US Cardiology Research Articles

Industry Payments to Cardiologists.

Industry Payments to Cardiologists.

Measurement of Low-Density Lipoprotein Cholesterol Levels in Primary and Secondary Prevention Patients: Insights From the PALM Registry.

BackgroundThe 2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommended testing low‐density lipoprotein cholesterol (LDL‐C) to identify untreated patients with LDL‐C ≥190 mg/dL, assess lipid‐lowering therapy adherence, and consider nonstatin therapy. We sought to determine whether clinician lipid testing practices were consistent with these guidelines.Methods and ResultsThe PALM (Patient and Provider Assessment of Lipid Management) registry enrolled primary and secondary prevention patients from 140 US cardiology, endocrinology, and primary care offices in 2015 and captured demographic data, lipid treatment history, and the highest LDL‐C level in the past 2 years. Core laboratory lipid levels were drawn at enrollment. Among 7627 patients, 2787 (36.5%) had no LDL‐C levels measured in the 2 years before enrollment. Patients without chart‐documented LDL‐C levels were more often women, nonwhite, uninsured, and non–college graduates (all P<0.01). Patients without prior lipid testing were less likely to receive statin treatment (72.6% versus 76.0%; P=0.0034), a high‐intensity statin (21.5% versus 24.3%; P=0.016), nonstatin lipid‐lowering therapy (24.8% versus 27.3%; P=0.037), and had higher core laboratory LDL‐C levels at enrollment (median 97 versus 92 mg/dL; P<0.0001) than patients with prior LDL‐C testing. Of 166 individuals with core laboratory LDL‐C levels ≥190 mg/dL, 36.1% had no LDL‐C measurement in the prior 2 years, and 57.2% were not on a statin at the time of enrollment.ConclusionsIn routine clinical practice, LDL‐C testing is associated with higher‐intensity lipid‐lowering treatment and lower achieved LDL‐C levels.

Managing Cardiovascular Disease Risk in Rheumatoid Arthritis: Clinical Updates and Three Strategic Approaches.

By critically reviewing literature published within the past 5years, we aim to clarify current knowledge and gaps regarding CVD risk management in RA. We examine recent guidelines, recommendations, and evidence and discuss three approaches: (1) RA-specific management including treat-to-target and medication management, (2) assessment of comprehensive individual risk, and (3) targeting traditional CVD risk factors (hypertension, smoking, hyperlipidemia, diabetes, obesity, and physical inactivity) at a population level. Considering that 75% of US RA visits occur in specialty clinics, further research is needed regarding evidence-based strategies to manage and reduce CVD risk in RA. This review highlights clinical updates including US cardiology and international professional society guidelines, successful evidence-based population approaches from primary care, and novel opportunities in rheumatology care to reduce CVD risk in RA.

Adoption of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline in Cardiology Practices Nationwide

