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Background: Patient outcomes after percutaneous coronary intervention (PCI) have improved over the last 30 years due to better techniques, therapies, and care processes. This study evaluated contemporary predictors of post-PCI major adverse cardiovascular events (MACE) and summarized risk in a parsimonious risk prediction model. Methods: The Cardiovascular Patient-Level Analytical Platform (CLiPPeR) is an observational dataset of baseline variables and longitudinal outcomes from the American College of Cardiology's CathPCI Registry® and national claims data. Cox regression was used to evaluate 2–6 years of patient follow-up (mean: 2.56 years), ending in December 2017, after index PCI between 2012 and 2015 (N = 1,450,787), to examine clinical and procedural predictors of MACE (first myocardial infarction, stroke, repeat PCI, coronary artery bypass grafting, and mortality). Cox analyses of post-PCI MACE were landmarked 28 days after index PCI. Results: Overall, 12.4% (n = 179,849) experienced MACE. All variables predicted MACE, with cardiogenic shock, cardiac arrest, four diseased coronary vessels, and chronic kidney disease having hazard ratios (HRs) ≥ 1.50. Other major predictors of MACE were in-hospital stroke, three-vessel disease, anemia, heart failure, and STEMI presentation. The index revascularization and discharge prescription of aspirin, P2Y12 inhibitor, and lipid-lowering medication had HR ≤ 0.67. The primary Cox model had c-statistic c = 0.761 for MACE versus c = 0.701 for the parsimonious model and c = 0.752 for the parsimonious model plus treatment variables. Conclusions: In a nationally representative US sample of post-PCI patients, predictors of longitudinal MACE risk were identified, and a parsimonious model efficiently encapsulated them. These findings may aid in assessing care processes to further improve care post-PCI outcomes. [ABSTRACT FROM AUTHOR]

By unloading the failing heart, left ventricular (LV) assist devices (LVADs) provide a favorable environment for reversing adverse structural and functional cardiac changes. Prior reports have suggested that an improved native LV function might contribute to the development of LVAD thrombosis. We used the Interagency Registry for Mechanically Assisted Circulatory Support and found that LV functional improvement is associated with a lower risk for device thrombosis. The risk for cerebrovascular accident and transient ischemic attack was comparable across post-LVAD LV function subgroups, while the risk of hemolysis was lower in subgroups of patients with better LV function on LVAD support. [ABSTRACT FROM AUTHOR]

Evolutionary studies of cultural complexity often assume that group members select the best information available in the group, effectively diffusing the best innovations, whose advantages are subsequently passed on to the next generation. This would seem to describe the ideal of the scientific process — each cohort of papers in a field surfacing the best innovations, refining them and passing on to the next "layer" or cohort of scientific works. Here, we use academic journal databases to explore this "forking" (branching) process in the evolution of a scientific paradigm. We apply citation network visualization and Latent Dirichlet allocation topic analysis to three different paradigms defined pragmatically as the set of papers citing a highly influential paper in each respective case. Our three case studies indicate a founder effect in how the seminal paper is highly-embedded in the citation network, and yet peripheral to the evolution of topics in subsequent "layers" of publications within the paradigm. This and additional evidence suggest certain topics are selected and followed, while others are left behind. From these case studies, we discuss how hitherto undeveloped ideas of the past might be located in the topic space of seminal works of the same fruitful time period. [ABSTRACT FROM AUTHOR]

In this study, we examine the impact of time on state-of-the-art news veracity classifiers. We show that, as time progresses, classification performance for both unreliable and hyper-partisan news classification slowly degrade. While this degradation does happen, it happens slower than expected, illustrating that hand-crafted, content-based features, such as style of writing, are fairly robust to changes in the news cycle. We show that this small degradation can be mitigated using online learning. Last, we examine the impact of adversarial content manipulation by malicious news producers. Specifically, we test three types of attack based on changes in the input space and data availability. We show that static models are susceptible to content manipulation attacks, but online models can recover from such attacks. [ABSTRACT FROM AUTHOR]

Introduction: CHA2DS2‐VASc and CHADS2 are computationally simple risk prediction tools used to guide anticoagulation decisions for stroke prophylaxis, but they have modest risk discrimination ability and use static dichotomous variables. The Intermountain Mortality Risk Scores (IMRS) are dynamic decision tools using standard clinical laboratory tests. This study derived new stroke prediction scores using variables from both CHA2DS2‐VASc and IMRS. Methods and Results: In outpatients with first atrial fibrillation (AF) diagnosis at the Intermountain Healthcare (females, n = 26 063 males, n = 29 807), sex‐specific "IMRS‐VASc" scores were derived using variables from CHA2DS2‐VASc, warfarin use, the complete blood count, and the comprehensive metabolic profile. Validation was performed in an independent Intermountain outpatient AF cohort (females, n = 11 021; males, n = 12 641). Stroke occurred among 3.1% and 3.1% of females and 2.3% and 2.5% of males in derivation and validation groups, respectively. IMRS‐VASc stratified stroke with similar ability in derivation (c‐statistics, females: c = 0.703, males: c = 0.697) and validation groups (females: c = 0.681, males: c = 0.685). CHA2DS2‐VASc (females: c = 0.581 and c = 0.605; males: c = 0.616 and c = 0.613 in derivation and validation, respectively) and CHADS2 (females: c = 0.581 and c = 0.608; males: c = 0.620 and c = 0.621 in derivation and validation, respectively) were substantially weaker stroke predictors. IMRS was the strongest mortality predictor (females: c = 0.783 and c = 0.782; males: c = 0.796 and c = 0.794 in derivation and validation, respectively) and all scores were poor at predicting bleeding risk. Conclusions: A temporally dynamic risk score, IMRS‐VASc was derived and validated as a predictor of stroke in outpatients with AF. IMRS‐VASc requires further validation and the evaluation of its use in guiding care and treatment decisions for patients with AF. [ABSTRACT FROM AUTHOR]

