Search

Physicians recommend electrophysiological (EP) procedures to patients with arrhythmic risk. This involves shared decision-making (SDM). Patients increasingly search for additional information online. Freely available online videos are an attractive source.We assessed freely available online videos for EP procedures from the perspective of SDM to determine if such videos can be shared with patients for SDM.We searched for freely available online videos related to 6 common EP procedures limited to English language and duration between 1 and 10 minutes using Google and Bing. Data collected included date and source of upload, number of hits, and duration. Videos were assessed systematically for understandability, actionability (PEMAT tool), relatability, teamwork, and mention of risk.A total of 78 videos met our inclusion criteria, out of 960 video links. Overall inter-rater agreement was moderate to good. Video upload dates spanned 12 years and number of hits ranged from 87 to 594,000. The majority of videos (63%) were produced by health care systems or academic institutions. For all 78 videos the mean total PEMAT tool score was 48.6%. Thirty-five percent of videos showed a patient engaged in a conversation with the physician or a team member; 41% of videos showed other team members. The potential for complications was mentioned in 10%.The majority of online, freely available videos for common EP procedures lack features useful for SDM and may not be helpful for sharing with patients from that perspective. It is possible to create high-quality videos that can facilitate SDM.

Background Minimizing direct patient contact among healthcare personnel is crucial for mitigating infectious risk during the coronavirus disease 2019 (COVID-19) pandemic. The use of remote cardiac telemetry as an alternative to 12‑lead electrocardiography (ECG) for continuous QTc monitoring may facilitate this strategy, but its application has not yet been validated or implemented. Methods In the validation component of this two-part prospective cohort study, a total of 65 hospitalized patients with simultaneous ECG and telemetry were identified. QTc obtained via remote telemetry as measured by 3 independent, blinded operators were compared with ECG as assessed by 2 board-certified electrophysiologists as the gold-standard. Pearson correlation coefficients were calculated to measure the strength of linear correlation between the two methods. In a separate cohort comprised of 68 COVID-19 patients treated with combined hydroxychloroquine and azithromycin, telemetry-based QTc values were compared at serial time points after medication administration using Friedman rank-sum test of repeated measures. Results Telemetry-based QTc measurements highly correlated with QTc values derived from ECG, with correlation coefficients of 0.74, 0.79, 0.85 (individual operators), and 0.84 (mean of all operators). Among the COVID-19 cohort, treatment led to a median QTc increase of 15 milliseconds between baseline and following the 9th dose (p = 0.002), with 8 (12%) patients exhibiting an increase in QTc ≥ 60 milliseconds and 4 (6%) developing QTc ≥ 500 milliseconds. Conclusions Cardiac telemetry is a validated clinical tool for QTc monitoring that may serve an expanding role during the COVID-19 pandemic strengthened by its remote and continuous monitoring capability and ubiquitous presence throughout hospitals.

The electrocardiography (ECG) has short-term prognostic value in coronavirus disease 2019 (COVID-19), yet its ability to predict long-term mortality is unknown. This study aimed to elucidate the predictive role of initial ECG on long-term all-cause mortality in patients diagnosed with COVID-19.In this prospective cohort study, adults with COVID-19 who underwent ECG testing within a 17-hospital health system in Northeast Ohio and Florida between 03/2020-06/2020 were identified. An expert ECG reader analyzed all studies blinded to patient status. The associations of ECG characteristics with long-term all-cause mortality and intensive care unit (ICU) admission were assessed using Cox proportional hazards regression model and multivariable logistic regression models, respectively. Status of long-term mortality was adjudicated on 01/07/2022.Of 837 patients (median age 65 years, 51% female, 44% Black), 683 (81.6%) were hospitalized, 281 (33.6%) required ICU admission, 67 (8.0%) died in-hospital, and 206 (24.6%) died at final follow-up after a median (IQR) of 21 (9-103) days after ECG. Overall, 179 (20.7%) patients presented with sinus tachycardia, 12 (1.4%) with atrial flutter, and 45 (5.4%) with atrial fibrillation (AF). After multivariable adjustment, sinus tachycardia (E-value for HR=3.09, lower CI=2.2) and AF (E-value for HR=3.13, lower CI=2.03) each independently predicted all-cause mortality. At final follow-up, patients with AF had 64.5% probability of death compared with 20.5% for those with normal sinus rhythm (P.0001).Sinus tachycardia and AF on initial ECG strongly predict long-term all-cause mortality in COVID-19. The ECG can serve as a powerful long-term prognostic tool in COVID-19.

Supplemental Digital Content is Available in the Text. The unprecedented nature of the COVID-19 pandemic has challenged how and whether patients with heart disease are able to safely access center-based exercise training and cardiac rehabilitation (CR). This commentary provides an experience-based overview of how one health system quickly developed and applied inclusive policies to allow patients to have safe and effective access to exercise-based CR., The unprecedented nature of the COVID-19 pandemic has challenged how and whether patients with heart disease are able to safely access center-based exercise training and cardiac rehabilitation (CR). This commentary provides an experience-based overview of how one health system quickly developed and applied inclusive policies to allow patients to have safe and effective access to exercise-based CR.

