Circulation Editors’ Picks Most Read Articles in Cardiovascular Quality and Outcomes Short- and Long-Term Outcomes of Coronary Stenting in Women Versus Men: Results From the National Cardiovascular Data Registry Centers for Medicare & Medicaid

The following articles are being highlighted as part of Circulation’s Topic Review series. This series will summarize the most important manuscripts, as selected by the editors, published in Circulation and the Circulation subspecialty journals. The studies included in this article represent the most read manuscripts published on the topic of cardiovascular quality and outcomes within the last year. ( Summary— The outcome of atrial fibrillation patients on warfarin partially depends on maintaining adequate time in therapeutic International Normalized Ratio (INR) range (TTR). Large differences in TTR have been reported between centers and countries, but the reasons are unclear. In the Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) trial, a warfarin dosing algorithm provided to participating centers recommended no change for in-range and 10% to 15% weekly dose changes for out-of-range INR values. We determined whether algorithm-consistent warfarin dosing could predict patient TTR and the composite outcome of stroke, systemic embolism, or major hemorrhage. Among 6022 nonvalvular atrial fibrillation patients from 44 countries, we found a strong association between the proportion of algorithm-consistent warfarin doses and mean country TTR ( R 2 =0.65). The degree of algorithm-consistent warfarin dosing accounted for a majority of the TTR variation between centers and countries. Each 10% increase in center algorithm-consistent dosing independently complications after catheter ablation were associated with advanced age, they were fairly infrequent, and few patients underwent repeat ablation. Randomized trials are needed to assess the efficacy of catheter ablation in older adults and to better inform risk-benefit calculations for older patients with drug-refractory, symptomatic atrial fibrillation. Conclusions— Major complications after catheter ablation for atrial fibrillation were associated with advanced age but were fairly infre-quent. Few patients underwent repeat ablation. Randomized trials are needed to inform risk-benefit calculations for older persons with drug-refractory, symptomatic atrial fibrillation. 2 after an index stent procedure. Additionally, the long-term safety and effectiveness of drug-eluting stents versus bare metal stents were compared in women and men. In the contemporary PCI era, our study shows that elderly women undergoing index PCI remain at higher risk of in-hospital mortality and other complications compared with men. In contrast, long-term outcomes are similar or better in women than in men. The use of drug-eluting stents is associated with a similar benefit in both men and women. Further studies are needed to understand the causative factors for these findings. Conclusions— In contemporary coronary stenting, women have a slightly higher procedural risk than men but have better long-term survival. In both sexes, use of a drug-eluting stent is associated with lower long-term likelihood for death, myocardial infarction, and revascularization. 3 Summary— Many of the decisions and processes that affect the speed of coronary artery reperfusion occur long before patients reach the cardiologist. Particularly in the case of patients who are diagnosed with ST-segment–elevation myocardial infarction (STEMI) on scene by paramedics, early catheterization laboratory activation can lead to reperfusion times <1 hour. Similarly, patients presenting to hospitals without primary percutaneous coronary intervention capability require coordinated protocols for diagnosis and transfer to be treated in <2 hours. In both scenarios, accelerated coronary reperfusion has been associated with improved survival. This article describes the largest voluntary statewide system for ST-segment–elevation myocardial infarction diagnosis and treatment. The North Carolina Regional Approach to Cardiovascular Emergencies (RACE) system included every percutaneous coronary intervention hospital (n=21), most hospitals lacking percutaneous coronary intervention capability (n=98), and >500 emergency medical service agencies in a state of 9 million people. Over a 2-year period, the implementation of common protocols resulted in significantly improved treatment times for patients presenting directly to percutaneous coronary intervention hospitals and patients requiring hospital transfer. Similar to prior work, treatment within guideline goals was associated with significantly lower mortality compared with those exceeding guideline goals (2.2% versus 5.7%; P <0.001). Conclusions— Through extension of regional coordination to an entire state, rapid diagnosis and treatment of ST-segment–elevation myocardial infarction has become an established standard of care independently of healthcare setting or geographic location. 