Cardiology Magazine

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Cover Story | Pulmonary Embolism: A Clinical Approach

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Feature | Bridging the Gender Gap in Heart Health: Women's Specialized Clinics

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From the Member Sections | Tackling the Polypharmacy Pandemic in CV Care

Focus on Heart Failure | Thinking Outside the Ice Box: Preservation Techniques, New Technologies in Transplantation

For the FITs | The Emergence of Substance Use Disorders and Their Implications in Cardiovascular Disease

Courageous Conversations | The Invisible Armor: A Personal Reflection on The Power of Resilience as a Black Woman in Cardiology

Quality Improvement For Institutions | NCDR Research: Data Driving Better Practice, Patient Outcomes

Prioritizing Health | Journey of the Health and Well-Being Coaching Profession

Heart of Health Policy | ACC Advocacy Welcomes New Members of Congress

Heart of Health Policy | Action Steps Following CCTA Coding Change From 2025 OPPS Final Rule; Coding Corner: How to Use New ASCVD Risk Assessment and Management Codes

JACC in a Flash | Aircraft Noise Poses Threats to Heart Health; More

The Pulse of ACC | Welcome to Camp Cardiac; ACC.25 Pre-Conference Opportunity: Renal Denervation

Number Check | Powering Quality Improvement

ACC Mission in Action | Making a Global Difference

Quality Improvement For Institutions | NCDR Research: Data Driving Better Practice, Patient Outcomes

Quality Improvement for Institutions

NCDR Research: Data Driving Better Practice, Patient Outcomes

ACC's NCDR suite of registries is a robust source of data for researchers, and a critical component in continuing to help hospitals, practices and clinicians advance the quality of cardiovascular care and improve patient outcomes for all.

Recent real-world evidence from NCDR provides insights on the relationship between race and the use of left atrial appendage occlusion (LAAO) as well as outcomes, and the association between procedure volumes for both the physician and the hospital and procedure success for patients undergoing ablation for atrial fibrillation (AFib). Other studies suggest that the off-label use of intravascular lithotripsy (IVL) may be a safe and feasible treatment to address in-stent restenosis ISR), a small proportion of patients experience ventricular arrhythmias after primary PCI for STEMI, and that there is an increased risk of death and readmission associated with bleeding post mitral transcatheter edge-to-edge repair (TEER).

Read on and then share your thoughts about the findings on social media using #NCDR and #CardiologyMag or join in discussions on the ACC's LinkedIn page.

LAAO Registry: Racial Disparities in LAAO Use and Outcomes at 1 Year

Among patients undergoing LAAO, rates of procedural success were similar across racial and ethnic groups, but Black patients had higher rates of death and bleeding at one year, according to a recent study published in the Journal of the American Heart Association.

Oluseun O. Alli, MBBS, FACC, included a total of 97,185 patients (90% White, 3.9% Black, 2.9% Hispanic/Latinx) from the ACC's LAAO Registry who underwent WATCHMAN FLX implantation through September 2022. They assessed differences in use of LAAO and outcomes at one year by race and ethnicity.

Adjusted risk of death and bleeding was significantly higher in Black patients vs. White patients at one year (death: hazard ratio [HR], 1.26 [95% CI, 1.06-1.50]; bleeding: HR, 1.36 [95% CI, 1.15-1.60]) while Hispanic and White patients exhibited similar risk. Risk of stroke at one year was similar among all three groups.

The authors note that "Black patients were more commonly discharged on anticoagulation plus aspirin or dual antiplatelet therapy instead of anticoagulation alone, which has been previously reported to be associated with higher rates of bleeding after LAAO."

Overall, Black and Hispanic patients who underwent the procedure were younger and had significantly higher comorbidities when compared with White patients. They also made up a disproportionately small fraction of all patients who undergo LAAO relative to their proportion of the U.S. population.

"The racial and ethnic representation among WATCHMAN FLX recipients in this study mirror the low enrollment of racial and ethnic minority patients in clinical trials involving these devices," state the authors. "An important consideration that affects access of racial and ethnic minority patients to LAAO procedures is the location of hospitals/centers that perform the procedures."