Mortality in patients with STEMI-associated cardiogenic shock (CS) is increasing. Whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) can improve their care delivery and mortality is unknown. We evaluated the impact of a CSP on incidence and outcomes in patients with STEMI-associated CS. We implemented a 4-step CSP including: (1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). We studied 1,272 consecutive STEMI patients who underwent PCI and assessed for CS incidence per National Cardiovascular Data Registry definitions within 24-hours of PCI, care delivery, and mortality before (January 1, 2011, to July 14, 2014; n = 723) and after (July 15, 2014, to December 31, 2016; n = 549) CSP implementation. Following CSP implementation, CS incidence was reduced (13.0% vs 7.8%, p = 0.003). Of 137 CS patients, 43 (31.4%) were in the CSP group. CSP patients had greater IABP-Shock II risk scores (1.9 ± 1.8 vs 2.8 ± 2.2, p = 0.014) with otherwise similar hemodynamic and baseline characteristics, cardiac arrest incidence, and mechanical circulatory support use. Administration of guideline-directed medical therapy was similar (89.4% vs 97.7%, p = 0.172) with significant improvements in trans-radial PCI (9.6% vs 44.2%, p < 0.001) and door-to-balloon time (129.0 [89:160] vs 95.0 [81:116] minutes, p = 0.001) in the CSP group, translating to improvements in infarct size (CK-MB 220.9 ± 156.0 vs 151.5 ± 98.5 ng/ml, p = 0.005), ejection fraction (40.8 ± 14.5% vs 46.7 ± 14.6%, p = 0.037), and in-hospital mortality (30.9% vs 14.0%, p = 0.037). In conclusion, CSP implementation was associated with improvements in CS incidence, infarct size, ejection fraction, and in-hospital mortality in patients with STEMI-associated CS. This strategy offers a potential solution to bridging the historically elusive gap in their care.

Introduction: Guidewire retention after intravascular catheter insertion is considered a “never event.” Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. Methods: All consecutive incidents of guidewire retention across 10 hospitals within the Cleveland Clinic Health System in Ohio from August 2007 to October 2015 were prospectively identified and retrospectively analyzed. Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention including patient, operator, and procedural characteristics. Results: A total of 24 guidewire retention events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m 2 . A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, 3 (12%) were performed by first-year trainees, 7 (29%) by residents, 3 (12%) by fellows, and 4 (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8AM - 5PM). In total, 22 (92%) guidewires were inserted non-emergently, with 2 (8%) during a cardiac arrest. Ultrasound guidance was used in all but 1 case. Conclusion: Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.

Introduction: Social determinants of health have an established impact on cardiovascular outcomes. STEMI quality improvement programs have resulted in reductions in door to balloon time (D2BT) and improved STEMI outcomes nationally. We evaluated whether a comprehensive STEMI protocol (CSP) improves care and outcomes in patients with moderate and high socioeconomic deprivation. Methods: Patients with STEMI treated with PCI at a single tertiary care hospital before (1/1/11-7/14/14, n=674) and after (7/15/14-7/15/19, n=1087) implementation of a CSP were included. Patients were stratified into low ( < 50 th percentile), medium (51-90 th percentile), and high (>90 th percentile) deprivation groups based on census block group level area deprivation index. Outcomes were D2BT and mortality. Results: Neighborhood deprivation was 29.0% low (174 pre-CSP, 338 post-CSP), 40.8% moderate (268 pre, 450 post), and 30.2% high (232 pre, 299 post). Female sex (low 28.3%, moderate 31.9%, high 38.6%, p=0.001) and black race (2.5%, 20.7%, 61.8%, p Conclusions: A CSP was associated with improvements in D2BT across all deprivation groups and a substantial mortality reduction in moderate/high deprivation groups. Standardized quality improvement initiatives may mitigate social determinants of health in time-sensitive high acuity conditions such as STEMI.

Background: Optimizing STEMI care processes for African Americans is a critical matter with important public health implications. We aimed to study if a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) could improve key process metrics in the African American (AA) population. Methods: We developed a 4-step CSP which included, 1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). Baseline characteristics and procedural characteristics were compared between all consecutive STEMI patients who underwent PCI at the Cleveland Clinic main campus between January 1, 2011, to July 14, 2014 (pre-CSP group) and July 15, 2014, to July 15, 2019 (post-CSP group). Results: There were a total of 208 AA patients in the pre-CSP group compared to 271 AA patients in the post-CSP group. Baseline characteristics were quite similar between the two groups except for a lower rate of MI in the post-CSP group (45% vs 30%, P=0.001). After implementation of our CSP, guideline-directed medical therapy increased from 71.6% to 81.9% (P=0.011), radial utilization went up from 14.4% to 73.8% (P Conclusion: Implementing a CSP was able to significantly improve the key STEMI process metrics for African American patients. Optimizing key STEMI process metrics is an important initiative to ensure equitable STEMI care.

Background We evaluated whether a comprehensive ST‐segment–elevation myocardial infarction protocol (CSP) focusing on guideline‐directed medical therapy, transradial percutaneous coronary intervention, and rapid door‐to‐balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011–July 14, 2014) and after (July 15, 2014– July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st –90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door‐to‐balloon time. Achievement of guideline‐recommend door‐to‐balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all P P noninferiority high versus moderate = 0.002, high versus low P =0.002) and risk‐adjusted (OR, 0.42 [95% CI, 0.23–0.77]; P =0.005) models. Conclusions A CSP was associated with improved ST‐segment–elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time‐sensitive conditions such as ST‐segment–elevation myocardial infarction.

