Machine Learning-Based Assessment of Survival and Risk Factors in Non-Alcoholic Fatty Liver Disease-Related Hepatocellular Carcinoma for Optimized Patient Management.

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, with an incidence that is exponentially increasing. Hepatocellular carcinoma (HCC) is the most frequent primary tumor. There is an increasing relationship between these entities due to the potential risk of developing NAFLD-related HCC and the prevalence of NAFLD. There is limited evidence regarding prognostic factors at the diagnosis of HCC. This study compares the prognosis of HCC in patients with NAFLD against other etiologies. It also evaluates the prognostic factors at the diagnosis of these patients. For this purpose, a multicenter retrospective study was conducted involving a total of 191 patients. Out of the total, 29 presented NAFLD-related HCC. The extreme gradient boosting (XGB) method was employed to develop the reference predictive model. Patients with NAFLD-related HCC showed a worse prognosis compared to other potential etiologies of HCC. Among the variables with the worst prognosis, alcohol consumption in NAFLD patients had the greatest weight within the developed predictive model. In comparison with other studied methods, XGB obtained the highest values for the analyzed metrics. In conclusion, patients with NAFLD-related HCC and alcohol consumption, obesity, cirrhosis, and clinically significant portal hypertension (CSPH) exhibited a worse prognosis than other patients. XGB developed a highly efficient predictive model for the assessment of these patients.

Prognostic Factors for Mortality in Hepatocellular Carcinoma at Diagnosis: Development of a Predictive Model Using Artificial Intelligence.

BACKGROUND: Hepatocellular carcinoma (HCC) accounts for 75% of primary liver tumors. Controlling risk factors associated with its development and implementing screenings in risk populations does not seem sufficient to improve the prognosis of these patients at diagnosis. The development of a predictive prognostic model for mortality at the diagnosis of HCC is proposed. METHODS: In this retrospective multicenter study, the analysis of data from 191 HCC patients was conducted using machine learning (ML) techniques to analyze the prognostic factors of mortality that are significant at the time of diagnosis. Clinical and analytical data of interest in patients with HCC were gathered. RESULTS: Meeting Milan criteria, Barcelona Clinic Liver Cancer (BCLC) classification and albumin levels were the variables with the greatest impact on the prognosis of HCC patients. The ML algorithm that achieved the best results was random forest (RF). CONCLUSIONS: The development of a predictive prognostic model at the diagnosis is a valuable tool for patients with HCC and for application in clinical practice. RF is useful and reliable in the analysis of prognostic factors in the diagnosis of HCC. The search for new prognostic factors is still necessary in patients with HCC.

Application of Machine Learning Techniques to Assess Alpha-Fetoprotein at Diagnosis of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary liver tumor and is associated with high mortality rates. Approximately 80% of cases occur in cirrhotic livers, posing a significant challenge for appropriate therapeutic management. Adequate screening programs in high-risk groups are essential for early-stage detection. The extent of extrahepatic tumor spread and hepatic functional reserve are recognized as two of the most influential prognostic factors. In this retrospective multicenter study, we utilized machine learning (ML) methods to analyze predictors of mortality at the time of diagnosis in a total of 208 patients. The eXtreme gradient boosting (XGB) method achieved the highest values in identifying key prognostic factors for HCC at diagnosis. The etiology of HCC was found to be the variable most strongly associated with a poorer prognosis. The widely used Barcelona Clinic Liver Cancer (BCLC) classification in our setting demonstrated superiority over the TNM classification. Although alpha-fetoprotein (AFP) remains the most commonly used biological marker, elevated levels did not correlate with reduced survival. Our findings suggest the need to explore new prognostic biomarkers for individualized management of these patients.

Long-term survival after cardiac arrest in patients undergoing emergent coronary angiography.

