Introduction: The healthcare system in Mexico is complex and fragmented which becomes an impediment to implementing national-wide quality improvement initiatives in the cardiovascular area. The American Heart Association Get With The Guidelines® (GWTG) Quality program has become an important tool to improve healthcare standards for patients in US. Aims: To develop for the first time, the “Calidad Con Corazon Program” to apply the AHA GWTG framework in Mexico to improve adherence to guideline-directed medical therapies(GDMT) for the treatment of patients with CAD. Methods/Approach: Calidad con Corazon program included 10 PCI-capable hospitals from five states in Mexico, representing both public and private health systems. Data included patients with ACS/STEMI/NSTEMI diagnosis. All hospitals were provided quality improvement consultations to identify barriers and develop action plans. This analysis includes data from the first 18 months of the project (Sep 2022 to May 2024). Results: We included 2087 patients; Overall, the mean age was 62.1±13.7 and included 73.8% males, with a history of hypertension (57.3%), dyslipidemia (13.6%), diabetes Mellitus (42%), and myocardial infarction (12.3%). Clinical presentation was predominantly STEMI in 66% (n=1378). A progressive improvement overtime was observed on the proportion of patients receiving an ECG in <10 min after arrival to the PCI-hospital, from 53.3% of cases pre-program to 86.2% at 12-18 months after the program (p<0.001). The result was a decrease from a mean of 22.8 minutes to 8.2 minutes respectively (p<0.001). STEMI/NSTEMI patients showed an increase in the proportion of GDMT at discharge for statins(95.2% to 96.9%), betablockers(81.5% to 86%), aspirin(95.4% to 97.1%) and ARB/ACEi(79.5% to 88%). Procedure improvements included a decrease in missing ECG documentation(11.7% to 4.1%), an increase in LVEF measurement (82.7% to 92%), and lipid profile measurement(42.9% to 83.3%). Conclusion: Hospitals participating in the first national quality improvement program in Mexico adopting the AHA’s GWTG framework for patients with ACS demonstrated improvement in hospital procedure protocols over a 18 months period, reflected as an improvement in the performance metrics.

Introduction: The use of Large Language Models (LLMs) in clinical practice seems increasingly possible, although comparative studies are needed to achieve standardization. GPT-4, Grok and Gemini are three commonly used LLMs. While these LLMs may exhibit some level of clinical reasoning, their performance could differ between them and between areas of cardiology. Aim: To evaluate the clinical reasoning of GPT-4, Grok and Gemini in distinct fields of cardiology. Methods: A total of 12 cases were selected from the AHA Circulation Journal, representing six cardiology areas: General Cardiology (GC), Interventional Cardiology (IC), Cardiac Imaging (CI), Electrophysiology (EP), Heart Failure (HF) and Congenital Heart Disease (CHD). Each area included two cases. We only provided the case presentation to the LLMs, ensuring they were unaware of the diagnosis and management. Four questions were asked with the following prompts: 1. What are the diagnostic steps?, 2. What is the most likely diagnosis?, 3. What is the differential diagnosis?, 4. What is the appropriate management?. The responses were systematically evaluated with a digital rubric through an international collaboration of 12 cardiologists from various institutions. Each cardiologist evaluated two cases in their area of expertise and was aware of the diagnosis and management. One-way ANOVA was used for analysis. Results: GPT-4 had a slightly best overall performance (Table 1) and the highest score in GC and CHD; Grok excelled in determining the management and was superior in CI, HF and IC; Gemini had the highest performance in EP, although these findings were not statistically significant (Table 2). Conclusions: This is one of the first studies comparing the clinical reasoning of LLMs in cardiology. Our results propose that GPT-4 has the best overall performance and Grok is superior indicating the management. More studies comparing LLMs are required for further standardization of their use.

Drug-coated balloons are approved outside the United States, not only for the treatment of peripheral arteries but also for coronary arteries. This review describes the technological basics, the scenarios of clinical application, and the current available data from clinical trials for the different coronary indications.

Aims: We aimed to explored the association between the use of optimal medical therapy (OMT) in patients with myocardial infarction (AMI) and diabetes mellitus (DM) and clinical outcomes. Methods: Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coro-nary Syndrome (BleeMACS) is an international registry that enrolled participants with acute coronary syndrome followed up for at least 1 year across 15 centers from 2003 to 2014. Baseline characteristics and endpoints were analyzed. Results: Among 3095 (23.2%) patients with AMI and DM, 1898 (61.3%) received OMT at hospital discharge. OMT was associated with significantly reduced mortality (4.3% vs. 10.8%, p < 0.001), re-AMI (4.4% vs. 8.1%, p < 0.001), and composite endpoint of death/re-AMI (8.0% vs. 17.6%, p < 0.001). No difference was observed among regions. Propensity score matching confirmed that OMT significantly associated with lower mortality. After adjusting for confounding variables, OMT, drug-eluting stents, and complete revascularization were in-dependent protective factors of 1-year mortality, whereas left ventricular ejection fraction and age were risk factors. Conclusions: Guideline-recommended OMT was prescribed at suboptimal frequencies with geographic variations in this worldwide cohort. OMT can improve long-term clinical outcomes in patients with DM and AMI. Clinical Trial Registration: NCT02466854 June 9, 2015.