The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline recommends moderate-intensity to high-intensity statin therapy in eligible patients. To examine adoption of the 2013 ACC/AHA guideline in US cardiology practices. Among 161 cardiology practices, trends in the use of moderate-intensity to high-intensity statin and nonstatin lipid-lowering therapy (LLT) were analyzed before (September 1, 2012, to November 1, 2013) and after (February 1, 2014, to April 1, 2015) publication of the 2013 ACC/AHA guideline among 4 mutually exclusive risk groups within the ACC Practice Innovation and Clinical Excellence Registry. Interrupted time series analysis was used to evaluate for differences in trend in use of moderate-intensity to high-intensity statin and nonstatin LLT use in hierarchical logistic regression models. Participants were a population-based sample of 1 105 356 preguideline patients (2 431 192 patient encounters) and 1 116 472 postguideline patients (2 377 219 patient encounters). Approximately 97% of patients had atherosclerotic cardiovascular disease (ASCVD). Moderate-intensity to high-intensity statin and nonstatin LLT use before and after publication of the 2013 ACC/AHA guideline. Time trend in the use of moderate-intensity to high-intensity statin and nonstatin LLT. In the study cohort, the mean (SD) age was 69.6 (12.1) years among 1 105 356 patients (40.2% female) before publication of the guideline and 70.0 (11.9) years among 1 116 472 patients (39.8% female) after publication of the guideline. Although there was a trend toward increasing use of moderate-intensity to high-intensity statins overall and in the ASCVD cohort, such a trend was already present before publication of the guideline. No significant difference in trend in the use of moderate-intensity to high-intensity statins was observed in other groups. The use of moderate-intensity to high-intensity statin therapy was 62.1% (before publication of the guideline) and 66.6% (after publication of the guideline) in the overall cohort, 62.7% (before publication) and 67.0% (after publication) in the ASCVD cohort, 50.6% (before publication) and 52.3% (after publication) in the cohort with elevated low-density lipoprotein cholesterol levels (ie, ≥190 mg/dL), 52.4% (before publication) and 55.2% (after publication) in the diabetes cohort, and 41.9% (before publication) and 46.9% (after publication) in the remaining group with 10-year ASCVD risk of 7.5% or higher. In hierarchical logistic regression models, there was a significant increase in the use of moderate-intensity to high-intensity statins in the overall cohort (4.8%) and in the ASCVD cohort (4.3%) (P < .01 for slope for both). There was no significant change for other risk cohorts. Nonstatin LLT use remained unchanged in the preguideline and postguideline periods in the hierarchical logistic regression models for all of the risk groups. Adoption of the 2013 ACC/AHA Cholesterol Management Guideline in cardiology practices was modest. Timely interventions are needed to improve guideline-concordant practice to reduce the burden of ASCVD.

Sex Differences in Faculty Rank Among Academic Cardiologists in the United States.

Studies demonstrate that women physicians are less likely than men to be full professors. Comprehensive evidence examining whether sex differences in faculty rank exist in academic cardiology, adjusting for experience and research productivity, is lacking. Therefore, we evaluated for sex differences in faculty rank among a comprehensive, contemporary cohort of US cardiologists after adjustment for several factors that impact academic advancement, including measures of clinical experience and research productivity. We identified all US cardiologists with medical school faculty appointments in 2014 by using the American Association of Medical Colleges faculty roster and linked this list to a comprehensive physician database from Doximity, a professional networking website for doctors. Data on physician age, sex, years since residency, cardiology subspecialty, publications, National Institutes of Health grants, and registered clinical trials were available for all academic cardiologists. We estimated sex differences in full professorship, adjusting for these factors and medical school-specific fixed effects in a multivariable regression model. Among 3810 cardiologists with faculty appointments in 2014 (13.3% of all US cardiologists), 630 (16.5%) were women. Women faculty were younger than men (mean age, 48.3 years versus 53.5 years, P<0.001), had fewer total publications (mean number: 16.5 publications versus 25.2 publications; P<0.001), were similarly likely to have National Institutes of Health funding (proportion with at least 1 National Institutes of Health award, 10.8% versus 10.4%; P=0.77), and were less likely to have a registered clinical trial (percentage with at least 1 clinical trial, 8.9% versus 11.1%; P=0.10). Among 3180 men, 973 (30.6%) were full professors in comparison with 100 (15.9%) of 630 women. In adjusted analyses, women were less likely to be full professors than men (adjusted odds ratio, 0.63; 95% confidence interval, 0.43-0.94; P=0.02; adjusted proportions, 22.7% versus 26.7%; absolute difference, -4.0%; 95% confidence interval, -7.5% to -0.7%). Among cardiology faculty at US medical schools, women were less likely than men to be full professors after accounting for several factors known to influence faculty rank.

Correction to: Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association.

