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Multiple studies have examined the association of early coronary angiography (CAG) among out-of-hospital cardiac arrest (OHCA) patients with conflicting results. However, patterns of use of CAG among OHCA patients in real-world settings are not well-described.Utilizing data from the Resuscitation Outcomes Consortium's Continuous Chest Compressions trial for our analysis, we stratified patients based on initial arrest rhythm and ST-elevation on initial post-resuscitation electrocardiogram (ECG) and examined the rates of CAG in resuscitated patients. We also examined the rates of CAG across different trial clusters in the overall study population as well as in pre-specified patient subgroups RESULTS: Of 26,148 patients in the CCC trial, 5,608 survived to hospital admission and were enrolled in the study. Among them, 26 % underwent CAG. Patients with ST-elevation underwent CAG at a significantly higher rate than patients presenting without ST-elevation (70 % vs 31 %, p 0.001). Similarly, patients presenting with shockable rhythms underwent CAG more frequently compared with patients with non-shockable rhythms (28 % vs 5 %, p 0.001). There was marked variation in CAG frequency across different trial clusters with the proportion of patients within a trial cluster receiving CAG ranging from 4 % - 41 %. The proportion varied more among patients with ST-elevation (16 % - 82 %) or initial shockable rhythm (11 % - 75 %) compared with no ST-elevation (2 % - 28 %) or initial non-shockable rhythm (0 % - 19 %).Among a national cohort of OHCA patients, large variation in the use of CAG exists, highlighting the existing uncertainty regarding perceived benefit from early CAG in OHCA.

Background: Studies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival. Methods: Patients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants. Results: Among 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P P =0.009) and had WLST (32.8% versus 29.8%, P =0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P P =0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P =0.005; adjusted odds ratio, 0.74 [95% CI, 0.60–0.91]) or did not have WLST (32.3% versus 50.7%, P =0.002; adjusted odds ratio, 0.73 [95% CI, 0.60–0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P =0.90) or had WLST (2.8% versus 2.4%, P =0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort. Conclusions: Among patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.

Background: Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular tachycardia. How this might be influenced by the route of drug administration is not known. Methods: In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration. Results: Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 [95% CI, 1.06–1.50]; adjusted absolute survival difference, 5.5% [95% CI, 1.5–9.5]) and intravenous lidocaine (adjusted risk ratio, 1.21 [95% CI, 1.02–1.45]; adjusted absolute survival difference, 4.7% [95% CI, 0.7–8.8]); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 [95% CI, 0.66–1.32]) or intraosseous lidocaine (adjusted risk ratio, 1.03 [95% CI, 0.74–1.44]). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant. Conclusions: We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.

Introduction: Current patterns of use of coronary angiography (CAG) among out-of-hospital cardiac arrest (OHCA) patients based on ST segment elevation (STE) on post-resuscitation ECG are not well described. Methods: Using data from the Continuous Chest Compressions trial between 2011 and 2016, we identified OHCA patients who survived to hospitalization. We examined rates of CAG across different trial clusters in the overall cohort and among pre-specified subgroups with presumed cardiac etiology of arrest e.g. initial shockable rhythm and STE on presenting ECG. Results: Of 26,148 OHCA patients across 49 trial clusters, 5608 survived to hospital admission. The mean age of patients was 64 years, with 65% men and 43% with initial shockable rhythm. Among patients with initial shockable rhythm 44% had STE on initial ECG compared with 18% of patients with initial non-shockable rhythm. Use of CAG was significantly higher in patients presenting with STE compared with no STE on initial ECG irrespective of initial rhythm: 70% vs. 31%, pFigure ). This variation persisted among pre-specified subgroups with the proportion of patients within a trial cluster receiving CAG ranged from 11% - 75% for patients with initial shockable rhythm, 0% to 19% with initial non-shockable rhythm, 16% - 82% with STE, 2% - 28% without STE and 0% - 63% in patients with initial shockable rhythm and no STE on presenting ECG ( Figure ). Conclusion: There is a higher use of CAG in STE and shockable cardiac arrest, consistent with presumed cardiac etiology of arrest; however, there is large variation in the use of CAG across sites, even among patients with a presumed cardiac etiology of cardiac arrest suggesting challenges with interpretation of current guidelines.

Background Cardiac troponin is routinely tested in the post-cardiac arrest setting, but its utility in identifying ischaemic aetiology and predicting left ventricular systolic dysfunction (LVSD) and survival is not known. Methods In a retrospective single center registry, we identified 145 consecutive patients who had achieved return of spontaneous circulation after cardiac arrest and had undergone serial cardiac troponin T (cTnT) testing, echocardiogram, and expert adjudication of aetiology. Initial and peak cTnT were evaluated for assessing ischaemic aetiology, LVSD, and survival to discharge using area under the receiver operating characteristic curve (AUROC). Results Mean age was 61 ± 14 years and 71% were men. Of the 145 arrests, 19% had an ischaemic aetiology, 68% had LVSD post-arrest, and 55% survived to discharge. All patients had a positive initial cTnT at 0.01 ng/mL (clinical cut-off). Even at higher cut-offs of 10×, 100× and 1000×, initial cTnT performed poorly (AUROC 0.57, 0.56, and 0.56) and peak cTnT performed modestly (AUROC 0.55, 0.61, and 0.62) as diagnostic tests for ischaemic aetiology. Similarly, even at higher cut-offs, initial (AUROC 0.60, 0.62, 0.55) and peak (AUROC 0.57, 0.61, and 0.62) cTnT performed poorly to modestly at predicting LVSD. The test performed poorly for predicting survival to discharge (AUROC for all Conclusions At both current and several-fold higher thresholds, cTnT does not perform sufficiently well to guide clinical decision-making or predict patient outcomes. Routine post-cardiac arrest testing of cTnT should be reevaluated.