BACKGROUND Haemoglobin drop is common in acute coronary syndrome (ACS) patients and correlates with poor prognosis. However, the association between mild haemoglobin drop and adverse clinical outcome remains insufficiently investigated. This study aimed to examine the association between in-hospital haemoglobin drop and risk for adverse clinical outcomes in ACS patients, especially those with mild drop. METHODS Included patients from the BleeMACS (Bleeding complications in a Multicenter registry of patients discharged after an Acute Coronary Syndrome) registry were categorized into three groups by the presence and amount of in-hospital haemoglobin drop (non-drop, mild drop and severe drop). The cut-off point between mild drop and severe drop is ≥ 3 g/dL. Multivariate Cox regression was used to assess the association between haemoglobin drop and major adverse cardiac endpoints (MACE). Patients taking potent P2Y12 inhibitors were selected for the additional analysis. Propensity score matching was used to avoid selective bias in the additional analysis. RESULTS Of 6911 patients, 4949 patients (71.6%) experienced in-hospital haemoglobin drop. Compare with non-drop group, patients with haemoglobin drop had higher risk of MACE [adjusted hazard ratio (HR) = 1.36, 95% CI: 1.03–1.80 for mild drop group; adjusted HR = 1.70, 95% CI: 1.07–2.68 for severe drop group]. Patients in mild drop group were less likely to receive potent P2Y12 inhibitors at discharge (mild drop group vs. severe drop group vs. non-drop group: 10.9% vs. 10.7% vs. 23.8%). After propensity score matching adjustment among patients with potent P2Y12 inhibitors, patients in mild drop group were not associated with an increased risk of MACE than those in non-drop group (adjusted HR = 1.52, 95% CI: 0.49–4.72). CONCLUSIONS In-hospital haemoglobin drop was common in ACS patients and associated with a higher risk for adverse events. Reduced prescription for potent P2Y12 inhibitors may be responsible for poor prognoses among patients with mild haemoglobin drop.

