A proof-of-concept study of cascade screening for Familial Hypercholesterolemia in the US, adapted from the Dutch model

BACKGROUND

The Dutch cascade screening model for FH was the most successful of such programs in the world. It remains unclear whether aspects of the Dutch model (i.e. direct engagement with FH probands and relatives outside usual healthcare settings) are feasible in the US. This is especially important since prior attempts at cascade screening in the US have had very low screening rates (<10% of families screened).

METHODS

We conducted a multi-site single-arm proof-of-concept study in which the US-based FH Foundation (a 501c3 research and advocacy organization) directly engaged with FH probands and relatives similar to the approach taken by the Dutch "Foundation for Tracing FH."

RESULTS

Eleven unrelated probands with genetically confirmed FH were enrolled. Mean age was 43 years; 82% were women, and 82% were of European ancestry. Prior to enrolling into the study, only 2 families (18% screening rate) were screened for FH with both lipid measurements and genetic testing. Two probands declined cascade screening due to fear over genetic discrimination. Nine total relatives engaged with the FH Foundation. Mean age was 43 years and 44% were women. Seven of those relatives (from 6 families; 55% screening rate) consented to be screened for FH with lipid measurement and genetic testing. The two additional relatives - men ages 39 and 49 - agreed to lipid measurements but not genetic testing, each noting he would like to think more about genetic testing.

CONCLUSIONS

Our proof-of-concept study demonstrates the feasibility of the FH Foundation engaging FH probands and their relatives outside the usual healthcare settings for cascade screening, similar to the Dutch model. We found only 18% of families had already been screened, and after engaging with the FH Foundation, 55% of families were willing to participate in cascade screening. These findings suggest the methods described here may improve cascade screening rates in the US.

Abstract 044: Association Of Cardiovascular Comorbidities With Sars-cov-2 Seropositivity In A Population-based Cohort

Background: Following the outbreak of SARS-COV2 > 7,750,000 Americans were diagnosed with COVID-19. Many comorbidities were found to be associated with increased risk of severe disease. Due to limited testing and high percent of asymptomatic cases the exact prevalence is unclear. Moreover, whether the presence of comorbidities is associated with an increased rate of COVID-19 remains unknown.

Methods: COVID-19 Community Research Partnership (CCRP) is a prospective cohort designed to collect information about the community's coronavirus exposures, symptoms, and prevalence (NCT04342884). Serological substudy is a prospective case series evaluating development of IgM or IgG in randomly selected 5000 participants from the CCRP cohort. Serological test kits are shipped to the volunteers monthly. Prevalence of comorbidities was estimated using electronic health records.

Results: There were 4902 patients included in the analysis (Figure). Of those, 2,832 (57.8%) were female, mean age±SD was 49.6±14.4. There were 3,871 (79%) Caucasians, 422 (8.6%) - African Americans and 242 (4.9%) - Hispanics (Table). From May 2020 to August 2020, 424 patients (8.7%) seroconverted (IgM or IgG positive): 327 (6.7%) were found to be IgM positive/ IgG negative, 38 (0.8%)- IgM negative/IgG positive and 59 (1.2%) - IgM positive/ IgG positive. Prevalence of comorbidities was low: 1,318 (26.9%) patients have hypertension, 1,379 (28.1%)- hyperlipidemia, 413 (8.4%)- diabetes, 217 (4.4%)- coronary artery disease, 156 (3.2%)- peripheral arterial disease, 132 (2.7%)- atrial fibrillation, 95 (1.9%)- history of deep venous thrombosis and pulmonary embolism, and 54 (1.1%)- history of heart failure (HF). Only the presence of HF was associated with an increased odds ratio of seroconversion OR 2.4, (1.21- 4.87), p<0.012. This association remained robust after controlling for age, sex and race.

Conclusion: Prevalence of seroconversion was near 9%. Presence of heart failure was independently associated with an increased odds ratio of seroconversion.

The impact of COVID-19 patients with troponin elevation on renal impairment and clinical outcome

Background

Cardiac involvement in coronavirus disease 2019 (COVID-19) is known, manifested by troponin elevation, and these patients have a worse prognosis than patients without myocardial injury.

Methods

We analyzed COVID-19-positive patients who presented to the MedStar Health system (11 hospitals in Washington, DC, and Maryland) during the pandemic (March 1–September 30, 2020). We compared renal function and subsequent in-hospital clinical outcomes based on the presence or absence of troponin elevation. The primary outcome was the incidence of acute kidney injury in COVID-19 patients with troponin elevation. We also evaluated in-hospital mortality, overall and based on the presence and absence of both troponin elevation and renal dysfunction.