7 Summary— In an acute cardiac event, access to timely and definitive care through specialist centers is critical to survival and to improving relationship between country-level economic and health system factors and the risk of elevated cholesterol (total cholesterol levels >200 mg/dL). The analysis was performed separately for patients with versus without previous history of hyperlipidemia; a higher proportion of the total variability in elevated cholesterol was at the country level for patients with (12.1%) versus without (7.4%) history of hyperlipidemia. Among patients with history of hyperlipidemia, after adjusting for patient-level demographic and clinical characteristics and average fat consumption at the country level, countries in the highest tertile of gross national income or World Health Organization index of health system achievement were found to have significantly lower odds of elevated cholesterol than those in each of the lower 2 tertiles, and the odds of elevated cholesterol was higher for countries in higher versus lower tertile of out-of-pocket health expenditures. No significant associations between country-level factors and elevated cholesterol were found for patients without history of hyperlipidemia. These results support the need for strengthening efforts toward effective cardiovascular disease prevention and control and may provide insight for health policy setting at the national level. Conclusions— Global variations in the prevalence of elevated cholesterol among patients with history of hyperlipidemia are associated with country-level economic development and health system indices. These results support the need for strengthening efforts toward effective cardiovascular disease prevention and control and may provide insight for health policy setting at the national level. 10 Most survival prediction for percutaneous coronary intervention are limited to in-hospital end points. Although short-term mortality rates remain multiple stakeholders, including providers, patients, and payers, will interested in long-term survival. We the broadly representative, real-world clinical data from the American College of Cardiology–National Cardiovascular Data Registry CathPCI Registry with vital statistics from the Medicare 100% denominator file to construct a robust, and comorbidities, of calibration, of the influence of clinical correlates on Summary— Most survival prediction models for coronary artery bypass grafting surgery are limited to in-hospital or 30-day end points. However, particularly as short-term mortality rates decrease, it is increasingly important for providers, patients, payers, and other stakeholders to better understand the likelihood of long-term survival. We linked broadly representative, real-world clinical data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database and vital status from Medicare claims data to construct a robust, long-term coronary artery bypass grafting surgery survival prediction model. This study included 348 341 patients aged ≥ 65 years who underwent isolated coronary artery bypass grafting surgery between model results late are by traditional Conversely, late increasingly mellitus dialysis-dependent renal and is valuable for shared decision making, comparative effectiveness research, quality improvement, patient and provider profiling. Conclusions— Using clinical registry data and longitudinal claims we developed a long-term survival prediction model for isolated coronary bypass grafting. This provides valuable information for shared decision making, comparative effectiveness quality and provider antithrombotic treatment was associated with increased bleeding risk regardless of admission INR level. Future clinical trials are critically needed to guide treatment decisions, to determine the optimal use and timing of anticoagulant therapy, and to formulate more definitive guideline recommendations that balance the prevention of adverse ischemic events with the risk of major bleeding in this vulnerable population. Conclusions— National patterns of early antithrombotic treatment for non–ST-segment–elevation myocardial infarction patients on home warfarin diverge from expert opinion provided by current practice guidelines. Early antithrombotic treatment was associated with increased bleeding risk regardless of admission INR level. 13 Conclusions— AKI is common and associated with mortality and bleeding, underscoring the importance of efforts to identify risk factors and to prevent AKI in acute myocardial infarction care. 16 a make on and potential study and comparison with alternative to routine statin (men and and (men) stress test in all intermediate-risk and and death after implantation of an implantable cardioverter-defibrillator using data from a national clinical registry of implantable cardioverter-defibrillator procedures. A significant inverse relationship between physician procedure volume and the rate of implantable cardioverter-defibrillator procedural complications was demonstrated, which was not explained by physician specialty, hospital volume, or patient characteristics. These data suggest that concentrating implantable