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Cardiac arrest (CA) is common and has been associated with adverse outcomes in patients with cardiogenic shock (CS). We sought to determine the prevalence, patient characteristics, and outcomes of CA in cardiovascular intensive care unit patients with CS. We queried cardiovascular intensive care unit admissions from 2007 to 2018 with an admission diagnosis of CS and compared patients with and without CA. Temporal trends were assessed using linear regression. The primary and secondary outcomes of in-hospital and 1-year mortality were analyzed using logistic regression and Cox proportional-hazards analysis, respectively. We included 1,498 patients, and CA was present in 510 patients (34%), with 258 (50.6% of patients with CA) having ventricular fibrillation (VF). Mean age was 68 ± 14 years, and 37% were females. The prevalence of CA decreased over time (from 43% in 2007 to 24% in 2018, p0.001). Hospital mortality was 33.3% and decreased over time in patients without CA (from 30% in 2007 to 22% in 2018, p = 0.05), but not in patients with CA (p = 0.71). CA was associated with a higher risk of hospital mortality (51.0% vs 24.2%, adjusted odds ratio 2.15, 95% confidence interval [CI] 1.52 to 3.05, p0.001), with no difference between VF CA and non-VF CA (p = 0.64). CA was associated with higher 1-year mortality (adjusted hazard ratio 1.53, 95% CI 1.24 to 1.89, p0.001). In conclusion, CA is present in 1 of 3 of CS hospitalizations and confers a substantially higher risk of hospital and 1-year mortality with no improvement during our 12-year study period contrary to prevailing trends.

Background: Coronary endothelial dysfunction (CED) causes angina/ischemia in patients with nonobstructive coronary artery disease (NOCAD). Patients with CED have decreased number and function of CD34+ cells involved in normal vascular repair with microcirculatory regenerative potential and paracrine anti-inflammatory effects. We evaluated safety and potential efficacy of intracoronary autologous CD34+ cell therapy for CED. Methods: Twenty NOCAD patients with invasively diagnosed CED and persistent angina despite maximally tolerated medical therapy underwent baseline exercise stress test, GCSF (granulocyte colony stimulating factor)-mediated CD34+ cell mobilization, leukapheresis, and selective 1×10 5 CD34+ cells/kg infusion into left anterior descending. Invasive CED evaluation and exercise stress test were repeated 6 months after cell infusion. Primary end points were safety and effect of intracoronary autologous CD34+ cell therapy on CED at 6 months of follow-up. Secondary end points were change in Canadian Cardiovascular Society angina class, as-needed sublingual nitroglycerin use/day, Seattle Angina Questionnaire scores, and exercise time at 6 months. Change in CED was compared with that of 51 historic control NOCAD patients treated with maximally tolerated medical therapy alone. Results: Mean age was 52±13 years; 75% were women. No death, myocardial infarction, or stroke occurred. Intracoronary CD34+ cell infusion improved microvascular CED (%acetylcholine-mediated coronary blood flow increased from 7.2 [−18.0 to 32.4] to 57.6 [16.3–98.3]%; P =0.014), decreased Canadian Cardiovascular Society angina class (3.7±0.5 to 1.7±0.9, Wilcoxon signed-rank test, P =0.00018), and sublingual nitroglycerin use/day (1 [0.4–3.5] to 0 [0–1], Wilcoxon signed-rank test, P =0.00047), and improved all Seattle Angina Questionnaire scores with no significant change in exercise time at 6 months of follow-up. Historic control patients had no significant change in CED. Conclusions: A single intracoronary autologous CD34+ cell infusion was safe and may potentially be an effective disease-modifying therapy for microvascular CED in humans. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03471611.

OBJECTIVE To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. METHODS Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio [aOR] 2.03 [95% confidence interval {CI} 1.97-2.09]; p

Objective To determine whether the Mayo Cardiac Intensive Care Unit (CICU) Admission Risk Score (M-CARS) accurately predicts 1-year mortality. Methods We retrospectively reviewed adult CICU patients admitted from January 1, 2007, through April 30, 2018, and calculated M-CARS using admission data. We examined the association between admission M-CARS, as continuous and categorical variables, and 1-year mortality. Results This study included 12,428 unique patients with a mean age of 67.6±15.2 years (4686 [37.7%] female). A total of 2839 patients (22.8%) died within 1 year of admission, including 1149 (9.2%) hospital deaths and 1690 (15.0%) of the 11,279 hospital survivors. The 1-year survival decreased incrementally as a function of increasing M-CARS (P Conclusion M-CARS predicted 1-year mortality among CICU admissions, with a plateau effect at high M-CARS of 3 or more for hospital survivors. Significant added predictors of 1-year mortality among hospital survivors included markers of frailty and chronic illness.