HomeCirculationVol. 143, No. 252020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUB2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report Ivor J. Benjamin, MD, FAHA, FACC, Conference Co-Chair, AHA C. Michael Valentine, MD, MACC, FAHA, Conference Co-Chair, ACC William J. Oetgen, MD, MBA, MACC, Executive Committee Author Task Force 2 Author, ACC Katherine A. Sheehan, PhD, Executive Committee Author, AHA Ralph G. Brindis, MD, MPH, MACC, FAHA, Task Force Co-Chair, ACC William H. Roach Jr, MS, JD, Task Force Co-Chair, AHA Robert A. Harrington, MD, FAHA, MACC, Author Glenn N. Levine, MD, FACC, FAHA, Author Rita F. Redberg, MS, MD, FACC, FAHA, Author Bernadette M. Broccolo, JD, Discussant Adrian F. Hernandez, MD, MHS, FAHA, Discussant Pamela S. Douglas, MD, MACC, FAHA, Task Force Co-Chair, ACC Ileana L. Piña, MD, MPH, FAHA, FACC, Task Force Co-Chair, AHA Emelia J. Benjamin, MD, ScM, FAHA, FACC, Author Megan J. Coylewright, MD, MPH, FACC, Author Jorge F. Saucedo, MD, MBA, FACC, FAHA, Author Keith C. Ferdinand, MD, FACC, FAHA, Discussant Sharonne N. Hayes, MD, FACC, FAHA, Discussant Athena Poppas, MD, FACC, FAHA, Discussant Karen L. Furie, MD, MPH, FAHA, Task Force Co-Chair, AHA Laxmi S. Mehta, MD, FACC, FAHA, Task Force Co-Chair, ACC John P. Erwin III, MD, FACC, FAHA, Author Jennifer H. Mieres, MD, FACC, FAHA, Author Daniel J. Murphy Jr, MD, FACC, Author Gaby Weissman, MD, FACC, Author and Discussant Colin P. West, MD, PhD, Author and Discussant Willie E. Lawrence Jr, MD, FACC, FAHA, Task Force Co-Chair, AHA Frederick A. Masoudi, MD, MSPH, FACC, FAHA, Task Force Co-Chair, ACC Camara P. Jones, MD, MPH, PhD, Author Daniel D. Matlock, MD, MPH, Author Jennifer E. Miller, PhD, Author John A. Spertus, MD, MPH, FACC, FAHA, Discussant Lynn Todman, PhD, Discussant Cathleen Biga, MSN, FACC, Task Force Co-Chair, ACC Richard A. Chazal, MD, FAHA, MACC, Task Force Co-Chair, AHA Mark A. Creager, MD, FAHA, FACC, Author Edward T. Fry, MD, FACC, Author Michael J. Mack, MD, MACC, Author Clyde W. Yancy, MD, MSc, MACC, FAHA, Author and Discussant Richard E. AndersonMD, Discussant Ivor J. BenjaminIvor J. Benjamin , C. Michael ValentineC. Michael Valentine , William J. OetgenWilliam J. Oetgen , Katherine A. SheehanKatherine A. Sheehan , Ralph G. BrindisRalph G. Brindis , William H. Roach JrWilliam H. Roach Jr , Robert A. HarringtonRobert A. Harrington , Glenn N. LevineGlenn N. Levine , Rita F. RedbergRita F. Redberg , Bernadette M. BroccoloBernadette M. Broccolo , Adrian F. HernandezAdrian F. Hernandez , Pamela S. DouglasPamela S. Douglas , Ileana L. PiñaIleana L. Piña , Emelia J. BenjaminEmelia J. Benjamin , Megan J. CoylewrightMegan J. Coylewright , Jorge F. SaucedoJorge F. Saucedo , Keith C. FerdinandKeith C. Ferdinand , Sharonne N. HayesSharonne N. Hayes , Athena PoppasAthena Poppas , Karen L. FurieKaren L. Furie , Laxmi S. MehtaLaxmi S. Mehta , John P. Erwin IIIJohn P. Erwin III , Jennifer H. MieresJennifer H. Mieres , Daniel J. Murphy JrDaniel J. Murphy Jr , Gaby WeissmanGaby Weissman , Colin P. WestColin P. West , Willie E. Lawrence JrWillie E. Lawrence Jr , Frederick A. MasoudiFrederick A. Masoudi , Camara P. JonesCamara P. Jones , Daniel D. MatlockDaniel D. Matlock , Jennifer E. MillerJennifer E. Miller , John A. SpertusJohn A. Spertus , Lynn TodmanLynn Todman , Cathleen BigaCathleen Biga , Richard A. ChazalRichard A. Chazal , Mark A. CreagerMark A. Creager , Edward T. FryEdward T. Fry , Michael J. MackMichael J. Mack , Clyde W. YancyClyde W. Yancy , and Richard E. AndersonRichard E. Anderson Originally published11 May 2021https://doi.org/10.1161/CIR.0000000000000963Circulation. 2021;143:e1035–e1087is corrected byCorrection to: 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference ReportTable of Contents1. Introduction e10361.1. Historical Perspective and Current Plan e10371.2. Context Framing e10381.3. The Tenets of Medical Ethics e10391.4. The Principles and Commitments of Medical Professionalism e10391.4.1. Principles of Professionalism e10391.4.2. Commitments of Professionalism e10391.5. The Obligations of Medicine's Social Contract e10401.5.1. Medical Practitioners Agree to:e10401.5.2. Society Agrees to:e10411.6. Organization of Writing Committee e10421.7. Document Review and Publication Approval e10421.8. Abbreviations e10422. Task Force Reports e10422.1. Task Force 1: Navigating Conflicts: RWIs and COIs in Teaching and Publications, Peer Review, Research Data, Technology, and Expert Testimony e10422.1.1. Recommendations Related to Disclosure of RWIs in Educational Activities and Scientific Publications e10432.1.2. Recommendations Related to Associational and Intellectual Interests e10442.1.3. Recommendations Related to External Assessments of Interests e10452.1.4. Recommendations Related to Research, Publication, Educational Activities, and Implementation Ethics e10462.1.5. Recommendations Related to Peer Review and Grant Study Sections e10472.1.6. Recommendations Related to Expert Testimony and Opinions e10482.2. Task Force 2: Diversity, Equity, Inclusion, and Belonging: Optimizing Cardiovascular Health Care, Research, and Education Through Equity and Respect and Eliminating Bias, Discrimination, Harassment, and Racism e10492.2.1. DEIB: General Concepts e10512.2.2. Specific Accountabilities and Special Groups e10522.2.3. Eradicating Bias, Harassment, Structural Racism, and Structural Sexism, Including Sexual Harassment e10542.2.4. Achieving Equity, Inclusion, and Belonging: A Road Map e10552.2.5. Coda e10562.3. Task Force 3: Enhancing the Well-Being of Clinicians e10562.3.1. Organizational Strategies to Promote Well-Being e10592.3.2. Addressing Well-Being Among Trainees and Researchers e10602.3.3. Well-Being Strategies Focused on Health Information Technology e10612.3.4. Identifying Symptoms of the Disruptive Physician e10622.3.5. Identifying and Assisting the Impaired Clinician e10632.3.6. Additional Considerations and Caveats e10642.4. Task Force 4: Patient Autonomy, Privacy, and Social Justice in Health Care e10642.4.1. Patient Autonomy e10652.4.2. Data Privacy, Transparency, and Access e10652.4.3. Social Justice e10652.4.4. Recommendations: Patient Autonomy e10662.4.5. Recommendations: Data Privacy, Transparency, and Access e10672.4.6. Recommendations: Social Justice and Racism e10692.4.7. Caveats e10702.5. Task Force 5: Modern Healthcare Delivery: Challenges Related to New Care Delivery Systems e10712.5.1. Addressing Potential COIs When Designing and Engaging in New Models and Venues of Cardiovascular Care Delivery e10722.5.2. Medical Professionalism for the Employed Clinician e10732.5.3. Ethical Challenges and Professionalism Related to Billing, Coding, Documentation, and EHRs e10752.5.4. Quadruple Aim: Does an Ethical and Professional Perspective Enhance or Obstruct Patient Satisfaction, Outcomes and Quality, Cost, and Clinician Satisfaction? e10762.5.5. Conclusions e1076References e1077Appendix 1. Author Relationships With Industry and Other Entities (Comprehensive) e1082Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) e10871. INTRODUCTIONIvor J. Benjamin, MD, FAHA, FACCWilliam J. Oetgen, MD, MBA, MACCKatherine A. Sheehan, PhDC. Michael Valentine, MD, MACC, FAHAThe 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics (2020 Consensus Conference) comes at a time even more fraught than the eras of the 3 previous meetings on the same topics. A virulent pathogen has challenged the physical and economic health of the entire country; a series of tragedies have awakened a sense of social justice previously unexpressed nationally; and the political climate rivals the divisiveness seen at the birth of the nation.1 Arguably, there could be no better time to review and take a fresh perspective on medical ethics and professionalism in the light of established norms and current stressors. In addition, the American Heart Association (AHA) and the American College of Cardiology (ACC) recognize that this important assessment should be undertaken on a more regular basis. There should be no more 16-year gaps.Building on a solid understanding of previous similar efforts and with a firm appreciation of the obligations of medicine's social contract, the tenets of medical ethics, and the principles and commitments of medical professionalism, the ACC and the AHA sponsored a conference on medical professionalism and ethics on October 19 to 20, 2020. Multiple medical professional organizations provided valuable input. The purpose of the present 2020 Consensus Conference is to address the practical management of professional and ethical behavior of cardiovascular clinicians and scientists and to make specific recommendations in light of contemporary issues of professionalism and ethics. The consensus committee reviewed previously published documents and current materials to formulate their recommendations.1.1. Historical Perspective and Current PlanThe AHA and the ACC have long individual and collective histories of formally addressing issues of medical ethics and medical professionalism. The 21st Bethesda Conference (Ethics in Cardiovascular Medicine) was held in October 19892; the 29th Bethesda Conference (Ethics in Cardiovascular Medicine [1997]) was held in October 19973; and the collaborative effort (ACC/AHA Consensus Conference on Professionalism and Ethics) was held in June 2004.4 The specific major topics and subtopics discussed in these conferences reflect the ethical and professional issues extant at the time of the assemblies.The 21st Bethesda Conference2 was devoted to discussions of ethical decision making in medicine; the relation of cardiovascular specialists to patients, other physicians, and physician-owned organizations; the allocation of limited resources in cardiovascular medicine; scientific responsibility and integrity in medical research; and the relation of cardiovascular specialists to industry, institutions, and organizations.Subtopics included in the 21st Bethesda Conference discussion were the following: acting in the patient's interest; respecting the patient's preferences; distributive justice; physician responsibilities to society; medical decision making; end-of-life decisions; AIDS and the cardiovascular physician; conflicts of interest (COIs) and ethics in medical education; resource limitations and distribution; end-of-life care; cost and efficacy of medical technology; the welfare of the individual patient and the welfare of society; responsibilities of clinical investigators, research objectivity, credibility, and COIs; specific physician relationships with industry (RWIs); physician ownership of healthcare facilities; and physicians' relationships to institutions and organizations.The 29th Bethesda Conference3 discussed external influences on the practice of cardiology, application of medical and surgical intervention near the end of life, and clinical research in a molecular era and the need to expand its ethical imperatives.Subtopics discussed in the 29th Bethesda Conference included managed care and the reinterpretations of ethical standards and the concept of professionalism; the relationship of medical ethics and business ethics; the application of medical and surgical interventions in elderly patients; palliative care; futile care; forgoing treatment and advance care planning; physician-assisted suicide; ethical considerations in the conduct of clinical trials; the ethical, legal, and social implications of the Human Genome Project; data confidentiality; and genetic information and its implications for medical insurance.The ACC/AHA Consensus Conference4 dwelt on codes of conduct in human subjects research (HSR); investigator participation in clinical research; disclosure of relationships with commercial interests and policies for educational activities and publications; appropriate clinical care and issues of self-referral; expert testimony and opinions; and a code of conduct for organizational staff and volunteer leadership.Subtopics treated in the ACC/AHA Consensus Conference were COIs and proper disclosure; formal scrutiny of research involving human subjects; confidentiality in research activities; indemnification