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Contrast-induced nephropathy (CIN) after coronary angiography or intervention is associated with substantial morbidity. The data supporting various prophylactic measures and adjunctive therapies to prevent this complication are conflicting. However, contrast volume is clearly related to CIN after percutaneous coronary intervention (PCI), and the risk of CIN has been shown to be directly related to contrast dose. Therefore, minimizing contrast exposure is a primary method to reduce the risk of CIN, especially in at-risk patients. We report a novel technique designed to deliver ultra-low (<15 cm(3)) volume contrast to patients with chronic kidney disease undergoing coronary angiography and PCI.

The period following heart failure hospitalization (HFH) is a vulnerable time with high rates of death or recurrent HFH.OBJECTIVE To evaluate clinical characteristics, outcomes, and treatment response to vericiguat according to prespecified index event subgroups and time from index HFH in the Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction (VICTORIA) trial. DESIGN, SETTING, AND PARTICIPANTSAnalysis of an international, randomized, placebo-controlled trial. All VICTORIA patients had recent (<6 months) worsening HF (ejection fraction <45%). Index event subgroups were less than 3 months after HFH (n = 3378), 3 to 6 months after HFH (n = 871), and those requiring outpatient intravenous diuretic therapy only for worsening HF (without HFH) in the previous 3 months (n = 801). Data were analyzed between May 2, 2020, and May 9, 2020.INTERVENTION Vericiguat titrated to 10 mg daily vs placebo. MAIN OUTCOMES AND MEASURESThe primary outcome was time to a composite of HFH or cardiovascular death; secondary outcomes were time to HFH, cardiovascular death, a composite of all-cause mortality or HFH, all-cause death, and total HFH. RESULTS Among 5050 patients in the VICTORIA trial, mean age was 67 years, 24% were women, 64% were White, 22% were Asian, and 5% were Black. Baseline characteristics were balanced between treatment arms within each subgroup. Over a median follow-up of 10.8 months, the primary event rates were 40.9, 29.6, and 23.4 events per 100 patient-years in the HFH at less than 3 months, HFH 3 to 6 months, and outpatient worsening subgroups, respectively. Compared with the outpatient worsening subgroup, the multivariable-adjusted relative risk of the primary outcome was higher in HFH less than 3 months (adjusted hazard ratio, 1.48; 95% CI, 1.27-1.73), with a time-dependent gradient of risk demonstrating that patients closest to their index HFH had the highest risk. Vericiguat was associated with reduced risk of the primary outcome overall and in all subgroups, without evidence of treatment heterogeneity. Similar results were evident for all-cause death and HFH. Addtionally, a continuous association between time from HFH and vericiguat treatment showed a trend toward greater benefit with longer duration since HFH. Safety events (symptomatic hypotension and syncope) were infrequent in all subgroups, with no difference between treatment arms.CONCLUSIONS AND RELEVANCE Among patients with worsening chronic HF, those in closest proximity to their index HFH had the highest risk of cardiovascular death or HFH, irrespective of age or clinical risk factors. The benefit of vericiguat did not differ significantly across the spectrum of risk in worsening HF.

Background Hospitalized patients are frequently referred for transthoracic echocardiograms (TTE). The availability of a pocket, mobile echocardiography (PME) device that can be incorporated on bedside rounds by cardiologists may be a useful and frugal alternative. Methods This was a cross-sectional study designed to compare the accuracy of PME images with those acquired by TTE in a sample of hospitalized patients. Each patient referred for echocardiography underwent PME acquisition and interpretation by a senior cardiology fellow with level II training in echocardiography. Subsequently, a TTE was performed by skilled ultrasonographers and interpreted by experienced echocardiographers. Both groups were blinded to the results of the alternative imaging modality. Visualizability and accuracy for all key echocardiographic parameters (ejection fraction, wall motion abnormalities, left ventricular end diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion) were determined and compared between imaging modalities. Results 240 hospitalized patients underwent echocardiography with PME and TTE. The mean age was 71 ± 17 years. PME imaging time was 6.3 ± 1.5 min. Sensitivity of PME varied by parameter; was highest for aortic stenosis (97%) and lowest for aortic insufficiency (76%). Specificity also varied by parameter; was highest for mitral regurgitation (100%) and lowest for left ventricular ejection fraction (92%). Equivalence testing revealed the PME outcomes to be significantly equivalent to the TTE outcomes with no discernible differences in image quality between the PME and TTE (p=7.22×10-7). All outcomes remain significant after correcting for multiple testing using the false discovery rate (FDR). Conclusion The results from rapid bedside PME examinations performed by experienced cardiology fellows compared favorably with those from formal TTE studies. For hospitalized patients, this finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies.