AIM: To determine long-term survival of patients after cardiac arrest undergoing emergent coronary angiography and therapeutic hypothermia. METHODS: We analysed data from patients treated within the regional STEMI Network from January 2015 to December 2020. The primary endpoint was all-cause mortality at median follow-up. Secondary endpoints were periprocedural complications (arrhythmias, pulmonary edema, cardiogenic shock, mechanical complication, stent thrombosis, reinfarction, bleeding) and 6-month all-cause death. A landmark analysis was performed, studying two time periods; 0-6 months and beyond 6 months. RESULTS: From a total of 24,125 patients in the regional STEMI network, 494 patients who suffered from cardiac arrest were included and divided into two groups: treated with (n = 119) and without therapeutic hypothermia (n = 375). At median follow-up (16.0 [0.2-33.3] months), there was no difference in the adjusted mortality rate between groups (51.3 % with hypothermia vs 48.0 % without hypothermia; HRadj1.08 95%CI [0.77-1.53]; p = 0.659). There was a higher frequency of bleeding in the hypothermia group (6.7 % vs 1.1 %; ORadj 7.99 95%CI [2.05-31.2]; p = 0.002), without difference for the rest of periprocedural complications. At 6-month follow-up, adjusted all-cause mortality rate was similar between groups (46.2 % with hypothermia vs 44.5 % without hypothermia; HRadj1.02 95%CI [0.71-1.47]; p = 0.900). Also, no differences were observed in the adjusted mortality rate between 6 months and median follow-up (9.4 % with hypothermia vs 6.3 % without hypothermia; HRadj2.02 95%CI [0.69-5.92]; p = 0.200). CONCLUSIONS: In a large cohort of patients with cardiac arrest within a regional STEMI network, those treated with therapeutic hypothermia did not improve long-term survival compared to those without hypothermia.

Fluoroscopy-free semirigid ureteroscopy for ureteral stone treatment: A prospective single-arm study of feasibility, efficacy, and safety.

Objectives: Patients with urolithiasis receive a significant amount of radiation during diagnosis, treatment, and follow-up of their pathology, with nearly 20% receiving more than the annual recommended, creating a growing concern regarding radiation exposure faced by patients and health personnel. The objectives of the study were to describe a standardized fluoroscopy-free (FF) semirigid (SR) ureteroscopy (URS) technique for ureteral stone treatment and to determine the feasibility, efficacy, and safety of this technique for the treatment of ureteral stones comparing it to a historical cohort of fluoroscopy-guided (FG) SR-URS. Materials and Methods: A prospective single-arm study of patients submitted to FF SR-URS was conducted. Visual and tactile cues were employed to avoid the use of ionizing radiation. The success (feasibility), stone-free (efficacy), and complication (safety) rates of each procedure were registered. The results were compared to a historical cohort of patients that underwent FG SR-URS at our center. Results: One hundred and five patients subjected to FF SR-URS were included in the study and compared to a historical cohort of 87 patients subjected to FG SR-URS. The main characteristics were comparable among groups. Ninety-seven patients (92.38%) were completed without any use of ionizing radiation. The stone-free rate was 92.45%, similar to the historical cohort. Only Clavien I and II complications were found without statistical difference between the study groups. The average dose of radiation exposure for the historical cohort was approximately 0.5 mSv. Conclusions: FF SR-URS is a feasible, efficacious, and safe technique for treating the ureteral stones for urologists with good practice of the traditional technique. Implementing this procedure allows a decrease in radiation exposure to both patients and health personnel.

Unraveling the Most Relevant Features for the Design of Iridium Mixed Oxides with High Activity and Durability for the Oxygen Evolution Reaction in Acidic Media.

Proton exchange membrane water electrolysis (PEMWE) is the technology of choice for the large-scale production of green hydrogen from renewable energy. Current PEMWEs utilize large amounts of critical raw materials such as iridium and platinum in the anode and cathode electrodes, respectively. In addition to its high cost, the use of Ir-based catalysts may represent a critical bottleneck for the large-scale production of PEM electrolyzers since iridium is a very expensive, scarce, and ill-distributed element. Replacing iridium from PEM anodes is a challenging matter since Ir-oxides are the only materials with sufficient stability under the highly oxidant environment of the anode reaction. One of the current strategies aiming to reduce Ir content is the design of advanced Ir-mixed oxides, in which the introduction of cations in different crystallographic sites can help to engineer the Ir active sites with certain characteristics, that is, environment, coordination, distances, oxidation state, etc. This strategy comes with its own problems, since most mixed oxides lack stability during the OER in acidic electrolyte, suffering severe structural reconstruction, which may lead to surfaces with catalytic activity and durability different from that of the original mixed oxide. Only after understanding such a reconstruction process would it be possible to design durable and stable Ir-based catalysts for the OER. In this Perspective, we highlight the most successful strategies to design Ir mixed oxides for the OER in acidic electrolyte and discuss the most promising lines of evolution in the field.