Background Cardiac telemetry monitoring is widely utilized for a variety of clinical indications, yet indication‐specific event rates for monitored patients are seldomly reported. Hypothesis High‐risk hospitalized patients for clinical deterioration can be identified using standardized telemetry monitoring indications. Methods Adjudicated data from events triggering emergency response team (ERT) activation were systematically characterized at the Cleveland Clinic from among standardized telemetry indications ordered over a 13‐month period. Results Among 72 199 orders created for telemetry monitored patients, ERT activation occurred in 2677 patients (3.7%), of which 1326 (49.5%) were cardiac‐related. Patients with deep venous thrombosis or pulmonary embolism (DVT/PE) demonstrated the highest overall event rate (ERT: n = 41 of 593 pts [6.9%]; 25/41 cardiac related [61%]). Cardiac‐related events were proportionally highest among patients with coronary disease awaiting revascularization (ERT: n = 19 of 847 patients [2.2%]; 13/19 cardiac‐related [68.4%]). Arrhythmia‐specific events were highest among patients who underwent cardiac surgery (n = 78 of 193 cardiac‐related ERT [40.4%]), and patients with known or suspected tachyarrhythmias (n = 318 of 788 cardiac‐related ERT [40.4%]). Bubble plot analysis identified patients hospitalized with DVT/PE, drug or alcohol exposures, and acute coronary syndrome as among the highest overall and cardiac‐related events while identifying patients with respiratory disorder monitoring indications as carrying the highest noncardiac event rate. Conclusion High‐risk hospitalized patients can be identified by telemetry indication and prioritized according to concerns for cardiac, arrhythmia‐specific and noncardiac clinical deterioration. This is particularly useful when monitored bed resources are constrained.

Aims To determine whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol is associated with reduced sex disparities over 5 years. Methods and results This was an observational cohort study of 1833 consecutive STEMI patients treated with percutaneous coronary intervention (PCI) before (1 January 2011–14 July 2014, control group) and after (15 July 2014–15 July 2019, protocol group) implementation of a protocol for early guideline-directed medical therapy (GDMT), rapid door to balloon time (D2BT), and use of trans-radial PCI. In the control group, females had less GDMT (77.1% vs. 68.1%, P = 0.03), similarly low trans-radial PCI (19.0% vs. 17.6%, P = 0.73), and longer D2BT [104 min (79, 133) vs. 112 min (85, 147), P = 0.02] corresponding to higher in-hospital mortality [4.5% vs. 10.3%, odds ratio (OR) 2.44 (1.34–4.46), P = 0.004], major adverse cardiac and cerebrovascular events [MACCE, 9.8% vs. 16.3%, OR 1.79 (1.14–2.84), P = 0.01], and net adverse clinical events [NACE, 16.1% vs. 28.3%, OR 2.06 (1.42–2.99), P < 0.001]. In the protocol group, no significant sex differences were observed in GDMT (87.2% vs. 86.4%, P = 0.81) or D2BT [85 min (64–106) vs. 89 min (65–111), P = 0.06], but trans-radial PCI was used less in females (77.6% vs. 71.2%, P = 0.03). In-hospital mortality [2.5% vs. 4.4%, OR 1.78 (0.91–3.51), P = 0.09] and MACCE [9.0% vs. 11.1%, OR 1.27 (0.83–1.92), P = 0.26] were similar between sexes, but higher NACE in females approached significance [14.8% vs. 19.4%, OR 1.38 (0.99–1.92), P = 0.05] due to higher bleeding risk [7.2% vs. 11.1%, OR 1.60 (1.04–2.46), P = 0.03]. Conclusions A comprehensive STEMI protocol was associated with sustained reductions for in-hospital ischaemic outcomes over 5 years, but higher bleeding rates in females persisted.

Pregnancy-associated myocardial infarction is a principal cause of cardiovascular disease with a steadily rising incidence of 4.98 AMI events/100,000 deliveries over the last four decades in the USA. It is also linked with significant maternal and fetal morbidity and mortality, with maternal case fatality rate ranging from 5.1 to 37%. The management of acute myocardial infarction can be challenging in pregnant patients since treatment modalities and medication use are limited by their safety during pregnancy. Limited guidelines exist regarding the management of pregnancy-associated myocardial infarction. Routinely used medications in myocardial infarction including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and statin therapy are contraindicated during pregnancy. Aspirin use is considered safe in pregnant women, but dual antiplatelet therapy and therapeutic anticoagulation can be associated with increased risk of maternal and fetal complications, and should only be used after a comprehensive benefit-to-risk assessment. The standard approach to revascularization requires additional caution in pregnant women. Percutaneous coronary intervention is generally considered safe but can be associated with high failure rates and poor outcomes depending on the etiology. Fibrinolytic therapy may have significant sequelae in pregnant patients, and hemodynamic management during surgery is complex and adds risk during pregnancy. Understanding the risks and benefits of the different treatment modalities available and their utility depending on the underlying etiology, encompassed with a multidisciplinary team approach, is vital to improve outcomes and minimize maternal and fetal complications.

