandemic and associates with a greater prevalence in all‐cause and cardiovascular mortality and morbidity. Open‐heart surgery is a form of acute stress that decreases circulating 25(OH)D concentrations and exacerbates the preponderance of low vitamin D in a patient population already characterized by low levels. Although supplemental vitamin D increases 25(OH)D, it is unknown if supplemental vitamin D can overcome the decreases in circulating 25(OH)D induced by open‐heart surgery. We sought to identify if supplemental vitamin D protects against the acute decrease in plasma 25(OH)D propagated by open‐heart surgery during perioperative care. Participants undergoing open‐heart surgery were randomly assigned (double‐blind) to one of two groups: (a) vitamin D (n = 75; cholecalciferol, 50,000 IU/dose) or (b) placebo (n = 75). Participants received supplements on three separate occasions: orally the evening before surgery and either orally or per nasogastric tube on postoperative days 1 and 2. Plasma 25(OH)D concentrations were measured at baseline (the day before surgery and before the first supplement bolus), after surgery on postoperative days 1, 2, 3, and 4, at hospital discharge (5–8 days after surgery), and at an elective outpatient follow‐up visit at 6 months. Supplemental vitamin D abolished the acute decrease in 25(OH)D induced by open‐heart surgery during postoperative care. Moreover, plasma 25(OH)D gradually increased from baseline to day 3 and remained significantly increased thereafter but plateaued to discharge with supplemental vitamin D. We conclude that perioperative vitamin D supplementation protects against the immediate decrease in plasma 25(OH)D induced by open‐heart surgery. ClinicalTrials.gov Identifier: NCT02460211., Open‐heart surgery induces acute stress and acute stress is detrimental to circulating 25‐hydroxyvitamin D (25(OH)D) concentration. We found that perioperative vitamin D supplementation abolished the decrease in circulating 25(OH)D following open‐heart surgery. Thus, supplemental vitamin D protects against the deleterious impact of acute stress on circulating 25(OH)D concentrations.

Background High CHA2DS2-VASc scores in atrial fibrillation (AF) patients are generally associated with increased risks of stroke and dementia. At lower CHA2DS2-VASc scores, there remains an unquantifiable cranial injury risk, necessitating an improved risk assessment method within these lower-risk groups. Objective The purpose of this study was to determine whether sex-specific Intermountain Mortality Risk Scores (IMRS), a dynamic measures of systemic health that comprises commonly performed blood tests, can stratify dementia risk overall and among CHA2DS2-VASc score strata in AF patients. Methods Female (n = 34,083) and male (n = 39,998) AF patients with no history of dementia were studied. CHA2DS2-VASc scores were assessed at the time of AF diagnosis and were stratified into scores of 0–1, 2, and ≥3. Within each CHA2DS2-VASc score stratum, patients were further stratified by IMRS categories of low, moderate, and high. Multivariable Cox hazard regression was used to determine dementia risk. Results High-risk IMRS patients were generally older and had higher rates of hypertension, diabetes, heart failure, and prior stroke. Higher CHA2DS2-VASc score strata (≥3 vs ≤1: women, hazard ratio [HR] 7.77, 95% confidence interval [CI] 5.94–10.17, P Conclusion Both CHA2DS2-VASc scores and IMRS were independently associated with dementia incidence among AF patients. IMRS further stratified dementia risk among CHA2DS2-VASc score strata, particularly among those with lower CHA2DS2-VASc scores.

Improving 30-day readmission continues to be problematic for most hospitals. This study reports the creation and validation of sex-specific inpatient (i) heart failure (HF) risk scores using electronic data from the beginning of inpatient care for effective and efficient prediction of 30-day readmission risk.HF patients hospitalized at Intermountain Healthcare from 2005 to 2012 (derivation: n=6079; validation: n=2663) and Baylor ScottWhite Health (North Region) from 2005 to 2013 (validation: n=5162) were studied. Sex-specific iHF scores were derived to predict post-hospitalization 30-day readmission using common HF laboratory measures and age. Risk scores adding social, morbidity, and treatment factors were also evaluated.The iHF model for females utilized potassium, bicarbonate, blood urea nitrogen, red blood cell count, white blood cell count, and mean corpuscular hemoglobin concentration; for males, components were B-type natriuretic peptide, sodium, creatinine, hematocrit, red cell distribution width, and mean platelet volume. Among females, odds ratios (OR) were OR=1.99 for iHF tertile 3 vs. 1 (95% confidence interval [CI]=1.28, 3.08) for Intermountain validation (P-trend across tertiles=0.002) and OR=1.29 (CI=1.01, 1.66) for Baylor patients (P-trend=0.049). Among males, iHF had OR=1.95 (CI=1.33, 2.85) for tertile 3 vs. 1 in Intermountain (P-trend0.001) and OR=2.03 (CI=1.52, 2.71) in Baylor (P-trend0.001). Expanded models using 182-183 variables had predictive abilities similar to iHF.Sex-specific laboratory-based electronic health record-delivered iHF risk scores effectively predicted 30-day readmission among HF patients. Efficient to calculate and deliver to clinicians, recent clinical implementation of iHF scores suggest they are useful and useable for more precise clinical HF treatment.

Statins are among the most prescribed medications because of the well-documented benefits of safely lowering low-density lipoprotein cholesterol. However, many patients are unable or unwilling to continue statin therapy because of real or perceived adverse effects. This study sought to increase understanding about which patients are unlikely to tolerate statin therapy. The Intermountain Healthcare's electronic data repository was queried from January 1, 1999, to December 31, 2013, to identify all adults who survived their first encounter of coronary artery disease (CAD), cerebral vascular disease, or peripheral artery disease and received statin therapy during follow-up. Statin intolerance (SI) was identified by the documentation of clinician-noted intolerance or allergy or by the use of pitavastatin. Patients were followed up for ≥3 years or until death. Of the 48,997 patients evaluated, 3049 (6.2%) were documented with SI. Of those with SI, 9.8% were prescribed a low-intensity, 73.4% a moderate-intensity, and 16.8% a high-intensity statin dose. After adjustment for covariables, significant predictors of SI were female sex [odds ratio (OR) = 1.47, P < 0.0001], age (65-74 vs.

