Shashank S. Sinha

COCATS 4: Securing the Future of Cardiovascular Medicine.

The latest iteration of the Core Cardiology Training Statement (COCATS 4) [Corrected] provides a potentially transformative advancement in cardiovascular fellowship training intended, ultimately, to improve patient care. This review addressed 3 primary themes of COCATS 4 from the perspective of fellows-in-training: 1) the evolution of training requirements culminating in a competency-based curriculum; 2) the development of novel learning paradigms; and 3) the establishment of task forces in emerging areas of multimodality imaging and critical care cardiology. This document also examined several important challenges presented by COCATS 4. The proposed changes in COCATS 4 should not only enhance the training experience but also improve trainee satisfaction. Because it embraces continual transformation of training requirements to meet evolving clinical needs and public expectations, COCATS 4 will enrich the cardiovascular fellowship training experience for patients, programs, and fellows-in-training.

Identifying Important Gaps in Randomized Controlled Trials of Adult Cardiac Arrest Treatments A Systematic Review of the Published Literature

Background—Cardiac arrest is a major public health concern worldwide. The extent and types of randomized controlled trials (RCT)—our most reliable source of clinical evidence—conducted in these high-risk patients over recent years are largely unknown. Methods and Results—We performed a systematic review, identifying all RCTs published in PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library from 1995 to 2014 that focused on the acute treatment of nontraumatic cardiac arrest in adults. We then extracted data on the setting of study populations, types and timing of interventions studied, risk of bias, outcomes reported, and how these factors have changed over time. Over this 20-year period, 92 RCTs were published containing 64 309 patients (median, 225.5 per trial). Of these, 81 RCTs (88.0%) involved out-of-hospital cardiac arrest, whereas 4 (4.3%) involved in-hospital cardiac arrest and 7 (7.6%) included both. Eighteen RCTs (19.6%) were performed in the United States, 68 (73.9%) were performed outside the United States, and 6 (6.5%) were performed in both settings. Thirty-eight RCTs (41.3%) evaluated drug therapy, 39 (42.4%) evaluated device therapy, and 15 (16.3%) evaluated protocol improvements. Seventy-four RCTs (80.4%) examined interventions during the cardiac arrest, 15 (16.3%) examined post cardiac arrest treatment, and 3 (3.3%) studied both. Overall, reporting of the risk of bias was limited. The most common outcome reported was return of spontaneous circulation: 86 (93.5%) with only 22 (23.9%) reporting survival beyond 6 months. Fifty-three RCTs (57.6%) reported global ordinal outcomes, whereas 15 (16.3%) reported quality-of-life. RCTs in the past 5 years were more likely to be focused on protocol improvements and postcardiac arrest care. Conclusions—Important gaps in RCTs of cardiac arrest treatments exist, especially those examining in-hospital cardiac arrest, protocol improvement, postcardiac arrest care, and long-term or quality-of-life outcomes.

The Evolution of the Fellows-in-Training and Early Career Professionals’ Page: Past, Present, and Future

Since he began his tenure as editor-in-chief of the Journal in July 2014, Dr. Valentin Fuster has been deeply committed to the personal and professional development of both trainees and early career professionals. Thus, the Fellows-in-Training (FIT) & Early Career (EC) Page was born. It soon

Changes in Primary Noncardiac Diagnoses Over Time Among Elderly Cardiac Intensive Care Unit Patients in the United States

Background— Early reports suggest the number of cardiac intensive care unit (CICU) patients with primary noncardiac diagnoses is rising in the United States, but no national data currently exist. We examined changes in primary noncardiac diagnoses among elderly patients admitted to a CICU during the past decade. Methods and Results— Using 2003 to 2013 Medicare data, we grouped elderly patients admitted to CICUs into 2 categories based on principal diagnosis at discharge: (1) primary noncardiac diagnoses and (2) primary cardiac diagnoses. We examined changes in patient demographics, comorbidities, procedure use, and risk-adjusted in-hospital mortality. Among 3.4 million admissions with a CICU stay, primary noncardiac diagnoses rose in prevalence from 38.0% to 51.7% between 2003 and 2013. The fastest rising primary noncardiac diagnoses were infectious diseases (7.8%–15.1%) and respiratory diseases (6.0%–7.6%; P<0.001 for both), whereas the fastest declining primary cardiac diagnosis was coronary artery disease (32.3%–19.0%; P<0.001). Simultaneously, the prevalence of both cardiovascular and noncardiovascular comorbidities rose: heart failure (13.9%–34.4%), pulmonary vascular disease (1.2%–7.1%), valvular heart disease (5.0%–9.8%), and renal failure (7.1%–19.6%; P<0.001 for all). As compared with those with primary cardiac diagnoses, elderly CICU patients with primary noncardiac diagnoses had higher rates of noncardiac procedure use and risk-adjusted in-hospital mortality (P<0.001 for all). Risk-adjusted in-hospital mortality declined slightly in the overall cohort from 9.3% to 8.9% (P<0.001). Conclusions— More than half of all elderly patients with a CICU stay across the United States now have primary noncardiac diagnoses at discharge. These patients receive different types of care and have worse outcomes than patients with primary cardiac diagnoses. Our work has important implications for the development of appropriate training and staffing models for the future critical care workforce.

