The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study.

STUDY OBJECTIVE: To determine whether risk stratification in the out-of-hospital setting could identify patients with chest pain who are at low and high risk to avoid admission or aid direct transfer to cardiac centers. METHODS: Paramedics prospectively enrolled patients with suspected acute coronary syndrome without diagnostic ST-segment elevation on the ECG. The History, ECG, Age and Risk Factors (HEAR) score was recorded contemporaneously, and out-of-hospital samples were obtained to measure cardiac Troponin I (cTnI) level on a point-of-care device, to allow calculation of the History, ECG, Age, Risk Factors, and Troponin (HEART) score. HEAR and HEART scores less than or equal to 3 and greater than or equal to 7 were defined as low and high risk for major adverse cardiac events at 30 days. RESULTS: Of 1,054 patients (64 years [SD 15 years]; 42% women), 284 (27%) experienced a major adverse cardiac event at 30 days. The HEAR score was calculated in all patients, with point-of-care cTnI testing available in 357 (34%). A HEAR score less than or equal to 3 identified 32% of patients (334/1,054) as low risk, with a sensitivity of 84.9% (95% confidence interval [CI] 80.7% to 89%), whereas a score greater than or equal to 7 identified just 3% of patients (30/1,054) as high risk, with a specificity of 98.7% (95% CI 97.9% to 99.5%). A point-of-care HEART score less than or equal to 3 identified a similar proportion as low risk (30%), with a sensitivity of 87.0% (95% CI 80.7% to 93.4%), whereas a score greater than or equal to 7 identified 14% as high risk, with a specificity of 94.8% (95% CI 92.0% to 97.5%). CONCLUSION: Paramedics can use the HEAR score to discriminate risk, but even when used in combination with out-of-hospital point-of-care cTnI testing, the HEART score does not safely rule out major adverse cardiac events, and only a small proportion of patients are identified as high risk.

Bypassing out-of-hospital cardiac arrest patients to a regional cardiac center: Impact on hemodynamic parameters and outcomes.

INTRODUCTION: Current guidelines recommend systematic care for patients who experience out-of-hospital cardiac arrest (OHCA) and the development of cardiac arrest centers (CACs). However, data regarding prolonged transport time of these often hemodynamically unstable patients are limited. METHODS: Data from a prospective OHCA registry of a regional CAC collected between 2013 and 2017, when all OHCA patients from the district were required to be transferred directly to the CAC, were analyzed. Patients were divided into two subgroups: CAC, when the CAC was the nearest hospital; and bypass, when OHCA occurred in a region of another local hospital but the subject was transferred directly to the CAC (7 hospitals in the district). Data included transport time, baseline characteristics, hemodynamic and laboratory parameters on admission (systolic blood pressure, lactate, pH, oxygen saturation, body temperature, and initial doses of vasopressors and inotropes), and final outcomes (30-day in-hospital mortality, intensive care unit stay, days on artificial ventilation, and cerebral performance capacity at 1 year). RESULTS: A total of 258 subjects experienced OHCA in the study period; however, 27 were excluded due to insufficient data and 17 for secondary transfer to CAC. As such, 214 patients were analyzed, 111 in the CAC group and 103 in the bypass group. The median transport time was significantly longer for the bypass group than the CAC group (40.5 min [IQR 28.3-55.0 min] versus 20.0 min [IQR 13.0-34.0], respectively; p˂0.0001). There were no differences in 30-day in-hospital mortality, 1-year neurological outcome, or median length of mechanical ventilation. There were no differences in baseline characteristics, initial hemodynamic parameters on admission, catecholamine dosage(s). CONCLUSION: Individuals who experienced OHCA and taken to a CAC incurred significantly prolonged transport times; however, hemodynamic parameters and/or outcomes were not affected. These findings shows the safety of bypassing local hospitals for a CAC.

Sex bias in admission to tertiary-care centres for acute myocardial infarction and cardiogenic shock.