Results

The cohort included 3386 COVID-19-positive admitted patients for whom troponin was drawn. Of these patients, 195 had troponin elevation (defined as ≥1.0 ng/mL), mean age was 61 ± 16 years, and 51% were men. In-hospital mortality was significantly higher (53.8%) in COVID-19-positive patients with concomitant troponin elevation than in those without troponin elevation (14.5%; p < 0.001). COVID-19-positive patients with troponin elevation had a higher prevalence of renal dysfunction (58.5%) than those without troponin elevation (23.4%; p < 0.001). Further analysis demonstrated that having both troponin elevation and renal dysfunction carried the worst in-hospital prognosis (in-hospital mortality 57.9%; intensive-care-unit admission 76.8%; ventilation requirement 63.2%), as compared to the absence or presence of either.

Conclusion

COVID-19 patients with troponin elevation are at higher risk for worsening renal function, and these patients subsequently have worse in-hospital clinical outcomes. Efforts should focus on early recognition, evaluation, and intensifying care of these patients.

Estimating Systolic Blood Pressure Intervention Trial Participant Posttrial Survival Using Pooled Epidemiologic Cohort Data

Background

Intensive systolic blood pressure treatment (<120 mm Hg) in SPRINT (Systolic Blood Pressure Intervention Trial) improved survival compared with standard treatment (<140 mm Hg) over a median follow‐up of 3.3 years. We projected life expectancy after observed follow‐up in SPRINT using SPRINT‐eligible participants in the NHLBI‐PCS (National Heart, Lung, and Blood Institute Pooled Cohorts Study).

Methods and Results

We used propensity scores to weight SPRINT‐eligible NHLBI‐PCS participants to resemble SPRINT participants. In SPRINT participants, we estimated in‐trial survival (<4 years) using a time‐based flexible parametric survival model. In SPRINT‐eligible NHLBI‐PCS participants, we estimated posttrial survival (≥4 years) using an age‐based flexible parametric survival model and applied the formula to SPRINT participants to predict posttrial survival. We projected overall life expectancy for each SPRINT participant and compared it to parametric regression (eg, Gompertz) projections based on SPRINT data alone. We included 8584 SPRINT and 10 593 SPRINT‐eligible NHLBI‐PCS participants. After propensity weighting, mean (SD) age was 67.9 (9.4) and 68.2 (8.8) years, and 35.5% and 37.6% were women in SPRINT and NHLBI‐PCS, respectively. Using the NHLBI‐PCS–based method, projected mean life expectancy from randomization was 21.0 (7.4) years with intensive and 19.1 (7.2) years with standard treatment. Using the Gompertz regression, life expectancy was 11.2 (2.3) years with intensive and 10.5 (2.2) years with standard treatment.

Conclusions

Combining SPRINT and NHLBI‐PCS observed data likely offers a more realistic estimate of life expectancy than parametrically extrapolating SPRINT data alone. These results offer insight into the potential long‐term effectiveness of intensive SBP goals.

Patient Selection for Intensive Blood Pressure Management Based on Benefit and Adverse Events

BACKGROUND

Intensive systolic blood pressure (SBP) treatment prevents cardiovascular disease (CVD) events in patients with high CVD risk on average, though benefits likely vary among patients.

OBJECTIVES

The aim of this study was to predict the magnitude of benefit (reduced CVD and all-cause mortality risk) along with adverse event (AE) risk from intensive versus standard SBP treatment.

METHODS

This was a secondary analysis of SPRINT (Systolic Blood Pressure Intervention Trial). Separate benefit outcomes were the first occurrence of: 1) a CVD composite of acute myocardial infarction or other acute coronary syndrome, stroke, heart failure, or CVD death; and 2) all-cause mortality. Treatment-related AEs of interest included hypotension, syncope, bradycardia, electrolyte abnormalities, injurious falls, and acute kidney injury. Modified elastic net Cox regression was used to predict absolute risk for each outcome and absolute risk differences on the basis of 36 baseline variables available at the point of care with intensive versus standard treatment.