Background We aimed to understand the characteristics and outcomes of patients readmitted with a recurrent myocardial infarction (RMI) within 90 days of discharge after an acute myocardial infarction (early RMI). Methods and Results We analyzed the timing of reinfarction, etiology, and outcome for all patients admitted with an early RMI within 90 days of discharge after an acute myocardial infarction between January 1, 2010 and January 1, 2017. We identified 6626 admissions for acute myocardial infarction (index myocardial infarction) which led to 168 cases of RMI within 90 days of discharge. The mean patient age was 65.1±13.1 years, and 37% were women. The 90‐day probability of readmission with an early RMI was 2.5%. Black race, medical management, higher troponin T, and shorter length of stay were independent predictors of early RMI. Medically managed group had a higher risk for early RMI compared with percutaneous coronary intervention ( P =0.04) or coronary artery bypass grafting ( P =0.2). Predominant mechanisms for reinfarction were stent thrombosis (17%), disease progression (12%), and unchanged coronary artery disease (11%). At 5 years, the all‐cause mortality rate for patients with an early RMI was 49% (95% CI, 40%–57%) compared with 22% (95% CI, 21%–23%) for patients without an early RMI ( P Conclusions Early RMI is a life‐threatening condition with nearly 50% mortality within 5 years. Stent‐related events and progression in coronary artery disease account for most early RMI. Medication compliance, aggressive risk factor management, and care transitions should be the cornerstone in preventing early RMI.

The role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents.To examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach.PubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised50% of patients receiving either percutaneous or surgical revascularization, and50% of patients must have received aspirin and statin as OMT in both arms.Seven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at -0.002 (95% CrI: -0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT0). The ARD for cardiac mortality was centred at -0.0025 (95%CrI: -0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT0). The ARD for MI was -0.02 (95% CrI: -0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT0, and 6% probability of ARD for stroke with revascularization vs. OMT0.Bayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone.The protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540].

Handwritten Mathematical Expression recognition and grading system is a challenging task in the field of pattern recognition. A lot of researchers have already worked on Handwritten Mathematical Expression recognition and have used various classifiers. In past, Convolutional Neural Network, also called CNN, has been highly used for recognizing patterns. In this paper, We propose an idea to recognize HME and evaluate offline using CNN for classification. The steps included are, first the worksheet is scanned and is sent to the work-spaces detection module where it will return all the rectangular work-spaces from the given worksheet, then the workspaces are sent to the line extraction module to extract all the lines. The extracted lines are then passed to the character segmentation module where it will segment the character and then characters will be classified using deep learning model DCCNN. Finally, the evaluation module will assess the line and draw a green/red bounding box depending on whether the line is correct or not.

The recommended duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention with a drug-eluting stent has changed from 1 year for all to a more personalized approach based on the patient's risks of ischemia and bleeding. The trend is toward shorter treatment in view of lower rates of late and very late stent thrombosis with newer drug-eluting stents and the risk of bleeding with DAPT. But some patients at high risk of ischemic events and low risk of bleeding may benefit from longer treatment.

Outpatient follow-up after hospital discharge improves continuity of care and reduces readmissions, but rates of follow-up remain low. It is not known whether electronic medical record (EMR)-based tools improve follow-up. The aim of this study was to determine if an EMR-based order to secure cardiology follow-up appointments at hospital discharge would improve follow-up rates and hospital readmission rates. A pre-post interventional study was conducted and evaluated 39,209 cardiovascular medicine discharges within an academic center between 2012 and 2017. Follow-up rates and readmission rates were compared during 2 years prior to EMR-order implementation (pre-order era 2012–2013, n = 12,852) and 4 years after implementation (EMR-order era 2014–2017, n = 26,357). The primary endpoint was 90-day cardiovascular follow-up rates within our health system. In the overall cohort, the mean age of patients was 69.3 years [SD 14.7] and 60.7% (n = 23,827) were male. In the pre-order era, 90-day follow-up was 56.7 ± 0.4% (7286 of 12,852) and increased to 67.9 ± 0.3% (17,888 of 26,357, P P P = 0.016) in the EMR-order era. An EMR-based appointment order for follow-up appointment scheduling was associated with increased cardiovascular medicine follow-up, but was not associated with an observed reduction in 30-day readmission rates.

Despite decades of improvement in the quality and outcomes of cardiovascular care, significant gaps remain. Existing quality improvement strategies are often limited in scope to specific clinical conditions and episodic care. Health services and outcomes research is essential to inform gaps in care but rarely results in the development and implementation of care delivery solutions. Although individual health systems are engaged in projects to improve the quality of care delivery, these efforts often lack a robust study design or implementation evaluation that can inform generalizability and further dissemination. Aligning the work of health care systems and health services and outcomes researchers could serve as a strategy to overcome persisting gaps in cardiovascular quality and outcomes. We describe the inception of the Cardiovascular Quality Improvement and Care Innovation Consortium that seeks to rapidly improve cardiovascular care by (1) developing, implementing, and evaluating multicenter quality improvement projects using innovative care designs; (2) serving as a resource for quality improvement and care innovation partners; and (3) establishing a presence within existing quality improvement and care innovation structures. Success of the collaborative will be defined by projects that result in changes to care delivery with demonstrable impacts on the quality and outcomes of care across multiple health systems. Furthermore, insights gained from implementation of these projects across sites in Cardiovascular Quality Improvement and Care Innovation Consortium will inform and promote broad dissemination for greater impact.

