Aims Persons living with HIV (PLWH) have increased cardiovascular mortality, which may in part be due to differences in the management of acute coronary syndromes (ACS). The purpose of this study was to compare the in-hospital and post-discharge management and outcomes of ACS among persons with and without HIV. Methods and Results This was a retrospective cohort study using data from Symphony Health, a data warehouse. All patients admitted between 1/1/2014–12/31/2016 with ACS were identified by ICD billing codes. Multivariate logistic regression models were used to examine in-hospital, 30-day and 12-month event rates between groups. 1,125,126 individuals were included, 6,612 (0.59%) with HIV. PLWH were younger (57.4 ± 10.5 vs 67.4 ± 12.9 years, p<.0001) and had more medical comorbidities. ACS type did not differ significantly with HIV status. PLWH were less likely to undergo coronary angiography (35.2% vs 37.2%, adjusted OR 0.87, 95% CI 0.83-0.92, p <.0001), and those with both HIV and STEMI underwent fewer drug eluting stents (60.1% vs 68.5%, adjusted OR 0.81, 95% CI 0.68-0.96, p = 0.016). PLWH had higher adjusted rates of inpatient mortality (OR 1.29, 95% CI 1.15-1.44, p <.0001), 30-day readmission (OR 1.18, 95% CI 1.09-1.27, p <.0001) and 12-month mortality (OR 1.32, 95% CI 1.22-1.44, p <.0001). 12 months following discharge, PLWH filled cardiac medications at lower rates. Conclusion In a contemporary cohort of persons hospitalized for ACS, PLWH received less guideline-supported interventional and medical therapies and had worse clinical outcomes. Strategies to optimize care are warranted in this unique population.

Sodium polystyrene sulfonate (sold under the brand names SPS, Kayexalate, and Kionex) is widely used for treatment of hyperkalemia. It is a synthetic cation-bound resin that exchanges sodium cations for potassium in the gastrointestinal (GI) lumen, resulting in increased fecal potassium excretion that in turn leads to decreased serum potassium levels. This drug was first introduced for treatment of hyperkalemia in 2 small uncontrolled case series in the early 1950s, and the US Food and Drug Administration (FDA) approved it for the short-term treatment of hyperkalemia in 1958.Despite its long history of use, there have been no robust randomized clinical trials documenting the efficacy and safety of sodium polystyrene sulfonate for long-term management of hyperkalemia. Uncontrolled observational studies and 1 small randomized clinical trial demonstrated small decreases in serum potassium levels of questionable clinical significance in patients with chronic kidney disease. [1][2][3][4] No study, to our knowledge, has addressed the association of sodium polystyrene sulfonate with clinical outcomes potentially related to hyperkalemia, such as cardiac arrhythmias.In addition to very weak evidence for positive outcomes, there is mounting evidence of harm caused by this drug. Cases of intestinal necrosis associated with sodium polystyrene sulfonate in sorbitol, the typical method of administration, were reported as early as the 1980s. 5 In 2009, the FDA warned of the risk of intestinal necrosis with administration of sodium polystyrene sulfonate in sorbitol and recommended avoiding the combination of these medications in postoperative patients and those with intestinal obstruction or chronic bowel disease, including constipation. 6 The mechanism of action was thought to be related to hyperosmotic load from sorbitol leading to adenosine triphosphate-dependent sodiumpotassium pump dysfunction, alteration of cellular membrane transport systems, and reduced intestinal blood flow. 5 Comorbidities such as intestinal obstruction, diabetes, or vascular disease were also thought to contribute. In a literature review published in 2010, 7 intestinal necrosis was described only as a complication of the combination of sodium polystyrene sulfonate and sorbitol; in particular, 70% sorbitol and sodium polystyrene sulfonate preparations without sorbitol were reported to be safe. More recently, however, case reports of intestinal necrosis following sodium polystyrene sulfonate administration without sorbitol have also emerged. 8 A systematic review of 48 cases of intestinal necrosis after drug administration found 17 cases among patients not taking sorbitol, suggesting that sodium polystyrene sulfonate alone could also cause this complication. 8