Background Emerging evidence links acute kidney injury (AKI) in patients with COVID‐19 with higher mortality and respiratory morbidity, but the relationship of AKI with cardiovascular disease outcomes has not been reported in this population. We sought to evaluate associations between chronic kidney disease (CKD), AKI, and mortality and cardiovascular outcomes in patients hospitalized with COVID‐19. Methods and Results In a large multicenter registry including 8574 patients with COVID‐19 from 88 US hospitals, data were collected on baseline characteristics and serial laboratory data during index hospitalization. Primary exposure variables were CKD (categorized as no CKD, CKD, and end‐stage kidney disease) and AKI (classified into no AKI or stages 1, 2, or 3 using a modification of the Kidney Disease Improving Global Outcomes guideline definition). The primary outcome was all‐cause mortality. The key secondary outcome was major adverse cardiac events, defined as cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, new‐onset nonfatal heart failure, and nonfatal cardiogenic shock. CKD and end‐stage kidney disease were not associated with mortality or major adverse cardiac events after multivariate adjustment. In contrast, AKI was significantly associated with mortality (stage 1 hazard ratio [HR], 1.72 [95% CI, 1.46–2.03]; stage 2 HR, 1.83 [95% CI, 1.52–2.20]; stage 3 HR, 1.69 [95% CI, 1.44–1.98]; versus no AKI) and major adverse cardiac events (stage 1 HR, 2.17 [95% CI, 1.74–2.71]; stage 2 HR, 2.70 [95% CI, 2.07–3.51]; stage 3 HR, 3.06 [95% CI, 2.52–3.72]; versus no AKI). Conclusions This large study demonstrates a significant association between AKI and all‐cause mortality and, for the first time, major adverse cardiovascular events in patients hospitalized with COVID‐19.

Introduction: Since March, the CDC has reported weekly excess deaths of up to 40% in the US. Spikes in excess deaths were associated with spikes in COVID-19 cases. In Texas, 55% of excess deaths from March 1 to May 30, 2020 were unattributed to COVID-19. One possible source of this unaccounted excess death is out-of-hospital cardiac arrest, which corresponds to a notable decline in hospitalizations for acute cardiovascular events. Objective: To compare the number of out-of-hospital cardiac arrest (OOHCA) and dead-on-scene cases in Dallas, Texas in years prior to and during the COVID-19 pandemic. Methods: The Dallas-Fort Worth Center for Resuscitation Research Cardiac Arrest Registry provided data for this IRB-approved study. Eligible cases were non-traumatic OOHCAs who received cardiopulmonary resuscitation (CPR) from emergency medical services (EMS) providers. We compared monthly case numbers in 2017, 2018, and 2019 with case numbers in 2020 at the time of the COVID-19 pandemic in Dallas, TX. Additionally, we compared the numbers of non-traumatic deaths (declared dead on scene without receiving CPR from EMS providers) in the same timeframes. Results: While total counts of out-of-hospital cardiac arrest during the months of March to June decreased from 2017 to 2019 by 9.2% and 1.2% respectively, the number of cardiac arrest cases rose dramatically by 47.9% in 2020 (p < 0.05).(Table) The percentage of OOHCAs with an initial rhythm of asystole increased as well, from 50.1% in 2018 and 2019 to 60.4% in 2020. The total number of dead-on-scene cases was also higher in March to June 2020 than in 2017 to 2019 (NS). Conclusion: Increased out-of-hospital cardiac arrest is likely contributing to the unattributed excess deaths noted during the months of the COVID-19 pandemic in Dallas, TX. The rise in cases may be indirectly attributable to COVID-19 as cardiovascular events go untreated or treated too late.

Objectives The authors performed a meta-analysis of randomized controlled trials to compare the efficacy of initial endovascular treatment with or without supervised exercise training (SET) versus SET alone in patients with intermittent claudication. Background Current guidelines recommend SET as the initial treatment modality for patients with intermittent claudication, in addition to optimal medical therapy. The role of endovascular therapy as primary treatment for claudication has been controversial. Methods The primary outcome was treadmill-measured maximal walk distance at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance on follow-up. Risk of revascularization or amputations was also compared. Pooled estimates of the difference in outcomes between endovascular therapy with or without SET and SET-only groups were calculated using fixed and random effects models. Results A total of 987 patients from 7 trials were included. In pooled analysis, compared with SET only (reference group), patients that underwent combined endovascular therapy and SET had significantly higher maximum walk distance (standardized mean difference 0.79 [95% confidence interval (CI): 0.18 to 1.39]; weighted mean difference 98.9 [95% CI: 31.4 to 166.4 feet], and lower risk of revascularization or amputation (odds ratio 0.19 [95% CI: (0.09 to 0.40]; p Conclusions Compared with initial SET only, endovascular therapy in combination with SET is associated with significant improvement in total walking distance, ABI, and risk of future revascularization or amputation. By contrast, endovascular therapy-only was not associated with any improvement in functional capacity or clinical outcomes over an intermediate duration of follow-up.

Therapeutic hypothermia, or targeted temperature management (TTM), is a strategy of reducing the core body temperature of survivors of sudden cardiac arrest (SCA) to minimize neurological damage caused by severe hypoxia. Initial clinical trials examining this technique demonstrated significant improvement in neurological function among survivors of out-of-hospital SCA with an initial shockable rhythm. Since then, TTM has become an integral part of the care provided to comatose survivors of SCA. However, multiple questions persist regarding the target cooling temperature, duration of cooling, and utility of TTM in patient populations such as survivors of out-of-hospital SCA with non-shockable rhythms or in-hospital SCA. This review article summarizes the current evidence regarding optimal application of TTM and compares the recommendations for TTM in current guidelines.

Background Cholesterol efflux capacity (CEC), which is a key step in the reverse cholesterol transport pathway, is independently associated with atherosclerotic cardiovascular disease (ASCVD). However, whether it predicts ASCVD beyond validated novel risk markers is unknown. Objectives This study assessed if CEC improved ACSVD risk prediction beyond using coronary artery calcium (CAC), family history (FH), and high-sensitivity C-reactive protein (hs-CRP). Methods CEC, CAC, self-reported FH, and hs-CRP were assessed among participants without baseline ASCVD who were enrolled in the Dallas Heart Study (DHS). ASCVD was defined as a first nonfatal myocardial infarction (MI) or stroke, coronary revascularization, or cardiovascular death, assessed over a median 9.4 years. Risk prediction was assessed using various modeling techniques and improvements in the c -statistic, the integrated discrimination index (IDI), and the net reclassification index (NRI). Results The mean age of the population (N = 1,972) was 45 years, 52% had CAC (>0), 31% had FH, and 58% had elevated hs-CRP (≥2 mg/l). CEC greater than the median was associated with a 50% reduced incidence of ASCVD in those with CAC (5.4% vs. 10.5%; p = 0.003), FH (5.8% vs. 10%; p = 0.05), and elevated hs-CRP (3.8% vs. 7.9%; p = 0.004). CEC improved all metrics of discrimination and reclassification when added to CAC ( c -statistic, p = 0.004; IDI, p = 0.02; NRI: 0.38; 95% confidence interval [CI]: 0.13 to 0.53), FH ( c -statistic, p = 0.006; IDI, p = 0.008; NRI: 0.38; 95% CI: 0.13 to 0.55), or elevated hs-CRP ( c -statistic p = 0.008; IDI p = 0.02; NRI: 0.36; 95% CI 0.12 to 0.52). Conclusions CEC improves ASCVD risk prediction beyond using CAC, FH, and hs-CRP and warrants consideration as a novel ASCVD risk marker.