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Objective To estimate the prevalence of guideline‐directed medical therapy (GDMT) in commercially insured US patients with heart failure with reduced ejection fraction (HFrEF) and examine the effect of GDMT on all‐cause mortality. GDMT for HFrEF includes pharmacologic therapies such as β‐blockers (BB), angiotensin‐converting enzyme inhibitors (ACE‐I), angiotensin receptor blockers (ARB), angiotensin receptor‐neprilysin (ARNI), mineralocorticoid receptor antagonists (MRA), and sodium‐glucose cotransporter inhibitors to reduce morbidity and mortality. Methods Patients in the Optum Integrated File from 2007 to 2019Q3, ≥18 years, with history of HFrEF, were identified. Patients prescribed both a BB and either an ACE‐I, ARB, or ARNI during 6‐month post‐diagnosis were assigned to the GDMT cohort. All others were assigned to the not on GDMT cohort. The GDMT cohort was further classified by those patients with a record of prescription fills for both classes of medications concurrently (GDMT concurrent medication fills). Mortality at 2 years was assessed with a Cox regression model accounting for baseline demographics, comorbidities, and diuretic use. Results This study identified 14 880 HFrEF patients, of which 70% had a record of GDMT, and 57% had a record of concurrent prescriptions. Patients in the not on GDMT cohort had 29% increased risk of mortality versus GDMT (hazard ratio 1.29; 95% CI (1.19–1.40); p < .0001). As a sensitivity analysis, the effect of patients not on GDMT compared to GDMT with concurrent medication fills was more pronounced, with a 37% increased mortality risk. Conclusion In a real‐world population of HFrEF patients, inadequate GDMT confers a 29% excess mortality risk over the 2‐year follow‐up.

Aim: This study sought to quantify the healthcare burden of Medicare patients with clinically significant mitral regurgitation (sMR). Materials & methods: Proxy definitions were used for sMR, including MR surgery, atrial fibrillation, pulmonary hypertension or >2 echocardiograms. Results: In this study, 11,173 patients had significant degenerative MR (sDMR); 25,402 had significant functional MR (sFMR); and 12,232 had significant uncharacterized MR (sUMR). Patients with sFMR (18,880) were more likely to be hospitalized and present to the emergency department compared with patients with sDMR (9,795) or sUMR (10,587). Annual healthcare expenditures for sMR patients were: US$29,328 for sFMR; US$17,112 for sUMR; and US$12,870 for sDMR. Conclusion: Novel therapeutic interventions merit further evaluation to reduce the substantial healthcare burden of sMR in the Medicare population.

Aims Heart failure (HF) carries a poor prognosis, and the impact of concomitant mitral regurgitation (MR) is not well understood. This analysis aimed to estimate the incremental effect of MR in patients newly diagnosed with HF. Methods and results Data from the IBM® MarketScan® Research Databases were analysed. Included patients had at least one inpatient or two outpatient HF claims. A 6 month post-period after HF index was used to capture MR diagnosis and severity. HF patients were separated into three cohorts: without MR (no MR), not clinically significant MR (nsMR), and significant MR (sMR). Time-to-event analyses were modelled to estimate the clinical burden of disease. The primary outcome was a composite endpoint of death or cardiovascular (CV)-related admission. Secondary outcomes were death and CV hospitalization alone. All models controlled for baseline demographics and co-morbidities. Patients with sMR were at significantly higher risk of either death or CV admission compared with patients with no MR [hazard ratio (HR) 1.26; 95% confidence interval (CI) 1.15-1.39]. When evaluating death alone, patients with sMR had significantly higher risk of death (HR 1.24; 95% CI 1.08-1.43) compared with patients with no MR. When evaluating CV admission alone, patients with MR were at higher risk of hospital admission vs. patients with no MR, and the magnitude was dependent upon the MR severity: sMR (HR 1.55; 95% CI 1.38-1.74) and nsMR (HR 1.23; 95% CI 1.08-1.40). Conclusions Evidence of MR in retrospective claims significantly increases the clinical burden of incident HF patients. Time to death and CV hospitalizations are increased when MR is clinically significant.