Studies have shown that CR is beneficial in reducing morbidity, mortality, hospitalizations, activity-related symptoms, and increasing quality of life. Similar findings have also been observed in patients with heart failure who underwent CR in addition to optimal medical management. The positive effects of CR are well established in patients with coronary disease. Recent literature is also showing a trend to benefit in patients with heart failure, though much of the evidence is limited to patients with systolic dysfunction. Despite recommendations by professional societies, the use of CR remains underutilized. Further investigation is needed to better understand the impact of CR in heart failure. Moreover, strategies to increase CR utilization must be explored.

Background Cardiac rehabilitation (CR) improves cardiorespiratory fitness (CRF) and has been shown to reduce cardiovascular events and death. However, data about predictors of fitness improvement during CR are limited and conflicting. The objective of this study was to determine predictors of improvement in metabolic equivalents of task (METs) based on formal exercise testing throughout phase II CR. Methods We retrospectively reviewed 20 671 patients enrolled in phase II CR at our center from 2006 to 2016. Patients who completed 36 sessions and had entry and exit exercise stress tests were included for study. The short form‐36 (SF‐36) questionnaire was used to assess quality‐of‐life. Univariate and multivariate regression analyses were performed to determine independent predictors of METs improvement. Results Of the full cohort, 827 patients completed 36 sessions and had entry/exit stress test data. The majority of patients (N = 647, 78.2%) had improvement in METs (mean Δ 2.0 ± 1.2 METs), including patients ≥65 and < 65 years old (77% vs 79%, P = 0.46 for difference). METs improvement was negatively associated with body mass index, diabetes, left ventricular dysfunction, and poor baseline fitness; and positively associated with SF‐36 score (P < 0.05 for all). After multivariable adjustment, improvement was no longer affected by age, ejection fraction, or baseline fitness. Patients with poor fitness (≤5 METS) and adequate fitness (> 5 METS) both had improvement, with no statistical difference between the groups (P = 0.36). Conclusions In a large cohort of phase II CR patients, improvement in CRF was seen in the majority of patients across all ages, genders, and levels of baseline fitness.

Objectives To assess the causes and predictors of readmission after NSTEMI. Background Studies on readmissions following non‐ST elevation myocardial infarction (NSTEMI) are limited. We investigated the rate and causes for readmission and the impact of coronary revascularization on 90‐day readmissions following a hospitalization for NSTEMI in a large, nationally representative United States database. Methods We queried the National Readmission Database for the year 2016 using appropriate ICD‐10‐CM/PCS codes to identify all adult admissions for NSTEMI. We determined the 90‐day readmissions for major adverse cardiac events (MACE). All‐cause readmission was a secondary endpoint. The association between coronary revascularization and the likelihood of readmission was analyzed using multivariate Cox regression analysis. Results A total of 296,965 adult discharges following an admission for NSTEMI were included in this study. The rate of readmissions for MACE was 5.2% (n = 15,637) and for any cause was 18.0% (n = 53,316). 38% of MACE readmissions and 40% of all‐cause readmissions occurred between 30‐ and 90‐days following the index hospitalization. During index hospitalization, 51.0% underwent coronary revascularization (40.8% with PCI and 10.2% with CABG). This was independently predictive of a lower risk of 90‐day readmission for MACE (adjusted HR 0.59, 95% confidence interval (CI) 0.56–0.63, p < .001) and for any cause (adjusted HR 0.65, 95% CI 0.63–0.67, p < .001). In‐hospital mortality for MACE readmissions was significantly higher compared to that of index hospitalization (3.8% vs. 2.6%, p < .001). Conclusion Readmissions following NSTEMI carry higher mortality than the index hospitalization. Coronary revascularization for NSTEMI is associated with a lower readmission rate at 90 days.

Coronavirus disease 2019 (COVID-19) is characterized by a clinical spectrum of diseases ranging from asymptomatic or mild cases to severe pneumonia with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. Extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy in appropriate patients with COVID-19 complicated by ARDS refractory to mechanical ventilation. In this study, we review the indications, challenges, complications, and clinical outcomes of ECMO utilization in critically ill patients with COVID-19-related ARDS. Most of these patients required venovenous ECMO. Although the risk of mortality and complications is very high among patients with COVID-19 requiring ECMO, it is similar to that of non-COVID-19 patients with ARDS requiring ECMO. ECMO is a resource-intensive therapy, with an inherent risk of complications, which makes its availability limited and its use challenging in the midst of a pandemic. Well-maintained data registries, with timely reporting of outcomes and evidence-based clinical guidelines, are necessary for the careful allocation of resources and for the development of standardized utilization protocols.

Introduction: Apixaban has been increasingly used over the past decade for the prevention of ischemic strokes in atrial fibrillation (AF) patients. Nonetheless, some patients may experience ischemic strokes despite apixaban therapy. There is scarce information about factors underlying apixaban failure in AF patients. Methods: A system wide search was employed at the Cleveland Clinic Health System using electronic records. All patients 18 years of age or older, who were diagnosed with AF, and developed an ischemic stroke while being treated with apixaban (January 2013 through May 2019) were included. A matched controls series (no stroke on apixaban) was included accounting for antiplatelet and statin therapy, and carotid artery disease. Multivariable analyses were performed to assess for associations between clinical characteristics and stroke on apixaban. Results: A total of 137 patients with stroke while on apixaban were identified and matched to 137 controls. Cases and controls were comparable in a large number of clinical characteristics. There was an association between apixaban dosing and risk of stroke. About 40% of the lower (2.5 mg BID) dose of apixaban was prescribed for patients who would have qualified for full dose. Being on inappropriately low dose of apixaban was associated with a higher risk of ischemic strokes compared to appropriately prescribed doses with an adjusted OR 3.37 [1.37-8.32]. Among appropriately prescribed doses, the 5 mg BID dose showed a statistically nonsignificant lower risk of ischemic stroke compared to the 2.5 mg BID dose, adjusted OR 0.55 [0.21-1.41]. Compared to the inappropriate use of the 2.5 mg dose, the appropriate prescription of the 2.5 mg dose was associated with a lower risk of stroke adjusted OR 0.34 [0.07-1.64]. Conclusion: In this series, there was a statistically significant association between being on an inappropriately low dose of apixaban and the odds of stroke while on apixaban therapy.

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