Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines-Heart Failure Registry.

Importance: Black adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown. Objective: To compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals. Design, Setting, and Participants: Patients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022. Exposures: Hospitals caring for high proportions of Black patients. Main Outcomes and Measures: Quality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients. Results: This study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based ß-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02). Conclusions and Relevance: Quality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.

Clinical utility of remote monitoring for patients with cardiac implantable electrical devices.

BACKGROUND: Remote monitoring of cardiac implantable electronic devices (CIEDs) offers practical and clinical benefits juxtaposed against burdens associated with high transmission volume. METHODS: We identified patients receiving de novo pacemakers (PPMs) and implantable cardiac defibrillators (ICDs) at a single academic medical center (January 2016-December 2019) with at least 1 year of follow-up device care. We collected patient- and device-specific data at time of implant and assessed all remote and in-person interrogation reports for clinically actionable findings based on pre-specified criteria. RESULTS: Among 963 patients (mean age of 71 (± 14) years, 37% female), 655 (68%) underwent PPM, and 308 (32%) underwent ICD implant. Median follow-up was 874 (627-1221) days, during which time patients underwent a mean of 13 (10-16) total interrogations; remote interrogations comprised 53% of all device evaluations; and of these, 96% were scheduled transmissions. Overall, 22% of all CIED interrogations yielded significant findings with a slightly higher rate in the PPM than in the ICD group (23% vs. 20%, p < 0.01). Only 8% of remote interrogations produced clinically meaningful results, compared with 38% of in-person ones. In adjusted models, routine, remote transmissions were least likely to be useful for both PPM and ICD patients (p < 0.001), whereas time from initial device implant was inversely associated with probability of obtaining a useful interrogation (p < 0.001). CONCLUSIONS: Routine remote interrogations constitute the majority of device evaluations performed, but uncommonly identify clinically actionable findings.

New Strategies to Prevent Rehospitalizations for Heart Failure.

Purpose of review: Heart failure (HF) hospitalizations are common, costly, associated with poor outcomes and potentially avoidable. Reducing HF hospitalizations is therefore a major objective of US healthcare. This review aims to outline causes for HF hospitalizations and provides actionable strategies for HF hospitalization prevention. Recent findings: Heart failure hospitalizations often have multifactorial and diverse etiologies associated with medical and social patient factors leading to increased congestion. The most recently updated American Heart Association/American College of Cardiology/Heart Failure Society of America Guidelines for the Management of HF were published in 2022 and utilize high-quality evidence to offer a framework for analyzing and preventing HF hospitalizations. Summary: Prevention of hospitalizations can be achieved by optimizing guideline-directed medical therapies, incorporating appropriate device-based technologies, and utilizing systems-based practices. By identifying treatment gaps and opportunities for improved HF care, this review comprehensively defines the challenges associated with HF rehospitalizations as well as potential solutions.

Patterns of Recovery in Cardiovascular Care after the COVID-19 Pandemic Surge.

BACKGROUND: Cardiovascular disease remains the number one cause of death globally. Patients with cardiovascular disease are at risk of poor outcomes from deferral of healthcare during the coronavirus disease 2019 (COVID-19) pandemic. Little is known about recovery of cardiovascular hospitalizations or procedural volume following the COVID-19 surges. We sought to examine the cardiovascular diagnoses requiring healthcare utilization surrounding the first and second COVID-19 waves and characterize trends in return to pre-pandemic levels at a tertiary care center in Massachusetts. MATERIALS AND METHODS: Using electronic health records and administrative claims data, we performed a retrospective analysis of patients undergoing cardiovascular procedures and admitted to inpatient cardiology services throughout the first two COVID surges. ICD-10 codes were used to categorize admissions. RESULTS: Patients who presented for care during the initial COVID-19 surge were younger, had higher comorbidity burden, and longer length-of-stay compared with pre- and post-surge. Marked declines in admissions in the first wave (to 29% of pre-surge levels) followed eventually by complete recovery were noted across all cardiac diagnoses, with smaller declines seen in the second wave. Cardiac procedural volume declined significantly during the initial surge but quickly rebounded post-surge, eventually eclipsing pre-COVID volume. CONCLUSIONS: There was a gradual but initially incomplete recovery to pre-surge levels of hospitalizations and procedures during the reopening phase, which eventually rebounded to meet or exceed pre-COVID-19 levels. To the extent that this reflects deferred or foregone essential care, it may adversely affect long-term cardiovascular outcomes. These results should inform planning for cardiovascular care delivery during future pandemic surges.