Background: Galectin-3, a novel binding-lectin involved in inflammation and fibrosis, is elevated in heart failure and is independently predictive of mortality in this condition. We sought to evaluate galectin-3 levels and its prognostic value in patients with pulmonary hypertension (PH), a known inflammatory state, in the setting of pulmonary arterial hypertension (PAH) and in heart failure with preserved ejection fraction-associated PH (HFpEF-PH).Methods: We measured galectin-3 levels in 76 patients with PH; 37 patients with PAH and 39 patients with HFpEF-PH. Baseline characteristics, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were assessed. Univariate and multivariate analyses were used to assess the prognostic value of galectin-3.Results: Median (IQR) galectin-3 (ng/mL) for the entire cohort was 24.65 (IQR=10.39, 32.90); 22.33 (IQR=18.94, 27.30) and 28.94 (IQR=21.67, 39.85) in the PAH and HFpEF-PH, respectively (p=0.07). After evaluation of the galectin-3 levels by tertile, mortality rates were 16% (4/25), 34.6% (9/26), and 48% (12/25) in tertiles 1-3, respectively, and Kaplan-Meier analysis revealed a significant increase in mortality across increasing galectin-3 tertiles (log-rank p=0.014). On Cox regression analysis, galectin-3 was a strong predictor of mortality on both univariate HR=2.09 per tertile (95% CI=1.21, 3.62 per tertile; p-trend=0.008) and multivariate analysis HR=2.19 per tertile (95% CI=1.06, 4.54; p-trend=0.035) after adjusting for age, sex, race, glomerular filtration rate (eGFR), NT-proBNP, medications, and aetiology of PH (PAH vs. HFpEF-PH).Conclusion: Galectin-3 is a strong, independent prognostic marker in PH, regardless of aetiology. Larger studies should further evaluate the role of galectin-3 as a prognostic biomarker and possible therapeutic target in PH. [ABSTRACT FROM AUTHOR]

Background The red cell distribution width ( RDW) predicts mortality among many populations. RDW is calculated as the standard deviation ( SD) of the red blood cell ( RBC) volume divided by mean corpuscular volume ( MCV). Because higher MCV also predicts mortality, we hypothesized that the RDW numerator (one SD of RBC volume or 1 SD- RDW) predicts mortality more strongly than the RDW. Material and methods Adult subjects hospitalized during a contemporary clinical era (10/2005-1/2014, N = 135 963) and a historical era (1/1999-9/2005, N = 119 530) were studied. The RDW was obtained from the complete blood count ( CBC), while 1 SD- RDW was calculated ( RDW multiplied by MCV and divided by 100). Results In univariable Cox regression (2005-2014 cohort), 1 SD- RDW (quintile 5 vs. 1: hazard ratio [ HR] = 8·38, 95% confidence interval [ CI] = 7·94, 8·85; P < 0·001) was a superior predictor of mortality compared to RDW (quintile 5 vs. 1: HR = 4·78, CI = 4·57, 5·00; P < 0·001). This superiority remained after adjustment for age, sex, basic metabolic profile components and other CBC factors excluding MCV (1 SD- RDW: HR = 2·41, CI = 2·28, 2·55; RDW: HR = 2·01, CI = 1·92, 2·11). Further adjustment for MCV strengthened the RDW association ( HR = 2·14, CI = 2·04, 2·24; P < 0·001), becoming indistinct from 1 SD- RDW ( HR = 2·20, CI = 2·08, 2·33; P < 0·001). Findings were similar for the 1999-2005 cohort. Conclusions The 1 SD- RDW predicted mortality more strongly than RDW, suggesting that 1 SD- RDW is superior to RDW as an individual risk predictor. Further, these results indicate that the dispersion of RBC volume and its mean are independent risk markers. Further research is required to understand the clinical value and mechanistic basis of these associations. [ABSTRACT FROM AUTHOR]

Stroke prevention in atrial fibrillation (AF) is guided by clinical factors with inadequate predictive power. Most thrombi observed in AF are observed in the left atrial appendage (LAA). This study was designed to determine (1) the association between LAA and the incidence of AF-related stroke and (2) the power of LAA to predict stroke. Patients (n=48) with a history of AF and stroke were compared with control subjects (n=48) with a history of AF but no history of stroke. Magnetic resonance images from both case and control populations were manually segmented to determine LAA volume. Patients with a history of stroke had larger LAA mean volumes than control subjects (28.8 ± 13.5 cm³ vs 21.7 ± 8.27 cm³, p [=0.002). Stroke risk is highest in patients with a LAA volume >34 cm³ (multivariable OR 7.11, p=[0.003). In conclusion, larger LAA volume is associated with stroke in the setting of AF, and this measure can potentially improve risk stratification for stroke risk management in AF patients. [ABSTRACT FROM AUTHOR]

Background: The Intermountain Risk Score (IMRS), composed of the complete blood count (CBC) and basic metabolic profile (BMP), predicts mortality and morbidity in medical and general populations. Whether longitudinal repeated measurement of IMRS is useful for prognostication is an important question for its clinical applicability. Methods: Females (N = 5,698) and males (N = 5,437) with CBC and BMP panels measured 6 months to 2.0 years apart (mean 1.0 year) had baseline and follow-up IMRS computed. Survival analysis during 4.0±2.5 years (maximum 10 years) evaluated mortality (females: n = 1,255 deaths; males: n = 1,164 deaths) and incident major events (myocardial infarction, heart failure [HF], and stroke). Results: Both baseline and follow-up IMRS (categorized as high-risk vs. low-risk) were independently associated with mortality (all p<0.001) in bivariable models. For females, follow-up IMRS had hazard ratio (HR) = 5.23 (95% confidence interval [CI] = 4.11, 6.64) and baseline IMRS had HR = 3.66 (CI = 2.94, 4.55). Among males, follow-up IMRS had HR = 4.28 (CI = 3.51, 5.22) and baseline IMRS had HR = 2.32 (CI = 1.91, 2.82). IMRS components such as RDW, measured at both time points, also predicted mortality. Baseline and follow-up IMRS strongly predicted incident HF in both genders. Conclusions: Repeated measurement of IMRS at baseline and at about one year of follow-up were independently prognostic for mortality and incident HF among initially hospitalized patients. RDW and other CBC and BMP values were also predictive of outcomes. Further research should evaluate the utility of IMRS as a tool for clinical risk adjustment. [ABSTRACT FROM AUTHOR]