of research activities; avoidance of bias in clinical trials; physician self-referral; direct-to-consumer advertising; cardiovascular specialty hospitals and physician financial COIs; antikickback statutes; Stark laws; expert testimony in professional liability, class action litigation, and patent issues; and nonprofit organizational governance, management, and potential COIs.For the 3 prior ACC or ACC/AHA ethics and professionalism conferences, there were 164 unique attendees; 11.6% were identified as women, and 2.4% were identified as Black. Twenty of the 164 attendees were present at 2 or 3 of the conferences. Of the 164 attendees, 20 were past, present, or future ACC presidents, and 13 were past, present, or future AHA presidents. No attendees were identified as early career or fellows-in-training.In the 2020 Consensus Conference, of the 61 participating attendees, 41.2% were women, 7.9% were Black, and 4.8% were Hispanic. Three of the 61 were present at the prior conference in 2004; 6 were past, present, or future ACC presidents; and 4 were past, present, or future AHA presidents. Two 2020 Consensus Conference attendees were identified as early career, and 4 were fellows-in-training. Figure 1 shows comparative attendee demographic data for the combined earlier conferences and for the 2020 Consensus Conference.Download figureDownload PowerPointFigure 1. American Heart Association (AHA)/American College of Cardiology (ACC) conferences on professionalism and ethics: attendee demographics.Figure 2 shows the academic degrees and professional representations of the attendees at the current conference and at each of the 3 previous conferences. It is important to note that for the purpose of the current conference, the ascendancy of the team care paradigm in 21st century cardiovascular medicine is recognized, and references to physicians in prior publications, by extension, include all members of the healthcare team. In this document, the terms clinician, practitioner, and medical professional will be used in lieu of the term provider.Download figureDownload PowerPointFigure 2. American Heart Association (AHA)/American College of Cardiology (ACC) Conferences on Professionalism and Ethics: attendee academic and professional representation. Mean conference attendance=63.This document is a comprehensive summary of the deliberations of the 5 task forces that made up the 2020 Consensus Conference. Throughout the preparation of this report, efforts were made to be as concise as reasonably possible; however, because this is envisioned to be a reference document, essential detail was deliberately not euthanized for the sake of brevity.1.2. Context FramingThese conferences have reinforced the notion that the operative underpinning for the practice of medicine in the United States is a set of principles of medical ethics. These principles also form the basis for medical professionalism and what has become known in more recent years as medicine's social contract. Ethical medical practice is an a priori assumption of medicine's social contract, and the principles of ethics shape that contract, giving rise to the concept of professionalism and the rules by which that contract is implemented from the perspective of the medical professional.5,6The American College of Physicians7 and the American Medical Association (AMA)8 have codes of ethics for physicians. The American College of Physicians' Ethics Manual provides context, for example, in reviewing the principles of medical ethics and reminding us thatMedicine is not, as Francis Peabody said, "a trade to be learned, but a profession to be entered." A profession is characterized by a specialized body of knowledge that its members must teach and expand; by a code of ethics and a duty of service that, in medicine, puts patient care above self-interest; and by the privilege of self-regulation granted by society. Physicians must individually and collectively fulfill the duties of the profession.7The tenets of medical ethics, the principles and commitments of medical professionalism, and the specific obligations of medicine's social contract form the basis of this joint AHA/ACC study of medical ethics and professionalism in the 21st century. By way of creating a common ground of understanding, in this introduction, each of these 3 sets of elements is reviewed.1.3. The Tenets of Medical EthicsThe classic ethical principles of medical practice are duties based in respect for autonomy, beneficence, nonmaleficence, and justice.7,9Respect for autonomy. The duty to protect and foster a patient's free, uncoerced choices.Beneficence. The duty to promote good and to act in the best interest of the patient.Nonmaleficence. The duty to do no harm in every interaction with patients.Justice. There should be fairness and equity in health care.1.4. The Principles and Commitments of Medical ProfessionalismThe Physician Charter on Medical Professionalism was published in 2002 as a collaboration between the American Board of Internal Medicine Foundation, the American College of Physicians–American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine.10 Both the ACC and the AHA have officially endorsed the charter, as have >100 other medical professional organizations across the world.11 The charter contains eloquent, succinct, and actionable expressions of the principles and commitments of medical professionalism. Its descriptors are reproduced here with permission.101.4.1. Principles of ProfessionalismPrimacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.Patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.Social justice. The medical profession must promote justice in the healthcare system, including the fair distribution of healthcare resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, sex, socioeconomic status, ethnicity, religion, or any other social category.1.4.2. Commitments of ProfessionalismProfessional competence. Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal.Honesty with patients. Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that in health care, medical errors that injure patients sometimes do occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.Patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with individuals acting on a patient's behalf when obtaining the patient's own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an increasing availability of genetic information. Physicians recognize, however, that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others).Maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.Improving quality of care. Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, to increase patient safety, to minimize overuse of healthcare resources, and to optimize the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to routinely assess the performance of all individuals, institutions, and systems responsible for healthcare delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care.Improving access to care. Medical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.A just distribution of limited finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care.Scientific knowledge. Much of medicine's contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience.Maintaining trust by managing COIs. Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, to disclose to the general public, and to deal with COIs that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.Professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximize patient care, to be respectful of one another, and to participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.1.5. The Obligations of Medicine's Social ContractMedicine's social contract is an agreement between 2 parties: society as a whole and medical practitioners.12,13 Some elements of the contract are tacit, and some are codified in the laws and regulations governing the practice of medicine. Examples of the latter are laws establishing the healthcare system, educational requirements, and licensure. The tacit elements are behaviors and attitudes expressed by practitioners such as honesty, commitment, compassion, and altruism, none of which are concepts suitable for legislative or regulatory actions. Contracts—tacit or written—document the obligations agreed to by the parties involved. The obligations of the healthcare social contract, as delineated by Cruess and Cruess,14 are as follows:1.5.1. Medical Practitioners Agree to:Fulfill the role of the healer. The healer is an elemental and well-defined role in all human societies. Attributes of the healer include caring and compassion; insight and self-awareness; openness; respect for the healing function; respect for patient dignity and autonomy; being fully present and without distraction for the patient; and accompanying the patient through the journey of healing.15Achieve and maintain proficiency in the knowledge of their area of practice. At the basic level for initial licensure, all US states require an allopathic or osteopathic medical degree, successful completion of a licensure examination, and between 1 and 3 years of postgraduate training.16 For license renewal, all US states except Colorado and South Dakota require continuing medical education.17 At the higher clinical functioning level, all boards require postgraduate training in an approved program and successful completion of a comprehensive examination for specialty certification. All specialty boards provide time-limited certification, and all require participation in a maintenance of certification program for recent diplomates.18Achieve and maintain a high level of skill in their area of practice. At the level of the medical student, clinical skills are assessed by Step 2 (Clinical Skills) of the United States Medical Licensing Examination process.19 The Accreditation Council for Graduate Medical Education (ACGME) sets skill standards for residents and fellows-in-training.20 For the practicing physician, fulfillment of this obligation of the social contract is aspirational. There is no formal organization or process for assessing and documenting clinical skills beyond clinical training, although hospital medical staff quality committees have the responsibility of monitoring procedural outcomes across a variety of specialties.Provide for the patient's needs ahead of their own. This is the fundamental expression of altruism, which is a basic tenet of all descriptions of professionalism. The modern concept of altruism is that it is not an inherent, fixed personality trait; rather, it can be objectively measured and increased by education, practice, role modeling, and reinforcement.21Provide access to needed care. Five steps have recently been highlighted with which physicians can advocate or act to improve access to care for the most vulnerable of our fellow Americans:– Ensure adequate funding of the Children's Health Insurance Program and retain Medicaid expansion and implement expansion in more states.– Stabilize individual insurance marketplaces and retain Affordable Care Act market reforms.– Address physician clinical workforce shortages.– Expand telehealth and remote patient monitoring.– Increase the efficiency of the existing workforce by instituting common-sense medical liability reforms and reducing government and insurance industry regulatory burdens such as prior authorization that detract from patient care and increase costs.22Behave with morality, integrity, and honesty within a delineated code of ethics. Both the ACC23 and the AHA24 have established codes of ethics that define the values and behaviors required of their respective members.Be trustworthy. Patients must be confident that physicians will act not in self-interest but in the interests of their patients. Avoidance of even the appearance of a COI is the responsibility of each physician and is a corollary to the fundamental altruistic obligation to put the patient's needs ahead of the physician's own needs.25Show respect for patient dignity and autonomy. Respect for the dignity and autonomy of the patient is foundational to the pract

