Introduction: Teen pregnancy (TP), defined as pregnancy between 10 and 19 years, is associated with adverse pregnancy outcomes and perpetuates socioeconomic disadvantage, but the impact in later life is not well studied. We investigated the association of TP with premature major adverse cardiovascular events (PMACE) Methods: We used data from the National Health and Nutrition Examination Survey 1999–2018. Surveys were linked with the National Death Index to ascertain mortality records. Only adult females aged 20 years and older were included in the analysis. Participants were divided into 3 groups based on age at their first life birth: 19 or younger (TP), 20 and above (non-TP), and nulliparous women (NP). TP was ascertained by age at first life birth ≤ 19 years, and PMACE was defined as any self-reported diagnosis of coronary artery disease, stroke, heart failure, or all-cause mortality occurring before age 65. We assessed the association between these groups and PMACE using univariate and multivariate logistic regression models. Result: Among 19,737 (weighted frequency of 83,450,668) adult females, 24.2% had a history of TP, 54.3% had a history of non-TP and 21.5% were NP. Compared with NP females, females with TP had a higher odd of PMACE with an unadjusted odd ratio of 3.75 (95%CI, 2.80 - 5.01) versus 2.07 (1.55 – 2.75) among non-TP. Adjusting for age, race, alcohol use, smoking, and social determinants of health factors such as income, educational status, insurance status, and food insecurity, TP remained independently associated with higher odds of PMACE with an adjusted odd ratio of 1.66 (95%CI, 1.19 – 2.30); p=0.003, but this association was not statistically significant among non-TP females with aOR 1.32 (0.95 – 1.84); p=0.10. Conclusion: Teen pregnancy was associated with higher likelihood of PMACE. This association may be indicative of the enduring impact of social determinants of health factors associated with teen pregnancy into adulthood.

Racial, Ethnic, Socioeconomic, and Geographic Inequities in Access to Mechanical Circulatory SupportJournal of the Society for Cardiovascular Angiography & Interventions101193PreviewHospital admissions for cardiogenic shock have increased in the United States. Temporary mechanical circulatory support (tMCS) can be used to acutely stabilize patients. We sought to evaluate the presence of racial, ethnic, and socioeconomic inequities in access to MCS in the United States among patients with cardiogenic shock. Full-Text PDF Open Access With advances in primary percutaneous coronary intervention and the integration of regionalized systems of care networks, in-hospital mortality following acute myocardial infarction (AMI) has dropped to <5%1McNamara R.L. Kennedy K.F. Cohen D.J. et al.Predicting in-hospital mortality in patients with acute myocardial infarction.J Am Coll Cardiol. 2016; 68: 626-635https://doi.org/10.1016/j.jacc.2016.05.049Crossref PubMed Scopus (158) Google Scholar; however, in the 5% to 12% of AMI complicated by circulatory collapse due to cardiogenic shock (CS), short-term mortality rates remain >40%.2Hochman J.S. Sleeper L.A. Webb J.G. et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock.N Engl J Med. 1999; 341: 625-634https://doi.org/10.1056/NEJM199908263410901Crossref PubMed Scopus (2377) Google Scholar, 3Kolte D. Khera S. Aronow W.S. et al.Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.J Am Heart Assoc. 2014; 3e000590https://doi.org/10.1161/JAHA.113.000590Crossref Scopus (420) Google Scholar, 4Sterling L.H. Fernando S.M. Talarico R. et al.Long-term outcomes of cardiogenic shock complicating myocardial infarction.J Am Coll Cardiol. 2023; 82: 985-995https://doi.org/10.1016/j.jacc.2023.06.026Crossref Scopus (1) Google Scholar In response to these discouraging outcomes, an increasing number of patients with CS due to AMI or acutely decompensated heart failure undergo implantation of temporizing mechanical circulatory support (tMCS) devices to support hemodynamics and end-organ perfusion as a bridge to myocardial recovery or advanced cardiac replacement therapies.5Shah M. Patnaik S. Patel B. et al.Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States.Clin Res Cardiol. 