Active and durable R2MnRuO7 pyrochlores with low Ru content for acidic oxygen evolution.

The production of green hydrogen in water electrolyzers is limited by the oxygen evolution reaction (OER). State-of-the-art electrocatalysts are based on Ir. Ru electrocatalysts are a suitable alternative provided their performance is improved. Here we show that low-Ru-content pyrochlores (R2MnRuO7, R = Y, Tb and Dy) display high activity and durability for the OER in acidic media. Y2MnRuO7 is the most stable catalyst, displaying 1.5 V at 10 mA cm-2 for 40 h, or 5000 cycles up to 1.7 V. Computational and experimental results show that the high performance is owed to Ru sites embedded in RuMnOx surface layers. A water electrolyser with Y2MnRuO7 (with only 0.2 mgRu cm-2) reaches 1 A cm-2 at 1.75 V, remaining stable at 200 mA cm-2 for more than 24 h. These results encourage further investigation on Ru catalysts in which a partial replacement of Ru by inexpensive cations can enhance the OER performance.

Clinical profile and prognosis of young patients with ST-elevation myocardial infarction managed by the emergency-intervention Codi IAM network.

INTRODUCTION AND OBJECTIVES: Data on the clinical profile and outcomes of younger patients with ST-elevation myocardial infarction (STEMI) is scarce. This study compared clinical characteristics and outcomes between patients aged<45 years and those aged ≥ 45 years with STEMI managed by the acute myocardial infarction code (AMI Code) network. Sex-based differences in the younger cohort were also analyzed. METHODS: This multicenter study collected individual data from the Catalonian AMI Code network. Between 2015 and 2020, we enrolled patients with an admission diagnosis of STEMI. Primary endpoints were all-cause mortality within 30 days, 1 year, and 2 years. RESULTS: Overall, 18 933 patients (23% female) were enrolled. Of them, 1403 participants (7.4%) were aged<45 years. Younger patients with STEMI were more frequently smokers (P<.001) and presented with cardiac arrest and TIMI flow 0 before pPCI (P<.05), but the time from first medical contact to wire crossing was shorter than in the older group (P<.05). All-cause mortality rates were lower in patients aged<45 years (P<.001). Among younger patients, cardiogenic shock was most prevalent in women than in their male counterparts (P=.002), with the time from symptom onset to reperfusion being longer (P<.05). Compared with men aged<45 years, younger women were less likely to undergo pPCI (P=.004). CONCLUSIONS: Despite showing high-risk features on admission, young patients exhibit better outcomes than older patients. Differences in ischemia times and treatment were observed between men and women.

Performance analysis of a STEMI network: prognostic impact of the type of first medical contact facility.

INTRODUCTION AND OBJECTIVES: Prognosis in ST-elevation myocardial infarction (STEMI) is determined by delay in primary percutaneous coronary intervention (PPCI). The impact of first medical contact (FMC) facility type on reperfusion delays and mortality remains controversial. METHODS: We performed a prospective registry of primary coronary intervention (PCI)-treated STEMI patients (2010-2020) in the Codi Infart STEMI network. We analyzed 1-year all-cause mortality depending on the FMC facility type: emergency medical service (EMS), community hospital (CH), PCI hospital (PCI-H), or primary care center (PCC). RESULTS: We included 18 332 patients (EMS 34.3%; CH 33.5%; PCI-H 12.3%; PCC 20.0%). Patients with Killip-Kimball classes III-IV were: EMS 8.43%, CH 5.54%, PCI-H 7.51%, PCC 3.76% (P <.001). All comorbidities and first medical assistance complications were more frequent in the EMS and PCI-H groups (P <.05) and were less frequent in the PCC group (P <.05 for most variables). The PCI-H group had the shortest FMC-to-PCI delay (median 82 minutes); the EMS group achieved the shortest total ischemic time (median 151 minutes); CH had the longest reperfusion delays (P <.001). In an adjusted logistic regression model, the PCI-H and CH groups were associated with higher 1-year mortality, OR, 1.22 (95%CI, 1.00-1.48; P=.048), and OR, 1.17 (95%CI 1.02-1.36; P=.030), respectively, while the PCC group was associated with lower 1-year mortality than the EMS group, OR, 0.71 (95%CI 0.58-0.86; P <.001). CONCLUSIONS: FMC with PCI-H and CH was associated with higher adjusted 1-year mortality than FMC with EMS. The PCC group had a much lower intrinsic risk and was associated with better outcomes despite longer revascularization delays.