Background: Cardiovascular mortality is decreasing but remains the leading cause of death world-wide. Respiratory infections such as influenza significantly contribute to morbidity and mortality in patients with cardiovascular disease. Despite of proven benefits, influenza vaccination is not fully implemented, especially in Latin America. Objective: The aim was to develop a regional consensus with recommendations regarding influenza vaccination and cardiovascular disease. Methods: A multidisciplinary team composed by experts in the management and prevention of cardiovascular disease from the Americas, convened by the Inter-American Society of Cardiology (IASC) and the World Heart Federation (WHF), participated in the process and the formulation of statements. The modified RAND/UCLA methodology was used. This document was supported by a grant from the WHF. Results: An extensive literature search was divided into seven questions, and a total of 23 conclusions and 29 recommendations were achieved. There was no disagreement among experts in the conclusions or recommendations. Conclusions: There is a strong correlation between influenza and cardiovascular events. Influenza vaccination is not only safe and a proven strategy to reduce cardiovascular events, but it is also cost saving. We found several barriers for its global implementation and potential strategies to overcome them.

Background: Treatment of acute myocardial infarction (AMI) patients with prior stroke is a common clinical dilemma. Currently, the application of optimal medical therapy (OMT) and its impact on clinical outcomes are not clear in this patient population. Methods: We retrieved 765 AMI patients with prior stroke who underwent percutaneous coronary intervention (PCI) during the index hospitalization from the international multicenter BleeMACS registry. All of the subjects were divided into two groups based on the prescription they were given prior to discharge. Baseline characteristics and procedural variables were compared between the OMT and non-OMT groups. Mortality, re-AMI, major adverse cardiovascular events (MACE), and bleeding were followed-up for 1 year. Results: Approximately 5% of all patients presenting with AMI were admitted to the hospital for ischemic stroke. Although the prescription rate of each OMT medication was reasonably high (73.3%–97.3%), 47.7% lacked at least one OMT medication. Patients receiving OMT showed a significantly decreased occurrence of mortality (4.5% vs 15.1%, p < 0.001), re-AMI (4.2% vs 9.3%, p = 0.004), and the composite endpoint of death/re-AMI (8.6% vs 20.5%, p < 0.001) compared to those without OMT. No significant difference was observed between the groups regarding bleeding. After adjusting for confounding factors, OMT was the independent protective factor of 1-year mortality, while age was the independent risk factors. Conclusions: OMT at discharge was associated with a significantly lower 1-year mortality of patients with AMI and prior stroke in clinical practice. However, OMT was provided to just half of the eligible patients, leaving room for substantial improvement. Clinical Trial Registration: NCT02466854