Background: There is an urgent need to identify strategies which improve outcomes for out-of-hospital cardiac arrest (OHCA). Determining the optimal access route to deliver medications during resuscitation from OHCA may be one such strategy. Methods: Using data from the Continuous Chest compression trial between 2011 and 2016, we examined rates of sustained return of spontaneous circulation (ROSC) i.e. ROSC on ER arrival, survival to discharge and survival with favorable neurological function (modified Rankin scale ≤3) among patients with attempted IV and IO access. Results: Among 19,731 patients with available access information, IO or IV access was attempted in 3,068 (15.5%) and 16,663 (84.5%) patients, respectively and was successful in 2,975 (97%) and 15,485 (92%) of these patients. Overall, patients with attempted IO access were younger, more likely female, received less bystander CPR, had lower proportions of shockable and witnessed arrests, marginally faster times to access and to epinephrine administration, and less frequently received therapeutic hypothermia and coronary angiography as compared with patients with IV access ( Table ) . Unadjusted rates of sustained ROSC, discharge survival and survival with favorable neurological function were significantly lower in patients with attempted IO access ( Table) . After adjustment for age, sex, initial rhythm, bystander CPR, public location, witnessed status, EMS response time and trial cluster, attempted IO access was associated with lower sustained ROSC rates (OR 0.79, 95% CI 0.71-0.89, p Conclusions: Among patients with OHCA, intraosseous access was attempted in 1 in 7 OHCA patients and associated with worse ROSC rates but no difference in survival. Further studies are necessary to elucidate the optimal access route among OHCA patients.

Background: Previous studies examining sex-based differences among out-of-hospital cardiac arrest (OHCA) patients have been conflicting. Methods: Patients with OHCA enrolled in the Continuous Chest Compression trial between 2011 and 2016 were included in the present analysis. Hierarchical multivariable logistic regression models were constructed to evaluate the association between sex and sustained ROSC i.e. ROSC on ER arrival, discharge survival and survival with favorable neurological function after adjustment for age, witnessed status, presenting rhythm, public location, bystander CPR, resuscitation duration, and EMS response time. Results: Among 22,540 OHCA patients, 8,099 (35.9%) were women. Women were older (median 71 vs. 67 years), received less bystander CPR (45% vs. 47%), and had a lower proportion of cardiac arrests that were witnessed (39% vs. 45%) or had an initial shockable rhythm (15% vs. 28%, pTable ) but no difference in likelihood of discharge survival and survival with favorable neurological function. In the adjusted landmark analysis beginning after achieving ROSC, women had significantly lower likelihood of discharge survival and survival with favorable neurological function ( Table ) . Conclusions: Among resuscitated OHCA patients, women have a higher likelihood of achieving sustained ROSC despite a higher burden of poor prognostic factors. However, after successful ROSC, the likelihood of discharge survival is significantly lower in women (vs. men). Future studies are needed to understand how care provided post-ROSC may modify the sex-disparities in discharge survival outcomes.

To examine outcomes associated with intraosseous access route attempt for delivery of medications during out-of-hospital cardiac arrest (OHCA) resuscitation.Using data from the Continuous Chest Compression trial, we examined rates of survival to hospital discharge, sustained return of spontaneous circulation (ROSC), and survival with favorable neurological function among patients with intraosseous and intravenous access attempts after adjusting for age, sex, initial rhythm, bystander cardiopulmonary resuscitation, public location, witnessed status, EMS response and trial randomization cluster.Among 19,731 patients, intraosseous access was attempted in 3068 patients and intravenous access in 16,663 patients respectively. Patients in whom intraosseous access was attempted were younger, more often female, and had marginally faster times to initial access and to initial drug administration. Unadjusted outcomes were significantly lower in patients with attempted intraosseous access compared with intravenous access: (4.6% vs. 5.7%, p = 0.01) for survival to discharge, (17.9% vs. 23.5%, p 0.001) for sustained ROSC and (2.8% vs. 4.2%, p 0.001) for survival with favorable neurological function. After adjustment, there were no differences in hospital survival (OR, 0.88, 95% CI 0.72-1.09, p = 0.24) or survival with favorable neurological function (OR, 0.87, 95% CI 0.67-1.12, p = 0.29) in patients with intraosseous access attempt (vs. intravenous access). However, intraosseous access continued to associate with lower rates of sustained ROSC (OR, 0.80, 95% CI 0.71 - 0.89, p 0.001).Among patients with OHCA, intraosseous access attempt was associated with worse ROSC rates but no difference in survival. Further studies are necessary to elucidate the optimal access route among OHCA patients.

This study sought to determine the use of intravenous fluids in the early care of patients with acute decompensated heart failure (HF) who are treated with loop diuretics.Intravenous fluids are routinely provided to many hospitalized patients.We conducted a retrospective cohort study of patients admitted with HF to 346 hospitals from 2009 to 2010. We assessed the use of intravenous fluids during the first 2 days of hospitalization. We determined the frequency of adverse in-hospital outcomes. We assessed variation in the use of intravenous fluids across hospitals and patient groups.Among 131,430 hospitalizations for HF, 13,806 (11%) were in patients treated with intravenous fluids during the first 2 days. The median volume of administered fluid was 1,000 ml (interquartile range: 1,000 to 2,000 ml), and the most commonly used fluids were normal saline (80%) and half-normal saline (12%). Demographic characteristics and comorbidities were similar in hospitalizations in which patients did and did not receive fluids. Patients who were treated with intravenous fluids had higher rates of subsequent critical care admission (5.7% vs. 3.8%; p 0.0001), intubation (1.4% vs. 1.0%; p = 0.0012), renal replacement therapy (0.6% vs. 0.3%; p 0.0001), and hospital death (3.3% vs. 1.8%; p 0.0001) compared with those who received only diuretics. The proportion of hospitalizations that used fluid treatment varied widely across hospitals (range: 0% to 71%; median: 12.5%).Many patients who are hospitalized with HF and receive diuretics also receive intravenous fluids during their early inpatient care, and the proportion varies among hospitals. Such practice is associated with worse outcomes and warrants further investigation.