J-chronic total occlusion score predictive capacity for percutaneous coronary intervention success of chronic total occlusion: Results from a European single center cohort with progressive experience over time.

BACKGROUND: Several scoring systems have been described to assess the level of difficulty and to predict the probability of success of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). The J-CTO score was initially developed to correlate CTO complexity with guidewire time crossing through the lesion within 30 min. Moreover, almost all scoring systems represent procedures performed by seasoned operators. Herein, this study sought to evaluate the predictive capacity of J-CTO for PCI success in a European single-center cohort with growing experience in the approach of CTO. METHODS: Five hundred twenty-six procedures were performed between 2007 and 2020 mainly by a single operator. The predictive power of J-CTO score was assessed by area under the receiver-operator characteristic curve (ROC) in the entire cohort and additionally in two separate periods. The goodnessof- fit of the model was evaluated by the Hosmer and Lemeshow statistic. RESULTS: Successful procedure in first-attempt PCI was 79.5% and the overall success including 47 repeated procedures was achieved in 85.8%. The retrograde approach was attempted in 14.4%. The score was inversely associated with procedural success with lower success rate in more difficult CTOs (p < 0.001). ROC curve for the entire cohort, and first block (case 1-200) and second block (case 201-526) was 0.696, 0.661 and 0.748, respectively. The model showed good calibration for the entire cohort (X2 = 1.7; p = 0.43). CONCLUSIONS: J-CTO score showed an acceptable predictive power for procedural success in this cohort although its discriminatory power is better as the level of experience is improved.

New scoring system for predicting percutaneous coronary intervention of chronic total occlusion success: Impact of operator's experience.

BACKGROUND: Several scoring systems have been developed in order to predict percutaneous coronary intervention (PCI) result of chronic total occlusion (CTO). The scores principally include anatomic and clinical variables. Operator experience is a decisive factor for achieving successful result. We sought to assess the real impact of operator growing experience on CTO-PCI success. METHODS: The angiographic and clinical variables of CTO-PCIs performed in our center between May 2007 and April 2021 were collected, and variables with potential association with procedural result were thoroughly reviewed. The influence of operator experience based on the number of previous CTO-PCIs was statistically assessed. A scoring system with combination of anatomic variables and operator experience was devised. RESULTS: A total of 540 PCIs in 457 patients were performed in our institution. The scoring model was developed from the derivation set (2/3 of the cohort). The final variables in logistic regression model were CTO length ≥ 20 mm, blunt stump, vessel tortuosity > 45o and operator experience < 100 PCIs. The model showed good performance in the derivation set (area under curve [AUC]: 0.768; confidence interval [CI]: 0706-0.830; p < 0.001) with no significant shrinkage in the validation set (AUC: 0.704; CI: 0.613-0.796; p < 0.001). CONCLUSIONS: This new score (E-CTO score) adequately predict the probability of CTO-PCI failure. The model includes a variable representing operator experience along with other anatomic variables.

Highly active and stable OER electrocatalysts derived from Sr2MIrO6 for proton exchange membrane water electrolyzers.

Proton exchange membrane water electrolysis is a promising technology to produce green hydrogen from renewables, as it can efficiently achieve high current densities. Lowering iridium amount in oxygen evolution reaction electrocatalysts is critical for achieving cost-effective production of green hydrogen. In this work, we develop catalysts from Ir double perovskites. Sr2CaIrO6 achieves 10 mA cm-2 at only 1.48 V. The surface of the perovskite reconstructs when immersed in an acidic electrolyte and during the first catalytic cycles, resulting in a stable surface conformed by short-range order edge-sharing IrO6 octahedra arranged in an open structure responsible for the high performance. A proton exchange membrane water electrolysis cell is developed with Sr2CaIrO6 as anode and low Ir loading (0.4 mgIr cm-2). The cell achieves 2.40 V at 6 A cm-2 (overload) and no loss in performance at a constant 2 A cm-2 (nominal load). Thus, reducing Ir use without compromising efficiency and lifetime.

