Navigating the Healthcare Conundrum: Leadership Perspective from a Premier Healthcare Organization in Loma Linda's Blue Zone.

Navigating the healthcare conundrum in the Blue Zone of Loma Linda, California, requires understanding the unique factors that make this region stand out in terms of health and longevity. But more important is understanding the healthcare system sustaining the Blue Zone in Loma Linda, California. In an era marked by soaring healthcare costs and diminishing reimbursement rates, hospitals and physicians face an unprecedented challenge: providing excellent patient care while maintaining financial sustainability. This leadership perspective publication paper delves into the multifaceted struggles encountered by healthcare and hospital leaders, exploring the root causes, implications, and potential solutions for this complex issue. As we examine the evolving healthcare landscape, we aim to shed light on the critical need for innovative approaches to sustain the future of healthcare excellence in one of the five original Blue Zones.

Percutaneous coronary intervention in patients with cancer and readmissions within 90 days for acute myocardial infarction and bleeding in the USA.

AIMS: The post-discharge outcomes of patients with cancer who undergo PCI are not well understood. This study evaluates the rates of readmissions within 90 days for acute myocardial infarction (AMI) and bleeding among patients with cancer who undergo percutaneous coronary intervention (PCI). METHODS AND RESULTS: Patients treated with PCI in the years from 2010 to 2014 in the US Nationwide Readmission Database were evaluated for the influence of cancer on 90-day readmissions for AMI and bleeding. A total of 1 933 324 patients were included in the analysis (2.7% active cancer, 6.8% previous history of cancer). The 90-day readmission for AMI after PCI was higher in patients with active cancer (12.1% in lung, 10.8% in colon, 7.5% in breast, 7.0% in prostate, and 9.1% for all cancers) compared to 5.6% among patients with no cancer. The 90-day readmission for bleeding after PCI was higher in patients with active cancer (4.2% in colon, 1.5% in lung, 1.4% in prostate, 0.6% in breast, and 1.6% in all cancer) compared to 0.6% among patients with no cancer. The average time to AMI readmission ranged from 26.7 days for lung cancer to 30.5 days in colon cancer, while the average time to bleeding readmission had a higher range from 38.2 days in colon cancer to 42.7 days in breast cancer. CONCLUSIONS: Following PCI, patients with cancer have increased risk for readmissions for AMI or bleeding, with the magnitude of risk depending on both cancer type and the presence of metastasis.

Length of Stay After Transfemoral Transcatheter Aortic Valve Replacement: An Analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

OBJECTIVES: The goal of this study was to investigate the trends, predictors, and outcomes of delayed discharge (>72 h) after transcatheter aortic valve replacement. BACKGROUND: Length of stay post-transcatheter aortic valve replacement may have significant clinical and administrative implications. METHODS: Data from the Transcatheter Valve Therapy Registry were used to identify patients undergoing nonaborted transfemoral transcatheter aortic valve replacement who survived to discharge, and data linked from the Centers for Medicare & Medicaid Services were used to provide 1-year events. Patients were categorized to early discharge (≤72 h) versus delayed discharge (>72 h). The trends, predictors, and adjusted 1-year outcomes were compared in both groups. RESULTS: From 2011 to 2015, a total of 13,389 patients (55.1%) were discharged within 72 h, whereas 10,896 patients (44.9%) were discharged beyond 72 h. There was a significant decline in rates of delayed discharge across the study period (62% vs. 34%; p < 0.01). This remained unchanged when stratified by Transcatheter Valve Therapy risk scores. Several factors were identified as independent predictors of early and delayed discharge. After adjustment for in-hospital complications, delayed discharge was an independent predictor of 1-year all-cause mortality (hazard ratio: 1.45; 95% confidence interval: 1.30 to 1.60; p < 0.01). CONCLUSIONS: Rates of delayed discharge have declined from 2011 to 2015. Delayed discharge is associated with a significant increase in mortality even after adjusting for in-hospital complications. Further work is necessary to determine if predictors of early discharge could be used to develop length of stay scores that might be instrumental in administrative, financial, or clinical policy development.

Functional assessment of anomalous right coronary artery using fractional flow reserve: An Innovative Modality to Guide Patient Management.

Anomalous origin of a coronary artery is a recognized cause of sudden cardiac death (SCD). To date, there is no standard test to predict which patients are at increased risk for SCD. Fractional flow reserve (FFR) is an invasive technique used to qualify focal obstructive coronary lesions. We present a case where FFR was used to guide therapy in a young patient with anomalous right coronary artery (ARCA) when standard noninvasive testing showed ischemic discrepancy. © 2016 Wiley Periodicals, Inc.

Challenges facing early career academic cardiologists.

Early career academic cardiologists currently face unprecedented challenges that threaten a highly valued career path. A team consisting of early career professionals and senior leadership members of American College of Cardiology completed this white paper to inform the cardiovascular medicine profession regarding the plight of early career cardiologists and to suggest possible solutions. This paper includes: 1) definition of categories of early career academic cardiologists; 2) general challenges to all categories and specific challenges to each category; 3) obstacles as identified by a survey of current early career members of the American College of Cardiology; 4) major reasons for the failure of physician-scientists to receive funding from National Institute of Health/National Heart Lung and Blood Institute career development grants; 5) potential solutions; and 6) a call to action with specific recommendations.