RESULTS

Among 8,828 SPRINT participants (mean age 67.9 years, 35% women), 600 CVD composite events, 363 all-cause deaths, and 481 treatment-related AEs occurred over a median follow-up period of 3.26 years. Individual participant risks were predicted for the CVD composite (C index = 0.71), all-cause mortality (C index = 0.75), and treatment-related AEs (C index = 0.69). Higher baseline CVD risk was associated with greater benefit (i.e., larger absolute CVD risk reduction). Predicted CVD benefit and predicted increased treatment-related AE risk were correlated (Spearman correlation coefficient = -0.72), and 95% of participants who fell into the highest tertile of predicted benefit also had high or moderate predicted increases in treatment-related AE risk. Few were predicted as high benefit with low AE risk (1.8%) or low benefit with high AE risk (1.5%). Similar results were obtained for all-cause mortality.

CONCLUSIONS

SPRINT participants with higher baseline predicted CVD risk gained greater absolute benefit from intensive treatment. Participants with high predicted benefit were also most likely to experience treatment-related AEs, but AEs were generally mild and transient. Patients should be prioritized for intensive SBP treatment on the basis of higher predicted benefit. (Systolic Blood Pressure Intervention Trial [SPRINT]; NCT01206062).

Angiotensin II receptor blocker or angiotensin-converting enzyme inhibitor use and COVID-19-related outcomes among US Veterans

BACKGROUND

Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) may positively or negatively impact outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We investigated the association of ARB or ACEI use with coronavirus disease 2019 (COVID-19)-related outcomes in US Veterans with treated hypertension using an active comparator design, appropriate covariate adjustment, and negative control analyses.

METHODS AND FINDINGS

In this retrospective cohort study of Veterans with treated hypertension in the Veterans Health Administration (01/19/2020-08/28/2020), we compared users of (A) ARB/ACEI vs. non-ARB/ACEI (excluding Veterans with compelling indications to reduce confounding by indication) and (B) ARB vs. ACEI among (1) SARS-CoV-2+ outpatients and (2) COVID-19 hospitalized inpatients. The primary outcome was all-cause hospitalization or mortality (outpatients) and all-cause mortality (inpatients). We estimated hazard ratios (HR) using propensity score-weighted Cox regression. Baseline characteristics were well-balanced between exposure groups after weighting. Among outpatients, there were 5.0 and 6.0 primary outcomes per 100 person-months for ARB/ACEI (n = 2,482) vs. non-ARB/ACEI (n = 2,487) users (HR 0.85, 95% confidence interval [CI] 0.73-0.99, median follow-up 87 days). Among outpatients who were ARB (n = 4,877) vs. ACEI (n = 8,704) users, there were 13.2 and 14.8 primary outcomes per 100 person-months (HR 0.91, 95%CI 0.86-0.97, median follow-up 85 days). Among inpatients who were ARB/ACEI (n = 210) vs. non-ARB/ACEI (n = 275) users, there were 3.4 and 2.0 all-cause deaths per 100 person months (HR 1.25, 95%CI 0.30-5.13, median follow-up 30 days). Among inpatients, ARB (n = 1,164) and ACEI (n = 2,014) users had 21.0 vs. 17.7 all-cause deaths, per 100 person-months (HR 1.13, 95%CI 0.93-1.38, median follow-up 30 days).

CONCLUSIONS

This observational analysis supports continued ARB or ACEI use for patients already using these medications before SARS-CoV-2 infection. The novel beneficial association observed among outpatients between users of ARBs vs. ACEIs on hospitalization or mortality should be confirmed with randomized trials.

Implications of Left Ventricular Function on Short-Term Outcomes in COVID-19 Patients With Myocardial Injury

BACKGROUND

Myocardial injury is a complication of coronavirus disease 2019 (COVID-19). We describe a large multi-center experience of COVID-19 patients with myocardial injury, examining the prognostic role left ventricular function plays on short-term outcomes.

METHODS/MATERIALS

We included adult COVID-19 patients admitted to our health system with evidence of myocardial injury and who underwent a transthoracic echocardiogram (TTE) during index admission. Patients were dichotomized into those with reduced ejection fraction (EF; <50%) and preserved EF (≥50%).