BACKGROUND: There are limited data on sex-specific outcomes and management of cardiogenic shock complicating ST-segment elevation myocardial infarction (CS-STEMI). We investigated whether any sex bias exists in the admission to revascularization capable hospitals (RCH) or intensive cardiac care units (ICCU) and its impact on in-hospital mortality. METHODS: We used the Spanish National Health System Minimum Basic Data from 2003 to 2015 to identify patients with CS-STEMI. The primary outcome was sex differences in in-hospital mortality. RESULTS: Among 340 490 STEMI patients, 20 262 (6%) had CS and 29.2% were female. CS incidence was higher in women than in men (7.9% vs 5.1%, P = .001). Women were older and had more hypertension and diabetes, and were less often admitted to RCH than men (from 58.7% in 2003 to 79.6% in 2015; and from 61.9% in 2003 to 85.3% in 2015; respectively, P = .01), and to ICCU centres (25.7% vs 29.2%, P = .001). Adjusted mortality was higher in women than men over time (from 79.5 ± 4.3% to 65.8 ± 6.5%; and from 67.8 ± 6% to 58.1 ± 6.5%; respectively, P < .001). ICCU availability was associated with higher use of Percutaneous coronary intervention (PCI) in women (46.8% to 67.2%; P < .001) but was even higher in men (54.8% to 77.4%; P < .001). In ICCU centres, adjusted mortality rates decreased in both sexes, but lower in women (from 74.9 ± 5.4% to 66.3 ± 6.6%) than in men (from 67.8 ± 6.0% to 58.1 ± 6.5%, P < .001). Female sex was an independent predictor of mortality (OR 1.18 95% CI 1.10-1.27, P < .001). CONCLUSIONS: Women with CS-STEMI were less referred to tertiary-care centres and had a higher adjusted in-hospital mortality than men.

Expansion of transcatheter aortic valve replacement in the United States.

BACKGROUND: Patterns of diffusion of TAVR in the United States (U.S.) and its relation to racial disparities in TAVR utilization remain unknown. METHODS: We identified TAVR hospitals in the continental U.S. from 2012-2017 using Medicare database and mapped them to Hospital Referral Regions (HRR). We calculated driving distance from each residential ZIP code to the nearest TAVR hospital and calculated the proportion of the U.S. population, in general and by race, that lived <100 miles driving distance from the nearest TAVR center. Using a discrete time hazard logistic regression model, we examined the association of hospital and HRR variables with the opening of a TAVR program. RESULTS: The number of TAVR hospitals increased from 230 in 2012 to 540 in 2017. The proportion of the U.S. population living <100 miles from nearest TAVR hospital increased from 89.3% in 2012 to 94.5% in 2017. Geographic access improved for all racial and ethnic subgroups: Whites (84.1%-93.6%), Blacks (90.0%- 97.4%), and Hispanics (84.9%-93.7%). Within a HRR, the odds of opening a new TAVR program were higher among teaching hospitals (OR 1.48, 95% CI 1.16-1.88) and hospital bed size (OR 1.44, 95% CI 1.37-1.52). Market-level factors associated with new TAVR programs were proportion of Black (per 1%, OR 0.78, 95% CI 0.69-0.89) and Hispanic (per 1%, OR 0.82, 95% CI 0.75-0.90) residents, the proportion of hospitals within the HRR that already had a TAVR program (per 10%, OR 1.07, 95% CI 1.03-1.11), P <.01 for all. CONCLUSION: The expansion of TAVR programs in the U.S. has been accompanied by an increase in geographic coverage for all racial subgroups. Further study is needed to determine reasons for TAVR underutilization in Blacks and Hispanics.

Outcomes of a Provincial Myocardial Infarction Reperfusion Strategy: A Population-Based, Retrospective Cohort Study.

BACKGROUND: Fibrinolysis is an acceptable treatment for acute ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be performed within 120 minutes. The American Heart Association has recommended Emergency Medical Services (EMS) interventions such as prehospital fibrinolysis (PHF), prehospital electrocardiogram (ECG), and hospital bypass direct to PCI center. Nova Scotia, Canada has incorporated these interventions into a unique province-wide approach to STEMI care. A retrospective cohort analysis comparing the primary outcome of 30-day mortality for patients receiving either prehospital or emergency department (ED) fibrinolysis (EDF) to patients transported directly by EMS from community or regional ED for primary PCI was conducted. METHODS: This retrospective, population-based cohort study included all STEMI patients in Nova Scotia who survived to hospital admission from July 2011 through July 2013. Three provincial databases were used to collect demographic, 30-day mortality, hospital readmission, and rescue PCI data. The results were grouped and compared according to reperfusion strategy received: PHF, EDF, patients brought by ambulance via EMS direct to PCI (EMS to PCI), and ED to PCI (ED to PCI). RESULTS: There were 1,071 STEMI patients included with 145 PHF, 606 EDF, 98 EMS to PCI, and 222 ED to PCI. There were no significant differences in 30-day mortality across groups (n, %): PHF 5(3); EDF 36(6); EHS to PCI <5(2); and ED to PCI 10(4); P = .28. There was no significant difference in patients receiving fibrinolysis who underwent rescue PCI. CONCLUSIONS: Prehospital fibrinolysis incorporated into a province-wide approach to STEMI treatment is feasible with no observed difference in patient 30-day mortality outcomes observed.