Aims The elderly are at risk of pericarditis from conditions such as malignancy, renal disease, and after cardiac surgery. However, the burden of pericarditis and, especially, the long-term outcomes associated with pericarditis have not been described before among the elderly. Methods and results We examined hospitalization rates; in-hospital, 30-day, and 1-year all-cause mortality rates; all-cause 30-day readmission rates; length of stay and health care expenditure for Medicare beneficiaries aged 65 years or older with a principal discharge diagnosis of pericarditis from 1999 to 2012. A total of 45 504 hospitalizations were identified. The hospitalization rate for pericarditis remained stable at 26 per 100 000 person-years across the study period and was consistently higher among men and the oldest old. The adjusted all-cause 30-day mortality rates decreased from 7.6% [95% confidence interval (CI) 6.9-8.2] in 1999 to 5.7% (95% CI 4.5-7.1) in 2012 and all-cause 1-year mortality rates decreased from 19.7% (95% CI 18.8-20.8) in 1999 to 17.3% (95% CI 15.3-20) in 2011 respectively. The 30-day all-cause readmission rate remained unchanged at 18% across the study period. The length of stay ranged from a mean of 5.8 days in 1999 to 5.5 days in 2012. The consumer price index adjusted cost per hospitalization increased from $8404 in 1999 to $9982 in 2012. Conclusion The hospitalization rate for acute pericarditis has remained unchanged among older adults. Although mortality rates associated with pericarditis have improved, hospitalization for pericarditis continues to signal a high risk of dying within a year.

Purpose of Review We review the potential role of coronary artery calcium (CAC) scoring in the initial evaluation and risk stratification of patients with low- to moderate-risk, stable and acute, chest pain.

Aims To examine the association of acute kidney injury (AKI) with long-term outcomes after myocardial infarction (MI), and evaluate whether effect modification is present according to baseline chronic kidney disease (CKD) status. Methods and results ACTION Registry records from 2008 to 2012 were linked to Medicare claims data, creating a cohort of 76 500 acute MI patients aged ≥ 65 years who survived to hospital discharge. Mild, moderate, and severe AKI were defined as changes in creatinine from baseline to peak of 0.3 to

Background— The epidemiology of aortic dissection (AD) has not been well described among older persons in the United States. It is not known whether advancements in AD care over the last decade have been accompanied by changes in outcomes. Methods and Results— The Inpatient Medicare data from 2000 to 2011 were used to determine trends in hospitalization rates for AD. Mortality rates were ascertained through corresponding vital status files. A total of 32 057 initial AD hospitalizations were identified. The overall hospitalization rate for AD remained unchanged at 10 per 100 000 person-years. For 30-day and 1-year mortality associated with AD, the observed rate decreased from 31.8% to 25.4% (difference, 6.4%; 95% confidence interval [CI], 6.2–6.5; adjusted, 6.4%; 95% CI, 5.7–6.9) and from 42.6% to 37.4% (difference, 5.2%; 95% CI, 5.1–5.2; adjusted, 6.2%; 95% CI, 5.3–6.7), respectively. For patients undergoing surgical repair for type A dissections, the observed 30-day mortality decreased from 30.7% to 21.4% (difference, 9.3%; 95% CI, 8.3–10.2; adjusted, 7.3%; 95% CI, 5.8–7.8) and the observed 1-year mortality decreased from 39.9% to 31.6% (difference, 8.3%; 95% CI, 7.5–9.1%; adjusted, 8.2%; 95% CI, 6.7–9.1). The 30-day mortality decreased from 24.9% to 21% (difference, 3.9%; 95% CI, 3.5–4.2; adjusted, 2.9%; 95% CI, 0.7–4.4) and 1-year decreased from 36.4% to 32.5% (difference, 3.9%; 95% CI, 3.3–4.3; adjusted, 3.9%; 95% CI, 2.5–6.3) for surgical repair of type B dissection. Conclusions— Although AD hospitalization rates remained stable, improvement in mortality was noted, particularly in patients undergoing surgical repair.

Coronary artery bypass grafting (CABG) is one of the most commonly performed surgical procedures today, and the internal mammary artery is the conduit of choice. Though grafting of this vessel leads to a substantial decrease of the blood supplied to the breast, ischemic necrosis of the breast remains a rare phenomenon. In the setting of chest radiation, however, subsequent damage to endothelial cells and fibroblasts can threaten the supplemental vasculature. In this report, we share a recent case of CABG-related breast necrosis in the setting of chest radiation, including presentation, diagnosis, and surgical management. We also discuss a comprehensive review of the CABG-related breast necrosis case literature. With increases in CABG procedures and more refined chemoradiation treatment modalities, it is critical that surgeons interacting with these patients be aware of and prepared to address the potentially great impact that chest radiation can have as a probable independent risk factor in the pathophysiologic pathway of ischemic breast necrosis. Level of Evidence: Level V, therapeutic study.

The authors performed a meta-analysis of randomized controlled trials to compare the efficacy of initial endovascular treatment with or without supervised exercise training (SET) versus SET alone in patients with intermittent claudication.Current guidelines recommend SET as the initial treatment modality for patients with intermittent claudication, in addition to optimal medical therapy. The role of endovascular therapy as primary treatment for claudication has been controversial.The primary outcome was treadmill-measured maximal walk distance at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance on follow-up. Risk of revascularization or amputations was also compared. Pooled estimates of the difference in outcomes between endovascular therapy with or without SET and SET-only groups were calculated using fixed and random effects models.A total of 987 patients from 7 trials were included. In pooled analysis, compared with SET only (reference group), patients that underwent combined endovascular therapy and SET had significantly higher maximum walk distance (standardized mean difference 0.79 [95% confidence interval (CI): 0.18 to 1.39]; weighted mean difference 98.9 [95% CI: 31.4 to 166.4 feet], and lower risk of revascularization or amputation (odds ratio 0.19 [95% CI: (0.09 to 0.40]; p 0.0001, number needed to treat = 8) over a median follow-up of 12.4 months. By contrast, revascularization was not associated with significant improvement in exercise capacity or risk of future revascularization or amputation, compared with SET alone. Follow-up ABI was significantly higher among patients that underwent endovascular therapy with or without SET as compared with SET alone.Compared with initial SET only, endovascular therapy in combination with SET is associated with significant improvement in total walking distance, ABI, and risk of future revascularization or amputation. By contrast, endovascular therapy-only was not associated with any improvement in functional capacity or clinical outcomes over an intermediate duration of follow-up.