2018; 107: 287-303https://doi.org/10.1007/s00392-017-1182-2Crossref PubMed Scopus (182) Google Scholar,6Schrage B. Becher P.M. Goßling A. et al.Temporal trends in incidence, causes, use of mechanical circulatory support and mortality in cardiogenic shock.ESC Heart Fail. 2021; 8: 1295-1303https://doi.org/10.1002/ehf2.13202Crossref PubMed Scopus (42) Google Scholar More recently, this surge in CS device-based therapy has been fueled by an increase in the deployment of microaxial left ventricular assist devices (mLVAD) and extracorporeal membrane oxygenation (ECMO), given their enhanced hemometabolic support capabilities compared with conventional intraaortic balloon pump (IABP).7Thiele H. Jobs A. Ouweneel D.M. et al.Percutaneous short-term active mechanical support devices in cardiogenic shock: a systematic review and collaborative meta-analysis of randomized trials.Eur Heart J. 2017; 38: 3523-3531https://doi.org/10.1093/eurheartj/ehx363Crossref PubMed Scopus (238) Google Scholar, 8Amin A.P. Spertus J.A. Curtis J.P. et al.The evolving landscape of Impella use in the United States among patients undergoing percutaneous coronary intervention with mechanical circulatory support.Circulation. 2020; 141: 273-284https://doi.org/10.1161/CIRCULATIONAHA.119.044007Crossref PubMed Scopus (242) Google Scholar, 9Syed M. Khan M.Z. Osman M. et al.Sixteen-year national trends in use and outcomes of VA-ECMO in cardiogenic shock.Cardiovasc Revasc Med. 2022; 44: 1-7https://doi.org/10.1016/j.carrev.2022.06.267Crossref Scopus (6) Google Scholar This trend continues despite an absence of randomized clinical trial (RCT) data demonstrating improvement in short-term survival with tMCS devices compared with medical therapy or IABP, and with clinical guidelines assigning their routine use in AMI-CS only a Class IIb (Level of Evidence: C) recommendation.10Karami M. Eriksen E. Ouweneel D.M. et al.Long-term 5-year outcome of the randomized IMPRESS in severe shock trial: percutaneous mechanical circulatory support vs. intra-aortic balloon pump in cardiogenic shock after acute myocardial infarction.Eur Heart J Acute Cardiovasc Care. 2021; 10: 1009-1015https://doi.org/10.1093/ehjacc/zuab060Crossref PubMed Scopus (24) Google Scholar, 11Thiele H. Zeymer U. Akin I. et al.Extracorporeal life support in infarct-related cardiogenic shock.N Engl J Med. 2023; 389: 1286-1297https://doi.org/10.1056/NEJMoa2307227Crossref Google Scholar, 12Levine G.N. Bates E.R. Blankenship J.C. et al.ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction.Circulation. 2016; 133: 1135-1147https://doi.org/10.1161/CIR.0000000000000336Crossref PubMed Scopus (339) Google Scholar Perhaps, the increased use of tMCS devices is fueled by data from dedicated North American CS registries that show that the early use of hemodynamically tailored tMCS at institutions with appropriate levels of expertise is associated with improved survival.13Basir M.B. Kapur N.K. Patel K. et al.Improved outcomes associated with the use of shock protocols: updates from the national cardiogenic shock initiative.Catheter Cardiovasc Interv. 2019; 93: 1173-1183https://doi.org/10.1002/ccd.28307Crossref PubMed Scopus (271) Google Scholar, 14Tehrani B.N. Truesdell A.G. Sherwood M.W. et al.Standardized team-based care for cardiogenic shock.J Am Coll Cardiol. 2019; 73: 1659-1669https://doi.org/10.1016/j.jacc.2018.12.084Crossref PubMed Scopus (277) Google Scholar, 15Papolos A.I. Kenigsberg B.B. Berg D.D. et al.Management and outcomes of cardiogenic shock in cardiac ICUs with versus without shock teams.J Am Coll Cardiol. 2021; 78: 1309-1317https://doi.org/10.1016/j.jacc.2021.07.044Crossref PubMed Scopus (62) Google Scholar To muddy the waters in this field even further, there is marked regional variation in the expertise, access to, and use of tMCS devices for CS patients who remain unresponsive to conventional treatment strategies.8Amin A.P. Spertus J.A. Curtis J.P. et al.The evolving landscape of Impella use in the United States among patients undergoing percutaneous coronary intervention with mechanical circulatory support.Circulation. 2020; 141: 273-284https://doi.org/10.1161/CIRCULATIONAHA.119.044007Crossref PubMed Scopus (242) Google Scholar,16Shaefi S. O’gara B. Kociol R.D. et al.Effect of cardiogenic shock hospital volume on mortality in patients with cardiogenic shock.J Am Heart Assoc. 2015; 4e001462https://doi.org/10.1161/JAHA.114.001462Crossref Scopus (120) Google Scholar, 17Geller B.J. Sinha S.S. Kapur N.K. et al.Escalating and de-escalating temporary mechanical circulatory support in cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2022; 146: e50-e68https://doi.org/10.1161/CIR.0000000000001076Crossref PubMed Scopus (35) Google Scholar, 18Elbadawi A. Elgendy I.Y. Omer M.A. et al.Hospital volume and in-hospital outcomes with Impella guided percutaneous coronary interventions: insights from a national database.Am J Cardiol. 