[Quality and performance in cardiac pacing and electrophysiology. An update to the 2010 Italian Association of Arrhythmology and Cardiac Pacing (AIAC) - Italian Federation of Cardiology (IFC) Document 'Structure and functional organization of Arrhythmology']. / Qualità e performance in Elettrostimolazione ed Elettrofisiologia. Aggiornamento al documento dell'Associazione Italiana di Aritmologia e Cardiostimolazione (AIAC) ­ Federazione Italiana di Cardiologia (FIC) 2010 "Struttura e organizzazione funzionale dell'Aritmologia".

In the last decade the field of cardiac pacing and electrophysiology underwent major advancements thanks to both new ways of arrhythmia management and technological innovations. At the same time, the clinical competence and the procedural qualitative level of Cardiac Rhythm Centers have increased significantly. In 2010 an ad hoc Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) and the Italian Federation of Cardiology (FIC) published a consensus document on the organization of Cardiac Rhythm Centers and on the standards of professional practice in pacing and electrophysiology in Italy. In particular, this document focused on the minimal requirements of a Center to be qualified as suitable to perform first, second and third-level cardiac pacing and electrophysiology activities. However, most of these indicators have been overcome over time. Thus, an update of the previously published organizational model appeared necessary. In this document several new requirements and indicators about the organization and performance of both operators and Cardiac Arrhythmia Centers have been introduced. These include: (i) "structural and procedural requirements" (types of diagnostic and therapeutic procedures performed, logistic structures, healthcare staff and technologies), (ii) "activity indicators" (number of procedures performed); (iii) "appropriateness indicators" (adherence to guideline recommendations); (iv) "outcome indicators" (procedural success and complications); and (v) "quality of care indicators" (management and continuity of care levels). By applying these requirements and indicators, each center can optimize its procedures, increasing its performance and effectiveness. Finally, a new model for the organization of the Italian network of Cardiac Arrhythmia Centers is also suggested.

In Hospital Complications of Atrial Septal Defect Device Closure at Shahid Gangalal National Heart Centre, Kathmandu, Nepal.

BACKGROUND: Atrial deptal defect device closure has become the preferred method in the treatment of atrial septal defect. We aim to study the in-hospital complications of atrial septal defect device closure procedure. METHODS: It was a single center, retrospective study conducted from Febuary 2016 to January 2019. Cardiac catheterization laboratory records of all consecutive patients who underwent atrial septal defect device closure was included and the in-hospital complications were been retrospectively reviewed. RESULTS: During the study period, a total of 566 patients were attempted for device closure. In 557 (98.4%) of cases device was implanted. Among the 557 patient in which device was implanted 401(71.9%) were female. Age ranged from 5 years to 72 years with the mean of 30.9 years. Transient ST segment elevation 15 (2.6 %)was the commonest complication followed by pericardial tamponade 4 (0.7%), and cardiac arrhythmias 3 (0.5%). CONCLUSIONS: Atrial deptal defect device closure can be done safely with a high success rate and a low complication rate.

Regional differences in exercise training implementation in heart failure: findings from the Exercise Training in Heart Failure (ExTraHF) survey.