HomeCirculationVol. 134, No. 23Correction to: Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection to: Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association Originally published6 Dec 2016https://doi.org/10.1161/CIR.0000000000000474Circulation. 2016;134:e652This article corrects the followingCurrent Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart AssociationIn the article by Bozkurt et al, “Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association,” which published ahead of print November 3, 2016, and appeared in the December 6, 2016, issue of the journal (Circulation. 2016;134:e579–e646. doi: 10.1161/CIR.0000000000000455), several corrections were needed.On page e579, in the author byline, “Vasan S. Ramachandran, MD, FAHA” has been updated to “Ramachandran S. Vasan, MD, FAHA.”On page e608, Figure 3, the figure legend read, “Figure 3. Pathophysiology of obesity cardiomyopathy. LV indicates left ventricular; RV, right ventricular. Modified from Alpert et al346a with permission from Elsevier. © 2014, Elsevier Inc.” It has been updated to read, “Figure 3. Pathophysiology of obesity cardiomyopathy. LV indicates left ventricular; RV, right ventricular. Modified from Alpert et al346a,347 with permission from Elsevier and Springer. © Springer Science+Business Media New York 2014.”On page e625, in the left column, the second paragraph, the first sentence, “Ramachandran VS” has been updated to “Vasan RS.”On page e626, in the Writing Group Disclosures table, “Vasan S. Ramachandran” has been updated to “Ramachandran S. Vasan.”These corrections have been made to the current online version of the article, which is available at http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000455.FootnotesCirculation is available at http://circ.ahajournals.org. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Joseph M and Davis M (2021) Counseling Women With Peripartum Cardiomyopathy About Subsequent Pregnancies, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-021-00915-4, 23:6, Online publication date: 1-Jun-2021. Luo X, Luo P and Zhang Y (2020) Identification of differentially expressed long non-coding RNAs associated with dilated cardiomyopathy using integrated bioinformatics approaches, Drug Discoveries & Therapeutics, 10.5582/ddt.2020.01010, 14:4, (181-186), Online publication date: 31-Aug-2020. Sigman S (2019) Diagnosis and Therapy of Cardiac Sarcoidosis: A Clinical Perspective, US Cardiology Review, 10.15420/usc.2018.3.1, 13:1, (41-45), Online publication date: 12-Mar-2019. Ovidiu T, Anca T, Larisa R, Madalina V, Elena R, Vlad P, Ioana I, Anca S, Mircea S, Cosmin V, Katalin B and Mircea-Ioachim P (2018) Dilated Cardiomiopathy - Anatomic-Clinical Study, Internal Medicine, 10.2478/inmed-2018-0002, 15:1, (17-24), Online publication date: 1-Mar-2018., Online publication date: 1-Mar-2018. Moore M, Dilcher B, MInardi J, Quedado K and Shaver E (2020) Point-of-care Echocardiogram as the Key to Rapid Diagnosis of a Unique Presentation of Dyspnea: A Case Report, Clinical Practice and Cases in Emergency Medicine, 10.5811/cpcem.2020.5.47012, 4:3, (424-427) Blagova O, Nedostup A, Sedov V, Zaitsev A, Novosadov V and Kogan E (2021) Effectiveness of myocarditis therapy depending on the diagnosis approach (with or without myocardial biopsy), Cardiovascular Therapy and Prevention, 10.15829/1728-8800-2021-2637, 20:3, (2637) Liang K, Nakou E, Del Buono M, Montone R, D'Amario D and Bucciarelli-Ducci C (2022) The Role of Cardiac Magnetic Resonance in Myocardial Infarction and Non-obstructive Coronary Arteries, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2021.821067, 8 Горбачова В and Плегуца О (2020) Obesity and Cardio-vascular Disorders: Review, Family Medicine, 10.30841/2307-5112.3.2020.211860, 0:3, (47-51) Related articlesCurrent Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart AssociationBiykem Bozkurt, et al. Circulation. 2016;134:e579-e646 December 6, 2016Vol 134, Issue 23 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIR.0000000000000474PMID: 27920080 Originally publishedDecember 6, 2016 PDF download Advertisement

The prevalence and management of angina among patients with chronic coronary artery disease across US outpatient cardiology practices: insights from the Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study