Background: Previous percutaneous coronary intervention risk models were focused on single outcome, such as mortality or bleeding, etc, limiting their applicability. Our objective was to develop contemporary percutaneous coronary intervention risk models that not only determine in-hospital mortality but also predict postprocedure bleeding, acute kidney injury, and stroke from a common set of variables. Methods: We built risk models using logistic regression from first percutaneous coronary intervention for any indication per patient (n=19 322, 70.6% with acute coronary syndrome) using the Mayo Clinic registry from January 1, 2000 to December 31, 2016. Approval for the current study was obtained from the Mayo Foundation Institutional Review Board. Patients with missing outcomes (n=4183) and those under 18 (n=10) were removed resulting in a sample of 15 129. We built both models that included procedural and angiographic variables (Models A) and precatheterization model (Models B). Results: Death, bleeding, acute kidney injury, and stroke occurred in 247 (1.6%), 650 (4.3%), 1184 (7.8%), and 67 (0.4%), respectively. The C statistics from the test dataset for models A were 0.92, 0.70, 0.77, and 0.71 and for models B were 0.90, 0.67, 0.76, and 0.71 for in-hospital death, bleeding, acute kidney injury, and stroke, respectively. Bootstrap analysis indicated that the models were not overfit to the available dataset. The probabilities estimated from the models matched the observed data well, as indicated by the calibration curves. The models were robust across many subgroups, including women, elderly, acute coronary syndrome, cardiogenic shock, and diabetes. Conclusions: The new risk scoring models based on precatheterization variables and models including procedural and angiographic variables accurately predict in-hospital mortality, bleeding, acute kidney injury, and stroke. The ease of its application will provide useful prognostic and therapeutic information to both patients and physicians.

Objectives The aim of this study was to examine the effect of CYP2C19 genotype on clinical outcomes in patients with coronary artery disease (CAD) who predominantly underwent percutaneous coronary intervention (PCI), comparing those treated with ticagrelor or prasugrel versus clopidogrel. Background The effect of CYP2C19 genotype on treatment outcomes with ticagrelor or prasugrel compared with clopidogrel is unclear. Methods Databases through February 19, 2020, were searched for studies reporting the effect of CYP2C19 genotype on ischemic outcomes during ticagrelor or prasugrel versus clopidogrel treatment. Study eligibility required outcomes reported for CYP2C19 genotype status and clopidogrel and alternative P2Y12 inhibitors in patients with CAD with at least 50% undergoing PCI. The primary analysis consisted of randomized controlled trials (RCTs). A secondary analysis was conducted by adding non-RCTs to the primary analysis. The primary outcome was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia. Meta-analysis was conducted to compare the 2 drug regimens and test interaction with CYP2C19 genotype. Results Of 1,335 studies identified, 7 RCTs were included (15,949 patients, mean age 62 years; 77% had PCI, 98% had acute coronary syndromes). Statistical heterogeneity was minimal, and risk for bias was low. Ticagrelor and prasugrel compared with clopidogrel resulted in a significant reduction in ischemic events (relative risk: 0.70; 95% confidence interval: 0.59 to 0.83) in CYP2C19 loss-of-function carriers but not in noncarriers (relative risk: 1.0; 95% confidence interval: 0.80 to 1.25). The test of interaction on the basis of CYP2C19 genotype status was statistically significant (p = 0.013), suggesting that CYP2C19 genotype modified the effect. An additional 4 observational studies were found, and adding them to the analysis provided the same conclusions (p value of the test of interaction Conclusions The effect of ticagrelor or prasugrel compared with clopidogrel in reducing ischemic events in patients with CAD who predominantly undergo PCI is based primarily on the presence of CYP2C19 loss-of-function carrier status. These results support genetic testing prior to prescribing P2Y12 inhibitor therapy.

Aims There are limited contemporary data on the use of initial fibrinolysis in ST‐segment elevation myocardial infarction cardiogenic shock (STEMI‐CS). This study sought to compare the outcomes of STEMI‐CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI). Methods Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI‐CS admissions receiving pre‐hospital/in‐hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI‐CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in‐hospital mortality, development of non‐cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do‐not‐resuscitate status. Results During 2009–2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non‐White, with lower co‐morbidity, and admitted on weekends and to small rural hospitals (all P

AIMS There are limited data on the trends and outcomes of mechanical circulatory support (MCS)-assisted early percutaneous coronary intervention (PCI) in acute myocardial infarction with cardiogenic shock (AMI-CS). In this study, we sought to assess the use, temporal trends, and outcomes of percutaneous MCS-assisted early PCI in AMI-CS. METHODS AND RESULTS Using the National Inpatient Sample database from 2005-2014, a retrospective cohort of AMI-CS admissions receiving early PCI (hospital day zero) was identified. MCS use was defined as intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD) and extracorporeal membrane oxygenation (ECMO) support. Outcomes of interest included in-hospital mortality, resource utilisation, trends and predictors of MCS-assisted PCI. Of the 110,452 admissions, MCS assistance was used in 55%. IABP, pLVAD and ECMO were used in 94.8%, 4.2% and 1%, respectively. During 2009-2014, there was a decrease in MCS-assisted PCI due to a decrease in IABP, despite an increase in pLVAD and ECMO. Younger age, male sex, lower comorbidity, and cardiac arrest independently predicted MCS use. MCS-assisted PCI was predictive of higher in-hospital mortality (31% vs 26%, adjusted odds ratio 1.23 [1.19-1.27]; p