Objectives This study sought to determine hospital variation in the use of positive inotropic agents in patients with heart failure. Background Clinical guidelines recommend targeted use of positive inotropic agents in highly selected patients, but data are limited and the recommendations are not specific. Methods We analyzed data from 376 hospitals including 189,948 hospitalizations for heart failure from 2009 through 2010. We used hierarchical logistic regression models to estimate hospital-level risk-standardized rates of inotrope use and risk-standardized in-hospital mortality rates. Results The risk-standardized rates of inotrope use ranged across hospitals from 0.9% to 44.6% (median: 6.3%, interquartile range: 4.3% to 9.2%). We identified various hospital patterns based on the type of agents: dobutamine-predominant (29% of hospitals), dopamine-predominant (25%), milrinone-predominant (1%), mixed dobutamine and dopamine pattern (32%), and mixed pattern including all 3 agents (13%). When studying the factors associated with interhospital variation, the best model performance was with the hierarchical generalized linear models that adjusted for patient case mix and an individual hospital effect (receiver operating characteristic curves from 0.77 to 0.88). The intraclass correlation coefficients of the hierarchical generalized linear models (0.113 for any inotrope) indicated that a noteworthy proportion of the observed variation was related to an individual institutional effect. Hospital rates or patterns of use were not associated with differences in length of stay or risk-standardized mortality rates. Conclusions We found marked differences in the use of inotropic agents for heart failure patients among a diverse group of hospitals. This variability, occurring in the context of little clinical evidence, indicates an urgent need to define the appropriate use of these medications.

The current guidelines suggest either intravenous (IV) or intraosseous (IO) access for drug administration in patients with out-of-hospital cardiac arrest (OHCA). However, their patterns of use in a real-world setting are not known. Using data from the multicenter Dallas-Fort Worth Resuscitation

Risk stratification for patients with an asymptomatic Wolff-Parkinson-White (WPW) electrocardiogram (ECG) pattern remains an area of controversy. A 33 year old man with a known history of WPW ECG pattern without prior symptoms presented to the emergency room with palpitations that occurred moments

Background: Chronic kidney disease (CKD) and acute kidney injury (AKI) have both been associated with adverse short-term outcomes after MI. However, the impact of AKI on long-term outcomes and the interaction of AKI with baseline renal function have not been well described. Methods: ACTION Registry®-GWTGTM records from 2008-2012 were linked to Medicare data yielding a population of 76,500 acute MI patients from 581 hospitals who survived to hospital discharge. We excluded patients with cardiogenic shock, cardiac arrest, and those undergoing CABG or currently on dialysis. CKD status was defined using the Kidney Disease Outcome Quality Initiative criteria based on admission GFR estimated using the MDRD equation. No, mild, moderate and severe AKI were defined as changes in creatinine (Cr) from baseline to peak of < 0.3, 0.3 to < 0.5, 0.5 to < 1.0 and ≥ 1.0 mg/dl respectively. Cox proportional hazard modeling was used to examine associations between AKI and 1-year mortality. Covariates for risk adjustment were adapted from the CRUSADE long-term mortality risk model. Results: The median age was 77 years, 30% had STEMI and 78% underwent diagnostic angiography.The incidence of mild, moderate and severe AKI was 7.5%, 6.0% and 3.0%. CKD stages 3, 4, and 5 were present in 41.2%, 6.7%, and 1.0% of patients. Both CKD and AKI were significantly associated with 1-year mortality (p< 0.0001 for each). A significant interaction was noted between CKD and AKI with respect to 1-year mortality (p-interaction Conclusion: One-year mortality increased in proportion to severity of AKI, with even a small increase in Cr associated with worse outcomes. The association of AKI with outcomes was modified by baseline Cr, with a greater impact of AKI observed among patients with higher baseline eGFR.

Introduction: Current guidelines recommend supervised exercise training (SET) as the initial treatment modality for patients with intermittent claudication (IC), in addition to optimal medical therapy. The role of endovascular revascularization (ER) as a primary treatment option has been controversial. We performed a meta-analysis to compare the efficacy of initial ER vs. initial SET in patients with IC using data from randomized controlled trials. Methods: The primary outcome was treadmill-measured maximum walking distance (MWD) at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance (ICD) on follow-up. Risk of adverse limb events (revascularization, amputations) was also compared between the two groups. Random effects models were used for all analyses. Results: We included 1,145 patients from nine trials with a mean follow up duration of 13.7 months (42% aortoiliac lesions; 35% stent use; mean baseline ABI 0.64 vs. 0.67 for ER vs. SET). Follow-up MWD was not significantly different between patients undergoing ER vs. SET [Weighted mean difference (WMD) (95% CI): 19.1 m (-79.6 to 117.8 m); publication bias p=0.86]. Metaregression did not identify significant differences based on stent use or presence of aortoiliac disease. ICD was also similar between the two groups [WMD (95% CI): 36.1 m (-99.4 to 171.5 m)]. In contrast, patients undergoing ER had higher resting ABI on follow-up [WMD (95% CI): 0.14 (0.11 to 0.17), p Conclusion: Compared with initial SET, initial ER significantly improves resting ABI values. Although longer walking distance and lower rates of adverse limb events also appeared favorable for ER, these differences were not statistically significant in these intermediate term studies. Longer-term studies and those incorporating contemporary revascularization techniques are necessary.