Although eliminating angina is a primary goal in treating patients with chronic coronary artery disease (CAD), few contemporary data quantify prevalence and severity of angina across US cardiology practices. The authors hypothesized that angina among outpatients with CAD managed by US cardiologists is low and its prevalence varies by site. Among 25 US outpatient cardiology clinics enrolled in the American College of Cardiology Practice Innovation and Clinical Excellence (PINNACLE) registry, we prospectively recruited a consecutive sample of patients with chronic CAD over a 1- to 2-week period at each site between April 2013 and July 2015, irrespective of the reason for their appointment. Eligible patients had documented history of CAD (prior acute coronary syndrome, prior coronary revascularization procedure, or diagnosis of stable angina) and ≥1 prior office visit at the practice site. Angina was assessed directly from patients using the Seattle Angina Questionnaire Angina Frequency score. Among 1257 patients from 25 sites, 7.6% (n = 96) reported daily/weekly, 25.1% (n = 315) monthly, and 67.3% (n = 846) no angina. The proportion of patients with daily/weekly angina at each site ranged from 2.0% to 24.0%, but just over half (56.3%) were on ≥2 antianginal medications, with wide variability across sites (0%-100%). One-third of outpatients with chronic CAD managed by cardiologists report having angina in the prior month, and 7.6% have frequent symptoms. Among those with frequent angina, just over half were on ≥2 antianginal medications, with wide variability across sites. These findings suggest an opportunity to improve symptom control.

Predictors of Physician Under-Recognition of Angina in Outpatients With Stable Coronary Artery Disease

Under-recognition of angina by physicians may result in undertreatment with revascularization or medications that could improve patients' quality of life. We sought to describe characteristics associated with under-recognition of patients' angina. Patients with coronary disease from 25 US cardiology outpatient practices completed the Seattle Angina Questionnaire before their clinic visit, quantifying their frequency of angina during the previous month. Immediately after the clinic visit, physicians independently quantified their patients' angina. Angina frequency was categorized as none, monthly, and daily/weekly. Among 1257 patients, 411 reported angina in the previous month, of whom 173 (42%) were under-recognized by their physician, defined as the physician reporting a lower frequency category of angina than the patient. In a hierarchical logistic model, heart failure (odds ratio, 3.06, 95% confidence interval, 1.89-4.95) and less-frequent angina (odds ratio for monthly angina [versus daily/weekly], 1.69; 95% confidence interval, 1.12-2.56) were associated with greater odds of under-recognition. No other patient or physician factors were associated with under-recognition. Significant variability across physicians (median odds ratio, 2.06) was observed. Under-recognition of angina is common in routine clinical practice. Although patients with less-frequent angina and those with heart failure more often had their angina under-recognized, most variation was unrelated to patient and physician characteristics. The large variation across physicians suggests that some physicians are more accurate in assessing angina frequency than others. Standardized prospective use of a validated clinical tool, such as the Seattle Angina Questionnaire, should be tested as a means to improve recognition of angina and, potentially, improve appropriate treatment of angina.

US Cardiologists Embrace Population Health.

Having achieved steadily declining rates of coronary heart disease in the United States during the past 4 decades,1 US cardiologists like former American Heart Association (AHA) president Clyde W. Yancy, MD, are turning their sights on a new goal, preventing cardiovascular disease through population health initiatives. Yancy, who continues to volunteer for AHA, said that the substantial evidence supporting the effectiveness of population health initiatives has driven the development of AHA’s population health programs like Life Simple 7, which outlines 7 steps individuals can take to improve their heart health. “[Physicians] are not passive participants in the life cycle of heart disease,” Yancy said. “We can be much more active in the process and can, in fact, prevent disease.” Although preventing a second or third heart attack has long been the core of many cardiology practices, many cardiologists have not had as much experience with primary prevention and managing population health. But that is changing as value-based health payment reform and evidence-based population health initiatives broaden the role of cardiologists beyond one-on-one patient care into population health. Groups like the AHA, the American College of Cardiology, and the US Department of Health and Human Services, as well, have all developed initiatives to help cardiologists as they take on this new role. “It is an evolution in medical care where the responsibility of the physician extends beyond …

Gaining a New Skill With the Risk of Losing One: The Effect of Radial Catheterization