BACKGROUND: Exercise training programmes (ETPs) are a crucial component in cardiac rehabilitation in heart failure (HF) patients. The Exercise Training in HF (ExTraHF) survey has reported poor implementation of ETPs in countries affiliated to the European Society of Cardiology (ESC). The aim of the present sub-analysis was to investigate the regional variations in the implementation of ETPs for HF patients. METHODS AND RESULTS: The study was designed as a web-based survey of cardiac units, divided into five areas, according to the geographical location of the countries surveyed. Overall, 172 centres replied to the survey, in charge of 78 514 patients, differentiated in 52 Northern (n = 15 040), 48 Southern (n = 27 127), 34 Western (n = 11 769), 24 Eastern European (n = 12 748), and 14 extra-European centres (n = 11 830). Greater ETP implementation was observed in Western (76%) and Northern (63%) regions, whereas lower rates were seen in Southern (58%), Eastern European (50%) and extra-European (36%) regions. The leading barrier was the lack of resources in all (83-65%) but Western region (37%) where patients were enrolled in dedicated settings and specialized units (75%). In 40% of centres, non-inclusion of ETP in the national or local guideline pathway accounted for the lack of ETP implementation. CONCLUSION: Exercise training programmes are poorly implemented in the ESC affiliated countries, mainly because of the lack of resources and/or national and local guidelines. The linkage with dedicated cardiac rehabilitation centres (as in the Western region) or the model of local rehabilitation services adopted in Northern countries may be considered as options to overcome these gaps.

Surgical Versus Medical Team Assignment and Secondary Palliative Care Services for Patients Dying in a Cardiac Hospital.

BACKGROUND:: Secondary palliative care (SPC) provides several benefits for patients with cardiovascular disease, but historically, it has been underutilized in this population. Prior research suggests a low rate of SPC consultation by surgical teams in general, but little is known about how surgical teams utilize SPC in the setting of severe cardiovascular disease. AIM:: To determine if surgical team assignment affects the probability of SPC for inpatients dying of cardiovascular disease. DESIGN:: Retrospective, cohort study. METHODS:: We identified all inpatients at a large cardiac hospital who had anticipated death under the care of a cardiology, cardiac surgery, or vascular surgery team in 2016. Our primary outcome was referral to SPC, including palliative medicine consultation or inpatient hospice care. Informed by univariate analysis, we created a multivariable logistic regression model, the significance of which was assessed with the Wald test. RESULTS:: Two hundred thirty-seven patients were included in our analysis: 93 (39%) received SPC and 144 (61%) were "missed opportunities." Secondary palliative care was less frequent in patients assigned to a surgical, versus medical, team (11% vs 47%, P < .001). On multivariate analysis, surgical versus medical team assignment was the strongest risk-adjusted predictor of SPC (odds ratio [OR]: 0.10, P < .001). Other predictors of SPC included do not resuscitate status on admission (OR: 14, P < .001), length of stay (OR = 1.05/day, P < .001), and having Medicare (OR = 3.9, P = .002). CONCLUSIONS:: Primary inpatient care by a surgical team had a strong inverse relationship with SPC. This suggests a possible cultural barrier within surgical disciplines to SPC.

Long-term Outcomes of Tetralogy of Fallot: A Study From the Pediatric Cardiac Care Consortium.

Importance: Tetralogy of Fallot (TOF) is a surgically repairable form of cyanotic congenital heart disease. Multicenter data for long-term survival following repair are sparse. Objective: To evaluate the long-term transplant-free survival of TOF by surgical strategy adjusted for era and patient characteristics. Design, Setting, and Participants: Retrospective cohort study enriched with data from the National Death Index and the Organ Procurement and Transplantation Network through 2014. Multicenter cohort from the Pediatric Cardiac Care Consortium (PCCC), a large, US-based clinical registry for interventions for congenital heart disease. The cohort included patients with adequate identifiers for linkage with the National Death Index and the Organ Procurement and Transplantation Network who were enrolled in the PCCC registry between 1982 and 2003 and survived surgical repair of simple TOF. Data were analyzed between September 2015 and April 2018. Exposures: We examined patient-associated and surgery-associated risk factors affecting survival. Main Outcomes and Measures: We analyzed the transplant-free survival during early (<6 years) and late (≥6 years) phase after TOF surgical repair. Results: Of the 3283 patients who survived repair for simple TOF and met the study's inclusion criteria, 56.4% were male and 43.6% were female. Twenty-five-year survival following TOF repair was 94.5%. Multivariable analysis demonstrated increased risk of early mortality with staged repair (HR, 2.68; 95% CI, 1.59-4.49) and non-valve-sparing operation (HR, 3.76; 95% CI, 1.53-9.19). Presence of a genetic abnormality was associated with increased risk of death both in the early (HR, 3.64; 95% CI, 2.05-6.47) and late postoperative phase (HR, 4.41; 95% CI, 2.62-7.44). Conclusions and Relevance: Long-term survival after simple TOF repair is excellent. Staged repair and non-valve-sparing operations were negatively associated with survival in the early postrepair phase but not the late postrepair phase. These data are important for patients with repaired TOF and their caretakers and may guide surgical strategies for optimizing the long-term outcomes of this population.