Introduction: Survivors of Myocardial Infarction (MI) remain at increased risk for another cardiovascular event. The purpose of our study was to assess the role of index treatment strategy in developing early recurrent MI after acute MI. Methods: We analyzed all cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017, and identified all cases of recurrent MI within 90 days of index MI. Early recurrent MI cases were further stratified depending on the treatment strategy for index MI. Reinfarctions were also stratified according to the time of readmission into early (0-30 days after discharge) and late (30-90 days after discharge) time periods. Results: We identified 6,626 patients admitted with an acute MI and 168 cases of recurrent MI within 90 days of discharge. Among the index MI patients, 4354 (66%) patients underwent revascularization whereas 2272 (34%) underwent medical management. An unadjusted comparison of the risk of readmission among the 3 different revascularization strategies showed that the CABG group appeared to have the lowest risk of readmission with a recurrent MI, and there was no significant difference in the late risk of readmission between PCI and CABG groups (P=0.8). The medically managed group had the highest late risk of readmission with a recurrent MI. Conclusions: The risk of readmission with a recurrent MI is higher in patients who undergo medical management for index MI. Aiming to improve the standard of care in these patients should be the focal point of interest to curb these reinfarctions.

The COVID-19 pandemic has dramatically impacted healthcare delivery worldwide. In hotspot areas such as Wuhan, Lombardy, and New York City, the disease has forced hospitals to focus on COVID-19 patients. Anecdotal reports have suggested that the pandemic has led to a decrease in patients presenting to these hospitals with serious cardiovascular and neurologic diseases such as ST-elevation myocardial infarction (STEMI) and stroke. We sought to measure the impact of the COVID-19 pandemic on emergency transfers for STEMI, stroke, and acute aortic emergencies within our regional health system.

Key Points Question Is psychological, social, and economic stress associated with coronavirus disease 2019 (COVID-19) associated with the incidence of stress cardiomyopathy? Findings This cohort study included 1914 patients with acute coronary syndrome to compare patients presenting during the COVID-19 pandemic with patients presenting across 4 timelines prior to the pandemic and found a significantly increased incidence of 7.8% of stress cardiomyopathy during the COVID-19 pandemic, compared with prepandemic incidences that ranged from 1.5% to 1.8%. Meaning These findings suggest that psychological, social, and economic stress related to the COVID-19 pandemic was associated with an increased incidence of stress cardiomyopathy., This cohort study compares the incidence of stress cardiomyopathy among patients presenting with acute coronary syndrome at 2 Ohio hospitals during the coronavirus disease 2019 pandemic vs prepandemic time points., Importance The coronavirus disease 2019 (COVID-19) pandemic has resulted in severe psychological, social, and economic stress in people’s lives. It is not known whether the stress of the pandemic is associated with an increase in the incidence of stress cardiomyopathy. Objective To determine the incidence and outcomes of stress cardiomyopathy during the COVID-19 pandemic compared with before the pandemic. Design, Setting, and Participants This retrospective cohort study at cardiac catheterization laboratories with primary percutaneous coronary intervention capability at 2 hospitals in the Cleveland Clinic health system in Northeast Ohio examined the incidence of stress cardiomyopathy (also known as Takotsubo syndrome) in patients presenting with acute coronary syndrome who underwent coronary arteriography. Patients presenting during the COVID-19 pandemic, between March 1 and April 30, 2020, were compared with 4 control groups of patients with acute coronary syndrome presenting prior to the pandemic across 4 distinct timelines: March to April 2018, January to February 2019, March to April 2019, and January to February 2020. Data were analyzed in May 2020. Exposures Patients were divided into 5 groups based on the date of their clinical presentation in relation to the COVID-19 pandemic. Main Outcomes and Measures Incidence of stress cardiomyopathy. Results Among 1914 patient presenting with acute coronary syndrome, 1656 patients (median [interquartile range] age, 67 [59-74]; 1094 [66.1%] men) presented during the pre–COVID-19 period (390 patients in March-April 2018, 309 patients in January-February 2019, 679 patients in March-April 2019, and 278 patients in January-February 2020), and 258 patients (median [interquartile range] age, 67 [57-75]; 175 [67.8%] men) presented during the COVID-19 pandemic period (ie, March-April 2020). There was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 period, with a total of 20 patients with stress cardiomyopathy (incidence proportion, 7.8%), compared with prepandemic timelines, which ranged from 5 to 12 patients with stress cardiomyopathy (incidence proportion range, 1.5%-1.8%). The rate ratio comparing the COVID-19 pandemic period to the combined prepandemic period was 4.58 (95% CI, 4.11-5.11; P

Background: Acute treatment of ST-elevation myocardial infarction (STEMI) has focused on early reperfusion, prompt defibrillation, and appropriate mechanical support to mitigate short-term mortality. Long-term patterns of death in a contemporary population are not well described. Methods: We reviewed consecutive cases of STEMI treated with percutaneous coronary intervention (PCI) at our center between January 1, 2011, and December 31, 2016, and divided patients into two groups: uncomplicated STEMI (US) and complicated STEMI (CS). CS was defined by presence of cardiac arrest or cardiogenic shock, ascertained from first-medical-contact to device time for PCI. We assessed for differences in characteristics and short- and long-term mortality between the groups. Results: We identified 1,272 patients with STEMI; 214 of which were CS (16.8%). Those with CS were significantly more likely to have heart failure (22.9% vs 11.3%, p Conclusion: Despite advances in the in-hospital care of patients with STEMI, there remains a significant risk of long-term mortality for both patients with uncomplicated and complicated STEMI. A substantial proportion of overall STEMI mortality now occurs after hospital discharge predominantly due to non-cardiovascular causes. Systems of care to mitigate this long-term risk are needed.