The adoption of radial catheterization has been relatively slow in the United States. This study was conducted to assess the perceived comfort level of cardiology fellows with radial catheterizations and to predict the practice patterns in the United States in the near future. A 21-question survey on cardiology fellows’ preferred cardiac catheterization access site was conducted between April and June 2015. Data on access preference and perceived competency were analyzed based on the fellow’s level of training and type of training program (university vs community). A total of 101 responses were received from a total of 250 invitations; 85 (85%) of these respondents completed all questions. Data were collected from fellows of several programs nationwide. Of the 85 respondents with complete data, 22%, 29%, and 19% were first-, second-, and third-year interventional fellows respectively. Most respondents (82%) were from university-based programs, 46.3% of respondents considered that their programs provided a balance of both radial and femoral training. Irrespective of the training year, most fellows seemed to prefer radial over femoral access. Senior fellows appeared to be equally comfortable with a femoral access approach (P = 0.03). There was no difference by training site (university vs community programs) (P = 0.921). In 2015, US cardiology fellows appear to prefer radial over femoral access for cardiac catheterizations. Although it is good to see the shift toward better radial access skills, we need to stress the importance of the femoral skills that would be necessary to keep in the armamentarium of interventional cardiologists.

Effect of angina under-recognition on treatment in outpatients with stable ischaemic heart disease.

Almost a third of outpatients with chronic coronary artery disease (CAD) report having angina in the prior month, which is frequently under-recognized by their cardiologists. Whether under-recognition is associated with less treatment escalation to control angina, and potential underuse of treatment, is unknown. Patients with CAD from 25 US cardiology outpatient practices completed the Seattle Angina Questionnaire (SAQ) prior to their clinic visit, and angina was categorized as daily, weekly, monthly and no angina. Cardiologists (n=155) independently quantified patients' angina, blinded to patients' SAQ scores. Under-recognition was defined as the physician reporting a lower category of angina frequency than the patient. Among 1257 patients with CAD, 411 reported angina in the past month, of whom 178 (43.3%) patients were under-recognized. Treatment escalation-defined as intensification (up-titration or addition) of antianginal medications, referral for diagnostic testing or revascularization, or hospital admission-occurred in 106 (25.8%) patients with angina. Patients with under-recognized angina were less likely to get treatment escalation than patients whose angina was appropriately recognized (8.4% vs 39.1%, P<0.001). In a hierarchical multivariable logistic regression model adjusting for demographic and clinical characteristics, as well as the burden of angina, under-recognition remained strongly associated with a lack of treatment escalation (adjusted OR 0.10, 95% CI 0.04-0.21, P<0.001). Under-recognition of angina in cardiology outpatient practices is associated with less aggressive treatment escalation and may lead to poorer angina control. Standardizing clinical recognition of angina using validated tools could reduce under-recognition of angina, facilitate treatment, and potentially improve outcomes.

Oral Anticoagulant Therapy Prescription in Patients With Atrial Fibrillation Across the Spectrum of Stroke Risk: Insights From the NCDR PINNACLE Registry.

Patients with atrial fibrillation (AF) are at a proportionally higher risk of stroke based on accumulation of well-defined risk factors. To examine the extent to which prescription of an oral anticoagulant (OAC) in US cardiology practices increases as the number of stroke risk factors increases. Cross-sectional registry study of outpatients with AF enrolled in the American College of Cardiology National Cardiovascular Data Registry's PINNACLE (Practice Innovation and Clinical Excellence) Registry between January 1, 2008, and December 30, 2012. As a measure of stroke risk, we calculated the CHADS2 score and the CHA2DS2-VASc score for all patients. Using multinomial logistic regression models adjusted for patient, physician, and practice characteristics, we examined the association between increased stroke risk score and prescription of an OAC. The primary outcome was prescription of an OAC with warfarin sodium or a non-vitamin K antagonist OAC. The study cohort comprised 429 417 outpatients with AF. Their mean (SD) age was 71.3 (12.9) years, and 55.8% were male. Prescribed treatment consisted of an OAC (192 600 [44.9%]), aspirin only (111 134 [25.9%]), aspirin plus a thienopyridine (23 454 [5.5%]), or no antithrombotic therapy (102 229 [23.8%]). Each 1-point increase in risk score was associated with increased odds of OAC prescription compared with aspirin-only prescription using the CHADS2 score (adjusted odds ratio, 1.158; 95% CI, 1.144-1.172; P < .001) and the CHA2DS2-VASc score (adjusted odds ratio, 1.163; 95% CI, 1.157-1.169; P < .001). Overall, OAC prescription prevalence did not exceed 50% even in higher-risk patients with a CHADS2 score exceeding 3 or a CHA2DS2-VASc score exceeding 4. In a large quality improvement registry of outpatients with AF, prescription of OAC therapy increased with a higher CHADS2 score and CHA2DS2-VASc score. However, a plateau of OAC prescription was observed, with less than half of high-risk patients receiving an OAC prescription.