Efecto bioconservante del propóleo y su aplicación en la conservación de matrices cárnicas / Bioconservative Effect of Propolis and its Application in the Conservation of Meat Matrices

Resumen: Antecedentes: los conservantes de origen sintético, como nitratos y nitritos, empleados en la industria alimentaria para la conservación de matrices cárnicas, han reportado efectos desfavorables a largo plazo en la salud de los consumidores recurrentes. Objetivo: conocer las características fisicoquímicas y antimicrobianas del propóleo como potencial bioconservante en matrices cárnicas de alto consumo. Materiales y métodos: se desarrolló una revisión bibliográfica de literatura acorde a la pregunta problema planteada por el grupo de investigación, y se llevó a cabo una búsqueda en las bases de datos Scopus, NCBI, SciELO, ScienceDirect y Google Scholar de artículos de revisión, artículos científicos, libros y trabajos de grado. Resultados: el propóleo es un compuesto natural con una variedad amplia de elementos útiles para la conservación de matrices cárnicas, por sus propiedades antimicrobianas y antioxidantes. Conclusiones: el propóleo presenta propiedades antimicrobianas y antioxidantes útiles en el campo de la industria alimentaria, por lo que se considera una de las alternativas más viables para la conservación de productos cárnicos y la disminución del uso de conservantes sintéticos en producción cárnica. No obstante, es fundamental el desarrollo de más investigaciones que permitan evaluar el comportamiento de los compuestos activos del propóleo en las diversas matrices cárnicas

Abstract: Background: Preservatives of synthetic origin, such as nitrates and nitrites, used in the food industry for the preservation of meat matrices, have reported long-term unfavorable effects on the health of recurrent consumers. Objective: To know the physicochemical and antimicrobial characteristics of propolis as a potential biopreservative in high consumption meat matrices. Materials and Methods: A bibliographic review of literature was developed according to the problem question posed by the research group, carrying out a search in the Scopus, NCBI, SciELO, ScienceDirect and Google Scholar databases of review articles, scientific articles, books and works degree. Results: Propolis is a natural compound with a wide variety of useful elements for the conservation of meat matrices, due to its antimicrobial and antioxidant properties. Conclusions: Propolis has useful antimicrobial and antioxidant properties in the field of the food industry, being considered one of the most viable alternatives for the preservation of meat products and the reduction of the use of synthetic preservatives in meat production. However, it is essential to develop more research to evaluate the behavior of the active compounds of propolis in the various meat matrices

A rare complication of jejunal extension of a percutaneous endoscopic gastrostomy tube for levodopa-carbidopa intestinal gel administration.

Direct intestinal administration of levodopa-carbidopa gel has shown good results in selected patients with Parkinson's disease (1, 2). We want to present a complication related to the device necessary for the administration of this drug. A 58-year-old man, diagnosed with Parkinson's disease, treated for six months with levodopa-carbidopa intestinal gel, administered through a percutaneous endoscopic gastrostomy (PEG) tube with jejunal extension, presented at the emergency department for abdominal pain. The patient complained abdominal discomfort that lasted two months. It was described as pain around the umbilical area that radiated to the left lumbar region, worsened after ingestion, and did not subside with conventional analgesia.

Five-year outcomes after intravitreal bevacizumab of treatment-naive eyes with macular edema secondary to CRVO in routine clinical practice: Results of the Pan-American Collaborative Retina Study (PACORES) group.

PURPOSE: The purpose of this study was to report the 5-year outcomes of treatment-naive eyes with cystoid macular edema secondary to central retinal vein occlusion treated with intravitreal bevacizumab in routine clinical practice. METHODS: We conducted multicenter retrospective non-comparative case series of 102 eyes. The main outcome measured was the change in best-corrected visual acuity (BCVA) at 5 years. Secondary outcomes included the number of injections and the change in CMT at 5 years. RESULTS: At 5 years, the mean BCVA improved from 1.22 ± 0.58 (Snellen 20/428) at baseline to 1.00 ± 0.68 logMAR (Snellen 20/200; p < 0.0001). At 5 years, 48 (47%) eyes had a gain of ≥ 3 lines, 41 (40.2%) eyes remained within 3 lines and 13 (12.7%) eyes had a loss of ≥ 3 lines of BCVA. The CMT improved from 740 ± 243 to 322 ± 179 µm (p < 0.0001). At 5 years, 59 (57.8%) eyes had a completely dry SD-OCT. Patients received a total of 10.6 ± 6.1 (range 6-27) injections. Baseline BCVA (p < 0.0001) and the duration of symptoms prior to initial anti-VEGF injection (p = 0.0274) were the only predictive factors for BCVA at 5 years. CONCLUSIONS: After 5 years with an average of 10.6 injections, there was a mean gain of 0.22 logMAR. In addition, more eyes achieved a BCVA of ≥ 20/40, gained ≥ 3 lines and less patients had a BCVA ≤ 20/200. Eyes with a better baseline BCVA and a shorter duration of symptoms were more likely to achieve better BCVA at 5 years.