Objective: To evaluate soluble (s) ST2 as a biomarker of rejection, allograft vasculopathy and mortality after orthotopic heart transplantation (OHT). Methods: sST2 concentrations were measured in 241 patients following OHT. Results: Elevated sST2 was associated with cellular rejection (CR) ≥1R, with highest rates of CR in the 4th sST2 quartile ( p = 0.003). No significant association between sST2 and antibody-mediated rejection or allograft vasculopathy was found. sST2 ≥30 ng/mL independently predicted death over 7-year follow-up (HR = 2.01; 95% CI 1.15-3.51; p = 0.01). Conclusion: Concentrations of sST2 are associated with the presence of CR and predict long-term mortality following OHT. [ABSTRACT FROM AUTHOR]

Previously we discovered that routine periodic fasting was associated with a lower prevalence of coronary artery disease (CAD). Other studies have shown that fasting increases longevity in animals. A hypothesis-generating analysis suggested that fasting may also associate with diabetes. This study prospectively tested whether routine periodic fasting is associated with diabetes mellitus (DM). Patients (n = 200) undergoing coronary angiography were surveyed for routine fasting behavior before their procedure. DM diagnosis was based on physician reports of current and historical clinical and medication data. Secondary end points included CAD (physician reported for ≥1 lesion of ≥70% stenosis), glucose, and body mass index (BMI). Meta-analyses were performed by evaluation of these patients and 448 patients from a previous study. DM was present in 10.3% of patients who fasted routinely and 22.0% of those who do not fast (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.17 to 0.99, p = 0.042). CAD was found in 63.2% of fasting and 75.0% of nonfasting patients (OR 0.42, CI 0.21 to 0.84, p = 0.014), and in nondiabetics this CAD association was similar (OR 0.38, CI 0.16 to 0.89, p = 0.025). Meta-analysis showed modest differences for fasters versus nonfasters in glucose concentrations (108 ± 36 vs 115 ± 46 mg/dl, p = 0.047) and BMI (27.9 ± 5.3 vs 29.0 ± 5.8 kg/m2, p = 0.044). In conclusion, prospective hypothesis testing showed that routine periodic fasting was associated with a lower prevalence of DM in patients undergoing coronary angiography. A reported fasting association with a lower CAD risk was also validated and fasting associations with lower glucose and BMI were found. [Copyright &y& Elsevier]

Background--Warfarin is characterized by marked variations in individual dose requirements and a narrow therapeutic window. Pharmacogenetics (PG) could improve dosing efficiency and safety, but clinical trials evidence is meager. Methods and Results--A Randomized and Clinical Effectiveness Trial Comparing Two Pharmacogenetic Algorithms and Standard Care for Individualizing Warfarin Dosing (CoumaGen-II) comprised 2 comparisons: (1) a blinded, randomized comparison of a modified 1-step (PG-1) with a 3-step algorithm (PG-2) (N=504), and (2) a clinical effectiveness comparison of PG guidance with use of either algorithm with standard dosing in a parallel control group (N= 1866). A rapid method provided same-day CYP2C9 and VKORC1 genotyping. Primary outcomes were percentage of out-of-range international normalized ratios at 1 and 3 months and percentage of time in therapeutic range. Primary analysis was modified intention to treat. In the randomized comparison, PG-2 was noninferior but not superior to PG-1 for percentage of out-of-range international normalized ratios at 1 month and 3 months and for percentage of time in therapeutic range at 3 months. However, the combined PG cohort was superior to the parallel controls (percentage of out-of-range international normalized ratios 31% versus 42% at 1 month; 30% versus 42% at 3 months; percentage of time in therapeutic range 69% versus 58%, 71% versus 59%, respectively, all f <0.001). Differences persisted after adjustment for age, sex, and clinical indication. There were fewer percentage international normalized ratios >4 and <1.5 and serious adverse events at 3 months (4.5% versus 9.4% of patients, P<0.001) with PG guidance. Conclusions--These findings suggest that PG dosing should be considered for broader clinical application, a proposal that is being tested further in 3 major randomized trials. The simpler 1-step PG algorithm provided equivalent results and may be preferable for clinical application. INSET: CLINICAL PERSPECTIVE. [ABSTRACT FROM AUTHOR]

Abstract: Background: Red cell distribution width (RDW) is associated with morbidity and mortality in coronary artery disease (CAD), but the connection of RDW with chronic inflammation is equivocal. Methods: In 1,489 patients with CAD and 8.4–15.2years of follow-up all-cause mortality and RDW were studied using Cox regression. RDW and its associations with inflammation, liver function, renal function, and body mass were assessed. A population of 449 normal (No-CAD) patients also was evaluated. Results: RDW predicted all-cause mortality in a step-wise manner (HR=1.37 per quintile; 95% CI=1.29, 1.46; p-trend<0.001). A significant but meaningless correlation between RDW and high-sensitivity C-reactive protein (hsCRP) was identified (r=0.181; p<0.001). With full adjustment, RDW remained significant (p-trend<0.001) and the strongest predictor of mortality among all factors included in the model. RDW also strongly predicted all-cause mortality in the normal control population (HR=1.33 per quintile, CI=1.15, 1.55; p-trend<0.001), but hsCRP did not predict mortality among normal controls. Conclusions: RDW was associated with mortality in patients with CAD and may provide clinically useful prognostication. Although RDW was correlated with hsCRP, they were independent predictors of mortality. RDW has been incorporated into risk prediction tool using data from basic chemistries available at: http://intermountainhealthcare.org/IMRS. [Copyright &y& Elsevier]

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) [ABSTRACT FROM AUTHOR]