Direct transport to a PCI-capable hospital is associated with improved survival after adult out-of-hospital cardiac arrest of medical aetiology.

AIM: To compare survival outcomes of adults with out-of-hospital cardiac arrest (OHCA) of medical aetiology directly transported to a percutaneous-coronary-intervention capable (PCI-capable) hospital (direct transport) with patients transferred to a PCI-capable hospital via another hospital without PCI services available (indirect transport) by emergency medical services (EMS). METHODS: This retrospective cohort study used the St John Ambulance Western Australia OHCA Database and medical chart review. We included OHCA patients (≥18 years) admitted to any one of five PCI-capable hospitals in Perth between January 2012 and December 2015. Survival to hospital discharge (STHD) and survival up to 12-months after OHCA were compared between the direct and indirect transport groups using multivariable logistic and Cox-proportional hazards regression, respectively, while adjusting for so-called "Utstein variables" and other potential confounders. RESULTS: Of the 509 included patients, 404 (79.4%) were directly transported to a PCI-capable hospital and 105 (20.6%) transferred via another hospital to a PCI-capable hospital; 274/509 (53.8%) patients STHD and 253/509 (49.7%) survived to 12-months after OHCA. Direct transport patients were twice as likely to STHD (adjusted odds ratio 1.97, 95% confidence interval [CI] 1.13-3.43) than those transferred via another hospital. Indirect transport was also associated with a possible increased risk of death, up to 12-months, compared to direct transport (adjusted hazard ratio 1.36, 95% CI 1.00-1.84). CONCLUSION: Direct transport to a PCI-capable hospital for post-resuscitation care is associated with a survival advantage for adults with OHCA of medical aetiology. This has implications for EMS transport protocols for patients with OHCA.

One year's activity and outcome data from an ambulatory cardiology unit.

In 2015, the Belfast Trust piloted an ambulatory cardiology unit (ACU). The ethos of the ACU was to reduce pressure on the Emergency Department by providing a unit where rapid evaluation, treatment and follow-up could be provided by the cardiology team and, at the same time, reduce inpatient admissions to cardiology beds. The service proved effective in reducing admissions to cardiology beds by 13.5% over a 1-year period, while patient outcomes at 30 days and 6 months demonstrated that the service is safe, with only 1.7% of patients readmitted at 30 days and 6 months with the same or a related complaint. The principles of ACU could be adopted by many other specialities.

Variations in Cardiac Arrest Regionalization in California.

INTRODUCTION: The development of cardiac arrest centers and regionalization of systems of care may improve survival of patients with out-of-hospital cardiac arrest (OHCA). This survey of the local EMS agencies (LEMSA) in California was intended to determine current practices regarding the treatment and routing of OHCA patients and the extent to which EMS systems have regionalized OHCA care across California. METHODS: We surveyed all of the 33 LEMSA in California regarding the treatment and routing of OHCA patients according to the current recommendations for OHCA management. RESULTS: Two counties, representing 29% of the California population, have formally regionalized cardiac arrest care. Twenty of the remaining LEMSA have specific regionalization protocols to direct all OHCA patients with return of spontaneous circulation to designated percutaneous coronary intervention (PCI)-capable hospitals, representing another 36% of the population. There is large variation in LEMSA ability to influence inhospital care. Only 14 agencies (36%), representing 44% of the population, have access to hospital outcome data, including survival to hospital discharge and cerebral performance category scores. CONCLUSION: Regionalized care of OHCA is established in two of 33 California LEMSA, providing access to approximately one-third of California residents. Many other LEMSA direct OHCA patients to PCI-capable hospitals for primary PCI and targeted temperature management, but there is limited regional coordination and system quality improvement. Only one-third of LEMSA have access to hospital data for patient outcomes.