2020; 125: 1753-1754https://doi.org/10.1016/j.amjcard.2020.03.007Abstract Full Text Full Text PDF Scopus (2) Google Scholar How tMCS use is influenced by patient demographic characteristics, such as race, ethnicity, and social determinants of health has not been well studied. In this issue of JSCAI, Nathan et al19Nathan A.S. Reddy K.P. Eberly L.A. et al.Racial, ethnic, socioeconomic, and geographic inequities in access to mechanical circulatory support.J Soc Cardiovasc Angiogr Interv. 2023; Google Scholar examined racial, ethnic, and socioeconomic disparities in access to tMCS in Medicare beneficiaries with an admission or diagnosis discharge of CS who were treated with IABP, mLVAD, or ECMO at 1829 percutaneous coronary intervention-capable acute care facilities at the 25 largest core-based statistical areas in the United States. These authors should be commended for performing an in-depth analysis that provides insight into this device-related health care disparity. Using Medicare demographic characteristics to identify race and ethnicity, and individual assessments of median household income, Medicaid dual-eligibility, and distressed community index scores to categorize socioeconomic status, the authors (1) compared patient socioeconomic and hospital characteristics of institutions with and without mLVAD or ECMO programs; (2) determined the likelihood of mLVAD or ECMO use based on race, ethnicity, and socioeconomic status; and (3) described variations in ZIP code-level age-adjusted rates of mLVAD utilization. The findings were sobering; widespread disparities in access to these cutting-edge therapies were observed based on race and ethnicity. More than 90% of sites with mLVAD and ECMO programs were located in metropolitan areas, and these hospitals were more likely to treat patients with high median household incomes. Only 3 centers with mLVAD and 1 with ECMO capabilities were identified in rural areas. Racial and ethnic disparities were equally stark, with <10% of all patients receiving an mLVAD self-identifying as African American. Using generalized linear mixed effects models, they elucidated associations between socioeconomic status, race, ethnicity, and the likelihood of receiving an mLVAD. African American and dual Medicaid-eligible CS patients were at significant disadvantages, with the odds of receiving these advanced device-based treatment strategies reduced by 37% and 20%, respectively. More pronounced findings were noted with ECMO, such that for each $1000 decrement in median household income there was a 35% reduction in the likelihood of receiving this form of cardiopulmonary support. Again, African Americans and dual Medicaid eligible patients fared most poorly, as their odds of undergoing cannulation for refractory circulatory collapse were reduced by 36% and 62%, respectively. Chloropleth maps of the core-based statistical areas in question graphically reinforced these study findings by demonstrating that African Americans, Hispanics, and patients who were dual Medicaid eligible had markedly attenuated rates of implantation of these devices. There is precedent for demographic and geographic variations in access to cutting-edge technologies across the spectrum of interventional cardiology.20Damluji A.A. Fabbro M. Epstein R.H. et al.Transcatheter aortic valve replacement in low-population density areas: assessing healthcare access for older adults with severe aortic stenosis.Circ Cardiovasc Qual Outcomes. 2020; 13e006245https://doi.org/10.1161/CIRCOUTCOMES.119.006245Crossref Scopus (11) Google Scholar, 21Steitieh D. Zaidi A. Xu S. et al.Racial disparities in access to high-volume mitral valve transcatheter edge-to-edge repair centers.J Soc Cardiovasc Angiogr Interv. 2022; 1100398https://doi.org/10.1016/j.jscai.2022.100398Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 22Kupsky D.F. Wang D.D. Eng M. et al.Socioeconomic disparities in access for watchman device insertion in patients with atrial fibrillation and at elevated risk of bleeding.Struct Heart. 2019; 3: 144-149https://doi.org/10.1080/24748706.2019.1569795Abstract Full Text Full Text PDF Google Scholar, 23Maknojia A. Gilani A. Ghatak A. Racial disparity in patients with chronic coronary total occlusion undergoing interventions.J Soc Cardiovasc Angiogr Interv. 