Background This study sought to assess the contemporary outcomes of patients transferred after receiving fibrinolytic therapy (‘drip-and-ship’) for ST-segment elevation myocardial infarction (STEMI) in the United States. Methods During 2009–2016, adults (>18 years) with STEMI (>18 years) without cardiac arrest and cardiogenic shock that received fibrinolytic therapy and were subsequently transferred were identified using the National Inpatient Sample (NIS). These admissions were divided into those undergoing fibrinolysis alone, subsequent coronary angiography (CA) without revascularization and subsequent CA with revascularization. Outcomes of interest included in-hospital mortality, resource utilization, and discharge disposition. Results A total of 27,454 STEMI admissions receiving a ‘drip-and-ship strategy’, 96.3% and 85.8% received subsequent coronary angiography and revascularization Admissions receiving CA and revascularization were younger, male, and with lower comorbidity. The fibrinolysis alone cohort had higher rates of organ failure, hemorrhagic sequelae, and intracranial hemorrhage. Compared to the fibrinolysis cohort, CA with revascularization (adjusted odds ratio [aOR] 0.17 [95% confidence interval {CI} 0.11–0.27]; p Conclusion Fibrinolysis with subsequent revascularization is associated with excellent outcomes in STEMI. Admissions receiving fibrinolysis alone were systematically different, sicker and had poorer outcomes.

Background: There are limited sex-specific data on patients receiving temporary mechanical circulatory support (MCS) for acute myocardial infarction-cardiogenic shock (AMI-CS). Methods: All admissions with AMI-CS with MCS use were identified using the National Inpatient Sample from 2005 to 2016. Outcomes of interest included in-hospital mortality, discharge disposition, use of palliative care and do-not-resuscitate (DNR) status, and receipt of durable left ventricular assist device (LVAD) and cardiac transplantation. Results: In AMI-CS admissions during this 12-year period, MCS was used more frequently in men—50.4% vs 39.5%; P < 0.001. Of the 173,473 who received MCS (32% women), intra-aortic balloon pumps, percutaneous LVAD, extracorporeal membrane oxygenation, and ≥ 2 MCS devices were used in 92%, 4%, 1%, and 3%, respectively. Women were on average older (69 ± 12 vs 64 ± 13 years), of black race (10% vs 6%), and had more comorbidity (mean Charlson comorbidity index 5.0 ± 2.0 vs 4.5 ± 2.1). Women had higher in-hospital mortality than men (34% vs 29%, adjusted odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.16-1.23; P < 0.001) overall, in intra-aortic balloon pumps users (OR: 1.20 [95% CI: 1.16-1.23]; P < 0.001), and percutaneous LVAD users (OR: 1.75 [95% CI: 1.49-2.06]; P < 0.001), but not in extracorporeal membrane oxygenation or ≥ 2 MCS device users (P > 0.05). Women had higher use of palliative care, DNR status, and discharges to skilled nursing facilities. Conclusions: There are persistent sex disparities in the outcomes of AMI-CS admissions receiving MCS support. Women have higher in-hospital mortality, palliative care consultation, and use of DNR status. Résumé: Contexte: On dispose de peu de données quant à l’influence du sexe sur les résultats pour les patients qui reçoivent une assistance circulatoire mécanique (ACM) temporaire à la suite d’un infarctus aigu du myocarde accompagné d’un choc cardiogénique (IAM-CC). Méthodologie: Nous avons recensé dans l’échantillon national des patients hospitalisés (NIS, National Inpatient Sample) tous les patients admis à l’hôpital pour un IAM-CC qui ont reçu une ACM de 2005 à 2016. Les résultats d’intérêt comprenaient la mortalité hospitalière, l’état à la sortie, le recours aux soins palliatifs et à une ordonnance de non-réanimation (ONR), l’implantation d’un dispositif d’assistance ventriculaire gauche (DAVG) permanent et la transplantation cardiaque. Résultats: Chez les patients admis à l’hôpital pour un IAM-CC durant la période de 12 ans étudiée, l’ACM a été utilisée plus fréquemment chez les hommes que chez les femmes (50,4 % vs 39,5 %; p < 0,001). Sur les 173 473 patients qui ont reçu une ACM (dont 32 % étaient des femmes), les méthodes employées se répartissaient comme suit : ballon de contre-pulsion intra-aortique, 92 %; assistance ventriculaire gauche percutanée, 4 %; oxygénation extracorporelle par membrane, 1 %; et au moins 2 types d’ACM, 3 %. Les femmes étaient plus âgées en moyenne (69 ± 12 ans vs 64 ± 13 ans), étaient plus souvent de race noire (10 % vs 6 %) et présentaient un plus grand nombre d’affections concomitantes (indice de comorbidité de Charlson moyen de 5,0 ± 2,0 vs 4,5 ± 2,1). Le taux de mortalité hospitalière était plus élevé chez les femmes que chez les hommes (34 % vs 29 %, risque relatif approché [RRA] corrigé : 1,19; intervalle de confiance [IC] à 95 % : de 1,16 à 1,23; p < 0,001) dans l’ensemble, ainsi que chez les utilisateurs d’un ballon de contre-pulsion intra-aortique (RRA : 1,20 [IC à 95 % : de 1,16 à 1,23]; p < 0,001), et chez les utilisateurs d’un DAVG percutané (RRA : 1,75 [IC à 95 % : 1,49 à 2,06]; p < 0,001), mais pas chez les utilisateurs de l’oxygénation extracorporelle par membrane ni chez les utilisateurs d’au moins 2 types d’ACM (p > 0,05). Le recours aux soins palliatifs, l’établissement d’une ordonnance de non-réanimation et l’orientation vers un établissement de soins infirmiers spécialisés à la sortie de l’hôpital étaient plus fréquents chez les femmes. Conclusions: Il existe toujours des disparités entre les sexes à l’égard des résultats pour les patients admis à l’hôpital pour IAM-CC recevant une ACM. Le taux de mortalité hospitalière était plus élevé chez les femmes, et celles-ci avaient plus souvent recours à une consultation en soins palliatifs et à une ONR.