Spontaneous intramural small-bowel hematoma: a cause of acute abdomen in anticoagulated patients.

Spontaneous intramural small-bowel hematoma (SISBH) is an uncommon cause of acute abdominal pain in anticoagulated patients.

Plaque modification in calcified chronic total occlusions: the PLACCTON study.

INTRODUCTION AND OBJECTIVES: Severe calcification is present in> 50% of coronary chronic total occlusions (CTOs) undergoing percutaneous intervention. We aimed to describe the contemporary use and outcomes of plaque modification devices (PMDs) in this context. METHODS: Patients were included in the prospective, consecutive Iberian CTO registry (32 centers in Spain and Portugal), from 2015 to 2020. Comparison was performed according to the use of PMDs. RESULTS: Among 2235 patients, wire crossing was achieved in 1900 patients and PMDs were used in 134 patients (7%), requiring more than 1 PMD in 24 patients (1%). The selected PMDs were rotational atherectomy (35.1%), lithotripsy (5.2%), laser (11.2%), cutting/scoring balloons (27.6%), OPN balloons (2.9%), or a combination of PMDs (18%). PMDs were used in older patients, with greater cardiovascular burden, and higher Syntax and J-CTO scores. This greater complexity was associated with longer procedural time but similar total stent length (52 vs 57mm; P=.105). If the wire crossed, the procedural success rate was 87.2% but increased to 96.3% when PMDs were used (P=.001). Conversely, PMDs were not associated with a higher rate of procedural complications (3.7 vs 3.2%; P=.615). Despite the worse baseline profile, at 2 years of follow-up there were no differences in the survival rate (PMDs: 94.3% vs no-PMDs: 94.3%, respectively; P=.967). CONCLUSIONS: Following successful wire crossing in CTOs, PMDs were used in 7% of the lesions with an increased success rate. Mid-term outcomes were comparable despite their worse baseline profile, suggesting that broader use of PMDs in this setting might have potential technical and prognostic benefits.

Revascularized ST-segment elevation myocardial infarction. Temporal trends in contemporary therapies and impact on outcomes.

INTRODUCTION AND OBJECTIVES: To assess, in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous intervention, the pace of introduction in clinical practice (2010-2017) of drug-eluting stents (DES), ticagrelor, prasugrel, and prolonged dual antiplatelet therapy (DAPT) duration, and their potential impact on the risk of 2-year outcomes. METHODS: Prospective and exhaustive community-wide cohort of 14 841 STEMI patients undergoing primary percutaneous intervention between 2010 and 2017. Index episodes were obtained from the Catalan Codi IAM Registry, events during follow-up from the Minimum Data Set and DAPT were defined by pharmacy dispensation. Follow-up was 24 months. The temporal trend for exposures and outcomes was assessed using regression models. RESULTS: Age> 65 years, diabetes, renal failure, previous heart failure, and need for anticoagulation at discharge were more frequent in later periods (P <.001). From 2010 to 2017, the use of DES increased from 31.1% to 69.8%, ticagrelor from 0.1% to 28.6%, prasugrel from 1.5% to 23.8%, and the median consecutive months on DAPT from 2 to 10 (P <.001 for all). Adjusted analysis showed a temporal trend to a lower risk of the main outcome over time: the composite of death, acute myocardial infarction, stroke and repeat revascularization (absolute odds reduction 0.005% each quarter; OR, 0.995; 95%CI, 0.99-0.999; P=.028). The odds of all individual components except stroke were reduced, although significance was only reached for revascularization. CONCLUSIONS: Despite a strong increase between 2010 and 2017 in the use and duration of DAPT and the use of ticagrelor, prasugrel and DES, there was no substantial reduction in major cardiovascular outcomes.