RESULTS

Across our 11-hospital system, 5032 adult patients were admitted with COVID-19 from March-September 2020. Of these, 235 had evidence of myocardial injury (troponin ≥1 ng/mL). Included were 134 patients who underwent TTE, of whom 43.3% (n = 58) had reduced EF and 56.7% (n = 76) preserved EF. A subset of 6 patients had newly reduced EF, with 5 demonstrating evidence of stress cardiomyopathy and subsequently dying. Overall, mortality was high in those with reduced EF and preserved EF (in-hospital: 34.5% vs. 28.9%; p = 0.494; 6 months: 63.6% vs. 50.0%; p = 0.167; Kaplan-Meier estimates: p = 0.2886). Readmissions were frequent in both groups (30 days: 22.2% vs. 26.0%; p = 0.162; 6 months: 52.0% vs. 54.5%; p = 0.839).

CONCLUSIONS

Many COVID-19 patients admitted with evidence of myocardial injury did not undergo TTE. For those who did, short-term mortality was high. Patients who survived hospitalization had frequent readmissions. In patients with newly reduced EF, most had evidence of stress cardiomyopathy and expired. Larger studies are needed to fully evaluate the prognosis of COVID-19 patients with evidence of myocardial injury and left ventricular dysfunction.

2021 ACC/AHA Key Data Elements and Definitions for Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Heart Failure)

Supplemental Digital Content is available in the text.

Cost-effectiveness analysis of percutaneous coronary intervention for single-vessel coronary artery disease: an economic evaluation of the ORBITA trial

OBJECTIVE

To evaluate the cost-effectiveness of percutaneous coronary intervention (PCI) compared with placebo in patients with single-vessel coronary artery disease and angina despite anti-anginal therapy.

DESIGN

A cost-effectiveness analysis comparing PCI with placebo. A Markov model was used to measure incremental cost-effectiveness, in cost per quality-adjusted life-years (QALYs) gained, over 12 months. Health utility weights were estimated using responses to the EuroQol 5-level questionnaire, from the Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial and UK preference weights. Costs of procedures and follow-up consultations were derived from Healthcare Resource Group reference costs and drug costs from the National Health Service (NHS) drug tariff. Probabilistic sensitivity analysis was undertaken to test the robustness of results to parameter uncertainty. Scenario analyses were performed to test the effect on results of reduced pharmaceutical costs in patients undergoing PCI, and the effect of patients crossing over from placebo to PCI due to refractory angina within 12 months.

SETTING

Five UK NHS hospitals.

PARTICIPANTS

200 adult patients with stable angina and angiographically severe single-vessel coronary artery disease on anti-anginal therapy.

INTERVENTIONS

At recruitment, patients received 6 weeks of optimisation of medical therapy for angina after which they were randomised to PCI or a placebo procedure.

OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER) expressed as cost (in £) per QALY gained for PCI compared with placebo.

RESULTS

The estimated ICER is £90 218/QALY gained when using PCI compared with placebo in patients receiving medical treatment for angina due to single-vessel coronary artery disease. Results were robust under sensitivity analyses.

CONCLUSIONS

The ICER for PCI compared with placebo, in patients with single-vessel coronary artery disease and angina on anti-anginal medication, exceeds the threshold of £30 000 used by the National Institute of Health and Care Excellence when undertaking health technology assessment for the NHS context.Trial registration: The ORBITA study is registered with ClinicalTrials.gov, number NCT02062593.

National trends and 30-day readmission rates for next-day-discharge transcatheter aortic valve replacement: An analysis from the Nationwide Readmissions Database, 2012-2016

Transcatheter aortic valve replacement (TAVR) has evolved toward a minimalist approach, resulting in shorter hospital stays. Real-world trends of next-day discharge (NDD) TAVR are unknown. This study aimed to evaluate underlying trends and readmissions of NDD TAVR.

METHODS

This study was derived from the Nationwide Readmissions Database from 2012 to 2016. International Classification of Diseases, Ninth and Tenth Revisions, codes were used to identify patients. Any discharge within 1 day of admission was identified as NDD. NDD TAVR trends over the years were analyzed, and any admissions within 30 days were considered readmissions. A hierarchical logistic regression model was used to identify predictors of readmission.

RESULTS

Of 49,742 TAVR procedures, 3,104 were NDD. The percentage of NDD TAVR increased from 1.5% (46/3,051) in 2012 to 12.2% (2,393/19,613) in 2016. However, the 30-day readmission rate remained the same over the years (8.6%). The patients' mean age was 80.3 ± 8.4 years. Major readmission causes were heart-failure exacerbation (16%), infections (9%), and procedural complications (8%). In 2016, there were significantly higher late conduction disorder and gastrointestinal bleeding readmission rates than in 2012-2015. Significant predictors of readmission were anemia, baseline conduction disease, cardiac arrhythmias, heart failure, chronic kidney disease, chronic obstructive pulmonary disease, neoplastic disorders, and discharge to facility.