2022; 1: E-21Google Scholar Using health care administrative inpatient claims data, Damluji et al20Damluji A.A. Fabbro M. Epstein R.H. et al.Transcatheter aortic valve replacement in low-population density areas: assessing healthcare access for older adults with severe aortic stenosis.Circ Cardiovasc Qual Outcomes. 2020; 13e006245https://doi.org/10.1161/CIRCOUTCOMES.119.006245Crossref Scopus (11) Google Scholar reported a nearly 7-fold difference in transcatheter aortic valve replacement utilization rates in the state of Florida, with the majority of dedicated valve centers located in high population density areas, and those residing in low population density areas having marked increases in travel time/distance and >6 fold higher procedural mortality. Parallel findings were noted in a contemporary analysis of 1567 hospital discharges following transcatheter edge-to-edge repair for severe mitral valve regurgitation from the Arizona, Colorado, Florida, Maryland, North Carolina, New Jersey, New York, and Virginia State Inpatient Databases. Specifically, there were significant racial disparities in access to high-volume mitral valve institutions, with African Americans and Hispanics being afforded 59% and 51% lower chances of access to transcatheter mitral valve repair at high-volume centers, respectively.21Steitieh D. Zaidi A. Xu S. et al.Racial disparities in access to high-volume mitral valve transcatheter edge-to-edge repair centers.J Soc Cardiovasc Angiogr Interv. 2022; 1100398https://doi.org/10.1016/j.jscai.2022.100398Abstract Full Text Full Text PDF Scopus (2) Google Scholar Hispanics were also 3 times more likely to experience in-hospital mortality post-procedure.21Steitieh D. Zaidi A. Xu S. et al.Racial disparities in access to high-volume mitral valve transcatheter edge-to-edge repair centers.J Soc Cardiovasc Angiogr Interv. 2022; 1100398https://doi.org/10.1016/j.jscai.2022.100398Abstract Full Text Full Text PDF Scopus (2) Google Scholar Unlike valve therapies, tMCS devices have not been associated with improved survival, and they are often implanted under emergency circumstances, in which the rates of major bleeding complications and acute limb ischemia may be as high as 40%.24Pahuja M. Ranka S. Chehab O. et al.Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock.Catheter Cardiovasc Interv. 2021; 97: 1129-1138https://doi.org/10.1002/ccd.29003Crossref PubMed Scopus (26) Google Scholar, 25Cheng R. Hachamovitch R. Kittleson M. et al.Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients.Ann Thorac Surg. 2014; 97: 610-616https://doi.org/10.1016/j.athoracsur.2013.09.008Abstract Full Text Full Text PDF PubMed Scopus (610) Google Scholar, 26Stone G.W. Abraham W.T. Lindenfeld J. et al.Five-year follow-up after transcatheter repair of secondary mitral regurgitation.N Engl J Med. 2023; 388: 2037-2048https://doi.org/10.1056/NEJMoa2300213Crossref PubMed Scopus (30) Google Scholar, 27Mack M.J. Leon M.B. Thourani V.H. et al.Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705https://doi.org/10.1056/NEJMoa1814052Crossref PubMed Scopus (2900) Google Scholar There exist well-established relationships between volume and outcomes in CS.16Shaefi S. O’gara B. Kociol R.D. et al.Effect of cardiogenic shock hospital volume on mortality in patients with cardiogenic shock.J Am Heart Assoc. 2015; 4e001462https://doi.org/10.1161/JAHA.114.001462Crossref Scopus (120) Google Scholar Therefore, another unwanted impact of the low use of tMCS devices in nonmetropolitan hospitals is that these facilities may experience worse outcomes and higher complication rates with the infrequent use of devices. In the context of recent observational data suggesting the potential for improved outcomes when tMCS devices are implanted using standardized team-based protocols, one may argue that the demographic and geographic differences in outcomes with CS seen today are in part due to the nonuniform patterns of patient selection seen in real-world clinical practice.13Basir M.B. Kapur N.K. Patel K. et al.Improved outcomes associated with the use of shock protocols: updates from the national cardiogenic shock initiative.Catheter Cardiovasc Interv. 