Recommendationse188 Antiplatelet Therapye189 Women: Recommendationse189 Anemia, Bleeding, and Transfusion: Recommendationse190 Thrombocytopeniae191 Cocaine and Methamphetamine Users: ...Recommendationse191 Vasospastic (Prinzmetal) Angina: Recommendationse192 ACS With Angiographically Normal Coronary Arteries: Recommendatione193 Stress (Takotsubo) Cardiomyopathy: Recommendationse193 Obesitye194 Patients Taking Antineoplastic/Immunosuppressive Therapye194 Quality of Care and Outcomes for ACS--Use of Performance Measures and Registriese194 Use of Performance Measures and Registries: Recommendatione194 Summary and Evidence Gapse194 Referencese195 Appendix 1 Author Relationships With Industry and Other Entities (Relevant)e216 Appendix 2 Reviewer Relationships With Industry and Other Entities (Relevant)e219 Appendix 3 Abbreviationse224 Appendix 4 Additional Tablese225 Preamble The American College of Cardiology (ACC) and the American Heart Association (AHA) are committed to the prevention and management of cardiovascular diseases through professional education and research for clinicians, providers, and patients. Since 1980, the ACC and AHA have shared a responsibility to translate scientific evidence into clinical practice guidelines (CPGs) with recommendations to standardize and improve cardiovascular health.
Objectives This study sought to assess percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) stenosis in routine U.S. clinical practice. Background Percutaneous ...coronary intervention for ULMCA stenosis is controversial; however, current use and outcomes of ULMCA PCI in routine U.S. clinical practice have not been described. Methods We evaluated 5,627 patients undergoing ULMCA PCI at 693 centers within the National Cardiovascular Data Registry Catheterization Percutaneous Coronary Intervention Registry for temporal trends in PCI use (2004 to 2008), patient characteristics, and in-hospital mortality. Thirty-month mortality and composite major adverse events (death, myocardial infarction, and revascularization) with drug-eluting versus bare-metal stents were compared using inverse probability weighted (IPW) hazard ratios (HRs) in a nonrandomized Medicare-linked (age ≥65 years) patient cohort (n = 2,765). Results ULMCA PCI was performed in 4.3% of patients with ULMCA stenosis. Unadjusted in-hospital mortality rates ranged from 2.9% for elective cases to 45.1% for emergent/salvage cases. By 30 months, 57.9% of the elderly ULMCA PCI population experienced death, myocardial infarction, or revascularization, and 42.7% died. Patients receiving drug-eluting stents (versus bare-metal stents) had a lower 30-month mortality (IPW HR: 0.84, 95% confidence interval CI: 0.73 to 0.96), but the composite of major adverse events were similar (IPW HR: 0.95, 95% CI: 0.84 to 1.06). Conclusions In the United States, ULMCA PCI is performed in <5% of patients with ULMCA disease and is generally reserved for those at high procedural risk. Adverse events are common in elderly patients and are related to patient and procedural characteristics, including stent type.
Background Atrial fibrillation (AF) is the most common cardiac dysrhythmia and contributes significantly to health care expenditures. We sought to assess the frequency and predictors of ...hospitalization in patients with AF. Methods The ORBIT-AF registry is a prospective, observational study of outpatients with AF enrolled from June 29, 2010, to August 9, 2011. The current analysis included 9,484 participants with 1-year follow-up. Multivariable, logistic regression was used to identify baseline characteristics that were associated with first cause-specific hospitalization. Results Overall, 31% of patients with AF studied (n = 2,963) had 1 or more hospitalizations per year and 10% (n = 983) had 2 or more. The most common hospitalization cause was cardiovascular (20 per 100 patient-years vs 3.3 bleeding vs 17 noncardiovascular, nonbleeding). Compared with those not hospitalized, hospitalized patients were more likely to have concomitant heart failure (42% vs 28%, P < .0001), higher mean CHADS2 (1 point for congestive heart failure, hypertension, age ≥75, or diabetes; 2 points for prior stroke or transient ischemic attack) scores (2.5 vs 2.2, P < .0001), and more symptoms (baseline European Heart Rhythm Association class severe symptoms 18% vs 13%, P < .0001). In multivariable analysis, heart failure (adjusted hazard ratio HR 1.57 for New York Heart Association III/IV vs none, P < .0001), heart rate at baseline (adjusted HR 1.11 per 10-beats/min increase >66, P < .0001), and AF symptom class (adjusted HR 1.37 for European Heart Rhythm Association severe vs none, P < .0001) were the major predictors of incident hospitalization. Conclusions Hospitalization is common in outpatients with AF and is independently predicted by heart failure and AF symptoms. Improved symptom control, rate control, and comorbid condition management should be evaluated as strategies to reduce health care use in these patients.