Atherosclerotic cardiovascular disease (ASCVD) is the most important cause of morbidity and mortality nationally and internationally. Improving ASCVD risk prediction is a high clinical priority. We sought to determine which of 3 ASCVD risk scores best predicts the need for revascularization and incident major adverse coronary events (MACE) in symptomatic patients at low-to-intermediate primary ASCVD risk referred for regadenoson-stress positron emission tomography (PET). Risk scores included the standard ASCVD pooled cohort equation (PCE), the multiethnic study of atherosclerosis (MESA) risk equation, and the coronary artery calcium score (CACS), obtained by PET. All qualifying patients in our institution at primary ASCVD risk referred for PET-stress tests in whom PCE, MESA, and CAC scores could be calculated were studied. CACS categories were: 0, 1 to 10, 11 to 299, 300 to 999, and 1000+. MESA and PCE scores were divided into quartiles. Logistic regression modeling was used to predict clinical/PET-driven early revascularization (within 90 days) and 1-year MACE (death, myocardial infarction, or any-time revascularization). A total of 981 patients (54% men, age 67 ± 10 years) qualified and were studied. Scores including CAC (MESA, CACS) performed better than PCE for predicting overall 1-year MACE (MESA p0.001, CACS p = 0.012 vs PCE), which was driven by early revascularization. In conclusion, in a large population of patients at primary ASCVD risk referred for PET-stress testing, risk scores including CAC (CACS, MESA), which better predicted early revascularization and 1-year MACE, may be particularly useful in primary coronary risk assessment when considering whom to refer for PET-stress testing.

Background: The Intermountain Mortality Risk Score (IMRS), a sex-specific mortality-prediction metric, has proven to be effective in various populations. IMRS is comprised of the complete blood count (CBC), basic metabolic panel (BMP), and age. Whether the addition of factors from the comprehensive metabolic panel (CMP) and white blood cell (WBC) differential count improves risk stratification is unknown. Methods: Patients with baseline complete metabolic panel (CMP) and IMRS measurements were randomly assigned (60%/40%) to independent derivation (n=84,913) and validation (n=56,584) populations. A sex-specific risk score based on IMRS methods was computed in the derivation population using adjusted multivariable regression weights from all significant and noncollinear CMP [expanded IMRS (eIMRS)] and, when available, WBC differential components (eIMRS+diff). Results: Age averaged 67±16 years for females and 67±15 years for males. Receiver operator characteristic (ROC) c-statistics for 30-day death showed marked improvement for the eIMRS compared to the IMRS in both females [0.895 (0.882, 0.908) vs. 0.865 (0.850, 0.880)] and males [0.861 (0.847, 0.876) vs. 0.824 (0.807, 0.841)]. These results persisted for 1-year death: females [0.854 (0.847, 0.862) vs. 0.828 (0.819, 0.836)] and males [0.835 (0.826, 0.844) vs. 0.796 (0.789, 0.808)]. In addition, the eIMRS significantly improved risk reclassification. Further precision was seen when WBC differential components were included. Conclusions: The addition of the CMP components to the IMRS improved risk prediction. WBC differential also improved risk score predictive ability. These results suggest that the eIMRS may function even better than IMRS as a tool in patient care, risk-adjustment, and clinical research settings for predicting outcomes.

Using augmented intelligence clinical decision tools and a risk score-guided multidisciplinary team-based care process (MTCP), this study evaluated the MTCP for heart failure (HF) patients' 30-day readmission and 30-day mortality across 20 Intermountain Healthcare hospitals.HF inpatient care and 30-day post-discharge management require quality improvement to impact patient health, optimize utilization, and avoid readmissions.HF inpatients (N = 6182) were studied from January 2013 to November 2016. In February 2014, patients began receiving care via the MTCP based on a phased implementation in which the 8 largest Intermountain hospitals (accounting for 89.8% of HF inpatients) were crossed over sequentially in a stepped manner from control to MTCP over 2.5 years. After implementation, patient risk scores were calculated within 24 hours of admission and delivered electronically to clinicians. High-risk patients received MTCP care (n = 1221), while lower-risk patients received standard HF care (n = 1220). Controls had their readmission and mortality scores calculated retrospectively (high risk: n = 1791; lower risk: n = 1950).High-risk MTCP recipients had 21% lower 30-day readmission compared to high-risk controls (adjusted P = .013, HR = 0.79, CI = 0.66, 0.95) and 52% lower 30-day mortality (adjusted P .001, HR = 0.48, CI = 0.33, 0.69). Lower-risk patients did not experience increased readmission (adjusted HR = 0.88, P = .19) or mortality (adjusted HR = 0.88, P = .61). Some utilization was higher, such as prescription of home health, for MTCP recipients, with no changes in length of stay or overall costs.A risk score-guided MTCP was associated with lower 30-day readmission and 30-day mortality in high-risk HF inpatients. Further evaluation of this clinical management approach is required.

Severe hyperlipidemia (LDL-C >=190mg/dL) is an indication for statin therapy, with LDL-C >=160mg/dL a treatment enhancing factor (2018 AHA/ACC Cholesterol Treatment Guideline). The CorCal Vanguard Trial randomly invited 3770 Intermountain patients of age >=50yo without ASCVD or statin use to

Statin therapy is standard for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, patients are not always adherent. It is proposed that patients may respond better to a recommendation for statin therapy if it is based on the results of a coronary artery calcium score

Glycoprotein IIb/IIIa inhibitors, used as a standard intravenous bolus followed by a prolonged infusion for 12 to 18 hours, reduces ischemic complications during percutaneous coronary interventions (PCI) but often at a cost of increased bleeding. Today, when dual oral antiplatelet therapy is routine, heparin use plus short-term (bolus alone or with a6 hours infusion) glycoprotein IIb/IIIa inhibitors, or bivalirudin monotherapy, have been proposed as potentially superior alternatives. This observational study evaluated the safety and efficacy of heparin plus short-term tirofiban versus bivalirudin monotherapy during PCI. Patients with successful PCI and no cardiogenic shock who were anticoagulated with either of the above regimens were followed for 30-day major bleeding and major adverse cardiovascular events (death, nonfatal myocardial infarction, and urgent target vessel revascularization) at 30 days, 1 year, and long term. A total of 727 patients receiving tirofiban (age = 63 ± 13 years, males = 76%, ACS presentation = 75%, radial access = 51%) and 459 patients receiving bivalirudin, (age = 65 ± 13 years, males = 71%, ACS presentation = 78%, radial access = 18%) were included. Thirty-day major bleeding was 0.7% and 4.1% for tirofiban and bivalirudin, respectively (adjusted odds ratio = 0.17 [0.06, 0.46], p = 0.001). During 30-day, 1-year, and long-term (1.7 ± 0.9 years) follow-up, major adverse cardiovascular events risk did not differ significantly between tirofiban and bivalirudin. However, long-term death was significantly lower in those receiving tirofiban (adjusted hazard ratio = 0.58 [0.34, 1.00], p = 0.05). In conclusion, in this observational study, PCI patients receiving heparin plus short-term tirofiban experienced significantly lower 30-day major bleeding, and improved long-term survival, than those receiving bivalirudin monotherapy.