The double jeopardy of chronic obstructive pulmonary disease and myocardial infarction

Despite several therapeutic advances in the last few decades, chronic obstructive pulmonary disease (COPD) is a burgeoning cause of morbidity and mortality worldwide and is the fourth leading cause of death globally.1 Yet a curious paradox persists. As the only common disease for which the prevalence and mortality rates continue to rise, COPD still remains as a remarkably underdiagnosed and undertreated disease.1 The worldwide prevalence may be underestimated for a host of reasons including missed diagnosis, delays in establishing the diagnosis, variable definitions of COPD and the lack of age-adjusted estimates. COPD is of more than academic interest to cardiologists. Patients with COPD are at an increased risk of an array of acute cardiovascular events, including myocardial infarction (MI) and have increased short-term and long-term mortality compared with their non-COPD counterparts.2 In fact, up to one-third of deaths in patients with COPD may be ascribed to cardiovascular disease.2 Cardiovascular mortality increases by 28% for every 10% decrement in forced expiratory volume in 1 s.2 Furthermore, it has been shown that patients with COPD are undertreated with standard, guideline-based post-MI pharmacotherapy. Finally, the presence of COPD is associated with worse long-term outcome in patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft.3 ,4 COPD and coronary artery disease share common risk factor profiles and potentially mechanistic pathways. Tobacco use and old age contribute to elevated risk for both of these disease entities. In a recent study analysing 25 857 patients with COPD in the Health Improvement Network database over a 2-year period, a COPD exacerbation was associated with over a twofold increased risk of MI during a 5-day period following the exacerbation.5 Notably, the risk returned to baseline within 5 days of treatment for the exacerbation.5 Although the exact pathogenesis remains to be …

Learning to Be a Clinician-Educator: A Fellow-Driven Curricular Reform

“Ideally, medical education should change as our knowledge base changes and as the needs, or the perceived needs, of patients, medical practitioners, and society change.”—David Kern, MD, MPH [(1)][1] Approximately 1 year ago, our fellowship program director posed the following questions to

Survival by the fittest: hospital-level variation in quality of resuscitation care.

Despite several advances in resuscitation care over the last decade, in-hospital cardiac arrest (IHCA) remains common and is linked to poor survival. Approximately 200 000 hospitalized patients suffer IHCA and undergo cardiopulmonary resuscitation in the United States annually, with fewer than 20%

Cultivating Skills for Success in Learning Health Systems: Learning to Lead

Fellows-in-training (FITs) and early career professionals (ECPs) are currently practicing in a complex health care environment. Indeed, there are multiple foci of interaction in a 21st-century academic medical center (AMC) extending beyond the traditional commitment to the tripartite mission of

Confluence of Cultural Context and Technological Innovation to Reduce Cardiovascular Disparities in India

Cardiovascular diseases (CVD) are a source of major morbidity and mortality worldwide, including in several low- to middle-income countries (LMICs). In fact, CVD represents the leading cause of death in India, accounting for a quarter of all mortality.1 CVD in India has quadrupled in the past 40 years, and estimates suggest that, by 2020, almost 60% of CVD patients worldwide will be Indians.2 Thus, India represents an accelerated epidemiological transition model (also observed in LMICs such as Brazil), where patients are living longer with chronic diseases.3 In combination with hypertension and diabetes mellitus as major risk factors for the burgeoning burden of CVD, ST-segment–elevation myocardial infarction (STEMI) carries a grave prognosis in India and other LMICs.3 Moreover, CVD disproportionately affects patients in poor and rural regions in India, and disparities in socioeconomic status accentuate this phenomenon.1 Those from lower socioeconomic status status less frequently receive optimal therapy, fueling adverse outcomes.1 Although cost-effective interventions have been developed for prevention and control of CVD risk factors, barriers to widespread use exist. Low detection rates, inadequate awareness, poor use of evidence-based interventions, and low adherence rates are a few of the challenges. Thus, innovative solutions are needed to surmount these barriers to improve CVD outcomes in India and other LMICs. A compelling opportunity to improve health lies in low-cost, high-impact technologies. India has the optimal milieu to foster technological innovation in reducing CVD disparities—bridging some of the age-old problems of income, caste, culture, and economic status. Importantly, the power of these technologies can be harnessed using a culturally tailored approach, such as pairing trusted community healthcare workers to deliver care to vulnerable, high-risk patients.4,5 We present 3 illustrative examples of healthcare providers using technological innovations—monitoring devices, mobile phone–based clinical decision support systems, and wearable …