Abstract 118: Are Patients with Atherosclerotic Cardiovascular Disease Receiving Appropriate Lipid Management? Insights from the PALM Registry

Background: Prior ATPIII lipid guidelines recommended statin therapy for patients with clinical ASCVD to achieve low density lipoprotein cholesterol (LDL-C) targets, while the 2013 ACC/AHA lipid guidelines recommend high-intensity statin therapy for all ASCVD patients. How closely these recommendations are followed in routine clinical practice is unknown. Methods: We evaluated statin use, intensity, and LDL-C values in 1,483 patients with ASCVD (coronary heart disease, cerebrovascular disease, and peripheral arterial disease) enrolled and seen serially at 62 geographically dispersed US cardiology and primary care clinics in the Patient and Provider Assessment of Lipid Management (PALM) Registry between May - September 2015. Factors associated with high intensity statin use (atorvastatin ≥40 mg or rosuvastatin ≥20 mg daily) and LDL-C &lt;70 mg/dL were evaluated in multivariable logistic regression. Results: Of 1,483 ASCVD patients, 86.2% were on a statin, but only 31.4% were on a high-intensity statin. Overall, 64.0% had an LDL-C &lt;100 mg/dL, but only 29.0% had an LDL-C &lt;70 mg/dL. Factors associated with high-intensity statin use in multivariable regression were younger age (OR 0.74 per 10 year increase, p&lt;0.001, 95% CI 0.66-0.83), male sex (OR 1.69, p&lt;0.001, 95% CI, 1.32-2.16), cerebrovascular disease (OR 1.55, p=0.008, 95% CI 1.12-2.13), coronary heart disease (OR 2.42, p&lt;0.001, 95% CI 1.67-3.50), and being seen by a cardiologist (OR 1.35, p =0.04, 95% CI 1.01-1.81). Factors associated with an increased likelihood of LDL-C&lt;70 were male sex (OR 1.55, p=0.001, 95% CI 1.20-2.01), white (OR 1.62, p=0.03, 95% CI 1.04-2.5-, diabetes (OR 1.64, p&lt;0.001, 95% CI 1.29-2.09) and being seen by a cardiologist (OR 1.94, p&lt;0.001, 95% CI 1.41-2.67). Discussion: Substantial gaps in care remain for secondary prevention of ASCVD despite simplified recommendations. While the majority of patients with ASCVD in community practice are on a statin, only one-third are on high intensity statins and over two-thirds have LDL ≥70 mg/dL.

Abstract 125: Burden &amp; Timing of Recurrent Angina in Patients With Incomplete Revascularization Following Percutaneous Coronary Intervention

Background: Angiographic incomplete revascularization (IR) has been reported in 30-60% of cases following percutaneous coronary intervention (PCI). The extent to which IR contributes to the burden, timing &amp; characteristics of angina &amp; the role of angina in contributing to adverse outcomes has not been defined. Methods: A retrospective review of 200 patients with IR after PCI from 9 US cardiology practices was performed to determine the frequency of recurrent angina. All angiograms were reviewed for residual coronary artery disease by an independent core laboratory. IR was defined as residual diameter stenosis &gt;50% by quantitative coronary angiography in any epicardial coronary or major side branch. Recurrent angina was defined as documented worsening of angina or initiation of either ranolazine or long-acting nitrates. Angina was assessed at 30 days, 3 months, 6 months, 9 months, 12 months, &amp; greater than 12 months. We report an interim analysis. Results: In the overall population of 200 patients, patients were mostly male (62%) with a mean age of 63.7±13.3 years, &amp; mean BMI of 30.2±6.4. There was a high prevalence of comorbidities including hypertension (93.4%), hyperlipidemia (88.5%), diabetes (52.5%), &amp; prior MI (36.1%). Of the 200 patients, 61 (30%) patients developed recurrent angina at a mean follow-up time of 549 days. Among those with recurrent angina, 26% of patients developed recurrent angina within 30 days of the index PCI procedure. At 3-, 6-, 9, &amp; 12-months, 46%, 62%, 67%, &amp; 80% of patients, respectively, had recurrent angina. The remaining 20% of patients experienced post-PCI angina after 12 months. Baseline demographic factors associated with recurrent angina included hypertension, diabetes, history of angina, prior PCI, &amp; African American ethnicity (See Table 1). Conclusions: Angiographically identified IR alone does not adequately identify patients at risk for the development of recurrent angina. Among a cohort of 200 patients with angiographically identified IR, only 30% of patients developed recurrent angina post-PCI. Almost half of patients with recurrent angina experienced it within 3 months of the index PCI procedure. Several common cardiovascular comorbidities including diabetes, hypertension &amp; prior PCI were associated with recurrent angina post-PCI. Complete analysis will be presented.