An Unusual Cause of Functional Mitral Stenosis: A Left Atrial Intimal Sarcoma.

Primary cardiac tumors are rare, with an incidence of <0.1% in postmortem series; sarcomas comprise 75% of these. Cardiac sarcomas may be life-threatening at the time of presentation. We describe a left atrial intimal sarcoma presenting with constitutional symptoms, obstructive shock, and systemic emboli, and treated with proton beam therapy. (Level of Difficulty: Intermediate.).

COVID-19: A Multimodality Review of Radiologic Techniques, Clinical Utility, and Imaging Features.

In this article we will review the imaging features of coronavirus disease 2019 (COVID-19) across multiple modalities, including radiography, CT, MRI, PET/CT, and US. Given that COVID-19 primarily affects the lung parenchyma by causing pneumonia, our directive is to focus on thoracic findings associated with COVID-19. We aim to enhance radiologists' understanding of this disease to help guide diagnosis and management. Supplemental material is available for this article. © RSNA, 2020.

A case report of cardiac toxicity from barracuda ingestion in Mexico.

BACKGROUND: Ciguatera toxicity is a fish-borne illness that initially manifests with gastrointestinal symptoms, followed by bizarre neurological symptoms including heat-cold sensation alteration, peculiar feeling of loose teeth, and peripheral neuropathy. However, cardiac manifestations are rare and underreported in the literature. CASE SUMMARY: A 73-year-old man presented with symptomatic bradycardia and hypotension after ingestion of barracuda fish in Mexico. He received atropine and dopamine with subsequent improvement in his symptoms, but continued to experience peripheral neuropathic and other odd sensations. Four of his family members ingested the same fish and had similar symptoms. He was managed conservatively and did not require temporary or permanent pacing. Within 1 week from toxin exposure, bradycardia had improved. Heart rate was 40-50 b.p.m. at rest, and he was discharged with an ambulatory monitor. Heart rate had increased to 77 b.p.m. at 1-month follow-up on repeat electrocardiogram (ECG). DISCUSSION: Although the predominant manifestations of ciguatera toxicity are neurological, cardiac complications tend to be more acute and require attention. Unlike neurological symptoms, bradycardia and hypotension are short-lived, often resolving within a week. Treatment continues to be largely supportive, and patients may require temporary treatment with positive chronotropic agents such as atropine or dopamine.

Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Prior Cerebrovascular Disease: Results From the EXCEL Trial.

OBJECTIVES: The aim of this study was to determine whether high-risk patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) preferentially benefit from revascularization by percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG). BACKGROUND: Patients with known CEVD requiring revascularization are often referred to PCI rather than CABG. There is a paucity of data regarding the impact of CEVD in patients with LMCAD undergoing revascularization. METHODS: In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with LMCAD and low or intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores were randomized to PCI with everolimus-eluting stents versus CABG. The effects of prior CEVD, defined as prior stroke, transient ischemic attack, or carotid artery disease, on 30-day and 3-year event rates were assessed. RESULTS: Prior CEVD was present in 233 of 1,898 patients (12.3%). These patients were older and had higher rates of comorbidities, including hypertension, diabetes, peripheral vascular disease, anemia, chronic kidney disease, and prior PCI, compared with those without prior CEVD. Patients with prior CEVD had higher rates of stroke at 30 days (2.2% vs. 0.8%; p = 0.05) and 3 years (6.4% vs. 2.2%; p = 0.0003) and higher 3-year rates of the primary endpoint of all-cause death, stroke, or myocardial infarction (25.0% vs. 13.6%; p < 0.0001). The relative effects of PCI versus CABG on the 30-day and 3-year rates of stroke (pinteraction = 0.65 and 0.16, respectively) and the 3-year rates of the primary composite endpoint (pinteraction = 0.14) were consistent in patients with and those without prior CEVD. CONCLUSIONS: Patients with LMCAD and prior CEVD compared with those without CEVD have higher rates of stroke and reduced event-free survival after revascularization. Data from the EXCEL trial do not a priori support a preferential role of PCI over CABG in patients with known CEVD.