OBJECTIVE: To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS). MATERIALS AND METHODS: A retrospective cohort of older (≥75 years) AMI-CS admissions during January 1, 2000, to December 31, 2014, was identified using the National Inpatient Sample. Interhospital transfers were excluded. Use of angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and noncardiac interventions was identified. The primary outcome was in-hospital mortality stratified by sex, and secondary outcomes included temporal trends of prevalence, in-hospital mortality, use of cardiac and noncardiac interventions, hospitalization costs, and length of stay. RESULTS: In this 15-year period, there were 134,501 AMI-CS admissions 75 years or older, of whom 51.5% (n=69,220) were women. Women were on average older, were more often Hispanic or nonwhite race, and had lower comorbidity, acute organ failure, and concomitant cardiac arrest. Compared with older men (n=65,281), older women (n=69,220) had lower use of coronary angiography (55.4% [n=35,905] vs 49.2% [n=33,918]), PCI (36.3% [n=23,501] vs 34.4% [n=23,535]), MCS (34.3% [n=22,391] vs 27.2% [n=18,689]), mechanical ventilation, and hemodialysis (all P

Objective: To assess the effects of weekend admission vs weekday admission on the management and outcomes of acute myocardial infarction (AMI). Methods: Adult ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) hospital admissions were identified using the National (Nationwide) Inpatient Sample (2000-2016). Interhospital transfers were excluded. Timing of coronary angiography (CA) and percutaneous coronary intervention (PCI) relative to the day of admission was identified. Outcomes of interest included in-hospital mortality, receipt of early CA, timing of CA and PCI, resource utilization, and discharge disposition for weekend vs weekday admissions. Results: Of the 9,041,819 AMI admissions, 2,406,876 (26.6%) occurred on weekends. Compared with 2000, in 2016 there was an increase in weekend STEMI (adjusted odds ratio [aOR], 1.12; 95% CI, 1.08-1.16; P

Aims The aim of this study is to evaluate the contemporary use of a pulmonary artery catheter (PAC) in acute myocardial infarction‐cardiogenic shock (AMI‐CS). Methods and results A retrospective cohort of AMI‐CS admissions using the National Inpatient Sample (2000–2014) was identified. Admissions with concomitant cardiac surgery or non‐AMI aetiology for cardiogenic shock were excluded. The outcomes of interest were in‐hospital mortality, resource utilization, and temporal trends in cohorts with and without PAC use. In the non‐PAC cohort, the use and outcomes of right heart catheterization was evaluated. Multivariable regression and propensity matching was used to adjust for confounding. During 2000–2014, 364 001 admissions with AMI‐CS were included. PAC was used in 8.1% with a 75% decrease during over the study period (13.9% to 5.4%). Greater proportion of admissions to urban teaching hospitals received PACs (9.5%) compared with urban non‐teaching (7.1%) and rural hospitals (5.4%); P < 0.001. Younger age, male sex, white race, higher comorbidity, noncardiac organ failure, use of mechanical circulatory support, and noncardiac support were independent predictors of PAC use. The PAC cohort had higher in‐hospital mortality (adjusted odds ratio 1.07 [95% confidence interval 1.04–1.10]), longer length of stay (10.9 ± 10.9 vs. 8.2 ± 9.3 days), higher hospitalization costs ($128 247 ± 138 181 vs. $96 509 ± 116 060), and lesser discharges to home (36.3% vs. 46.4%) (all P < 0.001). In 6200 propensity‐matched pairs, in‐hospital mortality was comparable between the two cohorts (odds ratio 1.01 [95% confidence interval 0.94–1.08]). Right heart catheterization was used in 12.5% of non‐PAC admissions and was a marker of greater severity but did not indicate worse outcomes. Conclusions In AMI‐CS, there was a 75% decrease in PAC use between 2000 and 2014. Admissions receiving a PAC were a higher risk cohort with worse clinical outcomes.