OTC medicines can worsen heart failure, US cardiologists warn

OTC medicines can worsen heart failure, US cardiologists warn

Foreword

It is my pleasure to welcome you to the inaugural issue of the relaunch for US Cardiology Review. I am excited to take on the role of Editor in Chief and look forward to working with an outstanding editorial board (see page 1) and staff to meet our mandate of providing timely and informative reviews and expert perspectives on current topics within the broad field of cardiovascular medicine.

Abstract P226: Decreasing Cardiovascular Risk via Hypertriglyceridemia Treatment: The Impact of Medical Education on Physician Understanding of the Role of Omega-3 Fatty Acids

Introduction: Triglycerides, although lacking the strong atherogenic potential of LDL-C, are an independent risk factor for cardiovascular disease (CVD), as demonstrated by the correlation between hypertriglyceridemia and cardiovascular (CV) death, CV events, and myocardial infarction. The impact of continuing medical education (CME) on improving the knowledge and competence of cardiologists in treating hypertriglyceridemia with omega-3 fatty acids was measured. Methods: Cardiologists in the US who treat patients with hypertriglyceridemia participated in an online CME activity on the role of omega-3 fatty acids in treating hypertriglyceridemia and the differences between available formulations. The educational impact was assessed using linked pre- and post-assessment questions, and participants were classified into one of 3 learning categories: improved learners (incorrect pre, correct post), reinforced learners (correct pre and post), and unaffected learners (incorrect pre and post). The educational effect size was calculated using Cohen's d formula. Results: A total of 169 cardiologists participated in the CME activity, completed the pre- and post-assessment, and were included in the analysis. Comparison of pre- and post-assessment responses for each individual question demonstrated a statistically significant improvement in knowledge and competence among cardiologists ( P &lt;.05). After completion of the CME activity, correct responses on post-assessment questions increased between 25% to 158% across all questions compared to pre-assessment responses, with an overall large effect size of 1.065 (Small effect ,&lt;0.4; intermediate effect, 0.4-0.8; large effect, &gt;0.8). Between 17% and 51% of participants showed improvement in understanding individual learning concepts; these concepts were reinforced in 18% to 28% of participants. Improvement was demonstrated in understanding recent American College of Cardiology (ACC)/American Heart Association (AHA) guideline recommendations on the treatment of hypertriglyceridemia. There was a need for further education in understanding the mechanism of action of omega-3 fatty acids, the differences between prescription and supplement forms of omega-3 fatty acids, and the pharmacodynamic differences between the different formulations of omega-3 fatty acids. Conclusion: This study demonstrated the success of a targeted educational intervention on improving the knowledge and competence of US cardiologists on the role of omega-3 fatty acids to treat hypertriglyceridemia and reduce CVD. However, the need for additional education was also demonstrated among cardiologists with regard to understanding the different omega-3 fatty acid formulations and their mechanisms of action in order to effectively use these agents.