Higher AFib Procedure Volumes Associated With Increased Procedural Success, Lower MAE Rates

Higher hospital and physician AFib ablation procedure volumes were associated with increased acute procedural success and lower rates of major adverse events (MAEs), according to a study published in Heart Rhythm.

Sharma Kattel, MD, PhD, et al., reviewed 70,296 first-time AFib ablations from 186 facilities reported to the ACC's AFib Ablation Registry between July 2019 and June 2022, investigating the association between hospital and physician procedure volume and procedural success and MAEs. Procedure volumes by hospital and physician were annualized and stratified into quartiles for the analysis.

Procedural success was attained in 98.5% of cases analyzed, and the overall rate of MAEs was 1%. Procedural success rates increased across hospital volume quartiles. The adjusted odds of procedural success when compared to the highest quartile (Q4) were lower in Q1 (odds ratio [OR], 0.44; p=0.0002), Q2 (OR, 0.50; p=0.001) and Q3 (OR, 0.60; p=0.011), with similar results for physician procedure volume.

MAE rates decreased with increasing hospital volume, and when compared to Q4, the adjusted odds of an MAE was significantly higher for Q1 (OR, 1.78; p=0.001), but not for Q2 (OR, 1.06; p=0.728) or Q3 (OR, 1.19; p=0.249). A statistically significant inverse relationship was noted for physician procedure volume in Q1 and Q2 but not for Q3.

The authors additionally found that "hospitals and physicians performing approximately 190 and 60 annual cases, respectively, are likely to contribute to consistently high procedural success (>98%) and safety (MAE rate <1%)."

"These findings suggest that moderate procedural volumes that are likely to be achievable across a variety of health care systems may be sufficient to maintain the necessary skills of hospital staff and physicians to achieve favorable procedural success and safety," write the authors. "These findings may inform future [AFib] ablation guideline recommendations and hospital and physician practice quality improvement initiatives and establish criteria for [AFib] centers of excellence."

Advancing Quality With ACC Accreditation

The College congratulates the latest hospitals to earn ACC Accreditation, HeartCARE Center Designation or Transcatheter Valve Certification. Click here to see if your site achieved accreditation in the fourth quarter of 2024.

CathPCI Registry: Safety and Feasibility of IVL as a Treatment For In-Stent Restenosis

Use of IVL for the treatment of ISR, although off-label, may be safe and feasible, according to a study reviewing data from the ACC's CathPCI Registry published in JACC: Cardiovascular Interventions.

There were 18,893 patients who underwent PCI with the C2 Coronary IVL system from March 2021 to March 2022 recorded in the registry, and Dean J. Kereiakes, MD, FACC, et al., found 3,686 of these patients were treated for ISR. Baseline characteristics, site-reported procedural outcomes and in-hospital mortality were included in the analysis. The authors also assessed observed vs. predicted in-hospital mortality by using the validated NCDR-derived bedside risk score model.

The site-reported mean diameter stenosis for IVL-treated lesions was 86.7±11.9%, while mean lesion length was 28.2±19.7 mm, type C lesion complexity was seen in 69.4% of cases and severe calcification noted in 45.3% of cases. According to the authors, "no additional information regarding the presence or morphology of calcium was recorded." Mean residual stenosis post procedure was 7.1±14.2%, with 95.6% of cases exhibiting <50% residual stenosis.

Adverse events occurred in 5.3% of patients, including bleeding complications in 1.6% of patients and cardiac arrest in 1.2% of patients. Among patients who experienced cardiac arrest, 64% presented with STEMI or NSTEMI.

In-hospital mortality among the ISR patient group was 1.3%. This observed rate was lower than the 1.7% prediction based on the NCDR-derived bedside risk score (relative risk, 0.75; 95% CI, 0.55-0.99; p=0.04).

"Future studies are warranted to define the optimal use of IVL and adjunctive strategies in the ISR treatment algorithm as well as longer-term outcomes," write the authors. "Nonetheless, the present encouraging outcomes suggest that IVL may be a safe and feasible treatment for ISR."

Chest Pain – MI Registry: What is the Risk of Ventricular Arrythmia After Primary PCI For STEMI?

A small proportion of patients with STEMI treated via primary PCI experienced late ventricular tachycardia (VT) or ventricular fibrillation (VF), occurring one or more days following the procedure, but late VT or VF with cardiac arrest occurred rarely, especially among patients with uncomplicated STEMI, according to a study published in JAMA Network Open.