CONCLUSIONS

The percentage of NDD TAVR increased over the years; however, readmission rates remained the same, with a higher rate of conduction abnormality-related hospitalizations in 2016. Careful discharge planning that includes identification of baseline factors that predict readmission and knowledge of etiologies may further prevent 30-day readmissions.

Drug-Coated Balloon for De Novo Coronary Artery Disease: JACC State-of-the-Art Review

Percutaneous coronary intervention with a drug-eluting stent is the most common mode of revascularization for coronary artery disease. However, restenosis rates remain high. Non-stent-based local drug delivery by a drug-coated balloon (DCB) has been investigated, as it leaves no metallic mesh. A DCB consists of a semicompliant balloon coated with antiproliferative agents encapsulated in a polymer matrix, which is released into the wall after inflation and contact with the intima. DCB have demonstrated effectiveness in treating in-stent restenosis. Clinical studies using DCB in de novo coronary artery disease have shown mixed results, with a major benefit in small-vessel disease. Differences in study results are not only due to variations in DCB technology but also to disparity in procedural approach, "leave nothing behind" or "combination therapy," and vessel size. This review focuses on the available evidence from randomized trials and proposes a design for future clinical trials.

The Role of National Registries in Improving Quality of Care and Outcomes for Cardiovascular Disease

Cardiovascular registries play an integral role in providing real-world data on a number of cardiovascular conditions and allowing measurement of quality metrics across a large cohort of patients. Over the past 35 years, the number of cardiovascular registries has skyrocketed, and their use will only continue to grow as data on novel procedures and devices will need to be collected and analyzed. The American College of Cardiology and Society of Thoracic Surgeons Transcatheter Valve Therapy Registry is just one example of a modern registry that plays a crucial role in collecting data on patients undergoing transcatheter valvular procedures. Through public reporting registries, data can be shared on a hospital and provider level for many quality performance measures. There remains much work to be done on allowing automated data extraction from the electronic medical record directly into registries. No matter how sophisticated and complete a registry is, it can never overcome the problem of treatment selection bias that is inherent in observational data. This review discusses the growth, benefits, and limitations of national registries and their role in developing evidence for best clinical practice, measuring outcomes, providing feedback to clinicians, and improving quality of care.

Admissions Rate and Timing of Revascularization in the United States in Patients With Non-ST-Elevation Myocardial Infarction

Clinical trials have shown improved outcomes with an early invasive approach for non-ST-elevation myocardial infarction (NSTEMI). However, real-world data on clinical characteristics and outcomes based on time to revascularization are lacking. We aimed to analyze NSTEMI rates, revascularization timing, and mortality using the 2016 Nationwide Readmissions Database. We identify patients who underwent diagnostic angiography and subsequently received either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Finally, revascularization timing and mortality rates (in-hospital and 30-day) were extracted. Our analysis included 748,463 weighted NSTEMI hospitalizations in 2016. Of these hospitalizations, 50.3% (376,695) involved diagnostic angiography, with 34.1% (255,199) revascularized. Of revascularized patients, 77.6% (197,945) underwent PCI and 22.4% (57,254) underwent CABG. Patients with more comorbidities tended to have more delayed revascularization. PCI was most commonly performed on the day of admission (32.9%; 65,155). This differs from CABG, which was most commonly performed on day 3 after admission (13.7%; 7,823). The in-hospital mortality rate increased after day 1 for PCI patients and after day 4 for CABG patients, whereas 30-day in-hospital mortality for both populations increased as revascularization was delayed. Our study shows that patients undergoing early revascularization differ from those undergoing later revascularization. Mortality is generally high with delayed revascularization, as these are sicker patients. Randomized clinical trials are needed to evaluate whether very early revascularization (<90 minutes) is associated with improved long-term outcomes in high-risk patients.