2019; 93: 1173-1183https://doi.org/10.1002/ccd.28307Crossref PubMed Scopus (271) Google Scholar Notwithstanding the absence of professional societal guideline support for the broad use of tMCS devices in CS, the findings of Nathan et al highlight pervasive racial and ethnic barriers to the use of advanced medical device therapies present in the US health care system. These inequities have historically and disproportionately affected segments of our society who not only have the greatest burden of health and social risk factors but who are also underrepresented in clinical trials and whose voices are often not heard28Caraballo C. Ndumele C.D. Roy B. et al.Trends in racial and ethnic disparities in barriers to timely medical care among adults in the US, 1999 to 2018.JAMA Health Forum. 2022; 10 (3)e223856https://doi.org/10.1001/jamahealthforum.2022.3856Crossref Scopus (7) Google Scholar, 29Epps K. Goel R. Mehran R. et al.Influence of race/ethnicity and sex on coronary stent outcomes in diabetic patients.J Soc Cardiovasc Angiogr Interv. 2023; 2https://doi.org/10.1016/j.jscai.2023.101053Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 30Ortega R.F. Yancy C.W. Mehran R. Batchelor W. Overcoming lack of diversity in cardiovascular clinical trials: a new challenge and strategies for success.Circulation. 2019; 140: 1690-1692https://doi.org/10.1161/CIRCULATIONAHA.119.041728Crossref PubMed Scopus (33) Google Scholar within the cacophony of health care discussions. In the case of tMCS, further research is needed in the form of pragmatic and adequately powered RCT enriched with broad patient subsets and prespecified definitions and protocols. Coupled with multicenter collaborations such as the American Heart Association’s Cardiogenic Shock Registry31Cardiogenic Shock Registryhttps://www.heart.org/en/professional/quality-improvement/cardiogenic-shock-registryDate accessed: October 12, 2023Google Scholar and regionalized shock networks, these efforts may provide further insight into the utilization and outcomes associated with advanced device-based interventions for CS across race, ethnicity, sex, rurality, and socioeconomic status. However, at their core, the findings of Nathan et al are disturbingly emblematic of a much more complex and challenging sociopolitical problem that is deeply rooted in the world’s richest health care system. Therefore, to truly level the “device therapy playing field” will require not only more targeted health-related outcomes research but a national commitment to improve health care access and quality, in general, and especially for those most in need of acute lifesaving therapies. Behnam Tehrani has received research grant funding support from Boston Scientific, and he is an advisor to Abbott Medical. Kelly Epps has no disclosures. Wayne Batchelor has served as a consultant for Boston Scientific, Abbott, Medtronic, and V-Wave. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Background Distal transradial access (dTRA) is an alternative to conventional forearm transradial access (fTRA) for coronary angiography (CAG). Differences in healing of the radial artery (RA) in the forearm have not been evaluated between these 2 access strategies. We sought to compare the mean difference in forearm RA intimal‐medial thickening (IMT) in patients randomized to dTRA versus fTRA. Methods and Results In this single‐center randomized clinical trial, 64 patients undergoing nonemergent CAG were randomized (1:1) to dTRA versus fTRA. Ultra–high‐resolution (55‐MHz) vascular ultrasound of the forearm and distal RA was performed pre‐CAG and at 90 days. The primary end point was the mean change in forearm RA IMT. Secondary end points included procedural characteristics, vascular injury, RA occlusion, and ipsilateral hand pain and function. Baseline demographics and clinical characteristics, mean forearm RA IMT, and procedural specifics were similar between the dTRA and fTRA cohorts. There was no difference in mean change in forearm RA IMT between the 2 cohorts (0.07 versus 0.07 mm; P=0.37). No RA occlusions or signs of major vascular injury were observed at 90 days. Ipsilateral hand pain and function (Borg pain scale score: 12 versus 11; P=0.24; Disabilities of the Arm, Shoulders, and Hand scale score: 6 versus 8; P=0.46) were comparable. Conclusions Following CAG, dTRA was associated with no differences in mean change of forearm RA IMT, hand pain, and function versus fTRA for CAG. Further investigation is warranted to elucidate mechanisms and predictors of RA healing and identify effective strategies to preserving RA integrity for repeated procedures. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04801901.