Percutaneous revascularization for stable coronary artery disease temporal trends and impact of drug-eluting stents.

OBJECTIVES: We sought to determine the characteristics, outcomes, and temporal trends among patients undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) from a single-center registry. BACKGROUND: There is controversy regarding the generalizability of the findings from randomized trials of PCI for stable CAD to daily practice. An important perspective on the significance of the trial results can be achieved by clearly documenting past and present practice of PCI. METHODS: This was a retrospective analysis of 8,912 consecutive patients undergoing elective PCI from 1979 through 2006 at a tertiary referral center. Clinical, angiographic, and procedural characteristics as well as in-hospital and long-term outcomes were measured in patients grouped into 4 eras depending on the dominant interventional strategy of that time: percutaneous transluminal coronary angioplasty, early stent, bare-metal stent, and drug-eluting stent. RESULTS: Procedural success rates have improved (81%, 92%, 96%, and 97%, respectively, p < 0.001), and in-hospital mortality has decreased significantly (1.0%, 0.8%, 0.1%, and 0.1%, respectively, p < 0.001) over time. Kaplan-Meier estimates of mortality at 4 years were 11%, 13%, 10%, and 10%, respectively (p = 0.4). The 1-year target lesion revascularization rates in the 4 groups were 29%, 26%, 13%, and 8%, respectively (p < 0.001). CONCLUSIONS: Procedural success rates in contemporary practice of PCI for stable CAD are excellent with very low in-hospital mortality. Introduction of drug-eluting stents has reduced target lesion revascularization but not mortality among all comers. Outcomes similar to that observed in recent clinical trials are being achieved in routine clinical practice.

Diagnosis and treatment of viral myocarditis.

Myocarditis, an inflammatory disease of heart muscle, is an important cause of dilated cardiomyopathy worldwide. Viral infection is also an important cause of myocarditis, and the spectrum of viruses known to cause myocarditis has changed in the past 2 decades. Several new diagnostic methods, such as cardiac magnetic resonance imaging, are useful for diagnosing myocarditis. Endomyocardial biopsy may be used for patients with acute dilated cardiomyopathy associated with hemodynamic compromise, those with life-threatening arrhythmia, and those whose condition does not respond to conventional supportive therapy. Important prognostic variables include the degree of left and right ventricular dysfunction, heart block, and specific histopathological forms of myocarditis. We review diagnostic and therapeutic strategies for the treatment of viral myocarditis. English-language publications in PubMed and references from relevant articles published between January 1, 1985, and August 5, 2008, were analyzed. Main keywords searched were myocarditis, dilated cardiomyopathy, endomyocardial biopsy, cardiac magnetic resonance imaging, and immunotherapy.

Isolated right ventricular infarction--an uncommon cause of acute anterior ST segment elevation.

We describe a case of isolated right ventricular myocardial infarction as the cause of anterior precordial lead ST segment elevation. This case illustrates that anterior ST segment elevation may occur with occlusion of the right coronary artery. It is important to recognize this scenario as the treatment of right ventricular myocardial infarction differs from that of left ventricular myocardial infarction.

Heart rate control in patients with atrial fibrillation referred for exercise testing.

Clinical practice guidelines for patients with atrial fibrillation (AF) recommended a heart rate (HR) of 60 to 80 beats/min at rest and 90 to 115 at moderate exercise. The degree to which HR control at rest and with exercise in patients with AF complies with these recommendations is unknown. HR at rest and at peak exercise was retrospectively examined in 1,097 consecutive patients with AF referred for exercise myocardial perfusion imaging. In a subgroup of 195 patients, HR was also measured at an intermediate "moderate" level. Median HR at rest was 80 beats/min, at the upper end of the recommended range of 60 to 80. Only patients administered a beta blocker (BB; 31%) had lower (p <0.001) median HRs at rest. Median HR at moderate exercise was 128 beats/min, higher than the range of 90 to 115 recommended by the guidelines. Only patients administered a BB had significantly reduced HRs (p <0.003) at moderate exercise. Median peak exercise HR was 147 beats/min. Forty-five percent of patients exceeded their age-predicted maximal HR. Patients administered BBs were significantly less likely (p <0.01) to exceed their age-predicted maximal HR. In conclusion, in patients with AF, HR control at rest and during exercise often did not comply with guideline recommendations. Regimens including a BB were more effective in achieving HR control.

Monogenic forms of low-renin hypertension.

Hypertension is an important public health problem affecting more than 50 million individuals in the US alone. The most common form, essential hypertension, results from the complex interplay between genetic predisposition and environmental influences. In contrast, monogenic (mendelian) forms of hypertension are caused by single gene mutations that are influenced little, if at all, by environmental factors. Most monogenic forms of hypertension affect either electrolyte transport in the distal nephron, or the synthesis or activity of mineralocorticoid hormones, leading to the common pathogenic mechanisms of increased distal tubular reabsorption of sodium and chloride, volume expansion and hypertension. In young patients with a family history of hypertension who present with severe or refractory hypertension and characteristic hormonal and biochemical abnormalities, the differential diagnosis should include monogenic forms of hypertension. Genetic testing, which is increasingly available, can facilitate timely diagnosis and treatment of these relatively uncommon disorders, such that the underlying defect can be corrected or ameliorated and the long-term consequences of poorly controlled hypertension prevented.