An integrated approach to simulating the vulnerable atherosclerotic plaque

Analyses of individual atherosclerotic plaques are mostly descriptive, relying, for example, on histological classification by spectral analysis of ultrasound waves or staining and observing particular cellular components. Such passive methods have proved useful for characterizing the structure and vulnerability of plaques but have little quantitative predictive power. Our aim is to introduce and discuss a computational framework to provide insight to clinicians and help them visualize internal plaque dynamics. We use partial differential equations (PDEs) with macrophages, necrotic cells, oxidized lipids, oxygen concentration, and platelet-derived growth factor (PDGF) as primary variables coupled to a biomechanical model to describe vessel growth. The model is deterministic, providing mechanical, morphological, and histological characteristics of an atherosclerotic vessel at any desired future time point. We use our model to create computer-generated animations of a plaque evolution that are in qualitative agreement with published serial ultrasound images and hypothesize possible atherogenic mechanisms. A systems biology model consisting of five differential equations is able to capture the morphology of necrotic cores residing within vulnerable atherosclerotic plaque. In the context of the model, the distribution of oxidized low-density lipoprotein (Ox-LDL) particles, endothelial inflammation, plaque oxygenation (via the presence of vasa vasora), and intimal oxygenation are four important factors that drive changes in core morphology.NEW & NOTEWORTHY In this article, we propose a quantitative framework to describe the evolution of atherosclerotic plaque. We use partial differential equations (PDEs) with macrophages, necrotic cells, oxidized lipids, oxygen concentration, and PDGF as primary variables coupled to a biomechanical model to describe vessel growth. A feature of our method is that it outputs color-coded vessel sections corresponding to regions of the plaque that are necrotic and fibrous, qualitatively similar to images generated by enhanced intravascular ultrasound.

The IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact (IMPROVE) trial: Study design and rationale

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has been shown in clinical trials, registries, and meta-analyses to reduce recurrent major adverse cardiovascular events after PCI. However, IVUS utilization remains low. An increasing number of high-risk or complex coronary artery lesions are treated with PCI, and we hypothesize that the impact of IVUS in guiding treatment of these complex lesions will be of increased importance in reducing major adverse cardiovascular events while remaining cost-effective. The "IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact" trial (registered on clinicaltrials.gov: NCT04221815) is a multicenter, international, clinical trial randomizing subjects to IVUS-guided versus angiography-guided PCI in a 1:1 ratio. Patients undergoing PCI involving a complex lesion are eligible for enrollment. Complex lesion is defined as involving at least 1 of the following characteristics: chronic total occlusion, in-stent restenosis, severe coronary artery calcification, long lesion (≥28 mm), or bifurcation lesion. The clinical investigation will be conducted at approximately 120 centers in North America and Europe, enrolling approximately 2,500 to 3,100 randomized subjects with an adaptive design. The primary clinical end point is the rate of target vessel failure at 12 months, defined as the composite of cardiac death, target vessel-related myocardial infarction, and ischemia-driven target vessel revascularization. The co-primary imaging end point is the final post-PCI minimum stent area assessed by IVUS. The primary objective of this study is to assess the impact of IVUS guidance on the PCI treatment of complex lesions.

Risk Prediction Tool for Assessing the Probability of Death or Myocardial Infarction in Patients With Stable Coronary Artery Disease

Several risk scores in acute coronary syndromes are available, but few models exist for stable coronary artery disease to guide decision-making and prognosis. A multivariate model was developed using 23 baseline candidate variables from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Therapy EvaluationTrial (n = 2,287 patients). Discrimination of the model was evaluated by the concordance c-index. The procedure was validated using 100 random half samples. We identified 9 independent predictors of death or myocardial infarction (MI) during a 5-year follow-up. The following predictors and points contributing to the risk score were: heart failure (3), number of diseased coronary arteries (1 for each vessel), diabetes (1), age (1 for each 15 years ≥ age 45), previous revascularization (1), current smoking (1), female (1), previous MI (1), and high-density lipoprotein cholesterol (1: 31 to 40 mg/dL; 2: <30 mg/dL). The risk tool had a potential range from 0 to 15, corresponding to 5-year event rates of 5.8% to 56%. C-indices ranged from 0.67 for the full data set to 0.62 for the validating subsamples. Respective observed versus predicted 5-year event rates for 3 predefined risk strata revealed: 30% had a low-risk score of 0 to 3 (9.3% vs 9.3%, or 1.9%/year); 59% had an intermediate-risk score of 4-6 (18.0% vs 18.1%, or 3.6%/year); and 11% had a high-risk score of 7-11 (36% vs 36.5%, or 7.2%/year). This stable coronary artery disease risk score permitted a prognostic assessment of 5-year probability of death or MI with an approximate 4-fold range in event rates from the lowest (9.3%) to the highest (36%) terciles, thus enabling better clinical practice decisions that allow physicians to tailor the intensity of treatment to the level of risk.