Patent Foramen Ovale (PFO) is a common congenital atrial septal defect present in 20%–35% of the general population. Although generally considered a benign anatomic variant, a PFO may facilitate passage of a thrombus from the venous to arterial circulation, thereby resulting in cryptogenic stroke or systemic embolization. A PFO is detected in nearly one half of patients presenting with cryptogenic stroke and often considered the most likely etiology when other causes have been excluded. In this review, we discuss the contemporary role of transcatheter closure of PFO in the treatment of cryptogenic stroke, including devices currently available for commercial use in the United States (Amplatzer PFOTM Occluder and GoreTM Cardioform Septal Occluder) and a novel suture-mediated device (NobleStitchTM EL) under clinical investigation. To provide the best care for cryptogenic stroke patients, practitioners should be familiar with the indications for PFO closure and corresponding treatment options.

AbstractAimsDespite significant morbidity and mortality, recent advances in cardiogenic shock (CS) management have been associated with increased survival. However, little is known regarding the management of patients who survive CS with heart failure (HF) with reduced left ventricular ejection fraction (LVEF, HFrEF), and the utilization of guideline‐directed medical therapy (GDMT) in these patients has not been well described. To fill this gap, we investigated the use of GDMT during an admission for CS and short‐term outcomes using the Inova single‐centre shock registry.MethodsWe investigated the implementation of GDMT for patients who survived an admission for CS with HFrEF using data from our single‐centre shock registry from January 2017 to December 2019. Baseline characteristics, discharge clinical status, data on GDMT utilization and 30 day, 6 month and 12 month patient outcomes were collected by retrospective chart review.ResultsAmong 520 patients hospitalized for CS during the study period, 185 (35.6%) had HFrEF upon survival to discharge. The median age was 64 years [interquartile range (IQR) 56, 70], 72% (n = 133) were male, 22% (n = 40) were Black and 7% (n = 12) were Hispanic. Forty‐one per cent of patients (n = 76) presented with shock related to acute myocardial infarction (AMI), while 59% (n = 109) had HF‐related CS (HF‐CS). The median length of hospital stay was 12 days (IQR 7, 18). At discharge, the proportions of patients on beta‐blockers, angiotensin‐converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor/neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRAs) were 78% (n = 144), 58% (n = 107) and 55% (n = 101), respectively. Utilization of three‐drug GDMT was 33.0% (n = 61). Ten per cent of CS survivors with HFrEF (n = 19) were not prescribed any component of GDMT at discharge. Multivariable logistic regression adjusted for baseline GDMT use revealed that patients with lower LVEF and those who transferred to our centre from an outside hospital were more likely to experience GDMT addition (P < 0.05). Patients prescribed at least one additional class of GDMT during admission had higher odds of 6 month and 1 year survival (P < 0.01): On average, 6 month survival odds were 7.1 times greater [confidence interval (CI) 1.9, 28.5] and 1 year survival odds were 6.0 times greater than those who did not have at least one GDMT added (CI 1.9, 20.5).ConclusionsMost patients who survived CS admission with HFrEF in this single‐centre CS registry were not prescribed all classes or goal doses of GDMT at hospital discharge. These findings highlight an urgent need to augment multidisciplinary efforts to enhance the post‐discharge medical management and outcomes of patients who survive CS with HFrEF.