Feasibility of real-time capture of routine clinical data in the electronic health record: a hospital-based, observational service-evaluation study.

OBJECTIVES: The electronic health record (EHR) is underused in the hospital setting. The aim of this service evaluation study was to respond to National Health Service (NHS) Digital's ambition for a paperless NHS by capturing routinely collected cardiac outpatient data in the EHR to populate summary patient reports and provide a resource for audit and research. DESIGN: A PowerForm template was developed within the Cerner EHR, for real-time entry of routine clinical data by clinicians attending a cardiac outpatient clinic. Data captured within the PowerForm automatically populated a SmartTemplate to generate a view-only report that was immediately available for the patient and for electronic transmission to the referring general practitioner (GP). RESULTS: During the first 8 months, the PowerForm template was used in 61% (360/594) of consecutive outpatient referrals increasing from 42% to 77% during the course of the study. Structured patient reports were available for immediate sharing with the referring GP using Cerner Health Information Exchange technology while electronic transmission was successfully developed in a substudy of 64 cases, with direct delivery by the NHS Data Transfer Service in 29 cases and NHS mail in the remainder. In feedback, the report's immediate availability was considered very or extremely important by >80% of the patients and GPs who were surveyed. Both groups reported preference of the patient report to the conventional typed letter. Deidentified template data for all 360 patients were successfully captured within the Trust system, confirming availability of these routinely collected outpatient data for audit and research. CONCLUSION: Electronic template development tailored to the requirements of a specialist outpatient clinic facilitates capture of routinely collected data within the Cerner EHR. These data can be made available for audit and research. They can also be used to enhance communication by populating structured reports for immediate delivery to patients and GPs.

Sex, race, and insurance status differences in hospital treatment and outcomes following out-of-hospital cardiac arrest.

BACKGROUND: Sex, race, and insurance status are associated with treatment and outcomes in several cardiovascular diseases. These disparities, however, have not been well-studied in out-of-hospital cardiac arrest (OHCA). OBJECTIVE: Our objective was to evaluate the association of patient sex, race, and insurance status with hospital treatments and outcomes following OHCA. METHODS: We studied adult patients in the 2011-2015 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database with a "present on admission" diagnosis of cardiac arrest (ICD-9-CM 427.5). Insurance status was classified as private, Medicare, and Medi-Cal/government/self-pay. Our primary outcome was good neurologic recovery at hospital discharge, which was determined by discharge disposition. Secondary outcomes were survival to hospital discharge, treatment at a 24/7 percutaneous coronary intervention (PCI) center, "do not resuscitate" orders within 24 h of admission, and cardiac catheterization during hospitalization. Data were analyzed with hierarchical multiple logistic regression models. RESULTS: We studied 38,163 patients in the OSHPD database. Female sex, non-white race, and Medicare insurance status were independently associated with worse neurologic recovery [OR 0.94 (0.89-0.98), 0.93 (0.88-0.98), and 0.85 (0.79-0.91), respectively], lower rates of treatment at a 24/7 PCI center [OR 0.89 (0.85-0.93), 0.88 (0.85-0.93), and 0.87 (0.82-0.94), respectively], and lower rates of cardiac catheterization [OR 0.61 (0.57-0.65), 0.90 (0.84-0.97), and 0.44 (0.40-0.48), respectively]. Female sex, white race, and Medicare insurance were associated with DNR orders within 24 h of admission [OR 1.16 (1.10-1.23), 1.14 (1.07-1.21), and 1.25 (1.15-1.36), respectively]. CONCLUSIONS: Sex, race, and insurance status were independently associated with post-arrest care interventions, patient outcomes and treatment at a 24/7 PCI center. More studies are needed to fully understand the causes and implications of these disparities.

Patient, health service factors and variation in mortality following resuscitated out-of-hospital cardiac arrest in acute coronary syndrome: Analysis of the Myocardial Ischaemia National Audit Project.