BACKGROUND. The red cell distribution width (RDW) is associated with health outcomes. Whether non-RDW risk information is contained in RBC sizes is unknown. This study evaluated the association of the percentage of extreme macrocytic RBCs (%Macro, RBC volume > 120 fl) and microcytic RBCs (%Micro, RBC volume < 60 fl) and the RDW–size distribution (RDW-sd) with mortality and morbidity. METHODS. Patients (females, n = 165,770; males, n = 100,210) at Intermountain Healthcare were studied if they had a hematology panel between May 2014 and September 2016. Adjusted sex-specific associations of %Macro/%Micro and RDW-sd with mortality and 33 morbidities were evaluated. RESULTS. Among females with fourth-quartile values of %Macro quartile and %Micro (referred to throughout as 4/4), there was an average of 7.2 morbidities versus 2.9 in the lowest risk (LR1) categories, 1/1, 1/2, 2/1, and 2/2 (P < 0.001). Among males, those in the 4/4 category had 8.0 morbidities, while those in the LR1 had 3.4 (P < 0.001). Cox regressions found %Macro/%Micro (4/4 vs. LR1, females: hazard ratio [HR] = 1.97 [95% CI = 1.53, 2.54]; males: HR = 2.17 [CI = 1.72, 2.73]), RDW-sd (quartile 4 vs. 1, females: HR = 1.33 [CI = 1.04, 1.69]; males: HR = 1.41 [CI = 1.10, 1.80]), and RDW (quartile 4 vs. 1, females: HR = 1.59 [CI = 1.26, 2.00]; males: HR = 1.23 [CI = 0.99, 1.52]) independently predicted mortality. Limitations include that the observational design did not reveal causality and unknown confounders may be unmeasured. CONCLUSIONS. Concomitantly elevated %Macro and %Micro predicted the highest mortality risk and the greatest number of morbidities, revealing predictive ability of RBC volume beyond what is measured clinically. Mechanistic investigations are needed to explain the biological basis of these observations. FUNDING. This study was supported by internal Intermountain Heart Institute funds and in-kind support from Sysmex America Inc.

High CHAThe purpose of this study was to determine whether sex-specific Intermountain Mortality Risk Scores (IMRS), a dynamic measures of systemic health that comprises commonly performed blood tests, can stratify dementia risk overall and among CHAFemale (n = 34,083) and male (n = 39,998) AF patients with no history of dementia were studied. CHAHigh-risk IMRS patients were generally older and had higher rates of hypertension, diabetes, heart failure, and prior stroke. Higher CHABoth CHA

BACKGROUND. Cardiac positron emission testing (PET) is more accurate than single photon emission computed tomography (SPECT) at identifying coronary artery disease (CAD); however, the 2 modalities have not been thoroughly compared in a real-world setting. We conducted a retrospective analysis of 60-day catheterization outcomes and 1-year major adverse cardiovascular events (MACE) after the transition from a SPECT- to a PET-based myocardial perfusion imaging (MPI) program. METHODS. MPI patients at Intermountain Medical Center from January 2011–December 2012 (the SPECT era, n = 6,777) and January 2014–December 2015 (the PET era, n = 7,817) were studied. Outcomes studied were 60-day coronary angiography, high-grade obstructive CAD, left main/severe 3-vessel disease, revascularization, and 1-year MACE-revascularization (MACE-revasc; death, myocardial infarction [MI], or revascularization >60 days). RESULTS. Patients were 64 ± 13 years old; 54% were male and 90% were of European descent; and 57% represented a screening population (no prior MI, revascularization, or CAD). During the PET era, compared with the SPECT era, a higher percentage of patients underwent coronary angiography (13.2% vs. 9.7%, P < 0.0001), had high-grade obstructive CAD (10.5% vs. 6.9%, P < 0.0001), had left main or severe 3-vessel disease (3.0% vs. 2.3%, P = 0.012), and had coronary revascularization (56.7% vs. 47.1%, P = 0.0001). Similar catheterization outcomes were seen when restricted to the screening population. There was no difference in 1-year MACE-revasc (PET [5.8%] vs. SPECT [5.3%], P = 0.31). CONCLUSIONS. The PET-based MPI program resulted in improved identification of patients with high-grade obstructive CAD, as well as a larger percentage of revascularization, thus resulting in fewer patients undergoing coronary angiography without revascularization. FUNDING. This observational study was funded using internal departmental funds.

Objective Post-myocardial infarction (MI) care is crucial to preventing recurrent major adverse cardiovascular events (MACE), but can be complicated to personalise. A tool is needed that effectively stratifies risk of cardiovascular (CV) events 1–3 years after MI but is also clinically usable. Methods Patients surviving ≥1 year after an index MI with ≥1 risk factor for recurrent MI (ie, age ≥65 years, prior MI, multivessel coronary disease, diabetes, glomerular filtration rate

To determine the relationship between coronary plaque detected with coronary computed tomographic (CT) angiography and clinical parameters and cardiovascular risk factors in asymptomatic patients with diabetes.All patients signed institutional review board-approved informed consent forms before enrollment. Two hundred twenty-four asymptomatic diabetic patients (121 men; mean patient age, 61.8 years; mean duration of diabetes, 10.4 years) underwent coronary CT angiography. Total coronary artery wall volume in all three vessels was measured by using semiautomated software. The coronary plaque volume index (PVI) was determined by dividing the wall volume by the coronary length. The relationship between the PVI and cardiovascular risk factors was determined with multivariable analysis.The mean PVI (±standard deviation) was 11.2 mm(2) ± 2.7. The mean coronary artery calcium (CAC) score (determined with the Agatston method) was 382; 67% of total plaque was noncalcified. The PVI was related to age (standardized β = 0.32, P.001), male sex (standardized β = 0.36, P.001), body mass index (BMI) (standardized β = 0.26, P.001), and duration of diabetes (standardized β = 0.14, P = .03). A greater percentage of soft plaque was present in younger individuals with a shorter disease duration (P = .02). The soft plaque percentage was directly related to BMI (P = .002). Patients with discrepancies between CAC score and PVI rank quartiles had a higher percentage of soft and fibrous plaque (18.7% ± 3.3 vs 17.4% ± 3.5 [P = .008] and 52.2% ± 7.2 vs 47.2% ± 8.8 [P.0001], respectively).In asymptomatic diabetic patients, BMI was the primary modifiable risk factor that was associated with total and soft coronary plaque as assessed with coronary CT angiography.