AimThe “2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy” provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy.MethodsA comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.StructureHypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the “2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy” have been updated with new evidence to guide clinicians.

More than 1 million transcatheter-based cardiovascular procedures across the spectrum of interventional cardiology are performed annually in the United States. With the expanded indications for and increased complexities associated with these procedures, interventional cardiologists are expected to possess the requisite expertise to complete these interventions safely and effectively. While the art of vascular access and closure remains a prerequisite and critical skillset in contemporary practice, there remain significant variations in the techniques employed, resulting in the bleeding and vascular complications encountered in clinical practice. With an increasing recognition of the potential merits to standardized approaches to vascular access and closure, cardiovascular societies have put forth recommendations around best practices for performing these procedures in the cardiac catheterization laboratories. In this review, we aim to: (1) Examine the evolving definitions of bleeding and vascular complications; (2) Review best practices for transradial and transfemoral access and closure, including for large bore procedures; and (3) Highlight knowledge gaps and proposed areas of clinical research pertaining to vascular access which may inform clinical practice and potentially optimize the outcomes of patients undergoing transcatheter-based cardiac and vascular interventions.

Introduction: Pregnancy at an advanced age is becoming increasingly common in developed countries. The relationship between advanced maternal age (AMA) (≥ 35 years) and major cardiovascular events (MACE) is not well studied. Therefore, we evaluated the association of AMA at the time of last childbirth with MACE in a large nationally representative sample. Methods: We analyzed data from the 1999–2018 National Health and Nutrition Examination Survey. Females aged ≥45 years with no missing pregnancy record were included in the analysis. Based on the age of their last childbirth, they were divided into 4 groups- those who delivered at <35 years (GROUP 1), 35-40 years (GROUP 2), >40 years (GROUP 3), and nulliparous (GROUP 4). MACE was defined as a composite of a history of congestive heart failure, coronary artery disease, stroke, or all-cause death. We assessed the association between these groups and MACE using univariate and multivariate logistic regression models. Results: Among 13,180 (weighted frequency = 53,636,595) females included in this analysis, 20% had a history of AMA (groups 2 and 3), 70.6% had no history of AMA (group 1), and 9.4% were nulliparous. Compared to nulliparous women, women with no history of AMA had an 83% higher odd of MACE with an OR 1.83 (95% CI 1.45 – 2.31), while those with history of childbirth between ages 35 – 40 years had a 84% higher odd of MACE with OR of 1.84 (95% CI 1.37 - 2.46), and women with childbirth >40 had 2.7 higher odds of MACE (2.73, (1.87 - 4.00)). However, after adjusting for demographic characteristics and surrogates for social determinants of health such as income, food insecurity, and insurance status, as well as cardiovascular (CV) risk factors like alcohol use, smoking, and comorbidities such as diabetes, dyslipidemia, and hypertension, this association was attenuated. (Table 1) Conclusion: Our study did not find a significant independent association between the maternal age of last childbirth and MACE. This suggests that maternal age alone may not be the primary risk factor; the effect of AMA might be mediated by other CV, social risk factors, and parity. This warrants further investigation to better risk stratify women with AMA as a documented risk factor.

Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown.The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial.One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure.Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29).Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522)

•Women with acute myocardial infarction complicated by cardiogenic shock and heart failure complicated by cardiogenic shock presented with higher acuity than men.•Women experienced similar major adverse cardiac events as men.•Women with heart failure complicated by cardiogenic shock had higher vascular complications and bleeding rates.•Female sex was not an independent predictor of these complications.•One-year survival was similar between women and men.