Value in Healthcare Initiative: Summary and Key Recommendations

In spring 2018, the American Heart Association convened the Value in Healthcare Summit to begin an important conversation about the challenges patients with cardiovascular disease face in accessing and deriving quality and value from the healthcare system. Following the summit and recognizing the collective momentum it created, the American Heart Association, in collaboration with the Robert J. Margolis Center for Health Policy at Duke University, launched the Value in Healthcare Initiative-Transforming Cardiovascular Care. Four areas of focus were identified, and learning collaboratives were established and proceeded to conduct concrete, actionable problem solving in 4 high-impact areas in cardiovascular care: Value-Based Models, Partnering with Regulators, Predict and Prevent, and Prior Authorization. The deliverables from these groups are being disseminated in 4 stand-alone articles, and their publication will initiate further work to test and evaluate each of these promising areas of reform. This article provides an overview of the initiative's findings and highlights key cross-cutting themes for consideration as the initiative moves forward.

Facilitating the identification of patients hospitalized for acute myocardial infarction and heart failure and the assessment of their readmission risk through the Patient Navigator Program

BACKGROUND

Optimal transition care mitigates early hospital readmission risk. Given limited resources, hospitals need to identify patients with high readmission risk. This article examines whether a coordinated quality improvement campaign can help achieve this objective.

METHODS

The American College of Cardiology Patient Navigator Program, a 2-year quality improvement campaign, sought to assess the impact of transition care interventions on 30-day readmission rates for patients with acute myocardial infarction (AMI) or heart failure (HF) at 35 hospitals. This article examines the change in 2 of the 36 performance metrics the campaign tracked: the number of AMI and HF patients identified predischarge and those whose readmission risk was assessed.

RESULTS

The number of facilities identifying AMI and HF patients predischarge increased from 24 (68.6%) and 28 (80.0%), respectively, at baseline, to 34 (97.1%) (P = .0016) and 34 (97.1%) (P = .014), respectively, at 2 years. The number of facilities assessing the readmission risk of AMI and HF patients risk increased from 9 (25.7%) and 11 (31.4%), respectively, at baseline, to 32 (91.4%) (P < .0001) and 33 (94.5%) (P < .0001), respectively, at 2 years. Importantly, baseline reporting of performance for both metrics was poor, with >25% of the hospitals missing data.

CONCLUSIONS

Implementation of a coordinated quality improvement campaign may increase the number of facilities identifying AMI and HF patients predischarge and assessing their readmission risk. Further research is needed to determine if increased identification reduces 30-day readmission or facilitates improvement in other important clinical outcomes.

Ischemic Versus Bleeding Outcomes After Percutaneous Coronary Interventions in Patients With High Bleeding Risk

Patients undergoing percutaneous coronary intervention (PCI) often have high-bleeding-risk (HBR) factors. Dual antiplatelet therapy (DAPT) further increases this risk of bleeding. We sought to compare clinical outcomes according to presence or absence of HBR factors in patients with elevated ischemic risk (DAPT score ≥ 2) undergoing PCI. We evaluated all patients undergoing PCI at MedStar Washington Hospital Center (January 2009 to July 2018) with DAPT score ≥2, which is associated with elevated risk of ischemic events. Patients were categorized as HBR group (HBR score ≥1) or low-bleeding-risk (LBR) group (HBR score = 0). Outcomes included major adverse cardiac events such as target vessel revascularization, stent thrombosis, death, and bleeding events at 30 days, 6 months, 1 year, and 2 years. The final cohort consisted of 7,499 patients: 3,949 patients had LBR features, and 3,550 patients had HBR features. The 2 groups were different at baseline, with HBR patients being older and having a higher prevalence of congestive heart failure and renal dysfunction than the LBR group. The mean DAPT score was 2.96±1.1 for the LBR group and 3.7±1.4 for the HBR group (p <0.001). During follow-up at 30 days, 6 months, and 1 and 2 years, the rates of target vessel revascularization and stent thrombosis were not significantly different between the 2 groups. Bleeding events and all-cause mortality were significantly more frequent in the HBR group than in the LBR group. In conclusion, patients undergoing PCI often have pre-existing risk factors that predispose them to ischemic and bleeding complications. Prolonged duration of DAPT to mitigate ischemic events could lead to a disproportionate increase in bleeding events, especially in HBR patients.