AIMS: To determine patient and health service factors associated with variation in hospital mortality among resuscitated cases of out-of-hospital cardiac arrest (OHCA) with acute coronary syndrome (ACS). METHODS: In this cohort study, we used the Myocardial Ischaemia National Audit Project database to study outcomes in patients hospitalised with resuscitated OHCA due to ACS between 2003 and 2015 in the United Kingdom. We analysed variation in inter-hospital mortality and used hierarchical multivariable regression models to examine the association between patient and health service factors with hospital mortality. RESULTS: We included 17604 patients across 239 hospitals. Overall hospital mortality was 28.7%. In 94 hospitals that contributed at least 60 cases, mortality by hospital ranged from 10.7% to 66.3% (median 28.6%, IQR 23.2% to 39.1%)). Patient and health service factors explained 36.1% of this variation. After adjustment for covariates, factors associated with higher hospital mortality included increasing serum glucose, ST-Elevation myocardial infarction (STEMI) diagnosis, and initial admission to a primary percutaneous coronary intervention (pPCI) capable hospital. Hospital OHCA volume was not associated with mortality. The key modifiable factor associated with lower mortality was early reperfusion therapy in STEMI patients. CONCLUSION: There was wide variation in inter-hospital mortality following resuscitated OHCA due to ACS that was only partially explained by patient and health service factors. Hospital OHCA volume and pPCI capability were not associated with lower mortality. Early reperfusion therapy was associated with lower mortality in STEMI patients.

Proximity to Pediatric Cardiac Surgical Care among Adolescents with Congenital Heart Defects in 11 New York Counties.

BACKGROUND: Many individuals with congenital heart defects (CHDs) discontinue cardiac care in adolescence, putting them at risk of adverse health outcomes. Because geographic barriers may contribute to cessation of care, we sought to characterize geographic access to comprehensive cardiac care among adolescents with CHDs. METHODS: Using a population-based, 11-county surveillance system of CHDs in New York, we characterized proximity to the nearest pediatric cardiac surgical care center among adolescents aged 11 to 19 years with CHDs. Residential addresses were extracted from surveillance records documenting 2008 to 2010 healthcare encounters. Addresses were geocoded using ArcGIS and the New York State Street and Address Maintenance Program, a statewide address point database. One-way drive and public transit time from residence to nearest center were calculated using R packages gmapsdistance and rgeos with the Google Maps Distance Matrix application programming interface. A marginal model was constructed to identify predictors associated with one-way travel time. RESULTS: We identified 2522 adolescents with 3058 corresponding residential addresses and 12 pediatric cardiac surgical care centers. The median drive time from residence to nearest center was 18.3 min, and drive time was 30 min or less for 2475 (80.9%) addresses. Predicted drive time was longest for rural western addresses in high poverty census tracts (68.7 min). Public transit was available for most residences in urban areas but for few in rural areas. CONCLUSION: We identified areas with geographic barriers to surgical care. Future research is needed to determine how these barriers influence continuity of care among adolescents with CHDs. Birth Defects Research 109:1494-1503, 2017.© 2017 Wiley Periodicals, Inc.

Cardiac rehabilitation in Portugal: Results from the 2013-14 national survey. / Reabilitação cardíaca em Portugal. Inquérito 2013­2014.

INTRODUCTION: In recent years, cardiac rehabilitation (CR) programs have evolved from being limited to exercise training to comprehensive secondary prevention programs. Given the solid scientific evidence supporting them, they are given a class I recommendation in the American and European guidelines for various cardiovascular diseases, but they continue to be underused in Portugal. OBJECTIVE: To analyze the situation of CR programs in Portugal in 2013-14 and to assess developments in recent years. METHODS: In November 2014, a questionnaire was sent to the centers offering CR programs that included the following items: name of the center; composition of the team; phases and components; number of participants and diagnoses; and funding bodies. The percentage of patients with myocardial infarction admitted to phase II CR programs in 2013 was calculated based on data from the Directorate-General of Health (DGS). RESULTS: Twenty-three centers offering CR programs were identified, 12 public and 11 private. The number of centers rose from 16 in 2007 to 23 in 2014. In 2013, 1927 patients participated in phase II programs, nearly three times the number rehabilitated in 2007 (638 patients). Myocardial infarction was the referral diagnosis in 999 patients, accounting for 51.8% of admissions. On the basis of DGS data, 8% of patients with myocardial infarction were admitted to phase II CRPs in 2013, as opposed to 3% in 2007. CONCLUSION: The number of patients admitted to CR programs, as well as the number of centers, increased considerably between 2007 and 2014 in Portugal. Despite these favorable developments, further improvements are still needed.