BackgroundHow diabetes mellitus (DM), race/ethnicity, and sex impact ischemic events following coronary artery stent procedures is unknown.MethodsUsing the PLATINUM Diversity and PROMUS Element Plus Post-Approval Pooled Study (N = 4184), we examined the impact of race/ethnicity, sex, and DM on coronary stent outcomes. Primary outcome was 1-year major adverse cardiac events (MACE) (MACE composite: death, myocardial infarction [MI], and target vessel revascularization).ResultsThe study sample included 1437 diabetic patients (501 White men, 470 White women, 246 minority men, 220 minority women) and 2641 patients without medically treated DM (561 minority, 1090 women). Mean age (years) ranged from 61 in minority men to 65 in White women. Diabetic patients had a higher prevalence of atherosclerotic risk factors and comorbidities. Diabetic minority women (DMW; 70% Black, 27% Hispanic) had similar atherosclerotic risk factors to other diabetics, but experienced higher 1-year MACE (14.4% vs 7.5%, P <.01) and MI (4.3% vs 1.6%, P <.01) rates compared with patients without medically treated DM. No other diabetic cohort (White men, White women, minority men) showed an increased risk of MACE vs patients without medically treated DM. The incremental risk of MACE in DMW was associated with insulin use and persisted after risk adjustment (adjusted odds ratio 1.6 vs patients without medically treated DM; 95% CI, 1.0-2.5). Independent predictors of 1-year MACE included insulin use, hyperlipidemia, renal disease, and prior MI.ConclusionsDMW face the highest risk of ischemic events following coronary stenting, driven, in part, by insulin use. Aggressive secondary prevention and strict glycemic control are imperative in this cohort, and further research is warranted to elucidate the biologic mechanisms underpinning these observations.Clinical Trial RegistrationNCT02240810 (http://clinicaltrials.gov/)

The Cardiovascular Disease in Women Committee of the American College of Cardiology convened a working group to develop a consensus regarding the continuing rise of mortality rates in young women aged 35 to 54 years. Heart disease mortality rates in young women continue to increase. Young women have increased mortality secondary to ischemic heart disease (IHD) compared with comparably aged men and similar mortality to that observed among older women. The authors reviewed the published evidence, including observational and mechanistic/translational data, and identified knowledge gaps pertaining to young women. This paper provides clinicians with pragmatic, evidence-based management strategies for young women at risk for IHD. Next-step research opportunities are outlined. This report presents highlights of the working group review and a summary of suggested research directions to advance the IHD field in the next decade.

BACKGROUND The benefits of standardized care for cardiogenic shock (CS) across regional care networks are poorly understood. OBJECTIVES The authors compared the management and outcomes of CS patients initially presenting to hub versus spoke hospitals within a regional care network. METHODS The authors stratified consecutive patients enrolled in their CS registry (January 2017 to December 2019) by presentation to a spoke versus the hub hospital. The primary endpoint was 30-day mortality. Secondary endpoints included bleeding, stroke, or major adverse cardiovascular and cerebrovascutar events. RESULTS Of 520 CS patients, 286 (55%) initially presented to 34 spoke hospitals. No difference in mean age (62 years vs 61 years; P = 0.38), sex (25% vs 32% women; P = 0.10), and race (54% vs 52% white; P = 0.82) between spoke and hub patients was noted. Spoke patients more often presented with acute myocardial infarction (50% vs 32%; P < 0.01), received vasopressors (74% vs 66%; P = 0.04), and intra-aortic balloon pumps (88% vs 37%; P < 0.01). Hub patients were more often supported with percutaneous ventricular assist devices (44% vs 11%; P < 0.01) and veno-arterial extracorporeal membrane oxygenation (13% vs 0%; P < 0.01). Initial presentation to a spoke was not associated with increased risk-adjusted 30-day mortality (adjusted OR: 0.87 [95% CI: 0.49-1.55]; P = 0.64), bleeding (adjusted OR: 0.89 [95% CI: 0.49-1.62]; P = 0.70), stroke (adjusted OR: 0.74 [95% CI: 0.31-1.75]; P = 0.49), or major adverse cardiovascular and cerebrovascutar events (adjusted OR 0.83 [95% CI: 0.50-1.35]; P = 0.44). CONCLUSIONS Spoke and hub patients experienced similar short-term outcomes within a regionalized CS network. The optimal strategy to promote standardized care and improved outcomes across regional CS networks merits further investigation. (C) 2022 by the American College of Cardiology Foundation.