OBJECTIVES The aim of this study was to assess 1-year clinical outcomes among high-risk patients with failed surgical mitral bioprostheses who underwent transseptal mitral valve-in-valve (MViV) with the SAPIEN 3 aortic transcatheter heart valve (THV) in the MITRAL (Mitral Implantation of Transcatheter Valves) trial. BACKGROUND The MITRAL trial is the first prospective study evaluating transseptal MViV with the SAPIEN 3 aortic THV in high-risk patients with failed surgical mitral bioprostheses. METHODS High-risk patients with symptomatic moderate to severe or severe mitral regurgitation (MR) or severe mitral stenosis due to failed surgical mitral bioprostheses were prospectively enrolled. The primary safety endpoint was technical success. The primary THV performance endpoint was absence of MR grade >=-2+ or mean mitral valve gradient >= 10 mm Hg (30 days and 1 year). Secondary endpoints included procedural success and all-cause mortality (30 days and 1 year). RESULTS Thirty patients were enrolled between July 2016 and October 2017 (median age 77.5 years [interquartile range (IQR): 70.3 to 82.8 years], 63.3% women, median Society of Thoracic Surgeons score 9.4% [IQR: 5.8% to 12.0%], 80% in New York Heart Association functional class III or IV). The technical success rate was 100%. The primary performance endpoint in survivors was achieved in 96.6% (28 of 29) at 30 days and 82.8% (24 of 29) at 1 year. Thirty-day all-cause mortality was 3.3% and was unchanged at 1 year. The only death was due to airway obstruction after swallowing several pills simultaneously 29 days post-MViV. At 1-year follow-up, 89.3% of patients were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.6 mm Hg (interquartile range: 5.5 to 8.9 mm Hg), and all patients had MR grade <= 1+. CONCLUSIONS Transseptal MViV in high-risk patients was associated with 100% technical success, low procedural complication rates, and very low mortality at 1 year. The vast majority of patients experienced significant symptom alleviation, and THV performance remained stable at 1 year. (J Am Coll Cardiol Intv 2021;14:859-72) (c) 2021 by the American College of Cardiology Foundation.

Background As cardiovascular disease is a leading cause of death in cancer survivors, the new subspecialty of Cardio-Oncology has emerged to address prevention, monitoring, and management of cardiovascular toxicities to cancer therapies. During the coronavirus disease of 2019 (COVID-19) pandemic, we developed a Virtual-Hybrid Approach to build a de novo Cardio-Oncology Clinic. Methods We conceptualized a Virtual-Hybrid Approach including three arms: information seeking in locations with existing Cardio-Oncology clinics, information gathering at the location for a new clinic, and information sharing to report clinic-building outcomes. A retrospective review of outcomes included collection and synthesis of data from our first 3 months (at pandemic peak) on types of appointments, cancers, drugs, and cardiotoxicities. Data were presented using descriptive statistics. Results A de-novo Cardio-Oncology clinic was developed structured from the ground up to integrate virtual and in-person care in a hybrid and innovative model, using the three arms of the Virtual-Hybrid Approach. First, we garnered in-person and virtual preparation through hands-on experiences, training, and discussions in existing Cardio-Oncology Clinics and conferences. Next, we gleaned information through virtual inquiry and niche-building. With partners throughout the institution, a virtual referral process was established for outpatient referrals and inpatient e-consult referrals to actualize a hybrid care spectrum for our patients administered by a multidisciplinary hybrid care team of clinicians, ancillary support staff, and clinical pharmacists. Among the multi-subspecialty clinic sessions, approximately 50% were in Cardio-Oncology, 20% in Preventive Cardiology, and 30% in General Cardiology. In the hybrid model, the Heart & Vascular Center had started to re-open, allowing for 65% of our visits to be in person. In additional analyses, the most frequent cardiovascular diagnosis was cardiomyopathy (34%), the most common cancer drug leading to referral was trastuzumab (29%), and the most prevalent cancer type was breast cancer (42%). Conclusion This Virtual-Hybrid Approach and retrospective review provides guidance and information regarding initiating a brand-new Cardio-Oncology Clinic during the pandemic for cancer patients/survivors. This report also furnishes virtual resources for patients, virtual tools for oncologists, cardiologists, and administrators tasked with starting new clinics during the pandemic, and innovative future directions for this digital pandemic to post-pandemic era.