Warfarin, the most common oral anticoagulant, is the ideal candidate for pharmacogenetic dosing and gene-based 'individualization' of care. A plethora of studies have shown that stable dose requirements can be predicted using sequence variants in the CYP2C9 and VKORC1 genes in both sexes and in different races. Multiple clinical trials of pharmacogenetic warfarin dosing have been conducted with various methods, including several randomized trials that have been completed. These studies have reported varying degrees of success and some have been met with substantial skepticism. Other much larger randomized trials are ongoing. This paper reviews and synthesizes the various clinical trials that have been published and touches on the potential that the ongoing trials offer. The emergence of new oral anticoagulants also raises the question of the relevance of pharmacogenetic warfarin dosing for the future. The cost of genotype-guided dosing is substantial, and none of the studies to date have shown a cost-benefit of using pharmacogenetic warfarin dosing in clinical practice. Although pharmacogenetics-guided warfarin dosing has been discussed for many years, the currently available data regarding this genetically individualized dosing suggest that pharmacogenetics remains unproven for use in clinical warfarin prescription. [ABSTRACT FROM AUTHOR]

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 and results Patients seen for coronary angiography (n = 3927) were evaluated using a design similar to a genome-wide association study. The Bonferroni correction for 102 tests required a P-value of ≤ 4.9 × 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) (Ptrend = 1.6 × 10−26), coronary disease (Ptrend = 2.6 × 10−11), myocardial infarction (MI) (Ptrend = 3.1 × 10−25), atrial fibrillation (Ptrend = 2.5 × 10−20), and chronic obstructive pulmonary disease (Ptrend = 4.7 × 10−4). Even more, IMRS predicted HF readmission [hazard ratio (HR) = 2.29/category, Ptrend = 1.2 × 10−6), incident HF (HR = 1.88/category, Ptrend = 0.02), and incident MI (HR = 1.56/category, Ptrend = 4.7 × 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. [ABSTRACT FROM AUTHOR]

The CATHGEN study reported associations of chromosome 3q13-21 genes ( KALRN, MYLK, CDGAP, and GATA2) with early-onset coronary artery disease (CAD). This study attempted to independently validate those associations. Eleven single nucleotide polymorphisms (SNPs) were examined (rs10934490, rs16834817, rs6810298, rs9289231, rs12637456, rs1444768, rs1444754, rs4234218, rs2335052, rs3803, rs2713604) in patients (N = 1618) from the Intermountain Heart Collaborative Study (IHCS). Given the higher smoking prevalence in CATHGEN than IHCS (41% vs. 11% in controls, 74% vs. 29% in cases), smoking stratification and genotype-smoking interactions were evaluated. Suggestive association was found for GATA2 (rs2713604, p = 0.057, OR = 1.2). Among smokers, associations were found in CDGAP (rs10934490, p = 0.019, OR = 1.6) and KALRN (rs12637456, p = 0.011, OR = 2.0) and suggestive association was found in MYLK (rs16834871, p = 0.051, OR = 1.8, adjusting for gender). No SNP association was found among non-smokers, but smoking/SNP interactions were detected for CDGAP (rs10934491, p = 0.017) and KALRN (rs12637456, p = 0.010). Similar differences in SNP effects by smoking status were observed on re-analysis of CATHGEN. CAD associations were suggestive for GATA2 and among smokers significant post hoc associations were found in KALRN, MYLK, and CDGAP. Genetic risk conferred by some of these genes may be modified by smoking. Future CAD association studies of these and other genes should evaluate effect modification by smoking. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: Background: 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. Methods: 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. Results: 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. Conclusion: 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. [Copyright &y& Elsevier]

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 <0.001). The presence of AF was associated with higher hs-CRP level across all scores (medians [mg/L], 0: 2.22 vs 1.98, P = 0.83, 1: 3.85 vs 2.86, P = 0.057, 2: 4.96 vs 3.29, P = 0.021, 3: 6.29 vs 3.17, P = 0.09, 4–5: 4.82 vs 4.50, P = 0.87). Conclusion: Risks factors associated with AF were associated with higher hs-CRP in an incremental manner. The presence of AF increased hs-CRP across the CHADS2 score strata is supportive of the concept that AF is an inflammatory process and may convey independent risk. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the influence of post-coronary artery disease (CAD) depression diagnosis on heart failure (HF) incidence. Background: Depression has been shown to be a risk factor for poor outcomes among CAD patients. However, little is known about the influence of depression on HF development in CAD patients. Methods: Patients (n = 13,708) without a diagnosis of HF and depression (International Classification of Diseases-Ninth Revision [ICD-9] codes: 296.2 to 296.36 and 311) and who were not prescribed antidepressant medication (ADM) at the time of CAD diagnosis (≥70% stenosis) were studied. For those with available medication records (n = 7,719), patients subsequently diagnosed with depression were stratified by use of ADM. Patients were followed until HF diagnosis (physician-diagnosed or ICD-9 code: 428) or death. Results were analyzed by Cox proportional hazards regression models. Results: A total of 1,377 patients (10.0%) had a post-CAD clinical depression diagnosis. The incidence of HF among those without a post-CAD depression diagnosis was 3.6 per 100 compared with 16.4 per 100 for those with a post-CAD depression diagnosis. Depression was associated with an increased risk for HF incidence (adjusted hazard ratio [HR]: 1.50, p < 0.0001). Results were similar among those with available follow-up medication information (vs. no depression: depression without ADM use [HR: 1.68, p < 0.0001]; depression with ADM use [HR: 2.00, p < 0.0001]). No difference was found between depressed patients with and without ADM treatment (HR: 0.84, p = 0.24). Conclusions: Depression diagnosis was shown to be associated with an increased incidence of HF after CAD diagnosis, regardless of ADM treatment. This finding suggests the need to further study the effect of depression on HF risk among CAD patients. [Copyright &y& Elsevier]

