Survival After Out-of-Hospital Cardiac Arrest in Children.

Background: Little is known about survival after out-of-hospital cardiac arrest (OHCA) in children. We examined whether OHCA survival in children differs by age, sex, and race, as well as recent survival trends.

Methods And Results: Within the prospective Cardiac Arrest Registry to Enhance Survival (CARES), we identified children (age <18 years) with an OHCA from October 2005 to December 2013.

Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest.

Importance: After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts.

Objective: To assess whether patients' decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis.

Design, Setting, And Participants: Within Get With The Guidelines-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 US hospitals.

Post-resuscitation care following out-of-hospital and in-hospital cardiac arrest.

Cardiac arrest is a leading cause of death in developed countries. Although a majority of cardiac arrest patients die during the acute event, a substantial proportion of cardiac arrest deaths occur in patients following successful resuscitation and can be attributed to the development of post-cardiac arrest syndrome. There is growing recognition that integrated post-resuscitation care, which encompasses targeted temperature management (TTM), early coronary angiography and comprehensive critical care, can improve patient outcomes.

Percutaneous Coronary Intervention Utilization and Appropriateness across the United States.

Background: Substantial geographic variation exists in percutaneous coronary intervention (PCI) use across the United States. It is unclear the extent to which high PCI utilization can be explained by PCI for inappropriate indications. The objective of this study was to examine the relationship between PCI rates across regional healthcare markets utilizing hospital referral regions (HRRs) and PCI appropriateness.

Intensive care units with low versus high volume of myocardial infarction: clinical outcomes, resource utilization, and quality metrics.

Background: The volume-outcome relationship associated with intensive care unit (ICU) experience with managing acute myocardial infarction (AMI) remains inadequately understood.

Methods And Results: Within a multicenter clinical ICU database, we identified patients with a primary ICU admission diagnosis of AMI between 2008 and 2010 to evaluate whether annual AMI volume of an individual ICU is associated with mortality, length-of-stay, or quality indicators. Patients were categorized into those treated in ICUs with low-annual-AMI volume (≤50th percentile, <2 AMI patients/month, n=569 patients) versus high-annual-AMI volume (≥90th percentile, ≥8 AMI patients/month, n=17 553 patients).

Effectiveness of implantable cardioverter-defibrillators in survivors of inhospital cardiac arrest.

Background: Although implantable cardioverter-defibrillators (ICDs) reduce mortality in patients with out-of-hospital cardiac arrest, their effectiveness in survivors of "inhospital" cardiac arrest-a population with different arrest etiologies and higher illness acuity than out-of-hospital cardiac arrest-is unknown. We therefore sought to conduct a comparative effectiveness study of ICD therapy in survivors of inhospital cardiac arrest.

Methods: We linked data from a national inpatient cardiac arrest registry with Medicare files and identified 1,200 adults from 267 hospitals between 2000 and 2008 who were discharged after surviving an inhospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia and who otherwise met traditional inclusion and exclusion criteria for secondary prevention ICD trials.

Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial).

Establishing the validity of appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) in the setting of stable ischemic heart disease can support their adoption for quality improvement. We conducted a post hoc analysis of 2,287 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial patients with stable ischemic heart disease randomized to PCI with optimal medical therapy (OMT) or OMT alone. Within appropriateness categories, we compared rates of death, myocardial infarction, revascularization subsequent to initial therapy, and angina-specific health status as determined by the Seattle Angina Questionnaire in patients randomized to PCI + OMT to those randomized to OMT alone.

Oral Anticoagulant Prescription in Patients With Atrial Fibrillation and a Low Risk of Thromboembolism: Insights From the NCDR PINNACLE Registry.

Objectives: We sought to investigate the prevalence and predictors of oral anticoagulation prescription among patients with atrial fibrillation (AF) at the lowest risk for thromboembolism, despite contemporary consensus guidelines that do not recommend anticoagulation therapy in this population.

Background: In young and healthy AF patients without significant thromboembolic risk factors, anticoagulant treatment carries bleeding risks that outweigh stroke prevention benefit.

Methods: Within a large contemporary registry of cardiology outpatients, we identified low-risk patients with AF meeting criteria for a contemporary consensus guideline class III indication against use of anticoagulation (age < 60 years, CHADS Score=0, and no structural heart disease) between 2008–2012, and a second cohort with the same criteria and a CHADS-VASc Score of 0.

Policies allowing family presence during resuscitation and patterns of care during in-hospital cardiac arrest.

Background: A growing number of hospitals have begun to implement policies allowing for family presence during resuscitation (FPDR). However, the overall safety of these policies and their effect on resuscitation care is unknown.

Methods And Results: We conducted an observational cohort study of 252 hospitals in the United States with 41,568 adults with cardiac arrest.

Coronary artery disease performance measures and statin use in patients with recent percutaneous coronary intervention or recent coronary artery bypass grafting (from the NCDR PINNACLE registry).

The association between coronary revascularization strategy (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) and compliance with coronary artery disease (CAD) performance measures is not well studied. Our analysis studied patients enrolled in the Practice Innovation and Clinical Excellence registry, who underwent coronary revascularization using PCI or CABG in the 12 months before their most recent outpatient visit in 2011. We compared the attainment of CAD performance measures and statin use in eligible patients with PCI and CABG using hierarchical logistic regression models.

Impact of the New ACC/AHA Guidelines on the Treatment of High Blood Cholesterol in a Managed Care Setting.

Background: In November 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) together issued new guidelines for the treatment of patients with high cholesterol, providing a new paradigm for the management of cholesterol in the primary and secondary prevention of coronary artery disease.

Objective: To examine the impact of the 2013 ACC/AHA cholesterol treatment guidelines on pharmacy utilization of cholesterol-lowering drugs in a real-world managed care setting.