Clinical trials have shown a consistent relationship between years of LDL-C reduction on statin therapy and magnitude of risk reduction. WOSCOPS found that 5 years of statins led to lifelong risk reduction, but little is known about real world persistence over this time frame. The objective of this

Routine, periodic fasting is associated with a lower prevalence of coronary artery disease (CAD). Animal studies show that fasting may increase longevity and alter biological parameters related to longevity. We evaluated whether fasting initiates acute changes in biomarker expression in humans that may impact short- and long-term health.Apparently-healthy volunteers (N = 30) without a recent history of fasting were enrolled in a randomized cross-over trial. A one-day water-only fast was the intervention and changes in biomarkers were the study endpoints. Bonferroni correction required p ≤ 0.00167 for significance (p0.05 was a trend that was only suggestively significant). The one-day fasting intervention acutely increased human growth hormone (p = 1.1 × 10⁻⁴), hemoglobin (p = 4.8 × 10⁻⁷), red blood cell count (p = 2.5 × 10⁻⁶), hematocrit (p = 3.0 × 10⁻⁶), total cholesterol (p = 5.8 × 10⁻⁵), and high-density lipoprotein cholesterol (p = 0.0015), and decreased triglycerides (p = 1.3 × 10⁻⁴), bicarbonate (p = 3.9 × 10⁻⁴), and weight (p = 1.0 × 10⁻⁷), compared to a day of usual eating. For those randomized to fast the first day (n = 16), most factors including human growth hormone and cholesterol returned to baseline after the full 48 h, with the exception of weight (p = 2.5 × 10⁻⁴) and (suggestively significant) triglycerides (p = 0.028).Fasting induced acute changes in biomarkers of metabolic, cardiovascular, and general health. The long-term consequences of these short-term changes are unknown but repeated episodes of periodic short-term fasting should be evaluated as a preventive treatment with the potential to reduce metabolic disease risk. Clinical trial registration (ClinicalTrials.gov): NCT01059760 (Expression of Longevity Genes in Response to Extended Fasting [The Fasting and Expression of Longevity Genes during Food abstinence {FEELGOOD} Trial]).

Intracardiac Ultrasound During Left Atrial Ablation for Atrial Fibrillation. Background: Esophageal injury during left atrial ablation is associated with a significant risk of mortality and morbidity. There are no validated approaches to reduce injury outside of avoidance, a strategy critically dependent on a precise understanding of the esophageal anatomy and location. Intracardiac ultrasound (ICE) can provide a real-time assessment of the esophagus during ablation. We hypothesized that ICE can accurately define esophageal anatomy and location to enhance avoidance strategies during ablation. Methods: Fifty patients underwent atrial fibrillation (AF) ablation. The left atrium and pulmonary vein anatomies were rendered by traditional electroanatomic mapping (CARTO). A Navistar catheter within the esophagus was used to create a traditional electroanatomic esophageal anatomy. ICE imaging was used to create a second geometry of the esophagus. The traditional and ICE anatomies of the esophagus were compared and the greatest border dimensions used to avoid injury. Results: The average age was 66 ± 10 years, 45% had persistent/longstanding persistent AF, and 18% had a prior AF ablation. The esophagus location was leftward in 17 (34%), midline in 22 (44%), and rightward in 11 (22%). Traditional esophagus and ICE imaging correlated within 1 cm in the greatest distance in 26 (52%) patients. Traditional imaging underestimated the esophageal location by >1–1.5 cm in 9 (18%) and >1.5 cm in 15 (30%). In those with poor correlation (>1.5 cm), the most common cause was the presence of a hiatal hernia. Ablation energy delivery was performed outside the greatest esophagus anatomy borders. Of those with 12-month follow-up, 75% were AF/atrial flutter free without antiarrhythmic drugs. No esophageal injuries were observed. One patient experienced a TIA greater than 6 months postablation. Conclusion: These data demonstrate that traditional means of mapping the esophagus using a catheter within the esophagus are insufficient and often grossly underestimate the actual anatomy. Imaging techniques that define the complete esophageal lumen should be considered to truly minimize esophageal injury risk. (J Cardiovasc Electrophysiol, Vol. 24, pp. 33-39, January 2013)

The Intermountain Risk Score (IMRS) encapsulates the mortality risk information from all components of the complete blood count (CBC) and basic metabolic profile (BMP), along with age. To individualize the IMRS more clearly, this study evaluated whether IMRS weightings for 1-year mortality predict age-specific survival over more than a decade of follow-up. Sex-specific 1-year IMRS values were calculated for general medical patients with CBC and BMP laboratory tests drawn during 1999-2005. The population was divided randomly 60% (N = 71,921, examination sample) and 40% (N = 47,458, validation sample). Age-specific risk thresholds were established, and both survival and life expectancy were compared across low-, moderate-, and high-risk IMRS categories. During 7.3 ± 1.8 years of follow-up (range, 4.5-11.1 years), the average IMRS of decedents was higher than censored in all age/sex strata (all P < 0.001). For examination and validation samples, every age stratum had incrementally lower survival for higher risk IMRS, with hazard ratios of 2.5-8.5 (P < 0.001). Life expectancies were also significantly shorter for higher risk IMRS (all P < 0.001): For example, among 50-59 year-olds, life expectancy was 7.5, 6.8, and 5.9 years for women with low-, moderate-, and high-risk IMRS (with mortality in 5.7%, 16.3%, and 37.0% of patients, respectively). In Men, life expectancy was 7.3, 6.8, and 5.4 for low-, moderate-, and high-risk IMRS (with patients having 7.3%, 19.5%, and 40.0% mortality), respectively. IMRS significantly stratified survival and life expectancy within age-defined subgroups during more than a decade of follow-up. IMRS may be used to stratify age-specific risk of mortality in research, clinical/preventive, and quality improvement applications. A web calculator is located at http://intermountainhealthcare.org/IMRS.

Background: Previous studies have observed that short-term exposure to elevated concentrations of particulate matter (PM) air pollution increases risk of acute ischemic heart disease events and heart failure hospitalization, alters cardiac autonomic function, and increases risk of arrhythmias. This study explored the potential associations between short-term elevations in PM exposure and atrial fibrillation (AF). Methods and Results: A case-crossover study design was used to explore associations between fine PM (PM2.5, particles with an aerodynamic diameter ≤2.5 μm) and 10,457 AF hospitalizations from 1993 to 2008 of patients who lived on Utah's Wasatch Front. Patients were hospitalized at Intermountain Healthcare facilities with a primary diagnosis of AF. Concurrent day exposure and cumulative lagged exposures for up to 21 days were explored and the data were stratified by sex, age, and previous or subsequent admission for myocardial infarction. Although the estimated associations between PM2.5 and AF hospitalizations for the various lag structures and strata were consistently positive suggestive of risk, they were not statistically significant and they were extremely small compared to previously observed associations with ischemic heart disease events and heart failure hospitalizations. Further, we observed no additive risk between PM2.5 and AF hospitalization in those with respiratory disease or sleep apnea. Conclusions: Unlike previously observed associations with ischemic heart disease events and heart failure hospitalizations using similar study design and approaches, this study found that hospitalization for AF was not significantly associated with elevations in short-term exposure to fine PM air pollution. (PACE 2011; 34:1475–1479)