Jennifer A. Rymer, MD, MBA, MHS, FACC, et al., included 174,126 patients with STEMI treated with primary PCI between April through December 2020 from the ACC's Chest Pain – MI Registry. The authors examined the risk of late VT or VF both with or without cardiac arrest. They also investigated the association between late VT or VF and in-hospital mortality among the overall cohort as well as with patients who had uncomplicated STEMI.

Out of all study-eligible patients, 8.9% exhibited VT or VF following primary PCI and 2.4% experienced late VT or VF. In addition, 57.4% of patients had uncomplicated STEMI, with risk of late VT or VF being 1.7% in this cohort. Late VT or VF was associated with increased likelihood of in-hospital mortality in both the overall (adjusted odds ratio [AOR], 6.40; 95% CI, 5.63-7.29) and uncomplicated STEMI cohorts (AOR, 8.74; 95% CI, 6.53-11.70).

Late VT or VF with cardiac arrest was seen in 0.4% of cases in the overall cohort and 0.1% of cases among patients with uncomplicated STEMI. The most significant factor associated with late VT or VF with cardiac arrest was decreasing left ventricular ejection fraction (AOR for every 5-unit decrease ≤40%: 1.67; 95% CI, 1.54-1.85).

"Identifying predictors of late VT or VF is paramount to identifying high-risk patients who should have longer in-hospital monitoring while also facilitating safe, early discharge for low-risk individuals after successful reperfusion," state the authors. "Our study showed that identifying factors associated with any late VT or VF is challenging, but identifying factors associated with late VT or VF and cardiac arrest can be achieved with higher accuracy."

Bleeding Post Mitral TEER Associated With Increased Risk of Death, Readmission

Bleeding following mitral TEER is associated with increased risk of death or hospital readmission, according to a study published Oct. 28 in JACC: Cardiovascular Interventions.

Nickpreet Singh, MD, et al., included 51,533 patients from the STS/ACC TVT Registry between 2013 and 2022 to compare the primary endpoint – the composite of death or hospital readmission at 30 days – among patients with in-hospital major or life-threatening bleeding vs. patients without bleeding. The authors also analyzed the association between bleeding events and death or readmission at one year and identified independent predictors of major in-hospital bleeding.

Of all patients included, 2.3% experienced in-hospital major bleeding, with rates decreasing over the study period (from 7.1% in 2013 to 2.0% in 2021; p<0.001). In-hospital bleeding was associated with increased risk of death or readmission at 30 days (adjusted odds ratio [aOR], 2.15 [95% CI, 1.81-2.54]; p<0.0001) as well as at one year (adjusted hazard ratio, 1.43; 95% CI, 1.27-1.60; p<0.0001).

Strongest independent predictors of in-hospital bleeding included female sex, prior PCI, baseline hemoglobin, greater procedure acuity and longer procedure duration.

"While we found that major bleeding events after [mitral TEER] were relatively uncommon in the last several years, bleeding still represents one of the most common complications of [mitral TEER]," write the authors. "Moreover, the association of bleeding with subsequent mortality and hospital readmission suggests that additional efforts to implement strategies to prevent periprocedural bleeding are warranted."

In an accompanying editorial comment, Roxana Mehran, MD, FACC, and Mauro Gitto, MD, add: "As awareness of the prognostic significance of bleeding grows, considerable effort is needed to improve the care of patients undergoing [mitral TEER]. Future trials should incorporate bleeding events as a key endpoint and investigate the optimal post-discharge antithrombotic strategy, as well as consider sex as an important biologic variable to evaluate the safety and efficacy of [mitral TEER] procedures."

NCDR: Data Powering Performance

More than 2,000 facilities worldwide participate in one or more the ACC's registries, forming a comprehensive network of cardiovascular care providers committed to ensuring evidence-based cardiovascular care, improving patient outcomes and lowering health care costs.

Learn more about all the NCDR registries and become a participant.

Bookmark the registry news page at www.acc.org/registrynews to keep up with the clinical insights from NCDR research.

Resources

Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Cardiology Magazine, ACC Publications, Registries, Atrial Fibrillation, Ethnic Groups