Cholesterol efflux capacity (CEC), which is a key step in the reverse cholesterol transport pathway, is independently associated with atherosclerotic cardiovascular disease (ASCVD). However, whether it predicts ASCVD beyond validated novel risk markers is unknown.This study assessed if CEC improved ACSVD risk prediction beyond using coronary artery calcium (CAC), family history (FH), and high-sensitivity C-reactive protein (hs-CRP).CEC, CAC, self-reported FH, and hs-CRP were assessed among participants without baseline ASCVD who were enrolled in the Dallas Heart Study (DHS). ASCVD was defined as a first nonfatal myocardial infarction (MI) or stroke, coronary revascularization, or cardiovascular death, assessed over a median 9.4 years. Risk prediction was assessed using various modeling techniques and improvements in the c-statistic, the integrated discrimination index (IDI), and the net reclassification index (NRI).The mean age of the population (N = 1,972) was 45 years, 52% had CAC (0), 31% had FH, and 58% had elevated hs-CRP (≥2 mg/l). CEC greater than the median was associated with a 50% reduced incidence of ASCVD in those with CAC (5.4% vs. 10.5%; p = 0.003), FH (5.8% vs. 10%; p = 0.05), and elevated hs-CRP (3.8% vs. 7.9%; p = 0.004). CEC improved all metrics of discrimination and reclassification when added to CAC (c-statistic, p = 0.004; IDI, p = 0.02; NRI: 0.38; 95% confidence interval [CI]: 0.13 to 0.53), FH (c-statistic, p = 0.006; IDI, p = 0.008; NRI: 0.38; 95% CI: 0.13 to 0.55), or elevated hs-CRP (c-statistic p = 0.008; IDI p = 0.02; NRI: 0.36; 95% CI 0.12 to 0.52).CEC improves ASCVD risk prediction beyond using CAC, FH, and hs-CRP and warrants consideration as a novel ASCVD risk marker.

Antianginal medications are an important aspect of optimal medical therapy for the management of angina in patients with stable ischemic heart disease. The lack of a standardized definition of effective antianginal therapy and the lack of clear understanding of the underlying evidence have often been cited as reasons for the large variations in the use of these particular classes of pharmacologic agents in contemporary clinical practice. Hence, we performed a search of the PubMed database and identified published manuscripts examining the effect of common antianginal agents on improving anginal parameters and on important clinical outcomes such as mortality, myocardial infarction, and repeat revascularization from multiple large randomized, controlled trials, systematic reviews, meta-analyses, and outcomes data from observational studies in patients with stable ischemic heart disease. The most commonly used antianginal agents (beta-blockers, nitrates, calcium channel blockers, and ranolazine) demonstrated equivalent efficacy in improving patient reported ischemic symptoms and quantitative exercise parameters. With regards to mortality, beta-blockers are beneficial in the setting of depressed left ventricular systolic function. In contrast, recent evidence points toward the lack of similar benefit of beta-blockers in patients with preserved systolic function, even in the setting of prior myocardial infarction. No survival benefit has been identified with the use of calcium channel blockers, nitrates, or ranolazine. Currently, guidance regarding objective measurement and up titration of antianginal therapy is missing. There is an unmet need for development of potentially novel and clinically relevant methodology to assess the intensity and/or efficacy of antianginal therapy.

BACKGROUND Electronic health records (EHRs) offer the opportunity to transform quality improvement by using clinical data for comparing hospital performance without the burden of chart abstraction. However, current performance measures using EHRs are lacking. METHODS With support from the Centers for Medicare & Medicaid Services (CMS), we developed an outcome measure of hospital risk-standardized 30-day mortality rates for patients with acute myocardial infarction for use with EHR data. As no appropriate source of EHR data are currently available, we merged clinical registry data from the Action Registry-Get With The Guidelines with claims data from CMS to develop the risk model (2009 data for development, 2010 data for validation). We selected candidate variables that could be feasibly extracted from current EHRs and do not require changes to standard clinical practice or data collection. We used logistic regression with stepwise selection and bootstrapping simulation for model development. RESULTS The final risk model included 5 variables available on presentation: age, heart rate, systolic blood pressure, troponin ratio, and creatinine level. The area under the receiver operating characteristic curve was 0.78. Hospital risk-standardized mortality rates ranged from 9.6% to 13.1%, with a median of 10.7%. The odds of mortality for a high-mortality hospital (+1 SD) were 1.37 times those for a low-mortality hospital (-1 SD). CONCLUSIONS This measure represents the first outcome measure endorsed by the National Quality Forum for public reporting of hospital quality based on clinical data in the EHR. By being compatible with current clinical practice and existing EHR systems, this measure is a model for future quality improvement measures.

Background: Healthcare burden associated with pericarditis is currently not known. The last decade has marked multiple advancements in the management of pericarditis and the impact of this emerging evidence on outcomes such as readmissions, mortality and costs associated with pericarditis is lacking. Methods: The Inpatient Medicare data from 1999 to 2012 were used to determine trends in hospitalization, readmission, mortality rates and costs associated with pericarditis. Patients aged ≥ 65 years who had a primary discharge diagnosis of acute pericarditis (ICD-9-CM codes 429.90 or 429.91 or 429.99) from 1999 to 2012 were including in the analysis. We linked the inpatient data with the Medicare denominator file to report hospitalization rates per one hundred thousand person-years. Mortality and readmission rates were ascertained through corresponding vital status and inpatient files. Results: A total of 45, 504 hospitalizations for pericarditis through the study were identified. The hospitalization rate for pericarditis decreased from 15 in 1999 to 9 per 100,000 person-years in 2012. Hospitalization rates for pericarditis decreased across all age, sex and race subgroups through the study period, with consistently higher rates among those aged 75-84 years and whites. No sex differences in hospitalizations were noted. The length of stay decreased from 6 (SD=6.2) days in 1999 to 5.2 (SD=5.3) days in 2012. The 30-day mortality decreased from 7.9% (95% Confidence interval [CI], 7.11% - 8.85%) in 1999 to 4.8% (95% CI, 4.00% - 5.76%) in 2012 and 1-year mortality slightly decreased from 20.1% (95% CI, 18.9 % - 21.4%) in 1999 to 18.1% (95% CI, 16.6-19.7) in 2011 respectively. The 30-day readmission rate increased marginally from 18.5% (95% CI, 17.2% - 19.9%) in 1999 compared with 20.5% (95% CI, 18.8% - 22.2%) in 2012. The CPI-adjusted cost per hospitalization increased slightly, from $11,649 in 1999 to $12,582 in 2012. Conclusion: Hospitalization for pericarditis is relatively uncommon. Although mortality rates associated with pericarditis have improved, mortality and readmission rates continue to remain high. These findings support a need to identify factors associated with high mortality and readmission rates.