Background: Though the prevalence of coronary artery disease is known to be highest in African Americans, it is unclear if there are any racial factors predisposing patients for a recurrent Myocardial Infarction (MI) after index MI. Methods: We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017 (29% STEMI, 71% NSTEMI), and we identified all cases of recurrent MI within 90 days of discharge after index MI. The patients were categorized according to their corresponding races into White Americans, African Americans, and Others. Result: Out of the 6626 initial cases of MI, 72% were white patients, 25% were African Americans and 3% belonged to other races. A total of 2051 patients were readmitted within 90 days of index admission, of which 168 patients were readmitted with an MI. Only 2.1% of White patients developed a recurrent MI whereas 4% of African Americans were readmitted with a recurrent MI (P=0.003). Conclusion: We observed that African Americans were more likely to be readmitted with a recurrent MI than White Americans. Understanding the reasons for this increased risk in MI can translate into improved care for African Americans.

Background: Readmissions following acute myocardial infarction (MI) are associated with increased cost, healthcare utilization, and morbidity. The purpose of this study was to assess racial factors in influencing time for readmission after being admitted with myocardial infarction. Methods: We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017 (29% STEMI, 71% NSTEMI), and we identified all readmissions within 90 days after index MI. The patients were categorized according to their race into White Americans (72%), African Americans (25%) and others (3%). Readmissions were stratified into early (0-30 days) and late (31-90 days) time periods depending on the timing of readmission and these readmissions were also separated according to their corresponding race into White Americans (62%), African Americans (35%) and others (3%). Since White Americans and African Americans contributed to the bulk of our patient population, we analyzed the difference between these two groups. Results: There were a total of 2051 readmissions within 90 days after index MI. Overall, 50% of readmissions were in the early time period and 50% in the late period (after 30 days). 46% of African Americans were readmitted in the early time period compared to 52% of white patients whereas 54% of African Americans were readmitted in the late time period compared to 48% of white patients (P=0.0037). Conclusions: The temporal pattern of readmissions after myocardial infarction differed between Whites and African Americans. These findings may have implications regarding the development of readmission reduction strategies.

Background: It is unclear how revascularization strategy (medical management vs percutaneous coronary intervention vs coronary artery bypass surgery), affects 90-day readmissions after Non-ST Elevation Myocardial Infarction (NSTEMI). Methods: We identified cases of NSTEMI at a single quaternary care medical center between January 1 st , 2010 to January 1 st , 2017 and readmissions within 90 days. Cases were categorized based on revascularization strategy into medical management, PCI (percutaneous coronary intervention) or CABG (coronary artery bypass surgery). The readmissions were categorized according to the time of readmission into early (0-30 days) and late (31-90 days) after discharge. The instantaneous risk of readmission following each treatment option was calculated using the parametric method. Results: We identified 6626 patients with index MI, of which 4692 patients had NSTEMI. There were a total of 2051 readmissions within 90 days. The risk of readmission for CABG and PCI treatment groups yielded an early peaking phase followed by a constant risk whereas the risk of readmission in the medically managed group showed an early decreasing phase followed by a constant risk. An unadjusted comparison of the risk of readmission between the three groups showed that the PCI group had the lowest early risk of readmission (P=0.03). The medically managed group had the highest risk of readmission. Conclusion: Patients with NSTEMI who are medically managed appear to be at higher risk for readmission than revascularized patients. Understanding the care processes for these patients may serve as a future opportunity to improve outcomes in these high-risk patients.

Background: Recurrent Myocardial Infarction (MI) after an index MI is a cause for considerable morbidity and mortality. However, the underlying factors that precipitate patients for a recurrent MI remain unclear. We aimed to assess the effect of index MI treatment strategy on the risk of developing a recurrent MI. Methods: We reviewed all cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017 and identified all cases of recurrent MI within 90 days after index MI. Readmissions were further stratified depending on the treatment strategy undertaken during index MI into medically managed and revascularized patients. The instantaneous risk of readmission following each of these treatment strategies was estimated by the parametric method. Results: We identified 6,626 patients admitted with an index MI, of which 168 patients were readmitted with a recurrent MI within 90 days. Among the index admissions, 4354 (66%) patients underwent revascularization and 2272 (34%) patients underwent medical management. Time-varying instantaneous risk of readmission analysis showed an early peaking risk followed by a late increasing risk in the revascularization group whereas, in the medically managed group, the analysis yielded an early peaking followed by a late almost constant risk of readmission for MI. Conclusion: Patients with acute MI who are medically treated are at a higher risk of developing a recurrent MI than patients who undergo revascularization. Defining the characteristics and underlying factors contributing to these readmissions can be pivotal in improving patient outcomes.

Background: Several comorbidities are known to increase the risk of coronary artery disease. However, the relationship between modifiable risk factors and recurrent Myocardial Infarction (MI) has not been clearly defined. The purpose of our study was to assess if there were certain comorbidities that increase the risk of recurrent myocardial infarction. Methods: We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017 (29% STEMI, 71% NSTEMI), and we identified all cases of readmission with a recurrent MI within 90 days after index MI. All patients with index MI were screened for accompanying comorbidities and compared with patients with recurrent MI. Results: There were a total of 2051 readmissions (31%) within 90-days of index MI, of which 168 readmissions were for recurrent MI. Hypertension and Dyslipidemia appeared to be the most prominent modifiable risk factors in patients with index MI and recurrent MI (86%, 94% for HTN & 81%, 93% for DLP). All comorbidities were substantially more prevalent in patients with recurrent MI than in patients with index MI. Conclusion: Patients with recurrent MI have a higher risk factor burden than the general population with MI. This highlights the importance of risk factor management in patients with acute Myocardial infarction.