Coronary artery disease (CAD) is common and multifactorial. Members of the Church of Jesus Christ of Latter-day Saints (LDS, or Mormons) in Utah may have lower cardiac mortality than other Utahns and the US population. Although the LDS proscription of smoking likely contributes to lower cardiac risk, it is unknown whether other shared behaviors also contribute. This study evaluated potential CAD-associated effects of fasting. Patients (n 1 = 4,629) enrolled in the Intermountain Heart Collaborative Study registry (1994 to 2002) were evaluated for the association of religious preference with CAD diagnosis (≥70% coronary stenosis using angiography) or no CAD (normal coronaries, <10% stenosis). Consequently, another set of patients (n 2 = 448) were surveyed (2004 to 2006) for the association of behavioral factors with CAD, with routine fasting (i.e., abstinence from food and drink) as the primary variable. Secondary survey measures included proscription of alcohol, tea, and coffee; social support; and religious worship patterns. In population 1 (initial), 61% of LDS and 66% of all others had CAD (adjusted [including for smoking] odds ratio [OR] 0.81, p = 0.009). In population 2 (survey), fasting was associated with lower risk of CAD (64% vs 76% CAD; OR 0.55, 95% confidence interval 0.35 to 0.87, p = 0.010), and this remained after adjustment for traditional risk factors (OR 0.46, 95% confidence interval 0.27 to 0.81, p = 0.007). Fasting was also associated with lower diabetes prevalence (p = 0.048). In regression models entering other secondary behavioral measures, fasting remained significant with a similar effect size. In conclusion, not only proscription of tobacco, but also routine periodic fasting was associated with lower risk of CAD. [Copyright &y& Elsevier]

Management of heart failure (HF) remains complex with low 5-year survival. The Seattle Heart Failure Model (SHFM) is a recently described risk score derived predominantly from clinical trial populations that may enable the prediction of survival in patients with HF. This study sought to validate the SHFM in an independent, nonclinical trial-based HF population. Patients (n = 4,077) from the hospital-based Intermountain Heart Collaborative Study registry with a diagnosis of HF were evaluated using prospectively collected data (mean ± SD follow-up 4.4 ± 3.1 years). The SHFM was used to calculate a risk score for each patient. Receiver-operating characteristic area under the curve provided SHFM predictive ability for a composite end point of survival free from death, transplantation, or left ventricular assist device implantation. Addition of creatinine, serum urea nitrogen, diabetes status, and B-type natriuretic peptide (BNP) to the SHFM was also evaluated. Patient age averaged 67 ± 13 years and 61% were men. Area under the curves were 0.70 (95% confidence interval 0.66 to 0.70), 0.67 (95% confidence interval 0.66 to 0.69), 0.67 (95% confidence interval 0.065 to 0.68), and 0.66 (95% confidence interval 0.63 to 0.67) for 1-, 2-, 3-, and 5-year survivals, respectively. Area under the curves were slightly attenuated in patients >75 years of age (n = 1,339), implantable cardioverter-defibrillator recipients (n = 693), and patients with an ejection fraction >40% (n = 1,634). BNP added significantly to the model (area under the curve +0.06). BNP was found to add additional predictive ability at 1 year (area under the curve change +0.05) and nominally at 5 years (area under the curve change +0.02). In conclusion, the SHFM predicts survival in patients with HF in a hospital-based population, with areas under the curve similar to those from data on which models were initially fit. [Copyright &y& Elsevier]

The article focuses on the event by which personhood is gained in human being. The author asserts that it is human DNA that makes a person and discusses recent molecular understanding of DNA in explaining why even a single cell can be a unique human. It concludes that conception is indeed the event at which personhood is obtained .

Objectives: The objective of this study was to identify associations of the cholesteryl ester transfer protein (CETP) gene with coronary artery disease (CAD) with tagging (t) single nucleotide polymorphisms (SNPs) chosen to optimally account for intra-genic variation. Background: The CETP gene plays a critical role in lipoprotein metabolism, but the common and well-studied TaqIB variant is inconsistently predictive of CAD. Methods: From a deoxyribonucleic acid bank of 10,020 individuals, nondiabetic nonsmoking patients (n = 4,811) with angiographically defined, clinically significant CAD (≥70% stenosis) or normal coronaries were genotyped for 11 CETP tSNPs. Myocardial infarction (MI) and lipid levels were evaluated as secondary end points. Results: Analysis of single tSNPs, corrected for multiple comparisons (p < 0.00485), identified allele +1086A to be associated with CAD (p = 0.0034). Suggestive allelic and significant genotypic associations were found for −631AA (odds ratio [OR] = 3.95, p = 0.004 vs. CC) and +2389GA (OR = 1.21, p = 0.003 vs. GG). Haplotype analysis by linkage disequilibrium (LD) group revealed a CAD association for LD group B (p = 0.0025 across T+1086A, C+878T, C+408T) and near significance for LD group A (p = 0.013 across C-631A, MspI, G+2389A). A weak protective trend for TaqIB was eliminated by adjustment for other tSNPs, and haplotype analyses suggested that TaqIB was simply a marker for other tSNPs or haplotypes. No tSNP or haplotype associations with MI were found. Conclusions: Multiple, less common SNPs and haplotype variants underlie CETP-related CAD risk, for which the common TaqIB variant is simply a poor marker. The occurrence of risk-related variants on separate haplotypes suggests genetic-risk complexity and allelic heterogeneity. (Database Registry of the Intermountain Heart Collaborative Study; http://clinicaltrials.gov/ct/show/NCT00406185?order=1; NCT00406185). [Copyright &y& Elsevier]