Although drug-eluting stents are still the default interventional treatment of coronary artery disease, drug-coated balloons (DCBs) represent a novel alternative therapeutic strategy in certain anatomic conditions. The effect of DCBs is based on the fast and homogenous transfer of antiproliferative drugs into the vessel wall during single balloon inflation by means of a lipophilic matrix without the use of permanent implants. Although their use is established for in-stent restenosis of both bare-metal and drug-eluting stents, recent randomized clinical data demonstrate a good efficacy and safety profile in de novo small-vessel disease and high bleeding risk. In addition, there are other emerging indications (e.g., bifurcation lesions, large-vessel disease, diabetes mellitus, acute coronary syndromes). Because the interaction among the different delivery balloon designs, doses, formulations, and release kinetics of the drugs used is important, there seems to be no “class effect” of DCBs. On the basis of the amount of recently published data, the International DCB Consensus Group provides this update of previous recommendations summarizing the historical background, technical considerations such as choice of device and implantation technique, possible indications, and future perspectives.

Although drug-eluting stents are still the default interventional treatment of coronary artery disease, drug-coated balloons (DCBs) represent a novel alternative therapeutic strategy in certain anatomic conditions. The effect of DCBs is based on the fast and homogenous transfer of antiproliferative drugs into the vessel wall during single balloon inflation by means of a lipophilic matrix without the use of permanent implants. Although their use is established for in-stent restenosis of both bare-metal and drug-eluting stents, recent randomized clinical data demonstrate a good efficacy and safety profile in de novo small-vessel disease and high bleeding risk. In addition, there are other emerging indications (e.g., bifurcation lesions, large-vessel disease, diabetes mellitus, acute coronary syndromes). Because the interaction among the different delivery balloon designs, doses, formulations, and release kinetics of the drugs used is important, there seems to be no “class effect” of DCBs. On the basis of the amount of recently published data, the International DCB Consensus Group provides this update of previous recommendations summarizing the historical background, technical considerations such as choice of device and implantation technique, possible indications, and future perspectives.

Cannabis, or marijuana, has potential therapeutic and medicinal properties related to multiple compounds, particularly Δ-9-tetrahydrocannabinol and cannabidiol. Over the past 25 years, attitudes toward cannabis have evolved rapidly, with expanding legalization of medical and recreational use at the state level in the United States and recreational use nationally in Canada and Uruguay. As a result, the consumption of cannabis products is increasing considerably, particularly among youth. Our understanding of the safety and efficacy of cannabis has been limited by decades of worldwide illegality and continues to be limited in the United States by the ongoing classification of cannabis as a Schedule 1 controlled substance. These shifts in cannabis use require clinicians to understand conflicting laws, health implications, and therapeutic possibilities. Cannabis may have therapeutic benefits, but few are cardiovascular in nature. Conversely, many of the concerning health implications of cannabis include cardiovascular diseases, although they may be mediated by mechanisms of delivery. This statement critically reviews the use of medicinal and recreational cannabis from a clinical but also a policy and public health perspective by evaluating its safety and efficacy profile, particularly in relationship to cardiovascular health.

BACKGROUND There is a paucity of data on the burden of in-stent restenosis (ISR) in the United States as well as on its presentation and appropriate treatment strategies. OBJECTIVES This study aims to provide an analysis of the temporal trends, clinical presentation, treatment strategies, and in-hospital outcomes of patients undergoing percutaneous coronary intervention (PCI) for ISR in the United States. METHODS This study is a retrospective analysis of data collected in the Diagnostic Catheterization and Percutaneous Coronary Intervention (CathPCI) registry of the National Cardiovascular Data Registry (NCDR) between 2009 and 2017. Of the total patients undergoing PCI, we identified those undergoing PCI for ISR lesions. For comparison of in-hospital outcomes, propensity-score matching was employed. RESULTS Among the 5,100,394 patients undergoing PCI, 10.6% of patients underwent PCI for ISR lesions. Patients with bare-metal stent ISR declined from 2.6% in 2009 Q3 to 0.9% in 2017 Q2 (p < 0.001), and drug-eluting stent ISR rose from 5.4% in 2009 Q3 to 6.3% in 2017 Q2 (p < 0.001). Patients with ISR PCI were less likely to present with non-ST-segment elevation myocardial infarction (MI) (18.7% vs. 22.5%; p < 0.001) or ST-segment elevation MI (8.5% vs. 15.7%; p < 0.001). In the propensity-matched population of patients, there were no significant differences between patients with ISR and non-ISR PCI for in-hospital complications and hospital length of stay. CONCLUSIONS ISR represents approximately 10% of all PCI and is treated most commonly with another stent. Approximately 25% of patients present with acute MI. In-hospital outcomes of patients with ISR PCI are comparable with those undergoing non-ISR PCI. (C) 2020 by the American College of Cardiology Foundation.