Background There are limited data on the timing and outcomes of in-hospital cardiac arrest (IHCA) in patients with ST-elevation myocardial infarction (STEMI) receiving primary percutaneous coronary intervention (pPCI). This study sought to examine the in-hospital mortality, temporal trends and resource utilization in early vs. delayed IHCA in STEMI. Methods Retrospective cohort study from the National Inpatient Sample of all STEMI admissions during 2000–2014 receiving pPCI on hospital day zero. Admissions transferred from other hospitals, with do-not-resuscitate status, without information on IHCA timing, and receiving surgical revascularization were excluded. IHCA was classified as early (hospital day zero) and delayed (on/after hospital day 1). The primary outcome was in-hospital mortality and secondary outcomes included prevalence, temporal trends, and resource utilization. Results During this 15-year period, 19,185 admissions met the inclusion criteria, with 15,404 (80%) experiencing an early IHCA. The cohort with delayed IHCA was on average older, female, with higher comorbidity, and greater prevalence of non-shockable rhythms and acute organ failure. There was a temporal increase in early IHCA (adjusted odds ratio [aOR] 1.67 [95% confidence interval {CI} 1.35–2.08]) and a decrease in delayed IHCA (aOR 0.60 [95% CI 0.48-0.74]) in 2014 compared to 2000. Compared to the early IHCA cohort, the delayed IHCA cohort had higher in-hospital mortality (aOR 5.35 [95% CI 4.83–5.94]), higher hospitalization costs ($115,165 ± 109,848 vs. 139,038 ± 142,745) and less frequent discharges to home (74% vs. 52%). Conclusions Delayed IHCA (on or after hospital day 1) was associated with higher in-hospital mortality and resource utilization compared to early IHCA.

The five-stage Society for Cardiovascular Angiography and Intervention (SCAI) cardiogenic shock classification scheme can stratify hospital mortality risk in patients admitted to the cardiac intensive care unit (CICU). We sought to evaluate the SCAI shock classification for prediction of post-discharge mortality in CICU survivors.We retrospectively analyzed hospital survivors admitted to a single CICU between 2007 and 2015. SCAI CS stages A through E were classified using CICU admission data using a previously published algorithm. All-cause post-discharge mortality was compared across SCAI stages using Kaplan-Meier analysis and Cox proportional hazards models.Among 9096 unique hospital survivors, 43.2% had acute coronary syndrome (ACS), 44.6% had heart failure (HF), and 8.7% had cardiac arrest (CA) on admission. The proportion of patients in each SCAI shock stage was: A, 49.1%; B, 30.6%; C, 15.2; D/E 5.2%. Kaplan-Meier survival at 5 years in each SCAI shock stage was: A, 88.2%; B, 81.6%; C, 76.7%; D/E, 71.7% (P .001 by log-rank). Each higher SCAI shock stage was associated with increased adjusted post-discharge mortality compared to SCAI shock stage A (all P .001); results were consistent among patients with ACS or HF. Late hemodynamic deterioration after 24 hours, but not an admission diagnosis of CA, was associated with higher post-discharge mortality.The SCAI shock classification assessed at the time of CICU admission was predictive of post-discharge mortality risk among hospital survivors, although an admission diagnosis of CA was not. The SCAI shock classification can be used for post-discharge mortality risk stratification.

Background: There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. Methods: Using the National Inpatient Sample (2000–2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer—self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. Results: Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P P P P P Conclusions: Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.