Although previous studies have demonstrated that various “statins” decrease levels of high-sensitivity C-reactive protein (hs-CRP), the dose-response relation for lowering hs-CRP by the clinically important drug simvastatin compared with lipid lowering is unclear. A 16-week, randomized, double-blind study was performed in patients with stable coronary artery disease and high hs-CRP levels (>3 mg/L). Subjects were randomized to placebo, 20 mg of simvastatin, or 80 mg of simvastatin for 12 weeks. Those currently on a statin first underwent a 4-week washout. Of the 107 total patients randomized, 96 completed the trial, and 89 were able to be evaluated for efficacy. Changes in hs-CRP differed across simvastatin and placebo groups (change score +1.6 vs −0.6 mg/L, p = 0.004), but no dose response was observed when comparing 80 with 20 mg/day (−0.6 vs −0.5 mg/L, respectively). A strong dose response was observed for changes in total (p <0.01) and low-density lipoprotein (p <0.001) cholesterol. hs-CRP changes did not correlate with low-density lipoprotein changes. In conclusion, this randomized trial in patients with chronic stable coronary artery disease showed a strong dose response for simvastatin for total and low-density lipoprotein cholesterol lowering but not for hs-CRP. [Copyright &y& Elsevier]

This Viewpoint summarizes evidence about the effects of intermittent fasting on chronic disease markers and considers potential concerns about fasting as a strategy for weight management and glycemic control in people with type 2 diabetes. [ABSTRACT FROM AUTHOR]

Full characterization of intragenic variation may improve candidate gene associations. This study selected tagging (t) single nucleotide polymorphisms (SNPs) to comprehensively represent genetic variability in the cholesteryl ester transfer protein ( CETP) gene. Nineteen SNPs were identified in 50 unrelated individuals in the SNP discovery phase, and 13 intronic SNPs were added from the literature. These 32 SNPs were genotyped in 339 apparently healthy individuals and 190 coronary artery disease (CAD) patients. Using phased haplotypes, linkage disequilibrium (LD) structure was characterized and tSNPs selected using a principal component analysis (PCA) method. In healthy individuals, seven LD groups were identified that accounted for 93.4% of the observed genetic variation. These LD groups highlighted a complex LD structure for CETP, including both recombination and mutation, and eleven tSNPs were selected. Among CAD patients the results were essentially the same. Results from PCA using diploid genotype data were reasonably comparable. Finally, the selected tSNPs successfully represented the association evidence discovered for all of the other SNPs studied. This study provides an optimal set of tSNPs for association analyses of CETP. The observed complexity of LD structure highlights the importance of using methods, such as PCA, that allow for multiple dynamics in intragenic LD structure. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular magnetic resonance (CMR) has superior spatial resolution compared with echocardiography, but assessment of normal measurements has lagged behind its increasing clinical application. We assessed atrial size by CMR in healthy and diseased subjects to determine normal adult ranges. Methods: Twenty normal adults and 20 cardiac patients with hypertrophic or dilated cardiomyopathy were studied. Four and two chamber left and four chamber right atrial areas and left and right atrial depths were measured and compared, and a normal range for these measures was proposed. Results: Normal four-chamber left and right atrial systolic areas each averaged 21 cm 2 . Average depths were 53 and 52 cm, respectively. For both the left and right atrium, a systolic area of [ABSTRACT FROM AUTHOR]

Objectives: We sought to determine the predictive ability of total white blood cell (WBC) count and its subtypes for risk of death or myocardial infarction (MI). Background: An elevated WBC count has been associated with cardiovascular risk, but which leukocyte subtypes carry this risk is uncertain. Methods: Consecutive patients without acute MI who were assessed angiographically for coronary artery disease (CAD) and were followed up long-term were studied. The predictive ability for death/MI of quartile (Q) 4 versus Q1 total WBC, neutrophil (N), lymphocyte (L), and monocyte (M) counts and N/L ratio were assessed using Cox regressions. Results: A total of 3,227 patients was studied. Mean age was 63 years; 63% of patients were male, and 65% had CAD. In multivariable modeling entering standard risk factors, presentation, and CAD severity, the total WBC (hazard ratio [HR] 1.4, p = 0.01) and M (HR 1.3, p &#60; 0.02) were weaker and N (HR 1.8, p &#60; 0.001), L (HR 0.51, p &#60; 0.001), and N/L ratio (HR 2.2, p &#60; 0.001) were independent predictors of death/MI. When WBC variables were entered together, N/L ratio and M were retained as independent predictors. Risk associations persisted in analyses restricted to CAD patients or including acute MI patients. Conclusions: Total WBC count is confirmed to be an independent predictor of death/MI in patients with or at high risk for CAD, but greater predictive ability is provided by high N (Q4 >6.6 × 103/μl) or low L counts. The greatest risk prediction is given by the N/L ratio, with Q4 versus Q1 (>4.71 versus &#60;1.96) increasing the hazard 2.2-fold. These findings have important implications for CAD risk assessment. [Copyright &y& Elsevier]

Background: The prevalence of the metabolic syndrome (MS) is growing. The Adult Treatment Panel (ATP) III provided a uniform definition of MS but no information on its predictive ability. Methods: We tested the ability of MS and its components to predict angiographic coronary artery disease (CAD) and incident death/myocardial infarction (D/MI) over 2.8 ± 2.3 years in a large cohort of patients undergoing angiography. ATP-III criteria were used for fasting glucose (FG), triglyceride (TG), high-density lipoprotein cholesterol (HDL), and blood pressure (BP); body mass index (BMI) >27 kg/m[sup 2] was used as a surrogate for waist circumference. Results: 3,128 subjects were studied; 65% had advanced CAD (≥70% stenosis), and 35%, no CAD. MS was present in 64% (high FG 40%; high TG 52%; low HDL 71%; high BP 76%; high BMI 58%). Presence of CAD was predicted by MS [adjusted odds ratio (OR) = 1.30, 95% CI 1.10–1.55, p = 0.003] and, individually, by high FG (OR = 1.90, CI 1.63–2.23) and low HDL (OR = 1.38, CI 1.18–1.62). In multivariable modeling, CAD was predicted by high FG (OR = 1.80, CI 1.51–2.16) and low HDL (OR = 1.57, CI 1.31–1.89) as well as by age, gender, family history, smoking, and LDL cholesterol (all p < 0.001). For secondary risk of incident D/MI, only high FG of MS features was predictive (adjusted hazard ratio 1.46, CI 1.17–1.82, p = 0.001), and this risk was carried by diabetes (adjusted hazard ratio 1.71, p < 0.001); other predictors were age, heart failure, revascularization strategy, renal insufficiency, prior MI, and number of diseased vessels. Conclusion: MS has primary predictive ability for CAD, carried primarily by high FG and low HDL. Secondary predictive ability of MS features for clinical outcomes, in the setting of established CAD, is carried by diabetes alone. Dysglycemia deserves specific attention as a target for prevention and treatment. Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