Objectives This study sought to develop a model that predicts bleeding complications using an expanded bleeding definition among patients undergoing percutaneous coronary intervention (PCI) in ...contemporary clinical practice. Background New knowledge about the importance of periprocedural bleeding combined with techniques to mitigate its occurrence and the inclusion of new data in the updated CathPCI Registry data collection forms encouraged us to develop a new bleeding definition and risk model to improve the monitoring and safety of PCI. Methods Detailed clinical data from 1,043,759 PCI procedures at 1,142 centers from February 2008 through April 2011 participating in the CathPCI Registry were used to identify factors associated with major bleeding complications occurring within 72 h post-PCI. Risk models (full and simplified risk scores) were developed in 80% of the cohort and validated in the remaining 20%. Model discrimination and calibration were assessed in the overall population and among the following pre-specified patient subgroups: females, those older than 70 years of age, those with diabetes mellitus, those with ST-segment elevation myocardial infarction, and those who did not undergo in-hospital coronary artery bypass grafting. Results Using the updated definition, the rate of bleeding was 5.8%. The full model included 31 variables, and the risk score had 10. The full model had similar discriminatory value across pre-specified subgroups and was well calibrated across the PCI risk spectrum. Conclusions The updated bleeding definition identifies important post-PCI bleeding events. Risk models that use this expanded definition provide accurate estimates of post-PCI bleeding risk, thereby better informing clinical decision making and facilitating risk-adjusted provider feedback to support quality improvement.
...the American Taxpayer Relief Act of 2012 (12) gave providers the option of satisfying the requirements of the Physician Quality Reporting System (PQRS) (13) by participating in qualifying ...registries.\n Physio-Control Inc., ZOLL Inc.), 2012-2015; PIlow * Hypothermia Duration After Resuscitation Trial (HART) Pilot Study (Submitted to NHLBI, CR Bard Medical Division Inc., Cincinnati Sub-Zero Inc., EMCOOLS AG, Gaymar/Stryker Inc. ZOLL Circulation Inc.; 2013-2015low * Mild hypothermia for resuscitated out-of-hospital cardiac arrest patients (R01-HL089554-01), 2007-2013; Co-I Randomized Trial of Hemofiltration After Resuscitation from Cardiac Arrest (NHLBI R21 HL093641-01A1), 2009-2011; PI Resuscitation Outcomes Consortium (National Institutes of Health U01 HL077863-05), 2004-2010; Co-PIdagger Sotera Wireless, San Diego, California Velocity Pilot Study of Ultrafast Hypothermia in Patients with ST-elevation Myocardial Infarction (Velomedix Inc.), 2012-2014; PI (waived personal compensation) Washington Study of Ultrasound in Resuscitation (Philips Healthcare Inc.), 2013-2014; PIlow * Medic One Foundationlow * Novel method of tracking location of monitor/defibrillators in time and spacelow * None Randal J. Thomas Content AHA GWTG Steering Committee None None None None None None Martha Radford Content NCDR Management Board None None None None None None Debra Ness Content: National Partnership for Women and Families None None None None None None Frederic Resnic Content: NCDR Science and Quality Oversight Committee St. Jude Medical None None None FDAdagger National Institutes of Healthdagger None * This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant.
Background Significant racial/ethnic differences exist in the incidence of atrial fibrillation (AF). However, less is known about racial/ethnic differences in quality of life (QoL), treatment, and ...outcomes associated with AF. Methods Using data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we compared clinical characteristics, QoL, management strategies, and long-term outcomes associated with AF among various racial/ethnic groups. Results We analyzed 9,542 participants with AF (mean age 74 ± 11 years, 43% women, 91% white, 5% black, 4% Hispanic) from 174 centers. Compared with AF patients identified as white race, patients identified as Hispanic ethnicity and those identified as black race were younger, were more often women, and had more cardiac and noncardiac comorbidities. Black patients were more symptomatic with worse QoL and were less likely to be treated with a rhythm control strategy than other racial/ethnic groups. There were no significant racial/ethnic differences in CHA2 DS2 -VASc stroke or ATRIA bleeding risk scores and rates of oral anticoagulation use were similar. However, racial and ethnic minority populations treated with warfarin spent a lower median time in therapeutic range of international normalized ratio (59% blacks vs 68% whites vs 62% Hispanics, P < .0001). There was no difference in long-term outcomes associated with AF between the 3 groups at a median follow-up of 2.1 years. Conclusion Relative to white and Hispanic patients, black patients with AF had more symptoms, were less likely to receive rhythm control interventions, and had lower quality of warfarin management. Despite these differences, clinical events at 2 years were similar by race and ethnicity.