PROspective Multicenter Imaging Study for Evaluation of chest pain: Rationale and design of the PROMISE trial

Suspected coronary artery disease (CAD) is one of the most common, potentially life-threatening diagnostic problems clinicians encounter. However, no large outcome-based randomized trials have been performed to guide the selection of diagnostic strategies for these patients. The PROMISE study is a prospective, randomized trial comparing the effectiveness of 2 initial diagnostic strategies in patients with symptoms suspicious for CAD. Patients are randomized to either (1) functional testing (exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram) or (2) anatomical testing with ≥64-slice multidetector coronary computed tomographic angiography. Tests are interpreted locally in real time by subspecialty certified physicians, and all subsequent care decisions are made by the clinical care team. Sites are provided results of central core laboratory quality and completeness assessment. All subjects are followed up for ≥1 year. The primary end point is the time to occurrence of the composite of death, myocardial infarction, major procedural complications (stroke, major bleeding, anaphylaxis, and renal failure), or hospitalization for unstable angina. More than 10,000 symptomatic subjects were randomized in 3.2 years at 193 US and Canadian cardiology, radiology, primary care, urgent care, and anesthesiology sites. Multispecialty community practice enrollment into a large pragmatic trial of diagnostic testing strategies is both feasible and efficient. The PROMISE trial will compare the clinical effectiveness of an initial strategy of functional testing against an initial strategy of anatomical testing in symptomatic patients with suspected CAD. Quality of life, resource use, cost-effectiveness, and radiation exposure will be assessed.

Medical professional liability risk among US cardiologists

Medical professional liability (MPL) remains a significant burden for physicians, in general, and cardiologists, in particular, as recent research has shown that average MPL defense costs are higher in cardiology than other specialties. Knowledge of the clinical characteristics and outcomes of lawsuits against cardiologists may improve quality of care and risk management. We analyzed closed MPL claims of 40,916 physicians and 781 cardiologists insured by a large nationwide insurer for ≥1 policy year between 1991 and 2005. The annual percentage of cardiologists facing an MPL claim was 8.6%, compared with 7.4% among physicians overall (P < .01). Among 530 claims, 72 (13.6%) resulted in an indemnity payment, with a median size of $164,988. Mean defense costs for claims resulting in payment were $83,593 (standard deviation (s.d.) $72,901). The time required to close MPL claims was longer for claims with indemnity payment than claims without (29.6 versus 18.9 months; P < .001). More than half of all claims involved a patient's death (304; 57.4%), were based on inpatient care (379; 71.5%), or involved a primary cardiovascular condition (416; 78.4%). Acute coronary syndrome was the most frequent condition (234; 44.2%). Medical professional liability claims involving noncardiovascular conditions were common (66; 12.5%) and included falls or mechanical injuries had while under a cardiologist's care and a failure to diagnose cancer. Rates of malpractice lawsuits are higher among cardiologists than physicians overall. A substantial portion of claims are noncardiovascular in nature.

Estimating the Adoption of Transcatheter Aortic Valve Replacement By US Interventional Cardiologists and Clinical Trialists

Despite extensive attention dedicated to transcatheter aortic valve replacement (TAVR) in both the medical literature and lay press, little is known about the anticipated utilization of TAVR by the US cardiology community. TAVR use is likely to outstrip its initial clinical indications. Four days after approval of the first TAVR device in November 2011 by the US Food and Drug Administration, we emailed an online questionnaire to 201 authors of major TAVR clinical trials (trialists) and 461 recent members of an interventional cardiology professional society (clinicians). Responses were compared using χ(2) , t tests, and analysis of variance. Of 205 surveys received (response rate 31%; 114 clinicians, 91 trialists), the majority of respondents were interventionalists (86%) working in academic practices (72%). Although most physicians anticipated referring <25% of their patients with severe aortic stenosis for TAVR, 68% believed that TAVR is equally efficacious as open-heart surgery, and 11% believed that moderate-surgical risk patients should also be considered for TAVR. More clinicians (98%) than trialists (81%) expected to routinely refer patients for TAVR (P < 0.001). Furthermore, the clinicians were anticipating less operator training and lower annual volume requirements for performing TAVR, when compared with the trialists (P ≤ 0.001). Our findings suggest optimism for TAVR acceptance in the United States., with more conservative expectations regarding training, procedural volume requirements, and anticipated referral patterns among TAVR trialists than clinical interventionalists.