This study sought to report outcomes from an efficiency improvement project in a large cardiac cath lab.Operational inefficiencies are common in the cath lab, yet solutions are challenging. A detailed report describing and providing solutions for these inefficiencies may be valuable in guiding improvements in productivity.In this observational study, the authors report metrics of efficiency before and after a cath lab quality improvement program in June 2014. Main outcomes included lab room start times, room turnaround times, laboratory use, and employee satisfaction. Time series analysis was used to assess trend over time. Chi-square testing and analysis of variance were used to assess change before and after the initiative.The principal changes included implementation of a pyramidal nursing schedule, increased use of an electronic scheduling system, and increased utilization of a preparation and recovery area. Comparing before with after the program, start times improved an average of 17 min, and on-time starts improved from 61.8% to 81.7% (p = 0.0024). Turnaround times improved from 20.5 min to 16.4 min (trend p 0.0001), and the proportion of days at full lab utilization improved from 7.7% to 77.3% (p 0.00001). There were no increases in overtime, night, or weekend cases. There was a reduction in full time employees from 36.1 in 2013 to 29.6 in 2016, with an improvement in employee satisfaction.A systematic approach to reducing inefficiencies can improve cath lab start times, turnaround times, and overall productivity. This knowledge may be helpful in assisting other cath labs in similar efficiency improvement initiatives.

In a select group, a PCI-first strategy does not reduce the risk of death, but it does relieve angina sooner.

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

Previous studies have suggested that maternal supplementation with n-3 long-chain polyunsaturated fatty acids may reduce the incidence of preterm delivery but may also prolong gestation beyond term; however, more data are needed regarding the role of n-3 long-chain polyunsaturated fatty acids in pregnancy.We performed a multicenter, double-blind, randomized trial in which women who were pregnant with single or multiple fetuses were assigned to receive either fish-oil capsules that contained 900 mg of n-3 long-chain polyunsaturated fatty acids (n-3 group) or vegetable-oil capsules that contained trace n-3 long-chain polyunsaturated fatty acids (control group) daily, beginning before 20 weeks of gestation and continuing to 34 weeks of gestation or delivery, whichever occurred first. The primary outcome was early preterm delivery, defined as delivery before 34 completed weeks of gestation. Other pregnancy and neonatal outcomes were also assessed.A total of 5544 pregnancies in 5517 women were randomly assigned at six centers in Australia; 5486 pregnancies were included in the primary analysis. Early preterm delivery occurred in the case of 61 of 2734 pregnancies (2.2%) in the n-3 group and 55 of 2752 pregnancies (2.0%) in the control group; the between-group difference was not significant (adjusted relative risk, 1.13; 95% confidence interval [CI], 0.79 to 1.63; P = 0.50). There were no significant differences between the groups in the incidence of interventions in post-term (41 weeks of gestation) deliveries, in adverse events, or in other pregnancy or neonatal outcomes, except that a higher percentage of infants born to women in the n-3 group than in the control group were very large for gestational age at birth (adjusted relative risk, 1.30; 95% CI, 1.02 to 1.65). Percentages of serious adverse events did not differ between the groups. Minor gastrointestinal disturbances were more commonly reported in the n-3 group than in the control group.Supplementation with n-3 long-chain polyunsaturated fatty acids from early pregnancy (20 weeks of gestation) until 34 weeks of gestation did not result in a lower incidence of early preterm delivery or a higher incidence of interventions in post-term deliveries than control. (Funded by the Australian National Health and Medical Research Council and the Thyne Reid Foundation; ORIP Australian New Zealand Clinical Trials Registry number, ACTRN12613001142729.).

Background: Outpatient follow up after hospital discharge improves transitions in care, reduces readmissions, and may improve mortality. However, there is no convincing evidence that electronic medical record (EMR)-based tools increase rates of post-discharge follow up. We implemented an EMR-based appointment scheduling order to secure cardiology follow up appointments at the time of hospital discharge and measured the impact on outpatient follow up rates. Methods: We performed an analysis of 39,211 discharges from the cardiology services within an academic center between 2012 and 2017. In the pre-implementation era, scheduling of follow up was at the discretion of clinical team (2012-2013). The EMR-based order ensured patients had scheduled follow up at time of discharge (2014-2017). We monitored follow up rates for six years and compared pre- (2012-2013, n=12,853) and post-implementation (2014-2017, n=26,358) era rates of follow up using chi square analysis. Multivariate logistic regression analysis was used to adjust for patient demographics and payor status. Results: The average age of our patients was 69.3 ± 14.7 and 60.7% were male. A majority of our patients were white (75.7%) and on Medicare (62.8%). The average rate of follow up within 90 days in the pre-implementation era was 56.7% (7,286 of 12,854) and increased to 67.6% (17,816 of 26,357, P < 0.0001) in the post-implementation era. Annualized rates of 90 day follow up increased from 57% in 2012 to 70% in 2017 (2012: 57% (3,598 of 6,349), 2013: 57% (3,688 of 6,505), 2014: 66% (4,267 of 6,445), 2015: 67% (4,441 of 6,650), 2016: 68% (4,465 of 6,642), 2017: 70% (4,643 of 6,620, P Conclusion: An EMR-based order for follow up appointment scheduling is successful in improving cardiovascular medicine follow up independent of patient demographics or payor status. This benefit was sustained over four years post-implementation. EMR-based tools are an attractive solution to improve patient follow-up after hospital discharge.