A Strategy of Rapid Cardioversion. Background: The significance of early recurrent atrial tachyarrhythmias after atrial fibrillation (AF) ablation is unclear. Atrial remodeling driven by these tachyarrhythmias can result in electrical, contractile, and structural changes that may impair long-term therapy success. Aggressive attempts to restore sinus rhythm in the temporal period of healing after ablation might improve outcomes. Methods: A total of 1,759 AF ablations were performed at Intermountain Medical Center or LDS Hospital. A total of 455 of those were among patients requiring repeat ablations. Patients were instructed to take their pulse daily and, if greater than 100 bpm or irregular, present the following business day fasting to the clinic for evaluation and cardioversion if AF or atrial flutter (AFL) were present. Results: Of the ablations performed, a total of 515 (29%, age: 65.6 ± 11.2 years, male: 57.9%) developed AF/AFL that required cardioverison. The majority of these arrhythmias first occurred in the initial 90 days (63.7%) postablation. During this period, 62.8% were on an antiarrhythmic drug (AAD). Only 25.1% were using an AAD at 3 months. The majority of ablations (75.6%) who experienced AF/AFL within the first 90 days after ablation were in sinus rhythm with no AAD at 1 year. Further, 48% of those with the first recurrence from 90 to 180 days were in sinus rhythm with no AAD at 1 year. Conclusions: The time at which the first recurrence of AF/AFL occurs impacts long-term outcomes. An aggressive strategy of rapid cardioversion postablation reduces the significance of recurrent AF/AFL during the first 6 months. (J Cardiovasc Electrophysiol, Vol. 22, pp. 761-766, July 2011)

BackgroundOral anticoagulation (OAC) therapy guidelines recommend using CHA2DS2-VASc to determine OAC need in atrial fibrillation (AF). A usable tool, CHA2DS2-VASc is challenged by its predictive ability. Applying components of the complete blood count and basic metabolic profile, the Intermountain Mortality Risk Score (IMRS) has been extensively validated. This study evaluated whether use of IMRS with CHA2DS2-VASc in patients with AF improves prediction.MethodsPatients with AF undergoing cardiac catheterisation (N=10 077) were followed for non-fatal stroke and mortality (mean 5.8±4.1 years, maximum 19 years). CHA2DS2-VASc and IMRS were calculated at baseline. IMRS categories were defined based on previously defined criteria. Cox regression was adjusted for demographic, clinical and treatment variables not included in IMRS or CHA2DS2-VASc.ResultsIn women (n=4122, mean age 71±12 years), the composite of non-fatal stroke/mortality was stratified (all p-trend 2DS2-VASc (1: 12.6%, 2: 22.8%, >2: 48.1%) and IMRS (low: 17.8%, moderate: 40.9%, high risk: 64.5%), as it was for men (n=5955, mean age 68±12 years) by CHA2DS2-VASc (2: 51.8%) and IMRS (low: 19.0%, moderate: 42.0%, high risk: 65.9%). IMRS stratified stroke/mortality (all p-trend 2DS2-VASc category.ConclusionsUsing IMRS jointly with CHA2DS2-VASc in patients with AF improved the prediction of stroke and mortality. For example, in patients at the OAC treatment threshold (CHA2DS2 -VASc = 2), IMRS provided ≈4-fold separation between low and high risk. IMRS provides an enhancing marker for risk in patients with AF that reflects the underlying systemic nature of this disease that may be considered in combination with the CHA2DS2-VASc score.

Aims The complete blood count (CBC) and basic metabolic profile are common, low-cost blood tests, which have previously been used to create and validate the Intermountain Risk Score (IMRS) for mortality prediction. Mortality is the most definitive clinical endpoint, but medical care is more easily applied to modify morbidity and thereby prevent death. This study tested whether IMRS is associated with clinical morbidity endpoints. Methods Patients seen for coronary angiography (n = 3927) were evaluated using a design similar to a genome-wide associand results ation study. The Bonferroni correction for 102 tests required a P-value of ≤ 4.9 x 10 -4 for significance. A second set of angiography patients (n = 10 413) was used to validate significant findings from the first patient sample. In the first patient sample, IMRS predicted heart failure (HF) (P trend = 1.6 x 10 -26 ), coronary disease (P trend = 2.6 x 10 -11 ), myocardial infarction (MI) (P trend = 3.1 x 10 -25 ) , atrial fibrillation (P trend = 2.5 × 10 -20 ), and chronic obstructive pulmonary disease (P trend = 4.7 × 10 -4 ). Even more, IMRS predicted HF readmission [hazard ratio (HR) = 2.29/category, P trend = 1.2 x 10 -6 ), incident HF (HR = 1.88/category, P trend = 0.02), and incident MI (HR = 1.56/category, P trend = 4.7 x 10 -4 ). These findings were verified in the second patient sample. Conclusion Intermountain Risk Score, a predictor of mortality, was associated with morbidity endpoints that often lead to mortality. Further research is required to fully characterize its clinical utility, but its low-cost CBC and basic metabolic profile composition may make it ideal for initial risk estimation and prevention of morbidity and mortality. An IMRS web calculator is freely available at http://intermountainhealthcare.org/IMRS. Trial Registration: Database registry ofthe Intermountain Heart Collaborative Study: NCT00406185 (ClinicalTrials.gov).

Background To reduce 30-day HF readmissions and provide transitional support after hospital discharge, Intermountain Healthcare (IH) partnered with CipherHealth (CH) to create an automated HF follow up call program (HFCalls). We sought to determine if HFCalls coupled with nursing escalation algorithms improved readmissions, to identify patient themes requiring nurse interventions, and to determine if this approach was acceptable to patients. Methods Beginning November 2016, IH conducted a staged roll-out of HFCalls after a HF hospitalization. Three calls were scheduled at 48 hours, 7 - and 21 days post-discharge. HFCalls were used for patients identified by IH's automated HF Identification and Risk Report and were designed to identify readmission risk factors by focusing on patient education specific to medications, activity, weight, diet, and symptoms (MAWDS). Patients who indicated issues to follow-up questions were routed automatically to nurses with IH's “Health Answers” team, who used internally developed and vetted escalation algorithms for prompt resolution. A multidisciplinary team reviewed the escalation process and documentation of patient issues and actions on a biweekly basis. The program was evaluated over a 12-month period. Results A pilot period of 6 months, led to refinement of the process prior to a staged rollout with full implementation and standardized workflow across the IH system by November 2017. Of the patients (n=1,167) who received HFCalls during January 2017 - December 2017, 79% (n=922) answered the call and 57.2% (n=668) engaged by answering the first question. The readmission rate among those who engaged was 9.3% (n=62), compared to 13.8% (n=69) among the unengaged (p = 0.01). Themes of escalated calls varied by the 3 timed calls: call 1- issues with symptoms, medications, weighing and follow up; call 2- low salt diet/fluid restriction and, follow up; call 3- issues with activity and medications. Overall, 66% of engaged patients were satisfied with HFCalls. Conclusion Integrating automated HFCalls with nursing escalation algorithms after HF hospitalizations was associated with a lower hospital readmission rate in a manner acceptable to patients. These results show the importance of access to nursing support after discharge and reveal how patient themes may be used to guide HF patient education. The HFCalls technology may be applicable to other chronic disease states, but this requires further study.

Background Patient education is essential for impacting HF quality indicators, however is limited by typical passive, paper-based approaches. Simulation-based education, SBE (experiential, scenario-based learning) is highly effective in clinicians but underused in patients. We sought to: 1) determine feasibility of SBE in HF patients, 2) explore its effect on patient-reported outcomes (PRO); quality of life and self-care. Methods A prospective, pre-posttest, qualitative design studied a convenience sampling of consented patients admitted with HF to two urban hospitals. Within 2 weeks of discharge, SBE was performed in groups focusing on 3 scenarios: self-monitoring, HF medications, HF diet. SBE occurred in a home-like environment, in-center (IC) or through virtual telehealth (VT), allowing two-way, interactive video connection from home. Feasibility was determined by patient experience, events in SBE, and costs. Subjects completed the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Self-care Index for Heart Failure (SCHFI) questionnaires prior to discharge and 1 month after SBE, when evaluation of their experience occurred. Changes in KCCQ and SCHFI were analyzed. Results 51 patients were consented, age 63.95± 13.28 yrs, 64.7% male, HFrEF and HFpEF (53% vs. 47%, respectively), 40 completed SBE; 18 via IC and 22 through VT. 21 family caregivers were present. Patient experience themes were positive; who either agreed or strongly agreed the topics were relevant (n=38, 97.4%), increased their consistency following self-care (n=36, 92.4%), and were timely after discharge (n=33, 84.6%). They recommend this type of training to other HF patients (n=37, 94.9%). The average session duration was 146 +/- 21 minutes, average cost was $304 +/- $138 per participant. Issues identified with feasibility related to scheduling and technology, with no patient safety events. Observed 30-day readmissions were 7.5% with no 30-day mortality. Both KCCQ and SCHFI increased after SBE (n=39) with a significant magnitude of change shown by others to impact outcomes, figure. Improvements were consistent in both IC and VT simulation (IC p Conclusions This novel use of SBE methodology in person or by virtual telehealth was feasible, well received by HF patients and was effective to educate and engage them in their care. Additionally, it was associated with significant improvements in PROs that are known to impact HF quality metrics. Further validation in a broader HF population would help better determine its cost-effectiveness and impact on morbidity and mortality outcomes.

Acute myocardial infarction (AMI) pts have significantly lower blood levels of vitamin D (VitD) than controls. Whether low VitD levels contribute to causing or exacerbating AMI or are simply a result of the acute AMI response, and how effective preemptive VitD supplementation (VitD-S) is on

Radiofrequency ablation is an effective treatment for atrial fibrillation (AF). With improved safety, the therapy has been offered to increasingly older populations. Arrhythmia mechanisms, medical comorbidities, and safety may vary in the very elderly population.Patients presenting for AF ablation were divided into two groups [or =80 years (n = 35),80 years (n = 717)]. AF ablation consisted of pulmonary vein antral isolation with or without additional linear lesions. A successful outcome was defined as no further AF and off all antiarrhythmic medications3 months following 1 + ablation procedures.The type of AF was similar in both groups (paroxysmal: 46% in the older group vs 54% in the younger, P = 0.33). Older patients were more likely to have a higher CHADS2 score, coronary artery disease, and less likely to have had a prior ablation. The hospital stay on average was longer in the older cohort (2.9 +/- 7.7 vs 2.1 +/- 1.1 days, P = 0.001). There was no increased risk of peri-procedural complications. One-year survival free of AF or flutter was 78% in those80 and 75% in those younger (P = 0.78). There was no difference between groups if the AF was paroxysmal (P = 0.44) or persistent/chronic (P = 0.74). Over a 3-year follow-up period, five patients died and four strokes occurred all in the younger cohort.Octogenarian patients, despite more coexistent cardiovascular diseases, have favorable outcomes after AF ablation measured by successful rhythm management. On an average their hospital stay is longer, but no significant increase in short- or long-term complications was observed. These data support AF ablation in select octogenarians.

Background: Atrial fibrillation (AF) is associated with an increased risk of mortality and stroke. However, it is unclear if AF is independently associated with these poor outcomes or it is merely a risk marker of other processes that convey the risk. Methods: Consecutive patients who underwent angiography for suspicion of coronary artery disease, but without a history of AF, were studied. Traditional CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes, stroke/transient ischemic attack) risk factors for each patient were recorded. Results: A total of 343 AF patients (age = 69 ± 10 years, 215 [63%] male) and 2,945 non-AF patients (age = 63 ± 12 years, 2,012 [67%] male) were studied. Among AF patients, 51 (15%) had a myocardial infarction (MI), 35 (10%) had a stroke, and 180 (52%) died. CHADS2 score incrementally increased risk of stroke (adjusted hazard ratio [HR] for 1:1.92, 2:2.30, 3:1.14, 4:3.83, 5:10.96; P-trend = 0.14), death (HR for 1:1.83, 2:2.34, 3:3.69, 4:2.27, 5:4.53; P-trend < 0.001), and major adverse cardiac event (MACE)(HR for 1:1.29, 2:1.54, 3:2.07, 4:2.41, 5:2.68; P-trend = 0.002). Among non-AF patients, CHADS2 score incrementally increased risk of stroke (HR for 1:1.18, 2:3.17, 3:5.08, 4:10.78, 5:7.50; P-trend < 0.001), MI (HR for 1:1.05, 2:1.46, 3:1.57, 4:0.53, 5:4.76; P-trend = 0.002), death (HR for 1:1.79, 2:3.22, 3:6.23, 4:9.09, 5:14.00; P-trend < 0.001), and MACE (HR for 1:1.47, 2:2.36, 3:4.16, 4:5.91, 5:7.56; P-trend < 0.001). Among all patients, both CHADS2 score (all P ≤ 0.001) and AF were independent risk factors for stroke (AF: P = 0.002), MI (AF: P = 0.035), death (AF: P < 0.001), and MACE (AF: P < 0.001). Conclusion: The CHADS2 score is a powerful predictor of stroke and death. AF increases the risk of these outcomes in an independent manner. These data support the concept that AF is a risk factor of future cardiovascular disease.

Some components of the complete blood count and basic metabolic profile are commonly used risk predictors. Many of their components are not commonly used, but they might contain independent risk information. This study tested the ability of a risk score combining all components to predict all-cause mortality.Patients with baseline complete blood count and basic metabolic profile measurements were randomly assigned (60%/40%) to independent training (N = 71,921) and test (N = 47,458) populations. A third population (N = 16,372) from the Third National Health and Nutrition Examination Survey and a fourth population of patients who underwent coronary angiography (N = 2558) were used as additional validation groups. Risk scores were computed in the training population for 30-day, 1-year, and 5-year mortality using age- and sex-adjusted weights from multivariable modeling of all complete blood count and basic metabolic profile components.Area under the curve c-statistics were exceptional in the training population for death at 30 days (c = 0.90 for women, 0.87 for men), 1 year (c = 0.87, 0.83), and 5-years (c = 0.90, 0.85) and in the test population for death at 30 days (c = 0.88 for women, 0.85 for men), 1 year (c = 0.86, 0.82), and 5 years (c = 0.89, 0.83). In the test, the Third National Health and Nutrition Examination Survey, and the angiography populations, risk scores were highly associated with death (P.001), and thresholds of risk significantly stratified all 3 populations.In large patient and general populations, risk scores combining complete blood count and basic metabolic profile components were highly predictive of death. Easily computed in a clinical laboratory at negligible incremental cost, these risk scores aggregate baseline risk information from both the popular and the underused components of ubiquitous laboratory tests.

Background: Inflammation has been shown to have a direct role in the initiation, maintenance, and recurrence of atrial fibrillation (AF) although the underlying mechanisms are unknown. Similarly, it is unclear if inflammatory markers are elevated due to the AF alone or the coexisting cardiovascular diseases that increase the risk of AF. Methods: Consecutive patients who underwent angiography for suspicion of coronary artery disease, but without a myocardial infarction, were studied. Serum was analyzed to determine high-sensitivity C-reactive protein (hs-CRP) level. Patients’ AF status was determined through ICD-9 codes, review of hospital discharge summaries, clinical evaluations, and electrocardiograms. Results: A total of 2,340 patients were studied (64±12 years). Comorbid diseases included 1,438 (61%) coronary artery disease, 1,309 (56%) hypertension, 433 (19%) diabetes, 345 (15%) congestive heart failure, and 43 (2%) a prior stroke. The hs-CRP level was significantly higher in patients with AF (n = 238) compared to those without (14.0 mg/L vs 9.1 mg/L, P < 0.001). Greater CHADS2 score was also significantly associated with higher hs-CRP in a linear fashion (medians [mg/L], 0: 1.99, 1: 2.91, 2: 3.49, 3: 3.89, 4–5: 4.82, P

Introduction: Statin therapy is potentially the most important treatment presently available to prevent the progression of atherosclerosis. Unfortunately, a significant number of patients cannot tolerate statins due to muscle aches. Vitamin D deficiency, which is also associated with a variety of muscular symptoms, is commonly identified among patients with an indication for statin therapy. Several small studies have proposed that vitamin D deficiency may contribute to statin intolerance, but this has not been definitively demonstrated. Hypothesis: Vitamin D deficiency is associated with greater risk of statin intolerance. Methods: In the Intermountain Healthcare electronic health record, 12,066 patients had an initial 25(OH) vitamin D (VitD) level available and an indication for statin therapy with either a documented statin intolerance or evidence of active statin therapy. Patient baseline clinical characteristics were collected and multivariable logistic regression analysis was used to evaluate associations between VitD levels (stratified into four categories (ng/ml): Results: Overall, 12,066 subjects (statin intolerant n=928 [7.7%]; age = 56±6 yrs; males = 37.5%, prior atherosclerotic cardiovascular disease = 1856 [15.4%]) were enrolled. Multivariable effects of VitD and other predictors on risk of statin intolerance are shown in the Table. Conclusion: In this large cohort of patients with an indication for statin therapy, baseline VitD levels were not significantly associated with statin intolerance. Characteristics that were associated with statin intolerance included older age, female gender, Caucasian race, diabetes and a prior diagnosis of hyperlipidemia.

Background: Randomized trials report that prolonged (>1 year) use of P2Y12 inhibitors with aspirin after myocardial infarction (MI) reduces stent thrombosis and cardiovascular (CV) events, including new MI, stroke, and CV death. Post-MI patients may benefit to a differing extent from long-term dual anti-platelet therapy (DAPT); thus, a method is needed to identify those at higher risk of CV events. Hypothesis: A low-cost, easy-to-use, and highly predictive risk stratification tool can be created to differentiate risk of CV events 1-3 years after MI. Methods: Patients surviving ≥1 year after an index MI who had ≥1 additional risk factor for MI were studied. Cox regression models were used to derive sex-specific Intermountain Acute Coronary Syndromes (IMACS) risk scores in 70% of patients (N=1,342 females; 3,047 males). Validation of IMACS scores was performed in the other 30% of patients (N=576 females; 1,290 males). Variables used in model creation were age, troponin I, B-type natriuretic peptide, hemoglobin A1c, and all components of the lipid panel, complete blood count, and comprehensive metabolic panel. The primary end point was a composite of CV death, MI, or stroke. Results: Age averaged 68.7±12 and 69.8±12 for females in the derivation and validation groups, respectively, and 63.6±12 and 63.9±12 for males. IMACS scores ranged from 0-11 for females (grouping scores of 0-2, 3-6, and 7-11 into low-, moderate-, and high-risk) and 0-14 for males (0-2, 3-7, 8-14). In the validation groups, IMACS categories stratified CV event risk (Figure). IMACS c-statistics for females were c=0.675 and c=0.734 in derivation and validation groups, respectively, and for males c=0.715 and c=0.672. Conclusion: Sex-specific IMACS risk scores strongly stratified 1- to 3-year post-MI risk of CV events. IMACS is an inexpensive electronic health record tool that empowers the evaluation of which post-MI patients may be the best candidates for more aggressive therapeutic management.