Methods: Pharmacy claims from OptumRx, a national pharmacy benefit management provider, for the period between January 1, 2013, and December 31, 2013 (baseline period), were used to identify candidates for cholesterol-lowering therapy and to estimate the number of potential patients who will be starting or intensifying statin therapy based on the updated cholesterol treatment guidelines.

Differences in anticoagulant therapy prescription in patients with paroxysmal versus persistent atrial fibrillation.

Background: Patients with paroxysmal and persistent atrial fibrillation experience a similar risk of thromboembolism. Therefore, consensus guidelines recommend anticoagulant therapy in those at risk for thromboembolism irrespective of atrial fibrillation classification. We sought to examine whether there are differences in rates of appropriate oral anticoagulant treatment among patients with paroxysmal vs persistent atrial fibrillation in real-world cardiology practices.

Implications of the 2013 ACC/AHA cholesterol guidelines for adults in contemporary cardiovascular practice: insights from the NCDR PINNACLE registry.

Background: In a significant update, the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines recommend fixed-dose statin therapy for those at risk and do not recommend nonstatin therapies or treatment to target low-density lipoprotein cholesterol (LDL-C) levels, limiting the need for repeated LDL-C testing.

Objectives: The goal of this study was to examine the impact of the 2013 ACC/AHA cholesterol guidelines on current U.S.

Recent trends in survival from out-of-hospital cardiac arrest in the United States.

Background: Despite intensive efforts over many years, the United States has made limited progress in improving rates of survival from out-of-hospital cardiac arrest. Recently, national organizations, such as the American Heart Association, have focused on promoting bystander cardiopulmonary resuscitation, use of automated external defibrillators, and other performance improvement efforts.

Methods And Results: Using the Cardiac Arrest Registry to Enhance Survival (CARES), a prospective clinical registry, we identified 70 027 U.

Readmission rates and long-term hospital costs among survivors of an in-hospital cardiac arrest.

Background: Although an in-hospital cardiac arrest is common, little is known about readmission patterns and an inpatient resource use among survivors of an in-hospital cardiac arrest.

Methods And Results: Within a large national registry, we examined long-term inpatient use among 6972 adults aged ≥65 years who survived an in-hospital cardiac arrest. We examined 30-day and 1-year readmission rates and inpatient costs, overall and by patient demographics, hospital disposition (discharge destination), and neurological status at discharge.

Contemporary use of dual antiplatelet therapy for preventing cardiovascular events.

Objectives: CHARISMA was a landmark randomized clinical trial that failed to demonstrate a benefit of dual antiplatelet therapy (DAPT) over aspirin alone for preventing cardiovascular events. However, subgroup analyses of the trial found fewer major adverse cardiovascular events (MACEs) for patients with established cardiovascular disease but more MACEs for patients with multiple risk factors without established cardiovascular disease. Our objective was to examine DAPT use in contemporary clinical practice after publication of CHARISMA results.

Rethinking composite end points in clinical trials: insights from patients and trialists.

Background: Many clinical trials use composite end points to reduce sample size, but the relative importance of each individual end point within the composite may differ between patients and researchers.

Methods And Results: We asked 785 cardiovascular patients and 164 clinical trial authors to assign 25 "spending weights" across 5 common adverse events comprising composite end points in cardiovascular trials: death, myocardial infarction, stroke, coronary revascularization, and hospitalization for angina. We then calculated end point ratios for each participant's ratings of each nonfatal end point relative to death.

Development and validation of a short version of the Seattle angina questionnaire.

Background: Clinical trials and national performance measures increasingly mandate reporting patients' perspectives of their health status: their symptoms, function, and quality of life. Although the Seattle Angina Questionnaire (SAQ) is a validated disease-specific health status instrument for coronary artery disease (CAD) with high test-retest reliability, predictive power, and responsiveness, its use in routine clinical practice has been limited, in part, by its length (19 items).

Methods And Results: Using data from 10 408 patients with CAD from 5 multicenter registries, we derived and validated a shortened version of the SAQ (SAQ-7) among patients presenting with stable CAD, undergoing percutaneous coronary intervention, and after acute myocardial infarction.

Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry.

Importance: Diagnostic coronary angiography in asymptomatic patients may lead to inappropriate percutaneous coronary intervention (PCI) due to a diagnostic-therapeutic cascade. Understanding the association between patient selection for coronary angiography and PCI appropriateness may inform strategies to minimize inappropriate procedures.

Objective: To determine if hospitals that frequently perform coronary angiography in asymptomatic patients, a clinical scenario in which the benefit of angiography is less clear, are more likely to perform inappropriate PCI.

Hospital variation in survival after pediatric in-hospital cardiac arrest.

Background: Although survival after in-hospital cardiac arrest is likely to vary among hospitals caring for children,validated methods to risk-standardize pediatric survival rates across sites do not currently exist.

Methods And Results: From 2006 to 2010, within the American Heart Association's Get With the Guidelines-Resuscitation registry for in-hospital cardiac arrest, we identified 1551 cardiac arrests in children (<18 years). Using multivariable hierarchical logistic regression, we developed and validated a model to predict survival to hospital discharge and calculated risk-standardized rates of cardiac arrest survival for hospitals with a minimum of 10 pediatric cardiac arrest cases.

Hospital variation in survival trends for in-hospital cardiac arrest.

Background: During the past decade, survival after in-hospital cardiac arrest has improved markedly. It remains unknown whether the improvement in survival has occurred uniformly at all hospitals or was driven by large improvements at only a few hospitals.

Methods And Results: We identified 93 342 adults with an in-hospital cardiac arrest at 231 hospitals in the Get With The Guidelines(®)-Resuscitation registry during 2000-2010.