Aims Excimer Laser Coronary Angioplasty with adjunctive contrast (ELCA-con) is described as one potential option to facilitate intra-coronary stent expansion; however, the benefits and risks of this technology remain incompletely understood. We performed a retrospective single center study to evaluate procedural success, risks, and clinical outcomes of ELCA-con assisted percutaneous coronary intervention (PCI) for stent under-expansion. Methods and results Twenty-six consecutive patients underwent ELCA-con assisted PCI from 2014 to 2019 for stent under-expansion. All cases used a 0.9 mm fiber with pulse frequency 80 Hz and fluency 80mJ/mm 2 and adjunctive contrast injection during laser activation. Stent expansion improved in all cases, with 81% of patient achieving ≤ 40% residual stenosis and 58% of patients achieving ≤ 20% residual stenosis. Nonfatal complications were observed in 15% of patients. All patients survived to hospital discharge. Upon follow up (median 13 months), rate of restenosis requiring target lesion revascularization was 3.8%. Four deaths were observed, one from cardiac arrest 2 days later and the others from unrelated causes. Conclusions ELCA-con is a useful technique to manage stent under-expansion and facilitate stent expansion in many cases. The complication rate indicates that careful patient selection is warranted.

Objective: To analyze outcomes of patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (PCI) triaged to the cardiac intensive care unit (CICU) vs a general telemetry unit by a Zwolle risk score–based algorithm. Methods: We introduced a quality improvement protocol in 2014 encouraging admission of STEMI patients with Zwolle score of 3 or less to general telemetry units unless they were hemodynamically unstable. We subsequently conducted a retrospective single-center cohort study of consecutive STEMI patients who had undergone primary PCI from January 1, 2014, to December 31, 2018. Outcomes studied include immediate complications, need for urgent unplanned intervention, need for CICU care, length of hospitalization, and survival. Results: We identified 547 patients, 406 with a Zwolle score of 3 or less. Of these, 192 (47.3%) were admitted to general telemetry and 214 (52.7%) to the CICU. Reasons for CICU admission included persistent chest pain, late presentation, and procedural complications. The average hospital length of stay was 2.1±1.4 days for non-CICU patients and 3.3±2.8 days for low-risk CICU patients (P

There are limited data on the temporal trends, incidence, and outcomes of ST-segment-elevation myocardial infarction-cardiogenic shock (STEMI-CS).Adult (18 years) STEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011, 2012-2017). Outcomes of interest included temporal trends, acute organ failure, cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay.In ∼4.3 million STEMI admissions, CS was noted in 368,820 (8.5%). STEMI-CS incidence increased from 5.8% in 2000 to 13.0% in 2017 (patient and hospital characteristics adjusted odds ratio [aOR] 2.45 [95% confidence interval {CI} 2.40-2.49]; P 0.001). Multiorgan failure increased from 55.5% (2000-2005) to 74.3% (2012-2017). Between 2000 and 2017, coronary angiography and percutaneous coronary intervention use increased from 58.8% to 80.1% and 38.6% to 70.6%, whereas coronary artery bypass grafting decreased from 14.9% to 10.4% (all P 0.001). Over the study period, the use of intra-aortic balloon pump (40.6%-37.6%) decreased, and both percutaneous left ventricular assist devices (0%-12.9%) and extra-corporeal membrane oxygenation (0%-2.8%) increased (all P 0.001). In hospital mortality decreased from 49.6% in 2000 to 32.7% in 2017 (aOR 0.29 [95% CI 0.28-0.31]; P 0.001). During the 18-year period, hospital lengths of stay decreased, hospitalization costs increased and use of durable left ventricular assist device /cardiac transplantation remained stable (P 0.05).In the United States, incidence of CS in STEMI has increased 2.5-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and PCI increased during the study period.

Background Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years. Methods We retrospectively reviewed unique CICU admissions at the Mayo Clinic from January 2007 to April 2018. Comorbidities, severity of illness scores, discharge diagnosis codes and CICU procedures and therapies were recorded, and temporal trends were assessed using linear regression and Cochran-Armitage trend tests. Trends in adjusted hospital mortality over time were assessed using multivariable logistic regression. Results We included 12,418 patients with a mean age of 67.6 years (including 37.7% females). Temporal trends in the prevalence of several comorbidities and discharge diagnoses were observed, reflecting an increase in the prevalence of non-coronary cardiovascular diseases, critical care diagnoses, and organ failure (all P ≪ .05). The use of several CICU therapies and procedures increased over time, including mechanical ventilation, invasive lines and vasoactive drugs (all P ≪ .05). A temporal decrease in adjusted hospital mortality was observed among the subgroup of patients with (adjusted OR per year 0.97, 95% CI 0.94–0.99, P = .023) and without (adjusted OR per year 0.91, 95% CI 0.85–0.96, P = .002) a critical care discharge diagnosis. Conclusions We observed an increasing prevalence of critical care and organ failure diagnoses as well as increased utilization of critical care therapies in this CICU cohort, associated with a decrease in risk-adjusted hospital mortality over time.

Objectives This study sought to determine whether machine learning can be used to better identify patients at risk for death or congestive heart failure (CHF) rehospitalization after percutaneous coronary intervention (PCI). Background Contemporary risk models for event prediction after PCI have limited predictive ability. Machine learning has the potential to identify complex nonlinear patterns within datasets, improving the predictive power of models. Methods We evaluated 11,709 distinct patients who underwent 14,349 PCIs between January 2004 and December 2013 in the Mayo Clinic PCI registry. Fifty-two demographic and clinical parameters known at the time of admission were used to predict in-hospital mortality and 358 additional variables available at discharge were examined to identify patients at risk for CHF readmission. For each event, we trained a random forest regression model (i.e., machine learning) to estimate the time-to-event. Eight-fold cross-validation was used to estimate model performance. We used the predicted time-to-event as a score, generated a receiver-operating characteristic curve, and calculated the area under the curve (AUC). Model performance was then compared with a logistic regression model using pairwise comparisons of AUCs and calculation of net reclassification indices. Results The predictive algorithm identified a high-risk cohort representing 2% of all patients who had an in-hospital mortality of 45.5% (95% confidence interval: 43.5% to 47.5%) compared with a risk of 2.1% for the general population (AUC: 0.925; 95% confidence interval: 0.92 to 0.93). Advancing age, CHF, and shock on presentation were the leading predictors for the outcome. A high-risk group representing 1% of all patients was identified with 30-day CHF rehospitalization of 8.1% (95% confidence interval: 6.3% to 10.2%). Random forest regression outperformed logistic regression for predicting 30-day CHF readmission (AUC: 0.90 vs. 0.85; p = 0.003; net reclassification improvement: 5.14%) and 180-day cardiovascular death (AUC: 0.88 vs. 0.81; p = 0.02; net reclassification improvement: 0.02%). Conclusions Random forest regression models (machine learning) were more predictive and discriminative than standard regression methods at identifying patients at risk for 180-day cardiovascular mortality and 30-day CHF rehospitalization, but not in-hospital mortality. Machine learning was effective at identifying subgroups at high risk for post-procedure mortality and readmission.

Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Second-generation drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES.The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded.A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0-90, 91-180, 181-365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0-90 days and 3.4 (0.8 to 15.3) at 91-180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655).The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT.

Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury.

Objective To explore the safety and efficacy of FFR-guided percutaneous coronary intervention (PCI) in vessels with severe diameter stenosis. Methods & Results Of 1090 patients undergoing fractional flow reserve (FFR) assessment from 2002 to 2009, we identified 167 patients in whom FFR was measured in at least one 70%–89% stenotic lesion. These patients were subdivided into an FFR-defer group (n = 49) if PCI was deferred (FFR > 0.80), and an FFR-perform group (n = 118) if PCI was performed (FFR ≤ 0.80). Comparatively, an additional 1176 patients undergoing PCI in at least one lesion with 70%–89% stenosis but without measurement of FFR served as a control (angiography-guided) group. Clinical outcomes were compared during a median follow-up of 49.0 months. The 5-year Kaplan-Meier estimated revascularization rates were 16% in the FFR-defer group and 33% in the FFR-perform group (P = 0.046). The incidence of major adverse cardiac events were comparable in these two groups (HR = 0.82, 95% CI: 0.37–1.82, P = 0.63). The number of stents placed was significantly lower in the FFR-guided group (0.9 ± 0.8 vs. 1.4 ± 0.8, P < 0.001). Conclusions Functional revascularization for lesions with visually severe stenosis is clinically safe and associated with fewer stents use. This study suggests that extending the use of FFR to more severe coronary lesions may be reasonable.

Background The role of race and ethnicity in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI) is incompletely understood. Methods and Results This was a retrospective cohort study of adult admissions with AMI‐CA from the National Inpatient Sample (2012–2017). Self‐reported race/ethnicity was classified as White, Black, and others (Hispanic, Asian or Pacific Islander, Native American, Other). Outcomes of interest included in‐hospital mortality, coronary angiography, percutaneous coronary intervention, palliative care consultation, do‐not‐resuscitate status use, hospitalization costs, hospital length of stay, and discharge disposition. Of the 3.5 million admissions with AMI, CA was noted in 182 750 (5.2%), with White, Black, and other races/ethnicities constituting 74.8%, 10.7%, and 14.5%, respectively. Black patients admitted with AMI‐CA were more likely to be female, with more comorbidities, higher rates of non–ST‐segment–elevation myocardial infarction, and higher neurological and renal failure. Admissions of patients of Black and other races/ethnicities underwent coronary angiography (61.9% versus 70.2% versus 73.1%) and percutaneous coronary intervention (44.6% versus 53.0% versus 58.1%) less frequently compared to patients of white race ( p P =0.007) whereas other races had higher in‐hospital mortality (OR, 1.11; 95% CI, 1.08–1.15; P P Conclusions Racial and ethnic minorities received less frequent guideline‐directed procedures and had higher in‐hospital mortality and worse outcomes in AMI‐CA.