Introduction: Diabetes mellitus (DM) is associated with poor cardiovascular disease (CVD) outcomes, especially in the setting of acute myocardial infarction (AMI). As both a first diagnosis (dx) of DM and missed dx of incident DM also may be associated with poor outcomes; we sought to determine their frequency and related CVD impact in patients presenting with AMI. Hypothesis: Many individuals with AMI have undiagnosed DM based on standard criteria, which leads to poor MACE outcomes. Methods: Patients (pts) presenting with AMI between 2002 and 2013 were studied (n=5719). Criteria-defined (CD)-DM was a fasting glucose (FG) ≥126 mg/dL, a random glucose (RG) ≥200, or a hemoglobin A1c ≥6.5%. DM groups were: 1) history (hx) of DM (n=1941, 34%), 2) no hx of DM, with CD-DM undiagnosed at AMI (n=500, 9%), 3) no hx of DM, with CD-DM diagnosed (dx) at hospitalization (n=207, 4%), and 4) no hx of DM and no CD-DM (n=3071, 53%). MACE (all-cause death, MI, stroke, heart failure hospitalization) was determined at 1 year post discharge. Results: Univariate comparisons are shown in the Table. After adjusting for covariables in a multivariate logistic regression using subjects with no hx of DM as the referent, hx of DM (OR=1.6; 95% CI: 1.3, 2.0; p Conclusions: The prevalence of DM is high in those presenting with AMI. Recognition of undiagnosed DM in the setting of CD-DM remains poor. Furthermore, MACE outcomes are 1.5 times higher with CD-DM undiagnosed than without DM, whereas outcomes are moderated if CD-DM is recognized at the time of AMI. Protocols for more aggressive identification of incident DM should be instituted and may importantly impact clinical outcomes for pts with previously undiagnosed DM.

Coronary artery calcification (CAC) is pathognomonic for atherosclerosis and has been demonstrated to be associated with elevated risk of cardiovascular (CV) events. Diabetes (DM) is considered a “coronary equivalent” suggesting a risk of a first CV event comparable to that in those who have had

Esophogeal Perforation, Stenting, and AF Ablation. Background: Left atrial catheter ablation (LACA) has emerged as a successful method to eliminate atrial fibrillation (AF). Recent reports have described atrio-esophageal fistulas, often resulting in death, from this procedure. Temporary esophageal stenting is an established therapy for malignant esophageal disease. We describe the first case of successful temporary esophageal stenting for an esophageal perforation following LACA. Case: A 48-year-old man with symptomatic drug refractory lone AF underwent an uneventful LACA. Fifty-nine ablations with an 8-mm tip ablation catheter (30 seconds, 70 Watts, 55°C), as guided by 3-D NavX™ mapping, were performed in the left atrium to isolate the pulmonary veins as well as a left atrial flutter and roof ablation line. In addition, complex atrial electrograms in AF and sites of vagal innervation were ablated. Two weeks later, he presented with sub-sternal chest pain, fever, and dysphagia. A chest CT showed a 3-mm esophageal perforation at the level of the left atrium with mediastinal soiling and no pericardial effusion. An urgent upper endoscopy with placement of a PolyFlex removable esophageal stent to seal off the esophago-mediastinal fistula was performed. After 3 weeks of i.v. antibiotics, naso-jejunal tube feedings, and esophageal stenting, the perforation resolved and the stent was removed. Over 18 months of follow-up, there have been no other complications, and he has returned to a physically active life and remains free from AF on previously ineffective anti-arrhythmic drugs. Conclusion: Early diagnosis of esophageal perforations following LACA may allow temporary esophageal stenting with successful esophageal healing. Prompt chest CT scans with oral and i.v. contrast should be considered in any patient with sub-sternal chest pain or dysphagia following LACA.

Background: CT coronary artery calcium scores (CAC) are predictive of future major adverse cardiovascular events (MACE). But it is proposed that non-calcified soft plaque may be more vulnerable, and actually increase risk. CT coronary angiography (CTCA), which requires contrast and higher doses of

Introduction: Epidemiologic studies have identified low testosterone (T) levels as an independent risk factor for cardiovascular (CV) and total mortality. However, the impact of T therapy on CV outcomes is controversial. A small trial in older men at high risk was stopped early due to increased CV events (NEJM 2010; 363:109). A recent observational study in veterans suggested modest risk (JAMA 2013; 3310:1829). We sought to assess the impact of T supplementation and achieved T levels across Intermountain Healthcare (IHC) facilities using a virtual controlled study design. Methods: IHC electronic medical records were searched between 1996 and 2011 to identify subjects who had a low initial total T level, a subsequent T level, and ≤3y follow-up. Levels were correlated with T supplement use. Primary outcomes were a composite of death, nonfatal myocardial infarction, and stroke (MACE) and death alone (D). Hazard ratios (HRs) comparing groups of persistent low (742 ng/dL, n=1919) achieved T were calculated by Cox regression, adjusting for 17 baseline variables. Results: A total of 5,695 men (age 62.3 ± 9.3 y, diabetes: 28%, CAD: 22%) were studied. Event rates at 1 and 3-y by T level, and adjusted HRs, are shown in the Table. Overall 3-y rates of MACE and D were 8.6% and 6.4%, respectively. Subjects supplemented to normal/high T had reduced 3-y MACE (HR 0.55, 95% CI 0.46-0.67) and D (HR 0.43, CI 0.35-0.54) compared to persistent low T subjects, with no signal for effect attenuation for MACE or D with higher T. Results were similar for 1-y MACE (HR 0.51, p Conclusions: In a large general healthcare population, T therapy in men with low T was associated with reduced MACE and D over 3-y compared to no or ineffective supplementation. Resolving the difference in CV risk impact of T therapy between this, and previous studies, warrants a large randomized clinical trial in a similar, younger population.

Introduction: Epidemiologic studies have identified high LDL cholesterol levels as an independent risk factor for cardiovascular (CV) disease, and randomized trials with statin therapy have demonstrated added clinical benefit when LDL levels are reduced to at least 70 mg/dL. However, whether targeting significantly lower secondary prevention LDL levels is beneficial, or perhaps actually may be unsafe, is not known. Methods: Patients undergoing coronary angiography who were documented to have significant (≥50% stenosis) coronary artery disease (CAD), discharged on statin therapy with an LDL level Results: A total of 5,222 patients (age = 66±12 yrs, men = 72%, hypertension = 69%, diabetes = 30%, smokers = 29%, ACS presentation = 69%) were studied. Follow-up for the ultra low, very low and low LDL categories was 6.1±4.3, 6.4±3.9 and 7.3±4.1 yrs respectively. Event rates and adjusted HRs are shown in the Table. Conclusions: In a large secondary prevention population with significant CAD on statin therapy, treating LDL cholesterol levels to

Accurate evaluation of biomarkers of acute myocardial injury is important. Both troponin-I and troponin-T are validated markers, but often only one or the other is available on any specific blood analysis platform. It is important to know the performance of each before choosing an institutional