No está clara la asociación entre los inhibidores de la enzima de conversión de la angiotensina (IECA) o los antagonistas del receptor de la angiotensina II (ARA-II) y la mortalidad de los pacientes con síndrome coronario agudo (SCA) sometidos a intervención coronaria percutánea (ICP) con fracción de eyección del ventrículo izquierdo (FEVI) conservada. Nuestro objetivo es determinar dicha asociación en pacientes con FEVI conservada o reducida. Se analizaron datos procedentes del registro BleeMACS. El objetivo principal fue la mortalidad a 1 año. Se aplicaron ponderación por la probabilidad inversa del tiempo de supervivencia y ajustes por regresión de Cox, puntuación de propensión y variables instrumentales. De los 15.401 pacientes con SCA sometidos a ICP, se prescribieron IECA/ARA-II al 75,2%. Se produjeron 569 muertes (3,7%) durante el primer año tras el alta hospitalaria. Después del ajuste multivariado, los IECA/ARA-II se asociaron con menor mortalidad, pero solo en los pacientes con FEVI ≤ 40% (HR = 0,62; IC95%, 0,43-0,90; p = 0,012). Con los IECA/ARA-II, la reducción del riesgo relativo de la mortalidad estimada fue del 46,1% en los pacientes con FEVI ≤ 40% y del 15,7% en aquellos con FEVI > 40% (pinteracción = 0,008). En los pacientes con FEVI > 40%, los IECA/ARA-II se asociaron con menor mortalidad solo por infarto agudo de miocardio con elevación del segmento ST (HR = 0,44; IC95%, 0,21-0.93; p = 0,031). El beneficio de los IECA/ARA-II en mortalidad tras ICP por SCA se concentra en pacientes con FEVI ≤ 40% y aquellos con FEVI > 40% e infarto agudo de miocardio con elevación del segmento ST. Se precisan estudios contemporáneos que analicen el impacto de los IECA/ARA-II en pacientes con SCA sin elevación del segmento ST y FEVI > 40%. For patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), it is unclear whether angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are associated with reduced mortality, particularly with preserved left ventricular ejection fraction (LVEF). The goal of this study was to determine the association between ACEI/ARB and mortality in ACS patients undergoing PCI, with and without reduced LVEF. Data from the BleeMACS registry were used. The endpoint was 1-year all-cause mortality. The prognostic value of ACEI/ARB was tested after weighting by survival-time inverse probability and after adjustment by Cox regression, propensity score, and instrumental variable analysis. Among 15 401 ACS patients who underwent PCI, ACEI/ARB were prescribed in 75.2%. There were 569 deaths (3.7%) during the first year after hospital discharge. After multivariable adjustment, ACEI/ARB were associated with lower 1-year mortality, ≤ 40% (HR, 0.62; 95%CI, 0.43-0.90; P = .012). The relative risk reduction of ACEI/ARB in mortality was 46.1% in patients with LVEF ≤ 40%, and 15.7% in patients with LVEF > 40% (P value for treatment-by-LVEF interaction = .008). For patients with LVEF > 40%, ACEI/ARB was associated with lower mortality only in ST-segment elevation myocardial infarction (HR, 0.44; 95%CI, 0.21-0.93; P = .031). The benefit of ACEI/ARB in decreasing mortality after an ACS in patients undergoing PCI is concentrated in patients with LVEF ≤ 40%, and in those with LVEF > 40% and ST-segment elevation myocardial infarction. In non–ST-segment elevation-ACS patients with LVEF > 40%, further studies are needed to assess the prognostic impact of ACEI/ARB.

INTRODUCTION:NVAF is estimated to affect between 6.4 and 7.4 million Americans in 2018, and increases the risk of stroke 5-fold. To mitigate this risk, guidelines recommend anticoagulating AF patients unless their stroke risk is very low. Despite these recommendations, 30.0-60.0% of NVAF patients do not receive indicated anticoagulation. To better understand why this may be, we surveyed PCPs and cardiologists nationwide on their attitudes, knowledge and practices toward managing NVAF with warfarin and direct-acting oral anticoagulants (DOACs).METHODS:We surveyed 1,000 PCPs and 500 cardiologists selected randomly from a master list of the American Medical Association, using a paper based, anonymous, self-administered, mailed scannable survey. The survey contained questions on key demographics and data concerning attitudes, knowledge and practices related to prescribing DOACs. The surveys went out in the fall/winter of 2017-8 with a $10 incentive gift card. Survey responses were scanned into an Excel database and analyzed using SAS 9.3 (Cary, NC) for descriptive and inferential statistics.RESULTS:Two hundred and forty-nine providers (167 PCPs, 82 cardiologists) participated in the study with a response rate of 18.8% (249/1320). Respondent mean years ±SD of experience since completing residency was 23.2 ± 13.8. Relative to cardiologists, less PCPs use CHADsVASC (36.8% vs. 74.4%) (p < 0.0001); more have never used HAS-BLED, HEMORR2HAGES, or ATRIA (38.5% vs. 9.8%) (p < .0001); more felt that their lack of knowledge/experience with DOACs was a barrier to prescribing the agents (p = 0.005); and more reported that they could use additional education on DOACs (87.0% vs. 47.0%) (p < 0.0001). Overall, cardiologists were more concerned about ischemic stroke outcomes, while PCPs were more concerned with GI bleeding. Cardiologists also felt that clinical trial data were most helpful in choosing the most appropriate DOAC for their patients, while PCPs felt that Real World Data was most useful.CONCLUSIONS:Cardiologists were more concerned with ischemic stroke while anticoagulating patients and utilized screening instruments like CHADsVASC in a majority of their patients. PCPs were concerned with GI bleeds when anticoagulating but nearly 40.0% utilized no screening tools to assess bleeding risk. Our findings show that future education about DOACs would be warranted especially with PCPs.