A 65-year-old man with a history of esophagitis, presented with low grade fever, poor appetite and a fall at home. Admission vitals were stable with temperature 37.9 C (100.1 F). He was found to be dehydrated, and a urinalysis was compatible with urinary tract infection. An admission chest X-ray study was unremarkable. He was admitted for intravenous hydration and antibiotics. He was doing well after admission, when overnight he complained of new onset shortness of breath and epigastric pain. He reported that he had vomited approximately 150 mL of ‘brownish material’ 30 min prior, and his symptoms had started after that. The physical examination was notable for tachycardia (heart rate 104 beats/min), tachypnea (respiratory rate 22 breaths/min), decreased breath sounds at bilateral lung bases, hypoxia (oxygen saturation 86 % on 2 L nasal cannula), and epigastric tenderness. A chest X-ray study demonstrated pneumomediastinum and bilateral pleural effusions. A CT scan of the chest confirmed the presence of bilateral pnemuothoraces, pneumomediastinum and bilateral pleural effusions (Fig. 1). Given the onset of symptoms after a bout of vomiting, the diagnosis of esophageal rupture was considered. Bilateral chest tubes were urgently placed. Primary open surgical repair was deferred. Upper gastrointestinal endoscopy showed necrotic tissue and a full thickness tear in the esophagus around a hiatal hernia. An esophageal stent was successfully placed, and broad spectrum antibiotics initiated with continued placement of bilateral chest tubes. Biopsy of the necrotic tissue showed chronic inflammation without evidence of malignancy. The stent was removed after 4 weeks at which time repeat upper gastrointestinal endoscopy revealed a healed tear. At this time, the patient was tolerating oral feeds, and he was discharged. The esophagus lacks a serosal layer containing collagen and elastic fibers, making the wall weaker and more likely to rupture at lower pressures than the rest of the gastrointestinal tract [1]. Most cases of esophageal rupture are iatrogenic, and the term ‘Boerhaave syndrome’ is reserved for those induced spontaneously by uncoordinated vomiting [2]. The syndrome is characterized by full thickness tear, usually involving the posterolateral wall of distal esophagus, due to barogenic trauma induced by uncoordinated vomiting. This causes an acute rise in intraluminal pressure with esophageal disruption and forceful expulsion of gastric contents into the mediastinum or pleura with consequent chemical and bacterial mediastinitis. Mackler’s classic triad of vomiting, chest pain and subcutaneous emphysema is seen in only 50 % of cases. The physical examination reveals few specific signs. Subcutaneous emphysema, dullness to percussion (secondary to a pleural effusion), decreased breath sounds (due to pneumothorax), Hamman’s sign (a crunch like noise over the precordium due to mediastinal air) are seen in 20–30 % of patients. A chest X-ray study may show pneumomediastinum, subcutaneous emphysema, pleural effusions, pneumothorax, mediastinal widening, or hydropneumothorax. In patients with a suggestive clinical presentation, chest radiography, CT scan or esophagogram should be promptly obtained. A CT scan allows rapid detection of minute amounts of air, and an esophagogram can pinpoint the lesion more & Arjun Gupta sujata.bhushan@va.gov

Body weight, and its extreme of obesity, has emerged as a major public health concern. Nearly 1/3 of the adult US population is now estimated to be obese, as defined by a body mass index (BMI, the weight in kilograms divided by the square of the height in meters) ≥ 30.1 The cost of obesity on the healthcare system is substantial; an estimated $147 billion in medical costs were attributed to obesity alone in US in 2008.2 Furthermore, the prevalence of childhood and adolescent obesity, which now affects 17% of children and adolescents,1 raises concerns for its impact on adulthood obesity and long-term health outcomes. In this month’s topic review in Circulation: Cardiovascular Quality and Outcomes , we concentrate on contemporary issues around body weight, obesity, and cardiovascular outcomes. Many hurdles remain in evaluating the relationship between body weight and cardiovascular (CV) outcomes. Debate continues as to the optimal measure of adiposity; body mass composition, and specifically excess adiposity, is perhaps a more appropriate marker of cardiovascular risk compared to body weight. BMI, although widely used, is an imperfect measure of excess adiposity with evidence favoring central obesity, as measured by the waist circumference, as a more sensitive indicator of adverse long-term cardiovascular events.3 Moreover, the effects of obesity on cardiovascular outcomes are complex. Studies have suggested that patients with higher BMIs had better survival compared with those with low BMIs; a phenomenon frequently referred to as the obesity-risk paradox.4 Obesity itself is often associated with multitude of other cardiovascular risk factors such as hyperlipidemia, diabetes, and hypertension; untangling the independent effects of obesity on outcomes thus remains challenging. Lastly, while evidence now suggests obesity is an independent risk factor for long-term adverse cardiovascular events, weight reduction remains an extremely challenging exercise for obese patients. …

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, which have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, as well as general cardiology audience. The studies included in this article represent the most significant research related to hypertension.

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research related to treatment of stable coronary artery disease (CAD).

The topic of variation in health care has garnered significant attention since Wennberg and Gittelsohn in 19731 identified up to 10-fold variation in use of tonsillectomy and other surgical procedures in small towns within Maine and Vermont. Wennberg and others further described large differences in the propensity to hospitalize patients in Boston and New Haven that were unrelated to case-fatality but highly related to bed supply.2 These findings suggested that regional treatment variation is in part driven by differences in physician preferences and heath resource capacity rather than the health status of patients. These observations of extensive geographic variation in treatment were most extensively formalized in the Dartmouth Atlas of Health Care, a massive undertaking that used Medicare claims data to describe differences in cost and utilization across more than 300 hospital referral regions (HRRs) that were built from zip codes and hospital service areas. The Dartmouth Atlas has been published by Wennberg and colleagues since 1996. More recently, greater attention has been directed to variation in treatment and outcomes at the hospital level. Health care payers including the Centers for Medicare and Medicaid Services have motivated the creation of performance measures that describe hospital variation in longitudinal outcomes such as rehospitalization and death.3–7 These measures have been endorsed by the National Quality Forum and are currently being used to direct financial penalties to hospitals with higher-than-expected rates of adverse outcomes for common conditions such as heart failure, acute myocardial infarction, and pneumonia. In the future, Medicare will likely assess hospital variation in outcomes for specific cardiovascular treatments including percutaneous coronary intervention and percutaneous valve replacement. Given the increased focus on treatment and outcomes variation at both regional and hospital levels, we have dedicated the reviews in this issue of Circulation: Cardiovascular Quality and Outcomes …