Background There are limited contemporary data on the use of emergent coronary artery bypass grafting (CABG) in acute myocardial infarction. Methods and Results Adult (aged >18 years) acute myocardial infarction admissions were identified using the National (Nationwide) Inpatient Sample (2000–2017) and classified by tertiles of admission year. Outcomes of interest included temporal trends of CABG use; age‐, sex‐, and race‐stratified trends in CABG use; in‐hospital mortality; hospitalization costs; and hospital length of stay. Of the 11 622 528 acute myocardial infarction admissions, emergent CABG was performed in 1 071 156 (9.2%). CABG utilization decreased overall (10.5% [2000] to 8.7% [2017]; adjusted odds ratio [OR], 0.98 [95% CI, 0.98–0.98]; P P P P Conclusions Utilization of CABG has decreased substantially in acute myocardial infarction admissions, especially in patients with ST‐segment–elevation myocardial infarction. Despite an increase in acuity and multiorgan failure, in‐hospital mortality consistently decreased in this population.

Extraordinary growth characterized the Catheterization Laboratory practice: the priorities were expansive driven by new technologies to treat patients and conditions/diseases (primarily CAD). It was also a transitionary time in that some of the new technology introduced in the 1980s did not prove effective in reducing problems and were either modified or replaced. Most of this technology was directed at understanding and treating the unmet issues in the field of revascularization for CAD. New collaborative networks of multinational investigators, types of technology available, scientific rigor along with expanded involvement from new additions to the staff as well as new trainees from around the world expanded the focus which remained on science, education, and patient care. New approaches to subset of coronary anatomy remained an important focus with an increasing number of acronyms: DCA, TEC, ELCA, VBT, and IVUS for devices and others for trials: CAVEAT 2, BARI, ISR, GUSTO, and SES. Mayo was the principle investigative site of the CAVEAT 2 trial of directional atherectomy for the treatment of saphenous vein graft disease. Restenosis continued to be a major focus – both clinically and scientifically. The newly developed animal laboratory under the direction of Rob Schwartz was oversubscribed with creative ideas; it developed a practical animal model which was used for multiple studies and facilitated testing and screening for both pharmacologic and device technologies to identify optimal strategies. Out of this came information which was important for VBT (vascular brachytherapy). The animal laboratory developed a radical approach of local site therapy for stroke prevention in the setting of non-valvular atrial fibrillation which came to fruition during the 2000s. Scientific studies focused on the role of natural killer “T” cells and inflammation in patients with acute ischemic syndromes. These acute coronary syndromes were also well studied with superb detailed delineation of important aspects of cardiogenic shock both in STEMI and NSTEMI. Close collaboration with regulatory agencies in developing standards of care as well as standards of performance for individual operators led to establishing an advanced qualification in interventional cardiology. New initiates were also undertaken with implementation of a robust program in vascular molecular biology staffed by the cardiac laboratory. There were other new initiatives – the development of a mobile catheterization laboratory service to provide diagnostic angiography at three of our outreach sites. This new approach, while controversial, was very successful, well received, and provided excellent, safe care. The most severe complication occurred when the mobile catheterization unit had a “run in” with a buck deer one early morning on the way to Austin, Minnesota. Only one party came away intact. With each of these, approaches to measure the long term benefit was developed. In this case, two of the three outreach facilities based on the initial experience with the mobile laboratory resulted in each of them developing their own stand alone facilities thus obviating the need for the mobile cath laboratory which was then retired.

Background: Previous studies have defined preshock as isolated hypotension or isolated hypoperfusion, whereas shock has been variably defined as hypoperfusion with or without hypotension. We aimed to evaluate the mortality risk associated with hypotension and hypoperfusion at the time of admission in a cardiac intensive care unit population. Methods: We analyzed Mayo Clinic cardiac intensive care unit patients admitted between 2007 and 2015. Hypotension was defined as systolic blood pressure 2 mmol/L, oliguria, or rising creatinine. Associations between hypotension and hypoperfusion with hospital mortality were estimated using multivariable logistic regression. Results: Among 10 004 patients with a median age of 69 years, 43.1% had acute coronary syndrome, and 46.1% had heart failure. Isolated hypotension was present in 16.7%, isolated hypoperfusion in 15.3%, and 8.7% had both hypotension and hypoperfusion. Stepwise increases in hospital mortality were observed with hypotension and hypoperfusion compared with neither hypotension nor hypoperfusion (3.3%; all P P =0.02) and not significant different from patients with both hypotension and hypoperfusion ( P =0.18). Conclusions: Hypotension and hypoperfusion are both associated with increased mortality in cardiac intensive care unit patients. Hospital mortality is higher with isolated hypoperfusion or concomitant hypotension and hypoperfusion (classic shock). We contend that preshock should refer to isolated hypotension without hypoperfusion, while patients with hypoperfusion can be considered to have shock, irrespective of blood pressure.