Do Not Resuscitate, with No Surrogate and No Advance Directive: An Ethics Case Study.

Do-not-resuscitate (DNR) orders are typically signed by physicians in conjunction with patients or their surrogate decision makers in order to instruct healthcare providers not to perform cardiopulmonary resuscitation (CPR). Both the medical literature and CPR guidelines fail to address when it is appropriate for physicians to sign DNR orders without any knowledge of a patient's wishes. We explore the ethical issues surrounding instituting a two-physician DNR for a dying patient with multiple comorbidities and no medical record on file, no advance directives, and no surrogate decision maker. Through this case we also highlight the issues of poor prognostication and the reversal of a DNR in such circumstances.

Percutaneous Coronary Intervention of Saphenous Vein Graft.

BACKGROUND: Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs) has historically been associated with a high risk of adverse ischemic events, but there is a paucity of contemporary data on the second-generation drug-eluting stent use within SVG, and the relative importance of high platelet reactivity (HPR) in SVG PCI versus native lesion PCI is unknown. We studied ischemic and bleeding events after SVG PCI and their association with HPR. METHODS AND RESULTS: Subjects in the prospective, multicenter ADAPT-DES study (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) were stratified according to whether they had PCI of an SVG or a non-SVG lesion. Two-year outcomes were compared between groups using univariate and multivariable Cox proportional hazards models. HPR was defined as on-clopidogrel P2Y12 platelet reaction units >208 as measured by the VerifyNow assay; major adverse cardiac events were defined as the composite of cardiac death, myocardial infarction, or stent thrombosis. Among 8582 subjects in ADAPT-DES, 405 (4.7%) had SVG PCI. SVG PCI was independently associated with a higher 2-year risk of major adverse cardiac events (adjusted hazard ratio, 2.34; 95% confidence interval, 1.69-3.23; P<0.0001), ischemia-driven target vessel revascularization (adjusted hazard ratio, 1.82; 95% confidence interval, 1.37-2.42; P<0.0001), and stent thrombosis (adjusted hazard ratio, 2.26; 95% confidence interval, 1.42-3.59; P=0.0006), but not of bleeding (adjusted hazard ratio, 0.99; 95% confidence interval, 0.68-1.46; P=0.97). There was no statistical interaction between HPR and SVG PCI in regard to major adverse cardiac events (adjusted Pinteraction=0.99). CONCLUSIONS: SVG PCI is associated with a considerably higher risk of 2-year adverse ischemic events, with HPR conferring similar risk in SVG and non-SVG PCI. More potent and longer antiplatelet therapy may be beneficial for patients undergoing SVG PCI. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794.

Acute coronary syndrome in young women under 55 years of age: clinical characteristics, treatment, and outcomes.

BACKGROUND: Young women with acute coronary syndrome (ACS) may represent a high risk group, but little is known about specific age and sex differences in clinical characteristics, treatment, outcomes, and trends over time. METHODS: Data from 3237 men and women admitted with an ACS event from 1999 to 2006 were analyzed. Patients were grouped by sex and age less than 55 years. Demographics, presentation, treatment, and outcomes at 6 months were analyzed. Primary outcomes included mortality, recurrent myocardial infarction, rehospitalization, and stroke at 6 months. Secondary analyses assessed risk factors, management, and trends over time. RESULTS: Women under 55 years represented 8% of the entire cohort, and 26% of patients under age 55 years. Compared to older women, young women were more likely to be smokers (51 vs. 14%, p < 0.001) and obese (44 vs. 34%, p = 0.006). Young women had more diabetes and hypertension than young men. Mortality was lowest among young women and did not change over time. Young women received less treatment with aspirin, beta blockers, lipid-lowering agents, and ACE inhibitors, and underwent less coronary angiography and stenting than young men (44 vs. 59%, p < 0.001). Rehospitalization was higher among young women than young men (37 vs. 27%, p < 0.001), with no change over time. CONCLUSIONS: Modifiable risk factors such as smoking, obesity, diabetes, and hypertension should be addressed in young women. Following ACS, young women received fewer evidence-based medications, were treated less invasively, and had higher readmission rates within 6 months compared to young men.