IMPORTANCEUp to 60% of patients in the US receive a stress test within 2 years of percutaneous coronary intervention (PCI), prompting concerns about the possible overuse of stress testing. OBJECTIVE To examine the proportion of patients who underwent stress testing within 2 years of elective PCI, proportion of patients who had symptoms that were consistent with coronary artery disease (CAD), timing of stress testing, and site-level variation in stress testing among symptomatic and asymptomatic patients. DESIGN, SETTING, AND PARTICIPANTS This cohort study used administrative claims data and clinical records from the US Department of Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking program. Patients who underwent stress testing within 2 years of elective PCI for stable CAD between November 1, 2013, and October 31, 2015, at 64 VA facilities were included in the analysis. Patients who received stress testing for staging purposes, cardiac rehabilitation evaluation, or preoperative testing before high-risk surgery were excluded. Data were analyzed from June to December 2020. MAIN OUTCOMES AND MEASURESThe main outcome was the proportion of patients who underwent stress testing and had symptoms that were consistent with obstructive CAD, using definitions from the 2013 clinical practice guideline (Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease). Secondary outcomes were the timing of stress testing (assessed using a cumulative incidence curve) and site-level variation in stress testing (assessed using multilevel logistic regression models). RESULTSA total of 3705 consecutive patients (mean [SD] age 66.3 [7.6] years; 3656 men [98.7%]; 437 Black individuals [11.8%], 3175 White individuals [85.7%], and 93 individuals [2.5%] of other races and ethnicities [Asian, Hispanic or Latinx, or unknown]) had elective PCI. Of these patients, 916(24.7%) received a stress test within 2 years, among whom 730 (79.7%) had symptoms that were consistent with obstructive CAD at the time of stress testing. Visual inspection of a cumulative incidence curve for stress testing showed no rapid increases in stress testing at 6 months or 1 year after PCI, which might coincide with routine clinical visits. The proportion of symptomatic patients who underwent stress testing at each VA site ranged from 67.7% to 100%, with no significant sitelevel variation in stress testing. CONCLUSIONS AND RELEVANCEResults of this study suggest that most veterans who underwent stress testing within 2 years after elective PCI had symptoms that were consistent with obstructive CAD. Therefore, measuring low-value stress testing using only administrative claims data may overestimate its prevalence, and concerns about overuse of post-PCI stress testing may be overstated.

Victor and Pinsky 1 use data from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening trial 2 to demonstrate an association between lack of adherence to cancer screening and increased mortality from causes not related to the screening. Participants in the PLCO Cancer Screening trial were 55 to 74 years of age and generally healthy. At trial entry, participants of both sexes in the screening arm were asked to undergo chest radiographs for lung cancer and flexible sigmoidoscopy for colon cancer, men were asked to undergo prostate-specific antigen tests and digital rectal examinations for prostate cancer, and women were asked to undergo cancer antigen 125 tests and transvaginal ultrasonography for ovarian cancer. Those randomized to the control group received usual care.Of the participants randomized to screening, 10.8% did not complete any of the recommended screening tests at baseline and were defined as nonadherents. After 10 years of followup, the risk for mortality (excluding mortality due to lung, colon, prostate, and ovarian cancers) was increased about 50% in nonadherents compared with full adherents who underwent all of the recommended tests at baseline. Increased mortality was due to a wide range of causes, including respiratory, digestive, and cardiovascular diseases, as well as cancers unrelated to screening. The comparison of nonadherents with full adherents was not randomized; this is an observational study of mortality rates among participants in the screening arm of the PLCO Cancer Screening trial and, like all observational studies, is susceptible to confounding.There is no way that nonadherence with cancer screening could cause increased mortality from a range of diseases not associated with screening. The analyses were adjusted for age, race/ethnicity, sex, educational level, cigarette smoking, body mass index, marital status, and major comorbidities, indicating that these health-related variables are unlikely to account for the findings. So, what does account for the increased risk of death? As the authors note, it is most likely that nonadherence with recommended screening is a marker for behaviors that are associated with increased mortality. Previous studies have shown that patients who are adherent to recommended medications are more likely to seek out other pre-

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