Noncardiac surgery ≤ 2 y after coronary stent placement was linked to perioperative MI and all-cause mortality

Question In patients who had coronary stent implantation, is subsequent noncardiac surgery associated with increased risk for perioperative adverse cardiac events? Methods Design Retrospective cohort study using data from national Veterans Affairs (VA) and Medicaid and Medicare databases, with 30-day follow-up after noncardiac surgery and equivalent follow-up after stent placement in a cohort of matched, nonsurgical patients. Setting USA. Patients 20590 patients (median age 63 y, 98% men) who had coronary stent implantation, identified by International Classification of Diseases codes, at a VA medical center between Oct 1999 and Sep 2009, and noncardiac surgery, identified by Current Procedural Terminology codes, 2 years later (surgery cohort). Each patient in the surgery cohort was matched with 2 patients who did not have surgery 2 years after stent implantation and were alive at the time of surgery in the matched patient (n =41180). Matching was based on age, race, year of stent placement, stent type (bare metal [BMS] or drug-eluting [DES]), variables from the revised Cardiac Risk Index, and other previously identified predictors* of major adverse cardiac events, including myocardial infarction (MI) 6 mo before stent implantation and peripheral vascular disease. Patients who had surgery 2 weeks after coronary stent implantation were excluded. Risk factor Noncardiac surgery 2 years after coronary stent implantation. Outcomes The primary outcome was a composite of cardiac events (acute MI or coronary revascularization using percutaneous coronary intervention or coronary artery bypass grafting). Other outcomes included all-cause mortality. Main result Noncardiac surgery 2 years after coronary stent placement was linked to a composite of adverse cardiac events, MI, and all-cause mortality, but not revascularization (Table). Conclusion Noncardiac surgery 2 years after coronary stent placement was linked to myocardial infarction and all-cause mortality. Association between noncardiac surgery 2 y after coronary stent placement and adverse cardiac events Outcomes Event rates At 30 d Noncardiac surgery No surgery RR (95% CI) Adverse cardiac events 3.1% 1.9% 1.67 (1.50 to 1.85) Myocardial infarction 2.5% 1.1% 2.27 (2.00 to 2.56) Revascularization 1.1% 1.0% 1.08 (0.92 to 1.27) All-cause mortality 1.4% 0.4% 3.70 (3.05 to 4.48) Abbreviations defined in Glossary. Patients who had noncardiac surgery were matched with patients who did not have surgery based on age; race; year of stent placement; stent type; revised Cardiac Risk Index variables; and other predictors of major adverse cardiac events, including myocardial infarction 6 mo before stent implantation and peripheral vascular disease. At 30 d after noncardiac surgery or corresponding time after stent placement in matched nonsurgery patients. Acute myocardial infarction or coronary revascularization. Commentary The landscape of perioperative risk stratification has evolved, as about 1 in 5 patients needs noncardiac surgery within 2 years of coronary stent implantation (1). The retrospective cohort study by Holcomb and colleagues informs our understanding of the relative contributions of cardiac and surgical factors to perioperative adverse cardiac events. Patients who had noncardiac surgery within 2 years after coronary stent placement had greater risk for adverse cardiac events than matched patients who did not have surgery; incremental risk with surgery was highest, at 3.5%, immediately after stenting and stabilized at 0.9% 6 months after stenting. Further, elective inpatient procedures, use of DESs, and patients at high risk were each associated with significant reductions in incremental risk when noncardiac surgery was done 6 months after stenting compared with earlier. Study limitations include a mostly older male cohort and potential for misclassification bias due to the use of administrative data. The study by Holcomb and colleagues has important clinical implications. It supports previous research showing that risk for perioperative complications was highest in the first 6 weeks after coronary stenting (2). It confirms that risk for adverse cardiac events remains elevated between 6 weeks and 6 months after stenting. The data also support 2014 European guidelines, which recommend delaying noncardiac surgery for at least 6 months after placement of second-generation DESs (3). Although patients with a BMS had higher rates of adverse cardiac events than those with a DES, Holcomb and colleagues provide a compelling rationale for a paradigm shift toward assessment of cardiac and surgical risk factors, rather than stent type, to determine timing of surgery after stent placement. Future studies evaluating risk associated with noncardiac surgery should consider other nuanced factors, including number and type of stents used, stent implantation techniques, and alternative perioperative strategies when dual antiplatelet therapy is interrupted.