Abstract Background Antithrombotic therapy for acute myocardial infarction (MI) with atrial fibrillation (AF) among higher risk older patients treated with percutaneous coronary intervention (PCI) ...remains unclear. Objectives This study sought to determine appropriate antithrombotic therapy for acute MI patients with AF treated with PCI. Methods We examined 4,959 patients ≥65 years of age with acute MI and AF who underwent coronary stenting (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines). The primary effectiveness outcome was 2-year major adverse cardiac events (MACE) comprising death, readmission for MI, or stroke; the primary safety outcome was bleeding readmission. Outcomes with dual antiplatelet therapy (DAPT) or triple therapy (DAPT plus warfarin) were compared using Cox proportional hazard modeling with inverse probability-weighted propensity adjustment. Results Among 4,959 patients, 27.6% (n = 1,370) were discharged on triple therapy. Relative to DAPT, patients on triple therapy had a similar risk of MACE (adjusted hazard ratio HR: 0.99 95% confidence interval (CI): 0.86 to 1.16) but significantly greater risk of bleeding requiring hospitalization (adjusted HR: 1.61 95% CI: 1.31 to 1.97) and greater risk of intracranial hemorrhage (adjusted HR: 2.04 95% CI: 1.25 to 3.34). Of 1,591 Medicare Part D patients, 90-day post-discharge warfarin persistence among patients discharged on warfarin was 93.2% (n = 412). Results of 90-day landmark analyses comparing triple therapy versus DAPT in patients persistently on warfarin versus those not discharged on warfarin who had not filled a warfarin prescription were similar to our primary findings. Conclusions Approximately 1 in 4 older AF patients undergoing PCI for MI were discharged on triple therapy. Those receiving triple therapy versus DAPT had higher rates of major bleeding without a measurable difference in composite MI, death, or stroke.
Background Although ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (AMI) have been the focus of intense clinical investigation, limited information exists on characteristics ...and hospital mortality of patients not enrolled in clinical trials. Previous large databases have reported declining mortality of patients with STEMI but have not noted substantial mortality change among those with NSTEMI. Methods The National Registry of Myocardial Infarction enrolled 2,515,106 patients at 2,157 US hospitals from 1990 to 2006. Of these, we evaluated 1,950,561 with diagnoses reflecting acute myocardial ischemia on admission. Results From 1990 to 2006, the proportion of NSTEMI increased from 14.2% to 59.1% ( P < .0001), whereas the proportion of STEMI decreased. Mean age increased (from 64.1 to 66.4 years, P < .0001) as did the proportion of females (from 32.4% to 37.0%, P < .0001). Patients were less likely to report prior angina, prior AMI, or family history of coronary artery disease but more likely to report history of diabetes, hypertension, current smoking, heart failure, prior revascularization, stroke, and hyperlipidemia. From 1994 to 2006, hospital mortality fell among all patients (10.4% to 6.3%), STEMI (11.5% to 8.0%), and NSTEMI (7.1% to 5.2%), (all P < .0001). After adjustment for baseline covariates, hospital mortality fell among all patients by 23.6% (odds ratio OR 0.764, 95% CI 0.744-0.785), STEMI by 24.2% (OR 0.758, 0.732-0.784), and NSTEMI by 22.6% (OR 0.774, 0.741-0.809), all P < .001. Conclusions This large, observational database from 1990 to 2006 shows increasing prevalence of NSTEMI and, despite higher risk profile on presentation, falling risk-adjusted hospital mortality in patients with either STEMI or NSTEMI.
Introduction Public reporting (PR) is a policy mechanism that may improve clinical outcomes for percutaneous coronary intervention (PCI). However, prior studies have shown that PR may have an adverse ...impact on patient selection. It is unclear whether alternatives to PR, such as collaborative quality improvement (CQI), may drive improvements in quality of care and outcomes for patients receiving PCI without the unintended consequences seen with PR. Methods Using National Cardiovascular Data Registry CathPCI Registry data from January 2011 through September 2012, we evaluated patients who underwent PCI in New York (NY), a state with PR (N = 51,983), to Michigan, a state with CQI (N = 53,528). We compared patient characteristics, the quality of care delivered, and clinical outcomes. Results Patients undergoing PCI in NY had a lower-risk profile, with a lower proportion of patients with ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, or cardiogenic shock, compared with Michigan. Quality of care was broadly similar in the 2 states; however, outcomes were better in NY. In a propensity-matched analysis, patients in NY were less likely to be referred for emergent, urgent, or salvage coronary artery bypass surgery (odds ratio OR 0.67, 95% CI 0.51-0.88, P < .0001) and to receive blood transfusion (OR 0.7, 95% CI 0.61-0.82, P < .0001), and had lower in-hospital mortality (OR 0.72, 95% CI 0.63-0.83, P < .0001). Conclusions Public reporting of PCI data is associated with fewer high-risk patients undergoing PCI compared with CQI. However, in comparable samples of patients, PR is also associated with a lower risk of mortality and adverse events. The optimal quality improvement method may involve combining these 2 strategies to protect access to care while still driving improvements in patient outcomes.
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