The American Journal of Cardiology

IntroductionAngina with no obstructive coronary artery disease (ANOCA) presents diagnostic and treatment challenges, significantly burdening healthcare resources as reported in previous studies. This study assessed temporal changes in emergency department (ED) visits and hospitalizations for ANOCA and factors associated with these outcomes. Methods/ResultsWe assessed a retrospective cohort of 85,573 individuals (26% with ANOCA, 31% female, mean age 62.1{+/-}12.0 years) who underwent their first cardiac catheterization for chest pain in Alberta from 2002 to 2017. Temporal trend analysis showed ED visits ranged from 26.3% to 30.7% ({beta}=0.21 [95%CI:-0.28 to 0.70];p=0.33) for ANOCA and from 47.7% to 53.1% ({beta}=-0.15[95%CI:-0.87 to 0.57];p=0.63) for obstructive CAD, with no temporal changes in either. Hospitalizations decreased from 6.5% to 3.8% ({beta}=-0.28 [95%CI:-0.47 to -0.09];p=0.010) for ANOCA and from 24.8% to 15.3% ({beta}=-1.45 [95%CI:-1.77 to -1.12];p<0.001) for obstructive CAD. Multivariable logistic regression analysis factors associated with ED visits in individuals with ANOCA included cerebrovascular disease (CEVD) (OR=1.73 [95%CI:1.40-2.15]), congestive heart failure (CHF) (OR=1.91 [95%CI:1.49-2.44]), peripheral artery disease (PAD) (OR=1.61 [95%CI:1.18-2.19), and unstable angina (UA) (versus (vs) stable angina (SA): OR=1.65 [95%CI:1.51-1.80]). Factors associated with hospitalizations in ANOCA included CEVD (OR=1.39 [95%CI:1.11-1.73]), CHF (OR=2.06 [95%CI:1.66-2.56]), hypertension (OR: 1.26 [95%CI:1.14-1.40]), PAD (OR=1.89 [95%CI:1.43-2.50]), and myocardial infarction (vs SA: OR=1.27 [95%CI:1.12-1.44]), and UA (vs SA: OR=1.36 [95%CI:1.22-1.52]). ConclusionsED visits for ANOCA remained stable, while hospitalizations declined over time. Understanding factors associated with recurrent visits may aid clinicians in treatment strategies. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIThis study was the first to characterize emergency department (ED) visits and assess temporal trends of ED visits and hospitalizations in individuals with ANOCA. C_LIO_LIED visits for individuals with ANOCA or obstructive CAD have remained stable over time, with a significant decline in hospitalizations for both groups. C_LIO_LIIn contrast to previous studies, individuals with obstructive CAD had higher ED visits and hospitalizations rates than those with ANOCA. C_LI What are the clinical implications?O_LIIncreased recognition of ANOCA may be responsible for decreasing hospitalizations. C_LIO_LIDespite increased awareness, individuals with ANOCA still frequently visit the ED, highlighting the need for improved education on persistent chest pain and unnecessary ED visits. C_LIO_LIThe development of specialized chest pain clinics using a multidisciplinary approach could reduce unnecessary ED visits and hospitalizations, thereby improving the quality of life for individuals with ANOCA. C_LI

BackgroundST-elevation myocardial infarction (STEMI) places a significant burden on the US healthcare system. However, there are gaps in our understanding of how patient demographics influence a STEMIs risk to be admitted and the length of stay (LOS). MethodsWe conducted a retrospective analysis of the 2019 Nationwide Emergency Department Sample of patients with a primary diagnosis of STEMI. Multivariate regressions were used to determine factors associated with being admitted and longer length of stay (LOS). ResultsIn 2019, 175,689 STEMI patients presented to the ED and 136,738 (77.8%) patients were admitted. Factors associated with higher risk of being admitted were coronary artery disease (OR:14.34, 95% confidence interval (CI): 12.43-16.54, p<0.001), modified Charlson Comorbidity Index (mCCI) of at least 3 (OR: 9.45, 95% CI: 7.33-12.17, p<0.001), and hyperlipidemia (OR:4.65, 95% CI:4.01-5.39, p<0.001). Black STEMI patients were less likely to be admitted than White STEMI patients (OR: 0.57, 95%CI: 0.43-0.75, p<0.001). Factors associated with a longer LOS include a mCCI of at least 3 (p<0.001), heart failure (p<0.001), and being an elderly patient (p<0.001). Black patients had a longer LOS than White patients (p<0.001). Medicaid beneficiaries were associated with a longer LOS than non-Medicaid beneficiaries (p<0.001). ConclusionRace and insurance status substantially affect a STEMI patients outcome in the ED.

BackgroundElectrophysiology (EP) procedures have revolutionized the management of arrhythmias, improving survival and overall outcomes. However, limited data exists evaluating the long-term outcomes of different EP procedures in underrepresented racial and ethnic groups. MethodsWe utilized data from the TriNetX US collaborative network and included adult participants who underwent EP procedures between 2013-2023 to create two cohorts: non-Hispanic Black and non-Hispanic White participants. Propensity score matching (PSM) was performed using predefined sociodemographic characteristics, medical comorbidities and medications used to ensure balance between groups. Primary outcomes were all-cause mortality at 30-days and 1-year post-EP procedures. Secondary outcomes included new-onset acute myocardial infarction (AMI), ischemic stroke, 3-point major adverse cardiovascular events (MACE), cardiac arrest, ventricular fibrillation (V-fib), ventricular tachycardia (VT), heart failure (HF), and procedure complications including pneumothorax and cardiac tamponade during follow-up. ResultsAfter PSM, we had improved balance between cohorts with 69,620 matched participants: 50.0% non-Hispanic Black participants with a mean age of 60.7 years; 43.6% females. Compared to non-Hispanic White participants, non-Hispanic Black participants had similar risk of all-cause mortality at 30-days (HR 0.94 95% CI; 0.84,1.06), and 1-year (HR 1.02 95% CI; 0.96,1.08) post-EP procedure after PSM. Moreover, non-Hispanic Black participants had significantly higher risk of developing AMI (HR 1.25 95% CI; 1.10,1.41), 3-point MACE (HR 1.15 95% CI; 1.04,1.27), VT (HR 1.29 95% CI; 1.18,1.42), V-fib (HR 1.28 95% CI; 1.09,1.51) and HF (HR 1.33 95% CI; 1.24,1.42) at 30 days, and these findings remained consistently significant at 1-year follow-up after PSM. No significant differences were noted in all other studied outcomes. ConclusionNon-Hispanic Black patients who underwent any EP procedure had a similar risk of 30-day, and 1-year mortality when compared to non-Hispanic White patients. However, non-Hispanic Black participants had higher rates of adverse cardiovascular events in the short and long-term than non-Hispanic White participants post-EP procedure. Clinical PerspectiveO_ST_ABSWhat is New?C_ST_ABSO_LIThis multi-institutional study addresses the question: Are the odds of developing an adverse cardiovascular outcome following an EP procedure the same for a non-Hispanic Black patient when compared to a non-Hispanic White patient? C_LIO_LINon-Hispanic Black patients who underwent any EP procedure had a similar risk of 30-day, and 1-year mortality when compared to non-Hispanic White patients. However, non-Hispanic Black patients showed a statistically significant higher prevalence of adverse cardiovascular outcomes such as 3-point major adverse cardiovascular events (MACE), acute myocardial infarction, ventricular tachycardia, ventricular fibrillation, and heart failure. C_LI What are the clinical implications?O_LIThis study addresses the racial differences in short- and long-term adverse cardiovascular events following an EP procedure. Better understanding of factors (such as socioeconomic status, health literacy, environmental circumstances etc.) that could potentially limit access to healthcare access among underrepresented racial and ethnic groups (UREG) will better inform policymakers to implement strategies to mitigate these differences. C_LI

Background: Chronic total occlusions (CTOs) are a common manifestation of coronary artery disease (CAD) and are associated with increased long-term mortality. While successful CTO revascularization improves symptoms and quality of life, a consistent mortality benefit has not been demonstrated in randomized trials. Outpatient cardiac rehabilitation (CR) has proven benefits in improving functional status, exercise capacity, and quality of life in patients with CAD, yet its impact on CTO patients has not been well studied. Objective: To evaluate the association between CR and long-term outcomes in CTO patients. Methods: Using the TriNetX Research Network, we analyzed de-identified patient data from 75 healthcare organizations using ICD codes. The study population included patients with CTO who started CR within 3 months of diagnosis vs patients with CTO who did not engage in CR. A secondary analysis was also conducted, which excluded patients with other indications for CR, including prior coronary artery bypass grafting (CABG) and prior or concurrent percutaneous coronary interventions (PCI). Results: Of 167,176 CTO patients, 10,021 enrolled in CR, including 1,608 without another CR indication. Patients were propensity-matched for independent risk factors for mortality. After 5 years, CR participation was associated with a significant reduction in mortality (HR 0.68; 95% CI, 0.61-0.75; p < 0.0001). This benefit was preserved even after excluding prior revascularization (HR 0.81; 95% CI, 0.67-0.99; p < 0.036). Conclusion: This study demonstrates that cardiac rehabilitation is associated with improved long-term survival in patients with CTOs.

BackgroundIn myocardial infarction with non-obstructive coronary arteries (MINOCA), there are limited patient-level data on outcomes by sex and race. ObjectiveAssess baseline demographics and 3-year outcomes by sex and race for MINOCA patients. MethodsPatients admitted to a single center with acute myocardial infarction (AMI) between January 1, 2012 and December 31, 2018, were identified by chart and angiographic review. The primary outcome was nonfatal MI with secondary outcomes including non-fatal cerebrovascular accident (CVA), chest pain readmission, and repeat coronary angiography. ResultsDuring the study period, 304 patients were admitted with MINOCA. The cohort was predominantly female (66.4%), and women were significantly older (64.6 vs. 59.2). One-sixth of the total population were Black patients, and nearly half of Black patients (47.2%) were male. Prior CVA (19.7%) and comorbid anxiety, depression, or post-traumatic stress disorder (41.1%) were common. Rates of non-fatal myocardial infarction (MI) were 6.3% without difference by sex or race. For secondary outcomes, rates of CVA were 1.7%, chest pain readmission were 22.4%, and repeat angiography were 8.9%. Men were significantly more likely to have repeat angiography (13.7% vs. 6.4%), and Black patients more likely to be readmitted for angina (34.0% vs. 19.1%). Over one-quarter of patients underwent repeat stress testing, with 8.9% ultimately undergoing repeat angiograms and low numbers (0.7%) undergoing revascularization. Men were more likely to be referred for a repeat angiogram (13.7% vs. 6.4%, p=0.035). In multivariate analysis, Black race (OR 2.31 [95% CI (1.06-5.03)] was associated with an increased risk of readmission for angina, while female sex was associated with decreased odds of repeat angiography (OR 0.36 [95% CI (0.14-0.90)] and current smoking was associated with increased odds of repeat angiography (OR 4.07 [95% CI (1.02-16.29)] along with hyperlipidemia (OR 4.65 [95% CI (1.22-17.7)]. ConclusionWhite women presented more frequently with MINOCA than White men, however Black men are equally as affected as Black women. Rates of non-fatal MI were low without statistical difference by sex or race.

BackgroundAtrial fibrillation (AF) is associated with increased cardiovascular mortality. Data regarding the relationship between coronary artery disease (CAD) and AF is mixed. It is uncertain if AF directly increases the risk for future coronary events and if such patients are appropriately evaluated for CAD. MethodsThis is a cross-sectional study performed on hospitalized patients with AMI and concurrent AF in 2019 using National Inpatient Sample from HCUP. Patients with missing information and type II non-ST elevation myocardial infarction (NSTEMI) were excluded. Using STATA 18, In-hospital mortality, ischemic evaluation, percutaneous treatment, rates of ventricular tachycardiac (VT), ventricular fibrillation (VF), cardiogenic shock, cardiac arrest, average length of stay (LOS), and total hospitalization charges were studied. Regression models were used for data analyses. ResultsA total of 600,645 patients met inclusion criteria (219,660 females [36.5%], 428,755 Caucasian [71%], 65,870 African American [10.9%], 51,155 Hispanic [8.5%]; mean [SD] age, 66.7 [0.5] years), including 166,680 (28%) STEMI and 433,965 (72%) NSTEMI patients. 109,520 (18%) patients with AMI had AF. For patients with AMI and AF, the adjusted odds of mortality increased by 23% (adjusted Odds ratio [aOR], 1.23; CI, 1.15-1.32; p<0.001). AF patients were less likely to undergo ischemic evaluation (aOR, 0.77; CI, 0.74-0.80; p<0.001) and ischemic intervention (aOR, 0.64; CI, 0.62-0.66; p<0.001). AF patients had higher odds of VT (aOR, 1.41; CI, 1.33-1.49; p<0.001), VF (aOR, 1.44; CI, 1.33-1.57; p<0.001), cardiogenic shock (aOR, 1.43; CI, 1.35-1.52; p<0.001), and cardiac arrest (aOR, 1.35; CI, 1.24-1.47; p<0.001). AF patients had longer LOS (mean, 1.39; SCD, 1.29-1.48; p<0.001) and higher total hospital charges (mean $22,188; 19,311-25,064, p<0.001). ConclusionAF was independently associated with increased mortality in patients admitted with AMI. AF was associated with higher rates of cardiac complications. Patients with AF were less likely to receive ischemic evaluation or percutaneous intervention and had overall higher healthcare resource utilization. This study encourages AF to be viewed as an independent risk factor for CAD and suggests more efforts to diagnose CAD in such patients. Clinical PerspectiveO_ST_ABSWhat is newC_ST_ABSO_LIPatients with acute myocardial infarction and atrial fibrillation have higher odds of mortality. C_LIO_LIAMI patients with AF are subjected to lesser odds of undergoing ischemic evaluation and intervention. C_LIO_LIHealthcare resource utilization is higher in this cohort. C_LI What are the clinical implicationsO_LIAF should be considered as an independent risk factor for increased mortality in AMI. C_LIO_LIEarly ischemic evaluation should be considered to diagnose coronary artery disease in this cohort. C_LIO_LIIncreased awareness to recognize all risk factors of coronary artery disease. C_LI

Background: Clinical genetic evaluation for patients with dilated cardiomyopathy (DCM) is minimally implemented and models of care are not defined. To understand current genetics care for DCM, a systematic needs assessment was conducted. Methods: Principal Investigators (PIs) of the DCM Consortium convened at the Summer Scientific Symposium in July 2025. An electronic needs assessment was collected from the 24 PIs in advance to define current care models by evaluating which Heart Failure Society of America-recommended genetic evaluation components are conducted, by whom, and time required. Descriptive statistics were generated to characterize model features. Focus group discussions explored barriers and facilitators to implementing genetic services. Results: Four care models emerged from the PI responses: 1 -- Traditional-Synchronous (25%, n=6, requiring the most time per patient), 2 -- Traditional-Asynchronous (33%, n=8), 3 -- Externally Sourced (17%, n=4), and 4 -- Physician/Advanced Practice Provider Conducted (25%, n=6, requiring the least time per patient). All models used genetic testing, whereas other components were implemented variably or not at all. Models 1 (15.7{+/-}4.1) and 2 (15.4{+/-}3.0) were rated more acceptable than Model 4 (9.8{+/-}2.9, 1 vs 4: p=0.027; 2 vs 4, p=0.023). Notably, 88% of PIs used genetic information for treatment decisions, including ICD placement (83%; n=20) or cardiac transplant (63%; n=15). Major facilitator themes from focus group discussions included having a genetic counselor on the HF team and developing authoritative standards directing provision of DCM genetic services. Barrier themes included operational challenges, limited personnel, clinician under-recognition, need for new service delivery models, and billing/reimbursement. Conclusions: DCM genetic care models and components were highly variable across the 24 sites of the DCM Consortium, even though all sites discussed similar factors that enable or hinder implementing genetic services for DCM. Understanding the basis of practice model variability may provide insight to yield more scalable care approaches.

PurposeHeart failure with preserved ejection fraction (HFpEF) has less guideline driven treatment options due to a lack of trials demonstrating medications with improved clinical outcomes for this patient population. The primary objective of this study is to determine which medications and dosages are related to high readmission rates for HFpEF patients. MethodsA retrospective, single center, chart review was performed on patients with HFpEF at an academic medical center. Heart failure patients ages between 18-89 with an ejection fraction [&ge;]45% from a transthoracic echocardiogram (TTE) were included. Primary outcomes include 30-day all cause readmission rates, prescribing patterns, and avoidance of potentially harmful medications. Descriptive statistics and multivariate logistic regression were used to assess potential risk factors. ResultsThis study analyzed 455 patient admissions. Univariate analysis shows patients who were not readmitted were more likely to be on furosemide (54% vs 42%; p = 0.019). Conversely, readmitted patients were more likely to be taking bumetanide (4% vs 1%; p = 0.039). Lisinopril was the only angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) associated with lower readmission rates (p = 0.036). Multivariate logistic regression showed bumetanide on admission (OR 14.6, p = 0.001), discharged on rosuvastatin (OR 6.29, p = 0.003) and meloxicam therapy (OR 6.33, p = 0.003) to be independent predictors of hospital readmission. ConclusionThree independent pharmacologic predictors for 30-day readmissions for patients with HFpEF were therapy with bumetanide, meloxicam, or rosuvastatin. Further research is needed to clarify the significance of these results.

BackgroundThe prevalence of severe symptomatic aortic stenosis (sSAS) continues to rise, yet women remain significantly less likely to receive timely intervention. Evidence indicates a 36% lower likelihood of diagnosis and a 20% lower likelihood of undergoing aortic valve replacement (AVR) compared with men. The purpose of this study was to examine the perspectives of interventional cardiologists and cardiothoracic surgeons who treat AS about late diagnosis and undertreatment of women with sSAS. MethodsA cross-sectional, web-based survey was distributed to interventional cardiologists and cardiothoracic surgeons across the United States. Participants completed a 10-item open-ended questionnaire developed from published literature. Responses were analyzed using descriptive statistics and qualitative content analysis to identify key issues related to diagnostic practices, referral patterns, and provider perceptions. ResultsNineteen physicians completed the survey (15% response rate). While most participants believed women receive timely AVR consistent with guidelines, they acknowledged delays due to multifactorial causes, including under-recognition of symptoms, diagnostic variability in community echocardiography practices, limited awareness of sex-specific guideline gaps, and socioeconomic barriers such as financial constraints, caregiver burden, and access to care. Although some respondents denied overt gender bias, others described subtle or unconscious bias influencing referral timing and symptom interpretation. ConclusionsSurvey respondents recognized complex clinical and systemic factors contributing to delayed diagnosis and undertreatment of women with sSAS. Enhanced provider education, improved access to diagnostic testing, and revision of sex-specific clinical guidelines are needed to promote equitable care and timely intervention for female patients.

BackgroundDespite CMS coverage expansion supporting cardiac rehabilitation (CR) in patients with heart failure (HF) in 2014, data suggest that utilization among patients with HF is low. We describe CR participation and adherence among HF patients in Colorado. MethodsData from the Colorado All-Payer Claims Database from 2010-2018 were used. Patients with HF were identified by [&ge;]2 claims with a HF diagnosis code, then grouped by type of HF (HFrEF, HFpEF, unspecified). CR participation and adherence were identified using CR CPT codes. Participation rates were calculated by quarter of each year. Cochran-Armitage tests determined whether temporal trends were significant. Association between CR participation and payer source was examined in adjusted logistic regression models. Results263,476 patients with HF were identified. 4.77% of all HF patients attended CR at least once; this result was similar for HFpEF (4.35%), unspecified HF (4.15%), and higher in the HFrEF group (8.25%). Overall adherence was poor (median 8 visits, IQR 3-18; full adherence=36 visits). CR participation over time increased (P<0.01) for all HF patients. Compared to patients with commercial insurance, patients with Medicare, Medicaid, or Medicare Advantage were less likely to have participated in CR at least once (P<0.01). Race, sex and presence of another indication for CR were also associated with at least one CR visit (P<0.01). ConclusionsIn the state of Colorado, CR participation improved from 2010-2018 among all patients with HF. Our data suggest that payer source, race, sex and presence of another indication for CR drive CR participation in patients with HF.

BackgroundThough ischemic cardiomyopathy is the leading cause of heart failure (HF), most patients do not undergo coronary assessment after heart failure diagnosis. In a safety-net population, referral patterns have not been studied, and it is unknown whether coronary assessment is associated with improved HF outcomes. MethodsUsing an electronic health record cohort of all individuals with HF within San Francisco Health Network from 2001-2019, we identified factors associated with completion of coronary assessment (invasive coronary angiography, nuclear stress, or coronary computed tomographic angiography). Then we emulated a randomized clinical trial of elective coronary assessment with outcomes of all-cause mortality and a composite outcome of mortality and emergent angiography. We used propensity scores to account for differences between groups. We used national death records to improve ascertainment of mortality. ResultsAmong 14,829 individuals with HF (median 62 years old, 5,855 [40%] women), 3,987 (26.9%) ever completed coronary assessment, with 2,467 (18.5%) assessed out of 13,301 with unknown CAD status at HF diagnosis. Women and older individuals were less likely to complete coronary assessment, with differences by race/ethnicity, medical history, substance use, housing, and echocardiographic findings. Among 5,972 eligible for inclusion in the "target trial," 627 underwent early elective coronary assessment and 5,345 did not. Coronary assessment was associated with lower mortality (HR 0.84; 95% CI 0.72-0.97; p=0.025), reduced risk of the composite outcome, higher rates of revascularization, and higher use of medical therapy. ConclusionsIn a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by CAD risk factors. Our target trial emulation suggests coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and GDMT use, but with low certainty that this is finding is not attributable to unmeasured confounding. O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=139 SRC="FIGDIR/small/23292331v1_ufig1.gif" ALT="Figure 1"> View larger version (51K): org.highwire.dtl.DTLVardef@1d3a31corg.highwire.dtl.DTLVardef@1798641org.highwire.dtl.DTLVardef@15d1a43org.highwire.dtl.DTLVardef@1672982_HPS_FORMAT_FIGEXP M_FIG O_FLOATNOGraphical Abstract:C_FLOATNO C_FIG

BackgroundPractice patterns and outcomes of protected left main (PLM) and unprotected left main (ULM) percutaneous coronary intervention (PCI), as well as the differences between these types of PCI, are not well defined in real-world clinical practice. MethodsData collected from all Veteran Affairs (VA) catheterization laboratories participating in the Clinical Assessment Reporting and Tracking Program between 2009 and 2019. The analysis included 4,351 patients undergoing left main PCI, of which 1,306 pairs of PLM and ULM PCI were included in a propensity matched cohort. Patients and procedural characteristics were compared between PLM and ULM PCI. Temporal trends were also assessed. Peri-procedural and one-year major adverse cardiovascular events (MACE) were compared using cumulative incidence plots. The primary outcome was MACE outcomes at 1-year, which was defined as a composite of all-cause mortality, rehospitalization for myocardial infarction (MI), rehospitalization for stroke or urgent revascularization. ResultsULM PCI patients in comparison to PLM PCI were older (71.5 vs 69.2; P < 0.001), more clinically complex and more likely to present with ACS. In the propensity matched cohort, radial access was used more often for ULM PCI (21% [273] vs. 14% [185], P < 0.001), and ULM PCI was more likely to involve the LM bifurcation (22% vs 14%; P = 0.003) and require mechanical circulatory support (10% [134] vs 1% [17]; P <0.001). One-year MACE occurred more frequently with ULM PCI compared to PLM PCI (22% [289] vs. 16% [215]; P = < 0.001) and all-cause mortality was also higher (16% [213] vs. 10% [125]; P = < 0.001). In the matched cohort there was a low incidence of rehospitalization for MI (4% [48] ULM vs. 4% [48] PLM; P = 1.000) or revascularization (7% [94] ULM vs. 6% [84] PLM; P = 0.485). ConclusionsVeterans undergoing PLM PCI had better one-year outcomes than those undergoing ULM PCI, but in both groups there was a high rate of mortality and MACE at one-year despite a relatively low rate of MI or revascularization.

BackgroundMethamphetamine use has increased dramatically over the past decade and is associated with the development of heart failure (HF). However, clinical characteristics and outcomes have not been well described. This study aimed to compare clinical characteristics and outcomes among individuals with HF who do and do not use methamphetamines in a safety-net hospital. MethodThis retrospective matched cohort study included all individuals with HF with history of methamphetamine use and age, gender-, and year-matched controls without history of methamphetamine use within a municipal health system from 2001-2019. 1,783 individuals with methamphetamine use and HF were identified; 12 were excluded due to inability to identify matched methamphetamine-negative controls. Therefore, 1,771 individuals with methamphetamine use and heart failure and 3,542 age, sex, and year-of-HF-diagnosis matched controls with heart failure without methamphetamine use were included. The primary outcome was all-cause mortality. Secondary outcomes included time to HF hospitalization, and 30-day, 90-day, and 1 year HF and all-cause readmissions. ResultsMedian age of the cohort was 52.1 years and 22.6% were female. There was no significant difference in mortality between the two groups (40% vs 36.6%, HR 1.00, 95% CI 0.91, 1.10, p=1.00). A subset had an index HF hospitalization (n=1,404) during the study period including 637 (35.9%) with history of methamphetamine use and 767 (21.7%) without history of methamphetamine use (relative risk 1.66, 95%CI 1.52-1.81, p<0.0001). Among those ever hospitalized for HF, individuals with methamphetamine use had increased odds of HF and all-cause readmission at 30 days, 90 days, and 1 year. ConclusionDespite having higher risk of both all cause and HF readmissions, individuals with methamphetamine-associated heart failure did not have higher risk of mortality. Measures to address frequent healthcare utilization among people with methamphetamine use and HF are needed.

IntroductionInterventional cardiologists are held accountable for delay in the door-to-balloon time (DBT) for patients undergoing primary percutaneous coronary intervention in the setting of ST-elevation myocardial infarction (STEMI) even though in the chain of STEMI activation, the interventional cardiologist is the last person that needs to be available to start angiography. The goal of our study is to conduct a thorough analysis of the DBT data to assess time delays by randomly evaluating two consecutive years at the University of Arizona Medical Center (UAMC). METHODSWe evaluated all available DBT data for STEMIs occurring in the fiscal years of 2011 and 2012 at the UAMC and calculated the time needed for the cardiologist to start the procedure after the patient was ready in the cardiac catheterization laboratory called Time to start the procedure (TSP) in addition to other time intervals. RESULTSMean TSP time was 4 minutes and 24 seconds, one of the shortest time delays in the chain of STEMI activation and DBT. The median TSP delay was 3 minutes. The longest delay interval was the STEMI teams arrival to with a mean of 17 minutes and 38 seconds. CONCLUSIONSOur data is the first to evaluate delays related to DBT revealing the least delay occurring due to the late arrival of Interventional cardiologists. Our data emphasizes the importance of performing a detailed time analysis of the DBT delay in order to objectively determine the actual areas of delay and provide a future pathway to improve them since we have specifically detected a delay in STEMI team and patient arrival to the catheterization laboratory as the main delay in the DBT time. in order to avoid blaming the wrong person and find the true root cause of the delay.

BackgroundIn patients with chronic coronary disease (CCD), it is unclear whether the use of potent P2Y12 inhibitors (ticagrelor or prasugrel) offers advantages to clopidogrel when prescribed in conjunction with aspirin in patients undergoing percutaneous coronary intervention (PCI) with atherectomy. MethodsConsecutive patients undergoing PCI with atherectomy for CCD at a tertiary care center between January 2011 to December 2020 were included. Patients discharged on ticagrelor or prasugrel were compared to patients on clopidogrel. The primary outcome was a composite of death or myocardial infarction (MI), secondary outcomes included individual components of the primary outcome, stroke, major bleeding, and target vessel revascularization at 1 year. Adjusted analyses were performed using propensity score stratification. ResultsOverall, 3,612 patients undergoing atherectomy were included in the analysis (clopidogrel [70.4%, n= 2,543], ticagrelor/prasugrel [29.5%, n=1,069]). Clopidogrel was prescribed more often in older patients with multimorbid risk factors, whereas ticagrelor/prasugrel was used more in patients with greater anatomical and procedural complexity. There was an increase in the use of potent antiplatelet agents over time (p<0.001). At 1-year follow-up, the primary outcome was observed in 5.2% and 4.0% of those taking clopidogrel and ticagrelor/prasugrel, respectively (adjusted hazard ratio (AHR) 0.87, 95% CI 0.58 - 1.3, p = 0.50). There were no significant differences in the rate of bleeding (5.5% vs 3.7%, AHR 0.98, 95% CI 0.66 - 1.46, p = 0.92) or other secondary outcomes between the two groups. ConclusionThe use of clopidogrel was associated with comparable ischemic and bleeding outcomes compared to ticagrelor/prasugrel in patients with CCD undergoing PCI with atherectomy.

BackgroundThere is limited data on temporal trends in clinical outcomes after ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) particularly beyond one year and in real world populations that include patients often excluded from randomized trials. ObjectivesWe sought to compare the temporal trends in the incidence of death and re-hospitalization for congestive heart failure (CHF) following anterior STEMI in a Medicare cohort of beneficiaries treated with primary PCI in 2005 (n = 1,479) with those treated in 2016 through quarter (Q) 2 of 2017 (n = 22,432). MethodsOutcomes were examined using both descriptive and regression analysis to control for differences in patient clinical characteristics over time. ResultsThe 1-year mortality rate trended higher in the late cohort (10.3 vs 8.9%, p=0.068). The 2-year mortality rate was significantly higher in the late cohort (14.5 vs 11.4%, p<0.01). The one-year re-hospitalization for CHF was lower in the late cohort (10.6 versus 16.7%, p<0.01), but the 2-year rate was unchanged (19.3 vs 20.7%, p=0.55). After adjustment for covariates with two models there were highly statistically significant increases in mortality at 1-year (2.3 - 4.1%) and 2-years (4.2 - 6.5%) in the late cohort. The unadjusted trends in re-hospitalization for CHF persisted after adjustment for covariates. ConclusionsDespite prior improvements in STEMI outcomes in the reperfusion era related to the broad adoption of timely PCI, there is a persistent high mortality and CHF burden in patients with anterior STEMI. New strategies that address reperfusion injury and enhance myocardial salvage are needed.

BackgroundConcomitant left atrial appendage exclusion (LAAE) during cardiac surgery is an effective method of reducing stroke risk in patients with atrial fibrillation. Previous studies have documented racial disparities in the performance of multiple cardiac procedures. We sought to evaluate if there were any disparities in the utilization and outcomes of concomitant LAAE. MethodsWe used the 2016-2020 National Inpatient Sample database to identify hospitalizations for cardiac surgery in patients with atrial fibrillation with concomitant LAAE. We utilized the weighted data to compare the in-hospital mortality and complications such as stroke, bleeding, infection, heart failure and pericardial complications among different race/ethnic groups. ResultsFrom 2016 to 2020, 432,244 hospitalizations were for cardiac surgery, of which 91,395 (21%) included concomitant LAAE. Of these, 77,440 (84.7%) were in White patients, 4,179 (4.6%) were in Black patients, 4,834 (5.3%) were in Hispanic patients, and 4,939 (5.4%) were in other races. Black and Hispanic patients had lower odds of undergoing concomitant LAAE during cardiac surgery compared to white patients (adjusted odds ratio (aOR) 0.85, 95% confidence interval (CI) 0.79-0.93 and aOR 0.85, 95% CI 0.79-0.93, respectively). There were no significant differences between Black and Hispanic patients in in-hospital mortality or procedural complications except for higher bleeding complications in Hispanic patients (aOR 2.38, 95% CI 1.27-2.86) compared to White patients. Through the study period, the proportion of patients receiving concomitant LAAE increased in all race/ethnic groups. ConclusionConcomitant LAAE during cardiac surgery is underutilized in Black and Hispanic patients compared to White patients, despite mostly similar clinical outcomes. Further comparative longitudinal studies are warranted to confirm these findings.

Atrial fibrillation (AF) is the most common sustained arrhythmia and frequently occurs in patients with acute coronary syndromes (ACS). Non-ST elevation myocardial infarction (NSTEMI) accounts for nearly 70% of ACS hospitalizations and poses significant morbidity and healthcare burden. Despite its prevalence, the impact of AF on in-hospital outcomes in NSTEMI remains underrecognized, and current risk models often exclude AF. MethodsWe conducted a retrospective cohort study using de-identified patient-level data from HCA Healthcare, capturing 31,649 NSTEMI admissions across 180 U.S. hospitals (2021-2022). Patients were stratified based on coronary artery bypass grafting (CABG) status. Multivariable logistic and linear regression models evaluated associations between AF and in-hospital mortality, 30-day readmission, and length of stay (LOS). ResultsAF was independently associated with worse in-hospital outcomes in both CABG and non-CABG groups. Among CABG patients, AF was linked to increased odds of in-hospital mortality (OR 2.02), 30-day readmission (OR 1.15), and prolonged LOS (OR 1.21). In non-CABG patients, AF was similarly associated with higher odds of mortality (OR 1.89), readmission (OR 1.23), and LOS (OR 1.31) (all p<0.05). Female sex, heart failure, CKD, and COPD were also linked to adverse outcomes. ConclusionIn this large, multicenter cohort, AF was significantly associated with increased in-hospital mortality, readmission, and LOS among NSTEMI patients, irrespective of CABG status. These findings highlight AF as a key clinical factor warranting consideration in NSTEMI management. Future studies should explore mechanisms underlying these associations and identify strategies for risk mitigation in this high-risk population.

BACKGROUNDExcimer laser coronary atherectomy (ELCA) is used for thrombotic culprit lesions in ST-segment elevation myocardial infarction (STEMI), but its efficacy is still unclear. The study objective was to investigate the clinical outcomes of STEMI patients after ELCA. METHODSData of consecutive patients undergoing primary percutaneous coronary intervention (PCI) within 24 hours of onset, in 12 healthcare facilities in Japan, were retrospectively analyzed. Patients were divided into ELCA and non-ELCA groups. The primary endpoint was target vessel-related major adverse cardiac events (TV-MACE). Cox regression analysis and propensity score matching were performed to adjust for selection bias in the cohort. RESULTSA total of 2593 patients, which included 427 patients treated with ELCA, were analyzed with a median follow-up of 815 (390-1385) days. There was no significant difference between the two groups in terms of TV-MACE-free survival rate. ELCA use was not a significant determinant of TV-MACE (hazard ratio [HR] 1.265, 95% confidence interval [CI], 0.910-1.757; p=0.161). Nevertheless, when the ELCA group was stratified by the ELCA catheter size, the large catheter (1.4 mm-1.7 mm) group showed better clinical outcomes than the others in univariate Cox regression analysis (HR 0.30, 95% CI 0.10-0.95, p=0.040). In the propensity score-matched cohort of 736 patients (368 pairs), the TV-MACE-free survival did not differ between the two groups. CONCLUSIONSELCA did not show clinical benefit in terms of the rate of adverse cardiac events in patients with STEMI. There was evidence of efficacy when a large ELCA catheter was used, warranting further prospective studies. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIIn a relatively large-scale registry of STEMI patients undergoing primary PCI, which included 427 patients treated with ELCA, the use of ELCA did not show clinical benefits in reducing target-vessel related adverse events. C_LIO_LIThe use of ELCA was not associated with improved coronary flow or myocardial perfusion, but rather with higher peak values of cardiac markers. C_LIO_LILarger ELCA catheters ([&ge;]1.4mm diameter) may be associated with better clinical outcomes compared to smaller (0.9mm) ELCA catheters, suggesting potential areas for future research. C_LI What are the clinical implications?O_LIThe routine use of ELCA may not reduce adverse cardiac events in primary PCI for patients with STEMI. C_LIO_LIThe use of ELCA should be limited to lesions where large-sized ELCA catheters can be safely applied. C_LI

BackgroundOptimal revascularization strategy in patients with cardiogenic shock and three-vessel coronary disease presenting with non-ST-elevation myocardial infarction (NSTEMI) is not well established. The goal of this study was to use the largest inpatient database to evaluate inpatient mortality of NSTEMI patients with three-vessel disease and cardiogenic shock undergoing coronary bypass surgery (CABG) vs percutaneous coronary intervention (PCI). MethodUsing the Nationwide Inpatient Sample (NIS) database, and ICD-10 coding for NSTEMI, cardiogenic shock, three-vessel CABG, and three-vessel PCI, we evaluate total inpatient mortality comparing three-vessel CABG vs three-vessel PCI in adults over age 18 years. ResultsA total of 2,805 NSTEMI patients with 3-vessel disease and cardiogenic shock underwent PCI vs.7,585 undergoing CABG. CABG in the setting of NSTEMI-related cardiogenic shock and three-vessel CAD is associated with much lower mortality compared to three-vessel PCI despite multivariate adjustment. Mortality was more than twice in patients undergoing PCI vs CABG (Mortality 25.31% vs 11.22%, P<0.001, OR for CABG patients: 0.37, CI: 0.29-0.48, P<0.001). After adjusting baseline characteristics and comorbidities in multivariate analysis, CABG remained significantly associated with lower mortality (CABG OR 0.41, CI: 0.31-0.54, p<0.001). ConclusionOur data suggests that three-vessel CABG is greatly superior to PCI in NSTEMI patients presenting with cardiogenic shock and three-vessel coronary artery disease.