: PurposeLow socioeconomic status (SES) predicts coronary artery disease (CAD) onset, but its value among patients with CAD is uncertain. Geographic measures (e.g., residential neighborhood) may predict risk, but this requires further evaluation.: MethodsA cohort of 3410 patients with significant, angiographically-defined CAD (≥1 lesion of ≥70% stenosis) joined a registry during the period between 1993 and 2000 and was followed for 6.7 years (median 3.7 years). A geographic SES measure—residential economic status (RES)—and insurance type were examined for association with mortality or myocardial infarction (MI).: ResultsIn Cox regression adjusting for 17 covariates, lower RES quartile was associated with increased death/MI (p-trend<0.001), death (p-trend = 0.001), and MI (p-trend = 0.07). First RES quartile (vs. fourth) predicted death/MI (hazard ratio [HR] = 1.32, 95% confidence interval [CI] = 1.07–1.62, p = 0.01) and death (HR = 1.46, CI = 1.12–1.91, p = 0.006), but not MI (HR = 1.18, p = 0.31). Compared with private insurance, self-pay (HR = 1.88, p = 0.053), charity care (HR = 1.71, p<0.001), and Medicaid (HR = 1.43, p = 0.24), but not Medicare (HR = 0.95, p = 0.68), were associated with death/MI.: ConclusionsBoth geographic (RES) and economic (insurance) measures of SES independently predicted risk of death/MI in a large population with angiographically-defined CAD. This suggests that SES remains a significant predictor of health outcomes after CAD has developed, and that geographic measures of SES deserve further evaluation. [Copyright &y& Elsevier]

Despite well-documented clinical benefit of the use of statins in patients with coronary artery disease (CAD) and even mild lipid elevations, studies have documented the presence of a significant "treatment gap" between those patients in whom treatment is indicated and those patients who actually receive it. It has been proposed that a prescription for statin therapy given to indicated patients at the time of initial angiographic diagnosis of CAD has the potential to improve long-term medication compliance, but this requires further evaluation. We prospectively followed 600 patients with angiographically demonstrated CAD (diameter stenosis > or = 70%) who met the National Cholesterol Education Project (NCEP) guidelines for statin therapy for an average of 3.0 years (range 2.0 to 4.6). Patients were an average of 65 years of age, 78% were men, 77% presented initially with acute ischemic syndrome, and 64 (10.7%) died during follow-up. Overall, 105 patients (18%) were discharged from the initial hospitalization with a statin prescription. At long-term follow-up, the number of patients taking statins had increased to 47%. However, long-term statin compliance was significantly higher among patients initially discharged with a statin prescription than those who were not (77% vs 40%; p < 0.0001). Additionally, those patients discharged with a statin prescription had significantly reduced mortality rate at long-term follow-up (5.7% vs 11.7%; p = 0.05). Cox hazard regression analysis, controlling for all known clinical baseline variables, confirmed the absence of a prehospital discharge statin prescription to be an independent predictor of increased mortality (hazard ratio 2.4) with a statistical trend (p = 0.06). Thus, this study demonstrates that after angiographic diagnosis of CAD, prescription of appropriate statin therapy at the time of hospital discharge improves long-term statin compliance and may significantly enhance survival. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity and functional limitation are associated with poor outcomes in heart failure (HF). However, the individual and combined effect of these on health‐related quality of life in patients with HF is not well understood. Methods: Patients aged ≥30 years with two or more HF diagnostic codes and one or more HF‐related prescription drugs from four U.S. institutions were mailed a survey to measure patient‐centric factors including functional status (activities of daily living [ADLs]) and health‐related quality of life (PROMIS‐29 Health Profile). Patients with HF from January 1, 2013 to February 1, 2018 were included. Multimorbidity was defined as ≥2 non‐cardiovascular comorbidities; functional limitation as any limitation in at least one of eight ADLs. Patients were categorized into four groups by multimorbidity (Yes/No) and functional limitation (Yes/No). We dichotomized the PROMIS‐29 sub‐scale scores at the median and calculated odd ratios for the four multimorbidity/functional limitation groups. Results: A total of 3330 patients with HF returned the survey (response rate 31%); 3020 completed the questions of interest and were retained. Among these patients (45% female; mean age 73 [standard deviation: 12] years), 29% had neither multimorbidity nor functional limitation, 24% had multimorbidity only, 22% had functional limitation only, and 25% had both. After adjustment, having functional limitation only was associated with higher anxiety (odds ratio [OR]: 3.44, 95% confidence interval [CI]: 2.66–4.45), depression (OR: 3.11, 95% CI: 2.39–4.06), and fatigue (OR: 4.19, 95% CI: 3.25–5.40); worse sleep (OR: 2.14, 95% CI: 1.69–2.72) and pain (OR: 6.73, 95% CI: 5.15–8.78); and greater difficulty with social activities (OR: 9.40, 95% CI: 7.19–12.28) compared with having neither. Results were similar for having both multimorbidity and functional limitation. Conclusion: Patients with only functional limitation have similar poor health‐related quality of life scores as those with both multimorbidity and functional limitation, underscoring the important role that physical functioning plays in the well‐being of patients with HF. [ABSTRACT FROM AUTHOR]

No abstract available Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article discusses nonlinear heart rate variability (HRV). The study analyzed 740 24-hour ambulatory ECG tapes from Cardiac Arrhythmia Suppression Trial (CAST), recorded before patients began their assigned antiarrhythmic therapy or placebo. Entry criteria for CAST included an acute myocardial infarction (MI) within 2 years, the presence of left ventricular dysfunction, and six or more ventricular premature complexes (VPCs) per hour. Researchers conclude that decreased longer-term, primarily diurnal, HRV and increased short- to intermediate-term "randomness" of heart rate contribute independently to risk, and adding nonlinear measures to prognostic models that include linear measures improves the predictive value of HRV, particularly in non-coronary artery bypass graft , nondiabetic patients.

Background: Most patients with heart failure (HF) have multimorbidity which may cause difficulties with self-management. Understanding the resources patients draw upon to effectively manage their health is fundamental to designing new practice models to improve outcomes in HF. We describe the rationale, conceptual framework, and implementation of a multi-center survey of HF patients, characterize differences between responders and non-responders, and summarize patient characteristics and responses to the survey constructs among responders. Methods: This was a multi-center cross-sectional survey study with linked electronic health record (EHR) data. Our survey was guided by the Chronic Care Model to understand the distribution of patient-centric factors, including health literacy, social support, self-management, and functional and mental status in patients with HF. Most questions were from existing validated questionnaires. The survey was administered to HF patients aged ≥ 30 years from 4 health systems in PCORnet® (the National Patient-Centered Clinical Research Network): Essentia Health, Intermountain Health, Mayo Clinic, and The Ohio State University. Each health system mapped their EHR data to a standardized PCORnet Common Data Model, which was used to extract demographic and clinical data on survey responders and non-responders. Results: Across the 4 sites, 10,662 patients with HF were invited to participate, and 3330 completed the survey (response rate: 31%). Responders were older (74 vs. 71 years; standardized difference (95% CI): 0.18 (0.13, 0.22)), less racially diverse (3% vs. 12% non-White; standardized difference (95% CI): -0.32 (-0.36, -0.28)), and had higher prevalence of many chronic conditions than non-responders, and thus may not be representative of all HF patients. The internal reliability of the validated questionnaires in our survey was good (range of Cronbach's alpha: 0.50–0.96). Responders reported their health was generally good or fair, they frequently had cardiovascular comorbidities, > 50% had difficulty climbing stairs, and > 10% reported difficulties with bathing, preparing meals, and using transportation. Nearly 80% of patients had family or friends sit with them during a doctor visit, and 54% managed their health by themselves. Patients reported generally low perceived support for self-management related to exercise and diet. Conclusions: More than half of patients with HF managed their health by themselves. Increased understanding of self-management resources may guide the development of interventions to improve HF outcomes. [ABSTRACT FROM AUTHOR]

Objectives: Vaccination reduces the risk of acute coronavirus disease 2019 (COVID-19) in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5 to 17 years. Methods: This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record program for visits after vaccine availability. We examined both probable (symptom-based) and diagnosed long COVID after vaccination. Results: The vaccination rate was 67% in the cohort of 1 037 936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, whereas diagnosed long COVID was 0.8%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5-44.7) against probable long COVID and 41.7% (15.0-60.0) against diagnosed long COVID. VE was higher for adolescents (50.3% [36.6-61.0]) than children aged 5 to 11 (23.8% [4.9-39.0]). VE was higher at 6 months (61.4% [51.0-69.6]) but decreased to 10.6% (-26.8% to 37.0%) at 18-months. Conclusions: This large retrospective study shows moderate protective effect of severe acute respiratory coronavirus 2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including electronic health record sources and prospective data. [ABSTRACT FROM AUTHOR]

Introduction: Improved heart failure (HF) outcomes are needed due to patient health, utilization, and government penalty considerations. Previously we created clinical decision tools (CDT) and a CDT-guided multidisciplinary team care pathway (MTCP) for HF inpatients. Objective: This study evaluated outcomes of stepped wedge MTCP implementation in HF inpatient care across Intermountain Healthcare. Methods: HF inpatients (N=6,182) were studied at 19 Intermountain hospitals from January 2013 to November 2016. Starting February 2014, the MTCP intervention was implemented sequentially over 2.5 years in the 8 largest hospitals (accounting for 89% of HF inpatients). Where MTCP was implemented, CDT mortality and readmission risk scores were delivered electronically to clinicians within 24 hours of admission and repeated daily. MTCP was used for CDT "high risk" inpatients (n=1,221); lower risk patients received standard HF care (n=1,220). Controls were categorized retrospectively as high risk (n=1,791) and lower risk (n=1,950) at admission. Results: Patient age averaged 71.1±14.7 years; 45.5% were female. In CDT high-risk patients, the MTCP intervention was associated with 25% lower 30-day readmission (HR=0.75, CI=0.63, 0.88, p<0.001) and 48% lower 30-day mortality (HR=0.52, CI=0.37, 0.72, p<0.001). Cox regression adjustment for demographics, comorbidities, and medications retained both findings (readmission: HR=0.82, CI=0.69, 0.97, p=0.023; mortality: HR=0.54, CI=0.39, 0.76, p<0.001). CDT lower-risk patients in MTCP-implemented hospitals had no significant 30-day changes (readmission: adjusted HR=0.89, p=0.21; mortality: adjusted HR=0.86, p=0.51). LOS was not lower for MTCP recipients (4.5 days vs. controls: 4.6 days, p=0.65) or lower risk (3.8 days vs. controls: 3.9 days, p=0.35). Total variable cost (index stay & any 30-day readmission) was not different for MTCP (median $6,960 vs. controls: $6,741, p=0.08), but was higher in lower risk (median $6,258 vs. controls: $5,933, p=0.034). Conclusions: A CDT-guided precision medicine MTCP for high-risk HF patients was associated with lower 30-day readmission and mortality. Costs increased in lower risk patients where inpatient care was minimized but not higher-risk MTCP recipients. [ABSTRACT FROM AUTHOR]

The author reflects on the roles of health institutions in combating climate change considering how air quality affects health. Topics include the actions of the American College of Physicians on calling the government to respond on the climate issue, the implication of ozone exposure on airway inflammation and risks of respiratory disease, and the establishment of Intermountain Air Quality and Health Workgroup which aim to reduce intermountain air impact to health.