Cardiovascular disease (CVD) in women has been historically understudied. For many years, heart disease had been thought to be primarily a “man’s disease.” Consequently, women have been significantly under-represented in longitudinal studies of disease history and in clinical trials. High-quality data from women at the extremes of age, with multiple co-morbidities, and from racial and ethnic minorities have been particularly rare. In order to increase awareness of cardiovascular prevention among women, in 1999 the American Heart Association (AHA) published its first women-specific clinical recommendations for the prevention of CVD.1 In 2004, the AHA and multiple other collaborating organizations subsequently sponsored “Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women,” which underwent updates in 2007 and 2011. As a result of these and other related initiatives, the rate of public awareness of CVD as the leading cause of death among US women has increased from 30% in 1997 to 54% in 2009.2 CVD-associated death among US women has declined significantly over this time period.3,4 Yet substantial work still needs to be done to improve women’s cardiovascular health. CVD remains the number one killer among women.4 As the obesity epidemic continues, we are actually finding increases in coronary heart disease (CHD) death among young women 35 to 54 years of age.2 Morbidity and mortality from stroke and hypertension remain high.4 In addition, substantial outcomes disparities continue for women from racial and ethnic minorities.4 We have therefore dedicated our topic summaries in this issue of Circulation: Cardiovascular Quality and Outcomes to CVD in women. We have included only those studies where authors provided a convincing a priori reason to study a particular disease process or clinical intervention in women and reported primary endpoints that were sex-specific. We have included articles on the representation of women …

A 28-year-old visiting from Central America presented with twenty-four hours of lower extremity swelling, dyspnea and orthopnea. Clinically, she was diagnosed with acute heart failure requiring inotropes with a transthoracic echocardiogram revealing severe mitral regurgitation with a normal ejection fraction. Subsequent transesophageal echocardiogram confirmed severe mitral regurgitation with aortic root dilatation (Z-score: 3.9). She was also found to have arachnodactyly, scoliosis on X-ray and severe mitral valve prolapse. Given her clinical features she was assessed for Marfan syndrome with the modified Ghent nosology systemic score and met diagnostic criteria. A FBN1 genetic test confirmed the diagnosis of Marfan syndrome discovering a frameshift mutation resulting in an inappropriate stop codon and peptide truncation. For patients presenting with heart failure at an atypical age without typical risk factors, rare conditions such as Marfan syndrome should be considered. Marfan syndrome can accurately and quickly be screened for and diagnosed using the systemic score from the modified Ghent nosology.

BACKGROUND Because relative value unit (RVU)-based costs vary across hospitals, it is difficult to use them to compare hospital utilization. OBJECTIVE To compare estimates of hospital utilization using RVU-based costs and standardized costs. DESIGN Retrospective cohort. SETTING AND PATIENTS Years 2009 to 2010 heart failure hospitalizations in a large, detailed hospital billing database that contains an itemized log of costs incurred during hospitalization. INTERVENTION We assigned every item in the database with a standardized cost that was consistent for that item across all hospitals. MEASUREMENTS Standardized costs of hospitalization versus RVU-based costs of hospitalization. RESULTS We identified 234 hospitals with 165,647 heart failure hospitalizations. We observed variation in the RVU-based cost for a uniform “basket of goods” (10th percentile cost $1,552; 90th percentile cost of $3,967). The interquartile ratio (Q75/Q25) of the RVU-based costs of a hospitalization was 1.35 but fell to 1.26 after costs were standardized, suggesting that the use of standardized costs can reduce the “noise” due to differences in overhead and other fixed costs. Forty-six (20%) hospitals had reported costs of hospitalizations exceeding standardized costs (indicating that reported costs inflated apparent utilization); 42 hospitals (17%) had reported costs that were less than standardized costs (indicating that reported costs underestimated utilization). CONCLUSIONS Standardized costs are a novel method for comparing utilization across hospitals and reduce variation observed with RVU-based costs. They have the potential to help hospitals understand how they use resources compared to their peers and will facilitate research comparing the effectiveness of higher and lower utilization. Journal of Hospital Medicine 2013;8:373–379. © 2013 Society of Hospital Medicine

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Reviews. This series will summarize the most important manuscripts, as selected by the Editor, which have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes as well as general cardiology audience. The studies included in this article represent the most significant research in the area of valvular heart disease. ( Circ Cardiovasc Quality and Outcomes . 2012;5:-e103.) In recent years, no field of clinical cardiology has experienced a great influx of transformational therapeutic options as has the area of valvular heart disease. Treatment of severe aortic stenosis (AS) has been revolutionized by transcatheter aortic valve replacement (TAVR), which has been shown to improve life expectancy and functional outcomes in patients with inoperable AS1,2 and to have short-term outcomes comparable to surgical aortic valve replacement (AVR) in patients at high perioperative risk.3,4 Analogously, mitral valve disease has been amenable to percutaneous valve replacement,5,6 as well as clipping procedures7 that can substantively reduce severe mitral regurgitation (MR) and improve functional outcomes. Even right-sided heart disease involving valves in pulmonary8,9 and tricuspid10 positions has been treated successfully with endovascular techniques. Yet, even with this growing focus on percutaneous valvular interventions, open surgical techniques remain the dominant treatment strategies and standard of care for most advanced lesions. Surgical valve repair and replacement account for 10% to 20% of all cardiac surgical procedures,11–13 approximately two thirds of which are for AS.11–13 For patients undergoing surgery, there remains considerable debate about risk stratification,14 intraoperative technique,15 and postoperative …

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of anticoagulation for cardiovascular disease.

Respiratory syncytial virus (RSV) is commonly known to cause an influenza-like illness. However, it can also cause more severe disease in young children and older adults comprising of organ transplant patients with immunocompromised status. Till date, only four cases of RSV infections have been reported in HIV-positive adults. We describe here a case of HIV-positive female with relatively preserved immune function who presented with RSV infection requiring ventilation and showed improvement after prompt treatment with intravenous immunoglobulin.

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes and general cardiology audience. The studies included in this article represent the most significant research in the area of cardiovascular disease in the elderly.