Background: The merits of creating follow up appointments at discharge are increasingly recognized, but interventions rarely translate to sustained improvements. We implemented an EMR-based appointment order to secure cardiology appointments prior to discharge and measured its long-term sustainability over four years. Methods: We performed an analysis of 26,358 patients discharged from the cardiology services within an academic center between 2014 and 2017. The electronic follow up order went live on January 1 st , 2014. Once the order was entered by a provider in the medical record system, it was routed to a scheduling pool. A scheduler created the appointment, text paged the provider with confirmation, and entered the information in the patient’s discharge paperwork. We analyzed order utilization for four years using Kendall Tau B analysis to understand the impact and sustainability of this process. Results: Average age of the patient was 68.7 years and 61% were male. In the 26,358 patient discharges, 18,068 discharges had a follow up order placed (69%). Between 2014 and 2017, order utilization steadily increased from 50% to 77% (p=0.01). In 2014, 3,216 of 6,446 discharges utilized the order (50%). In 2015, 4,795 of 6,651 discharges utilized the order (72%). In 2016, 4,981 of 6,643 discharges utilized the order (75%). In 2017, 5,079 out of 6,621 discharges utilized the order (77%). Conclusion: The EMR-based follow up order is a sustainable mechanism for securing cardiology follow up appointments after hospital discharge. Higher rate of appointments created could translate into meaningful improvement of outcomes and reduce readmissions.

Background: There has been intense focus on 7 day follow up in congestive heart failure patients, but this approach has not been emphasized in all cardiology patients. We measured baseline early follow up rates and implemented an electronic medical record (EMR)-based order to secure early follow up at discharge for all cardiology patients. Methods: We performed an analysis of 39,211 patient discharges from the cardiovascular medicine services within an academic center between 2012 and 2017. In the pre-implementation era, scheduling of follow up appointments was at the discretion of clinical team. The EMR-based order scheduled appointments at time of discharge. The order provided an option for a 7 day visit with a physician assistant and/or 30 day follow up with the physician. Follow up rates were monitored for six years; pre (2012-2013) and post-implementation (2014-2017) era rates were compared using chi square analysis. Results: The average age of the patient was 69.3 ± 14.7, 60.7% were male, 75.7% were white and 20.8% were black. In the pre-implementation era between 2012 and 2013, average rate of follow up at 7 days after discharge was 13.4% (1,723 of 12,854). In the post-implementation era, the average rate of follow up at 7 days after discharge increased to 19.8% (5,225 of 26,357, p < 0.0001). Conclusion: An EMR-based appointment order led to improvement of 7 day follow up rates. However, absolute rates of follow up remained low indicating the need for further refinements of the process and patient engagement to increase follow up rates.

Background: Systems to improve ST-segment–elevation myocardial infarction (STEMI) care have traditionally focused on improving door-to-balloon time. However, prompt guideline-directed medical therapy and transradial primary percutaneous coronary intervention (PCI) are also associated with reduced STEMI mortality. The incremental prognostic value of each facet of STEMI care on clinical outcomes within a STEMI system of care is unknown. Methods and Results: We implemented systems-based strategies at our hospital to improve 3 STEMI care metrics: (1) prompt guideline-directed medical therapy before sheath insertion for PCI, (2) use of transradial primary PCI, and (3) door-to-balloon time. We assessed the incremental association of metrics achieved with in-hospital adverse events and 30-day mortality. Of 1272 consecutive patients with STEMI treated with PCI at our hospital (January 1, 2011, to December 31, 2016), the percentage with achievement of zero, 1, 2, or 3 STEMI care metrics was 7.1%, 24.1%, 43.8%, and 25.1%; and 30-day mortality was 15.6%, 8.6%, 3.6%, and 3.2%, respectively (log-rank P P =0.041). Each metric provided incremental prognostic value when modeled in stepwise order of their occurrence in clinical practice (final model C statistic, 0.677; P Conclusions: Prompt guideline-directed medical therapy before sheath insertion for PCI, transradial primary PCI, and door-to-balloon time add incremental prognostic value in STEMI care. Expanding STEMI systems of care from a singular focus on door-to-balloon time to a comprehensive focus on multifaceted STEMI care offers an opportunity to further improve STEMI outcomes.

To ensure that guidelines reflect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modified and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines (“Task Force”) has issued this focused update to revise guideline recommendations on the basis of recently published data. This update is not based on a complete literature review from the date of previous guideline publications, but it has been subject to rigorous, multilevel review and approval, similar to the full guidelines. For specific focused update criteria and additional methodological details, please see the ACC/AHA guideline methodology manual.1 ### Modernization In response to published reports from the Institute of Medicine2,3 and ACC/AHA mandates,4–7 processes have changed leading to adoption of a “knowledge byte” format. This entails delineation of recommendations addressing specific clinical questions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommodates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving technology (eg, smart phone apps), and supports the evolution of guidelines as “living documents” that can be …

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair [∗∗][1] Nancy M. Albert, PhD, RN, FAHA[∗∗][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD