Mid America Heart Institute Research Articles

Target Aortic Stenosis: A National Initiative to Improve Quality of Care and Outcomes for Patients With Aortic Stenosis.

Target Aortic Stenosis: A National Initiative to Improve Quality of Care and Outcomes for Patients With Aortic Stenosis.

Editorial introductions.

Editorial introductions.

Highlights From the Circulation Family of Journals

Highlights From the <i>Circulation</i> Family of Journals

2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society

2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society

Abstract 9779: The Utility of Endoscopic Screening in Mitigating the Risk of Gastrointestinal Bleeding After Left Ventricular Assist Device Placement. A Retrospective Chart Review Study

Introduction: Left ventricular assist device (LVAD) is a lifesaving bridge to transplantation or destination therapy for patients with end-stage heart failure. More than one-third of patients suffer from gastrointestinal (GI) bleeding within one year of placement. We investigated the yield and safety of endoscopic screening for potential sources of GI bleeding before LVAD insertion. Hypothesis: Endoscopic screening prior to LVAD placement does not necessarily reduce the risk of GI bleed post LVAD. Methods: We performed a retrospective chart review study of patients at Saint Luke’s Mid America Heart Institute who underwent continuous-flow LVAD implantation from 2010 to 2020. Study participants were categorized based on whether or not they underwent screening endoscopy prior to LVAD implantation. Patients were followed for one year after implantation, and outcomes were collected to determine the yield and safety of these procedures. A multivariable logistic regression analysis was performed using SPSS® controlling for the following confounding factors: age, gender, race, and history of GI bleeding. Results: Among 205 patients with an LVAD, 169 patients were included in the study after excluding those with lack of data or those lost to follow up. 68 (40.23%) patients who received pre-LVAD screening by either upper and/or lower endoscopies, and 42 (24.85%) patients who had post-LVAD GI bleed. Patients who underwent pre-LVAD screening had similar rates of GI bleeding after LVAD compared to those who were not screened (odds ratio 1.66, 95% CI 0.648-4.264, P=0.2). Moreover, in patients with post LVAD GI bleed, endoscopy findings were typically different than those pre LVAD. No complications to the endoscopic interventions were reported. Conclusions: While endoscopic screening appears to be safe in patients before LVAD implantation, it had no association with GI bleeding risk or etiology after LVAD.

Guidance and Best Practices for Nuclear Cardiology Laboratories During the COVID-19 Pandemic: An Information Statement From ASNC and SNMMI.

Guidance and Best Practices for Nuclear Cardiology Laboratories During the COVID-19 Pandemic: An Information Statement From ASNC and SNMMI.

Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association.

Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association.

Survival After In-Hospital Cardiac Arrest in Critically Ill Patients: Implications for COVID-19 Outbreak?

The coronavirus disease 2019 (COVID-19) outbreak is placing a considerable strain on U.S. healthcare systems by requiring both significant acute resources and endangering healthcare team members th...

Abstract 369: Secondary Risk Reduction in Patients With Type 2 Diabetes and Cardiovascular Disease: Experience From a Cardiometabolic Center of Excellence

Background: Optimal guideline-directed medical therapy is delivered to only 6.9% of patients with type 2 diabetes (T2D) and cardiovascular disease (CVD) nationally, despite guideline recommendations emphasizing aggressive comprehensive secondary risk reduction. While there are many potential explanations, lack of effective clinical care delivery models is a key contributor. The Haverty Cardiometabolic Center of Excellence at Saint Luke’s Mid America Heart Institute was designed to address this unmet need, by delivering a patient-centric, collaborative model of care which focuses on aggressive and comprehensive secondary risk reduction in patients with T2D and CVD. Patients are managed by a multidisciplinary team comprised of preventative cardiologists, advanced practice providers and nurses cross-trained in T2D and CVD management, certified diabetes educator, dietician, pharmacist, and other professionals, in close coordination with endocrinologists and primary care clinicians. We aimed to determine whether patients receiving care in the Center had experienced better intermediate outcomes with similar patients receiving routine care in conventional settings. Methods: We analyzed data from the initial 60 patients seen in the Center who had at least one follow-up visit, and propensity matched them 1:3 to similar patients with T2D and CVD treated in conventional care settings. Propensity model included age, sex, baseline weight, HbA1c, systolic blood pressure (SBP), history of CVD, and duration between visits. Linear mixed models with a random effect for matched groups was used to compare between-group differences for changes in weight, LDL-C, and HbA1c. Results: At baseline, patients in the Center weighed 241.3 lbs ± 51.0 and had HbA1c 7.4 ± 1.4 and LDL 68.0 ± 27.0 as compared to 245.5 lbs ± 55.3, HbA1c 7.5 ± 1.5, and LDL 79.1 ± 37.1 in controls. Average duration between follow up visits was 138.3 days ± 52.5 in patients seen in the Center and 138.9 days ± 54.7 in controls. Patients seen in the Center had greater degree of weight loss (12.3 lbs vs 3.8 lbs, p &lt;0.001) and reduction in HbA1c (0.5 vs 0.0%, p = 0.04) and LDL-C (-8.4 vs +4.0 mg/dL, p = 0.04) as compared with controls. Patients receiving care at the Center were more likely to be treated with an SGLT-2i (70.0% [42/60] vs 22.8% [41/180], p&lt;0.001) and/or a GLP-1RA (91.7% [55/60] vs 15.6% [28/180], p&lt;0.001) than those in the standard of care cohort. Conclusion: Patients with T2D and CVD, seen in a specialized, comprehensive Cardiometabolic Center experienced higher use of guideline-directed medical therapies and greater reduction in multiple CVD risk factors within ~4 months, as compared to those seen in the conventional setting. Although longer follow up is needed, these preliminary data suggest that such novel clinical care delivery models may improve the implementation of clinical practice guidelines.

Code Blue During the COVID-19 Pandemic.

The surging COVID-19 pandemic has raised ethical and moral dilemmas that Western nations with first-rate medical care facilities rarely confront-how to best allocate standard life-saving medical resources when escalating demand outstrips supply. Sadly, these quandaries are familiar challenges in resource-poor countries. What makes this pandemic notable is that the scope and number of reported cases have been primarily in First World nations, raising questions in some settings about the use of emergency treatments like resuscitation care for in-hospital cardiac arrest (IHCA). This perspective reviews the debate around these ethical and moral dilemmas more broadly but focuses specifically on IHCA and the response of the medical community.

1279-P: Socioeconomic Factors Associated with Poor Glycemic Control in People with Type 2 Diabetes: The DISCOVER Study

Background: DISCOVER is a 3-year, observational study of patients with type 2 diabetes (T2D) initiating second-line glucose-lowering therapy in 38 countries. We assessed socioeconomic factors associated with poor glycemic control (HbA1c ≥ 9.0%) at baseline. Methods: In total, 15 342 participants from 36 countries were evaluated. HbA1c levels were recorded in 12 261 participants (79.9%). Factors associated with an increased likelihood of having HbA1c ≥ 9.0% were assessed using a hierarchical logistic regression model. Results: The mean HbA1c level was 8.4% (SD: 1.7%); 48.9%, 23.4% and 27.7% of patients had HbA1c &amp;lt; 8.0%, ≥ 8.0 to &amp;lt; 9.0%, and ≥ 9.0%, respectively. Socioeconomic factors associated with an increased likelihood of having HbA1c ≥ 9.0% (Figure) included living in lower middle-income (vs. high-income) countries, being treated at a site with public/governmental or mixed (vs. private) funding, having public or no (vs. private) health insurance and having primary or no formal (vs. secondary or higher) education. Male sex and being younger than 50 years of age were also associated with an increased likelihood of having HbA1c ≥ 9.0%. Conclusions: Lower socioeconomic status is associated with an increased likelihood of having HbA1c ≥ 9.0% in people with T2D initiating second-line therapy. Efforts are needed to address social determinants of health in patients with T2D. Disclosure M.B. Gomes: Advisory Panel; Self; AstraZeneca. Consultant; Self; Merck KGaA. Research Support; Self; CNPq, FAPERJ. F. Tang: Employee; Self; Mid America Heart Institute. Research Support; Self; AstraZeneca. H. Chen: Employee; Self; AstraZeneca. J. Cid-Ruzafa: Employee; Self; Evidera. P. Fenici: Employee; Self; AstraZeneca. K. Khunti: Advisory Panel; Self; Amgen Inc., AstraZeneca, Eli Lilly and Company, Merck Sharp &amp; Dohme Corp., Novo Nordisk A/S, Sanofi. Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck Sharp &amp; Dohme Corp., Novartis AG, Novo Nordisk A/S, Pfizer Inc., Sanofi-Aventis, Servier, Takeda Pharmaceutical Company Limited. Research Support; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Merck Sharp &amp; Dohme Corp., Novartis AG, Novo Nordisk A/S, Pfizer Inc., Sanofi-Aventis. Speaker's Bureau; Self; AstraZeneca, Berlin-Chemie AG, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Menarini Group, Merck Sharp &amp; Dohme Corp., Novartis AG, Novo Nordisk A/S, Roche Pharma, Sanofi, Servier, Takeda Pharmaceutical Company Limited. S. Pocock: Consultant; Self; AstraZeneca. W. Rathmann: Advisory Panel; Self; AstraZeneca. Consultant; Self; Boehringer Ingelheim International GmbH. Research Support; Self; Novo Nordisk A/S. Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk A/S. M.V. Shestakova: Advisory Panel; Self; AstraZeneca. Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Merck Sharp &amp; Dohme Corp., Novo Nordisk A/S, Sanofi, Servier. Research Support; Self; Novo Nordisk A/S, Sanofi. F. Surmont: Employee; Self; AstraZeneca. H. Watada: Research Support; Self; Astellas Pharma Inc., Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo Company, Limited, Kissei Pharmaceutical Co., Ltd., Merck Sharp &amp; Dohme Corp., Mitsubishi Tanabe Pharma Corporation, Novartis Pharmaceuticals Corporation, Novo Nordisk A/S, Pfizer Inc., Sanofi, Sumitomo Dainippon Pharma Co., Ltd., Takeda Pharmaceutical Company Limited, Teijin Pharma Limited. Speaker's Bureau; Self; Astellas Pharma Inc., Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo Company, Limited, Eli Lilly and Company, Merck Sharp &amp; Dohme Corp., Mitsubishi Tanabe Pharma Corporation, Novo Nordisk A/S, Ono Pharmaceutical Co., Ltd., Sanofi, Takeda Pharmaceutical Company Limited, Terumo Medical Corporation. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Kowa Pharmaceutical Europe Co. Ltd., Merck Sharp &amp; Dohme Corp., Mitsubishi Tanabe Pharma Corporation, Ono Pharmaceutical Co., Ltd., Sanwa Chemical Industry Co. Ltd., Takeda Pharmaceutical Company Limited. J. Medina: Employee; Self; AstraZeneca. S.M. Sadikot: Consultant; Self; AstraZeneca. I. Shimomura: Advisory Panel; Self; AstraZeneca, Novo Nordisk Pharma Ltd., Sanwa Kagaku Kenkyusho. Consultant; Self; MSD K.K., Novo Nordisk Pharma Ltd., Taisho Pharmaceutical Co., Ltd. Research Support; Self; Astellas Pharma Inc., AstraZeneca, Daiichi Sankyo Company, Limited, Eli Lilly Japan K.K., Kaken Pharmaceutical Co., Ltd., Kowa Pharmaceutical Co., Ltd., Kyowa Hakko Kirin Co., Ltd., Mitsubishi Tanabe Pharma Corporation, MSD K.K., Novartis Pharma K.K., Novo Nordisk Pharma Ltd., Shionogi &amp; Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd., Takeda Pharmaceutical Company Limited, Teijin Pharma Limited. Speaker's Bureau; Self; Astellas Pharma Inc., AstraZeneca, Daiichi Sankyo Company, Limited, Eli Lilly Japan K.K., Kowa Pharmaceutical Co., Ltd., Lotte Co., Ltd., Mitsubishi Tanabe Pharma Corporation, MSD K.K., Novartis Pharma K.K., Novo Nordisk Pharma Ltd., Ono Pharmaceutical Co., Ltd., Sanofi K.K., Sanwa Kagaku Kenkyusho, Taisho Toyama Pharmaceutical Co., Ltd., Takeda Pharmaceutical Company Limited, Teijin Pharma Limited. G. Luporini Saraiva: Employee; Self; AstraZeneca. A. Nicolucci: Consultant; Self; AstraZeneca, Eli Lilly and Company, Medtronic, Novo Nordisk A/S. Research Support; Self; Artsana S.p.A., Dexcom, Inc., Novo Nordisk A/S, Sanofi-Aventis. Funding AstraZeneca

1628-P: Changes in HbA1c and Treatment in the Second Year following Initiation of Second-Line Therapy in People with T2D—The Global DISCOVER Study

1628-P: Changes in HbA1c and Treatment in the Second Year following Initiation of Second-Line Therapy in People with T2D—The Global DISCOVER Study

Abstract 33: Impact of a Mobile Application for ACLS on House Staff Performance During Cardiac Arrest Simulations

Background: Effective and timely delivery of cardiac arrest interventions during a resuscitation for in-hospital cardiac arrest (IHCA) is associated with a higher likelihood of survival. House staff play a pivotal role in leading resuscitations during IHCA. Whether a mobile application (App) that provides real-time reminders and dosing recommendations for defibrillation and vasoactive medications improves adherence to ACLS guidelines remains unknown. Methods: As part of a quality improvement initiative, internal medicine residents at Saint Luke’s Mid America Heart Institute underwent two different cardiac arrest simulations and were randomized to do one simulation with the App and one without. All simulations included 4 rhythm cycles and were video recorded to ensure accuracy in endpoint assessments. The co-primary endpoints were chest compression fraction (i.e., time doing chest compressions / total time of the simulation) and number of correct interventions (e.g., defibrillation, epinephrine or amiodarone within the correct time frame and with accurate dosing) out of 7 in each simulation. The secondary endpoint was incorrect interventions, defined as interventions not indicated by ACLS guidelines (e.g., atropine for asystole). Paired t-tests compared performance with and without the App. Results: Among 53 residents, 26 were randomized to do the first simulation with the App and 27 without the App. Use of the App was associated with a higher number of correct ACLS interventions (out of 7): mean of 6.2 vs. 5.1; absolute difference of 1.1 (95% CI: 0.6, 1.6); P&lt;0.001) as well as fewer incorrect ACLS interventions (mean of 0.3 vs. 1.0; absolute difference of -0.7 (95% CI: -0.3, -1.0); P&lt;0.001). Simulations performed with the App also had a marginally higher chest compression fraction (mean: 90.9% vs. 89.0%; absolute difference 2.0% (95% CI: 0.6%, 3.4%; P=0.007). Conclusion: Use of a mobile application by residents during simulations was associated with better adherence to ACLS performance measures. This proof-of-concept study suggests this novel mobile App may improve adherence to ACLS, but its effectiveness on survival in real-world resuscitations remains unknown.

Individualized HbA1c Targets in People with Type 2 Diabetes Initiating Second-Line Therapy—The Global DISCOVER Study

Background: International guidelines recommend setting individualized HbA1c targets for people with type-2 diabetes (T2D). DISCOVER (NCT02322762) is an observational study of patients with T2D initiating second-line glucose-lowering therapy in 37 countries. We report the proportion of patients set individualized targets, the proportion meeting these targets after 1 year, and factors associated with meeting these targets. Methods: Patients included had HbA1c data at baseline and at 1 year. Factors associated with meeting targets were assessed using multivariable logistic regression. Results: Of the 7225 patients with complete HbA1c data who remained in the study after 1 year, 5070 (70.2%) had been set an individualized glycaemic control target. Targets were 7.0% for 2513 patients (49.6%), &amp;lt; 7.0% for 2073 patients, (40.9%) and &amp;gt; 7.0% for 484 patients (9.6%). Overall, 1744 of these patients (34.4%) met their target after 12 months of follow-up (range across regions: 21.4-42.7%). Factors associated with meeting HbA1c targets are shown in the Figure. Conclusions: Twelve months after initiating second-line therapy, almost one third of patients with set individualized HbA1c targets had met their targets, with considerable variation between regions. Older age, higher education level, lower baseline HbA1c level and higher target were factors associated with meeting targets. Disclosure K. Khunti: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company, Sanofi-Aventis, Merck Sharp &amp; Dohme Corp., Novo Nordisk A/S. Consultant; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck Sharp &amp; Dohme Corp., Novartis AG, Novo Nordisk A/S, Sanofi-Aventis, Takeda Development Centre Europe Ltd., Servier. Research Support; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Merck Sharp &amp; Dohme Corp., Novartis AG, Sanofi-Aventis, Pfizer Inc.. Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck Sharp &amp; Dohme Corp., Novartis AG, Novo Nordisk A/S, Sanofi-Aventis, Takeda Development Centre Europe Ltd., Servier. Research Support; Self; Novo Nordisk A/S. Consultant; Self; Pfizer Inc.. Research Support; Self; Novo Nordisk A/S. H. Chen: Employee; Self; AstraZeneca. J. Cid-Ruzafa: Employee; Self; Evidera. P. Fenici: Employee; Self; AstraZeneca. M.B. Gomes: Advisory Panel; Self; AstraZeneca. Consultant; Self; Merck KGaA. N. Hammar: Employee; Self; AstraZeneca. Stock/Shareholder; Self; AstraZeneca. K. Kennedy: Research Support; Self; AstraZeneca. Employee; Self; Mid America Heart Institute. M. Kosiborod: Advisory Panel; Self; AstraZeneca. Consultant; Self; AstraZeneca, Amgen Inc., Sanofi, Boehringer Ingelheim GmbH, GlaxoSmithKline plc., Glytec Systems, Merck &amp; Co., Inc., Novo Nordisk A/S, Janssen Pharmaceuticals, Inc., ZS Pharma, Inc., Intarcia Therapeutics, Inc., Novartis AG. Research Support; Self; AstraZeneca, Boehringer Ingelheim GmbH. S. Pocock: Consultant; Self; AstraZeneca. M.V. Shestakova: None. I. Shimomura: Research Support; Self; Appliance Company, Panasonic Corporation. Speaker's Bureau; Self; Astellas Pharma Inc., AstraZeneca, Covidien Japan Inc.. Research Support; Self; Daiichi Sankyo Company, Limited. Speaker's Bureau; Self; Daiichi Sankyo Company, Limited. Research Support; Self; Eli Lilly Japan K.K., Eli Lilly Japan K.K., Kaken Pharmaceutical Co., Ltd.. Speaker's Bureau; Self; Kowa Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Corporation, Mochida Pharmaceutical Co., Ltd., MSD K.K., Nippon Boehringer Ingelheim Co. Ltd., Novartis Pharma K.K.. Research Support; Self; Novo Nordisk Pharma Ltd.. Speaker's Bureau; Self; Novo Nordisk Pharma Ltd., Ono Pharmaceutical Co., Ltd.. Research Support; Self; Roche DC Japan K.K., Rohto Pharmaceutical Co., Ltd. Speaker's Bureau; Self; Rohto Pharmaceutical Co., Ltd, Sanwa Kagaku Kenkyusho Co., Ltd.. Research Support; Self; Sanofi K.K.. Speaker's Bureau; Self; Sanofi K.K.. Research Support; Self; Shionogi &amp; Co., Ltd.. Speaker's Bureau; Self; Sumitomo Dainippon Pharma Co., Ltd.. Research Support; Self; Taisho Toyama Pharmaceutical Co., Ltd.. Speaker's Bureau; Self; Taisho Toyama Pharmaceutical Co., Ltd.. Research Support; Self; Takeda Pharmaceutical Company Limited. Speaker's Bureau; Self; Takeda Pharmaceutical Company Limited. Research Support; Self; Teijin Pharma Limited. Speaker's Bureau; Self; Teijin Pharma Limited. F. Surmont: Employee; Self; AstraZeneca. L. Ji: Advisory Panel; Self; AstraZeneca. Consultant; Self; AstraZeneca, Eli Lilly and Company, Bristol-Myers Squibb Company, Novartis AG, Novo Nordisk A/S, Merck &amp; Co., Inc., Bayer AG, Merck Sharp &amp; Dohme Corp., Takeda Development Center Asia, Pte. Ltd., Sanofi, Roche Pharma, Boehringer Ingelheim GmbH. Research Support; Self; AstraZeneca, Roche Pharma, Sanofi, Merck Sharp &amp; Dohme Corp., Novartis AG, Eli Lilly and Company, Bristol-Myers Squibb Company.

Temporal Trends in the Use of Sodium-Glucose Cotransporter 2 Inhibitors—The Global DISCOVER Study

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk of cardiovascular (CV) events in patients with type 2 diabetes (T2D), first demonstrated in the EMPA-REG OUTCOME trial (EMPA-REG). We examined trends in the use of SGLT2i during the first year of DISCOVER (NCT02322762), a 3-year observational study of patients with T2D initiating second-line glucose-lowering therapy in 37 countries. Methods: Patients who weren’t receiving an SGLT2i at first-line and who had data on glucose-lowering medications at baseline, 6 and 12 months were included (N = 11 706). We assessed the numbers and characteristics of patients who were initiated on an SGLT2i (initiation of second-line therapy at baseline, or later-line therapy during the first year of follow-up) overall and according to whether the date of initiation was before or after EMPA-REG. Results: Overall, 1138 patients were prescribed an SGLT2i at baseline or during follow-up (9.7%; across-country range: 0.0-68.9%). There were no substantial differences in patient characteristics among those who were prescribed an SGLT2i before or after EMPA-REG: 10.4% (before) and 14.4% (after) of patients had a history of macrovascular complications, compared with 12.9% of patients prescribed a different class of medication (p = 0.24). At baseline (initiation of second-line therapy), the proportion of patients who received an SGLT2i was higher when the initiation occurred after vs. before EMPA-REG (8.4% vs. 5.9%, p &amp;lt; 0.001). Conclusions: The overall proportion of patients prescribed an SGLT2i was low, but varied greatly across countries. SGLT2i use increased modestly after EMPA-REG. Although the CV benefits of SGLT2i use have been best demonstrated in people with established macrovascular disease, the clinical decision to prescribe these agents does not appear to be primarily driven by the presence of macrovascular complications. Disclosure M. Kosiborod: Advisory Panel; Self; AstraZeneca. Consultant; Self; AstraZeneca, Amgen Inc., Sanofi, Boehringer Ingelheim GmbH, GlaxoSmithKline plc., Glytec Systems, Merck &amp; Co., Inc., Novo Nordisk A/S, Janssen Pharmaceuticals, Inc., ZS Pharma, Inc., Intarcia Therapeutics, Inc., Novartis AG. Research Support; Self; AstraZeneca, Boehringer Ingelheim GmbH. H. Chen: Employee; Self; AstraZeneca. J. Cid-Ruzafa: Employee; Self; Evidera. P. Fenici: Employee; Self; AstraZeneca. M.B. Gomes: Advisory Panel; Self; AstraZeneca. Consultant; Self; Merck KGaA. N. Hammar: Employee; Self; AstraZeneca. Stock/Shareholder; Self; AstraZeneca. K. Khunti: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company, Sanofi-Aventis, Merck Sharp &amp; Dohme Corp., Novo Nordisk A/S. Consultant; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck Sharp &amp; Dohme Corp., Novartis AG, Novo Nordisk A/S, Sanofi-Aventis, Takeda Development Centre Europe Ltd., Servier. Research Support; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Merck Sharp &amp; Dohme Corp., Novartis AG, Sanofi-Aventis, Pfizer Inc.. Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck Sharp &amp; Dohme Corp., Novartis AG, Novo Nordisk A/S, Sanofi-Aventis, Takeda Development Centre Europe Ltd., Servier. Research Support; Self; Novo Nordisk A/S. Consultant; Self; Pfizer Inc.. Research Support; Self; Novo Nordisk A/S. S. Pocock: Consultant; Self; AstraZeneca. M.V. Shestakova: None. I. Shimomura: Research Support; Self; Appliance Company, Panasonic Corporation. Speaker's Bureau; Self; Astellas Pharma Inc., AstraZeneca, Covidien Japan Inc.. Research Support; Self; Daiichi Sankyo Company, Limited. Speaker's Bureau; Self; Daiichi Sankyo Company, Limited. Research Support; Self; Eli Lilly Japan K.K., Eli Lilly Japan K.K., Kaken Pharmaceutical Co., Ltd.. Speaker's Bureau; Self; Kowa Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Corporation, Mochida Pharmaceutical Co., Ltd., MSD K.K., Nippon Boehringer Ingelheim Co. Ltd., Novartis Pharma K.K.. Research Support; Self; Novo Nordisk Pharma Ltd.. Speaker's Bureau; Self; Novo Nordisk Pharma Ltd., Ono Pharmaceutical Co., Ltd.. Research Support; Self; Roche DC Japan K.K., Rohto Pharmaceutical Co., Ltd. Speaker's Bureau; Self; Rohto Pharmaceutical Co., Ltd, Sanwa Kagaku Kenkyusho Co., Ltd.. Research Support; Self; Sanofi K.K.. Speaker's Bureau; Self; Sanofi K.K.. Research Support; Self; Shionogi &amp; Co., Ltd.. Speaker's Bureau; Self; Sumitomo Dainippon Pharma Co., Ltd.. Research Support; Self; Taisho Toyama Pharmaceutical Co., Ltd.. Speaker's Bureau; Self; Taisho Toyama Pharmaceutical Co., Ltd.. Research Support; Self; Takeda Pharmaceutical Company Limited. Speaker's Bureau; Self; Takeda Pharmaceutical Company Limited. Research Support; Self; Teijin Pharma Limited. Speaker's Bureau; Self; Teijin Pharma Limited. F. Surmont: Employee; Self; AstraZeneca. F. Tang: Research Support; Self; AstraZeneca. Employee; Self; Mid America Heart Institute. L. Ji: Advisory Panel; Self; AstraZeneca. Consultant; Self; AstraZeneca, Eli Lilly and Company, Bristol-Myers Squibb Company, Novartis AG, Novo Nordisk A/S, Merck &amp; Co., Inc., Bayer AG, Merck Sharp &amp; Dohme Corp., Takeda Development Center Asia, Pte. Ltd., Sanofi, Roche Pharma, Boehringer Ingelheim GmbH. Research Support; Self; AstraZeneca, Roche Pharma, Sanofi, Merck Sharp &amp; Dohme Corp., Novartis AG, Eli Lilly and Company, Bristol-Myers Squibb Company.

Incidence of Left Ventricular Thrombus in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated with Percutaneous Coronary Intervention

Previous studies using 2-dimensional non-contrast echocardiography have reported a post-ST segment elevation myocardial infarction (STEMI) left ventricular (LV) thrombus incidence of 3% to 24%. However, these studies were not performed with ultrasound contrast agents (UCAs), which improve accuracy in the diagnosis of LV thrombus. We aimed to determine the early incidence and clinical correlates of LV thrombus in a large consecutive cohort of patients with STEMI. This study included consecutive patients admitted to Saint Luke's Mid America Heart Institute with STEMI who also underwent early percutaneous coronary intervention (PCI) and an echocardiogram. A total of 1,698 patients (1,205 men, mean age 61 ± 13 years) comprised the study group. Echocardiography was performed on hospital day 2, and a UCA was used in 1,292 patients (76%). LV thrombus was identified in 28 (1.6%) patients. A multivariable logistic regression model showed that left anterior descending intervention was independently associated with LV thrombus (odds ratio = 7.58, 95% confidence interval [CI] 2.20 to 26.19, p = 0.001), thrombolysis in myocardial infarction III flow was marginally associated with less LV thrombus (odds ratio = 0.41, 95% CI 0.16 to 1.04, p = 0.060), and higher LVEF was associated with less LV thrombus (odds ratio = 0.96, 95% CI 0.91 to 0.97, p <0.001). In conclusion, LV thrombus was identified in only 1.6% of patients in a large STEMI cohort, significantly lower than previous studies. A UCA was used in most echocardiograms, and it improves accuracy in the detection and exclusion of LV thrombus.

Patient-Centered Outcomes Research: Early Evidence From A Burgeoning Field.

Patient-Centered Outcomes Research: Early Evidence From A Burgeoning Field.

One in 10 Heart Attack Patients has Diabetes

Ten percent of patients presenting with an acute myocardial infarction had undiagnosed diabetes at the time of their heart attack, underlining the importance of evaluating such patients for diabetes while they are being treated, investigators have reported.The study found that 287 (10.1%) of the 2,854 patients enrolled in a 24-site U.S. acute MI registry, who were not known to have type 2 diabetes at hospital admission, actually had diabetes, reported Suzanne V. Arnold, MD, a cardiologist at Saint Luke's Mid America Heart Institute, Kansas City, MO. The data were presented at the American Heart Association's Quality of Care and Outcomes Research conference.The diabetes diagnosis was based on hemoglobin A levels of 6.5% or higher. If no HbA result was available, the diagnosis was based on at least two fasting glucose levels of 126 mg/dL or higher, or at least one fasting glucose level of 126 mg/dL or higher plus a glucose level at presentation of at least 200 mg/dL.Of the 287 patients who were identified as having unrecognized diabetes in the study, almost 70% (198) had not been diagnosed by the physician who treated them during their hospitalizations. This lack of a diagnosis was indicated by patients not having received education about diabetes while hospitalized or not being discharged with a diabetes medication.If a physician checked the HbA1c for a patient with an acute MI as part of routine clinical care, however, the likelihood that the patient would be diagnosed with diabetes was increased 18-fold, a statistically significant finding, Dr. Arnold said.The registry study is the TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status) study. Ten percent of patients presenting with an acute myocardial infarction had undiagnosed diabetes at the time of their heart attack, underlining the importance of evaluating such patients for diabetes while they are being treated, investigators have reported. The study found that 287 (10.1%) of the 2,854 patients enrolled in a 24-site U.S. acute MI registry, who were not known to have type 2 diabetes at hospital admission, actually had diabetes, reported Suzanne V. Arnold, MD, a cardiologist at Saint Luke's Mid America Heart Institute, Kansas City, MO. The data were presented at the American Heart Association's Quality of Care and Outcomes Research conference. The diabetes diagnosis was based on hemoglobin A levels of 6.5% or higher. If no HbA result was available, the diagnosis was based on at least two fasting glucose levels of 126 mg/dL or higher, or at least one fasting glucose level of 126 mg/dL or higher plus a glucose level at presentation of at least 200 mg/dL. Of the 287 patients who were identified as having unrecognized diabetes in the study, almost 70% (198) had not been diagnosed by the physician who treated them during their hospitalizations. This lack of a diagnosis was indicated by patients not having received education about diabetes while hospitalized or not being discharged with a diabetes medication. If a physician checked the HbA1c for a patient with an acute MI as part of routine clinical care, however, the likelihood that the patient would be diagnosed with diabetes was increased 18-fold, a statistically significant finding, Dr. Arnold said. The registry study is the TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status) study.

Shared Decision Making

A primary challenge to the American healthcare system is to improve quality by being more evidence based, cost-effective, and patient centered.1,2 The first 2 markers of quality are familiar to physicians and policy makers, wherein disease-specific performance measures and cost data are commonly used to gauge outcomes. The third quality parameter, patient-centered care, has gained increased awareness among the healthcare community but remains elusive to many. Patient-centered outcomes focus on patients’ experiences (eg, symptoms, quality of life) and preferences for these and other outcomes. Thus, the best outcome may be different for different individuals, depending on their priorities, values, and goals. For example, in assessing the outcome of implanting a defibrillator in an 80-year-old patient, we may need to look beyond 1-year mortality and ask whether the decision is consistent with the patient’s values concerning dying and acceptance of potential inappropriate shocks.3 In a patient-centered model, the focus is on high-quality decision making, stemming from the exchange of (1) balanced, evidence-based, disease-specific information; (2) presentation of treatment options and their inherent benefits and tradeoffs; (3) assessment of patient values, priorities, and goals; and (4) alignment of patient values with treatment decisions.4 This process of shared decision making (SDM) has the potential to advance patients’ desired wishes and to achieve better patient-centered outcomes while lowering the costs of care should patients choose less expensive treatment options.5,6 Decision aids are commonly used to facilitate SDM, conveying information about a particular disease and the risks and benefits associated with different treatment strategies, including no treatment at all.7 Decision aids may take the form of a Web-based tool, video, or pamphlet and may be administered in the hospital or office or even independently by patients before their visit. To date, >86 randomized trials have been …

Circulation: Cardiovascular Quality and Outcomes Annual Report, 2012

With this issue, we mark 4 complete years of publication of Circulation: Cardiovascular Quality and Outcomes (CQO). Thank you to our editors, readers, authors, reviewers, and supporters—and especially to Emily Picillo, Katie Sullivan, Karen Barry, and the rest of the outstanding Circulation staff—for helping CQO to mature as a publication with impact. Earlier this year, we submitted a report to the Scientific Publishing Committee of the American Heart Association. We would like to share the key aspects of the report. The mission of CQO is to improve clinical care and healthcare delivery for patients with, or at risk for, cardiovascular disease and stroke. We pursue this mission through a format that promotes scholarship, education, and constructive debate. The audience includes researchers, clinicians, policymakers, administrators, health plan executives, and government agency professionals. In addition to serving as a venue for high-quality scholarship, we seek to be a catalyst for good science, a vehicle for strengthening and expanding the community that is committed to improving clinical care and population health, and a means to inspire junior investigators to engage in scholarly activities of consequence. CQO has included original research, methods (describing studies that have been implemented) and methodological (describing specific research methods) articles, commentaries, data reports, quality improvement articles, and editorial perspectives. Our original articles span a broad set of disciplines. We consider the journal to be a home for high-quality epidemiology studies that have relevance for patient outcomes and public health. In a word cloud from the titles of 100 articles published in CQO earlier in the year (Figure 1), with word size proportionate to frequency of use, it is most heartening that the largest word is patients . Figure 1. Word cloud created from text contained in a sample of 100 articles published in CQO in 2012. Although the impact factor, defined …