Angela Lowenstern

BACKGROUND: Operator experience is a key determinant of outcomes after transcatheter aortic valve replacement (TAVR). However, whether early-career operators achieve comparable results to more experienced peers is unknown. Herein, we evaluate case volumes, patient risk profiles, and 30-day outcomes of early-career versus non–early-career operators performing TAVR in the United States. METHODS: Using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry, we identified isolated TAVR procedures from October 2011 through March 2024. Early-career status was defined as ≤5 years in independent practice (based on board certification or first TAVR date); non–early-career status was >5 years. Multivariable hierarchical models adjusted for patient-, procedural-, operator-, and site-level factors, including annualized institutional TAVR volume, while accounting for clustering of procedures within operators and operators within sites. Primary outcomes were 30-day mortality and a composite of death, stroke, major bleeding, stage III acute kidney injury, or moderate-to-severe paravalvular leak. RESULTS: A total of 634 723 TAVR procedures were performed by 3126 operators across 847 sites, including 90 376 (14.2%) by early-career operators. Median annualized lifetime volume was lower for early-career operators (13 [interquartile range, 5–31] versus 19 [interquartile range, 7–42] cases per year; P P =0.293), whereas the composite end point was lower among early-career operators (11.19% versus 11.77%; risk ratio, 0.95 [95% CI, 0.93–0.98]; P <0.001). CONCLUSIONS: In a national TAVR registry, early-career operators performed fewer cases but achieved similar 30-day mortality and a modestly lower adjusted composite event rate relative to more experienced peers. These findings suggest that within the structured, team-based environment of contemporary TAVR programs, early-career status alone is not associated with inferior procedural outcomes and should not be viewed as a barrier to independent practice.

BACKGROUND: Heart failure (HF) remains a significant burden following transcatheter aortic valve replacement, adversely impacting survival and quality of life. Identification of patients who may benefit from closer monitoring or adjunctive medical therapy to reduce the risk of HF is an unmet need. The objective of this study was to develop and internally validate a clinical prediction model to determine the 1-year risk of HF hospitalization or death after transcatheter aortic valve replacement. METHODS: Using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, we analyzed patients who underwent successful transcatheter aortic valve replacement for aortic stenosis and survived to discharge between 2016 and 2019. Covariates were selected based on expert opinion and prior literature. A hierarchical cumulative odds regression model was used to predict a composite outcome of (1) all-cause death, (2) ≥2 HF readmissions, or (3) 1 HF readmission at 1 year. RESULTS: Among 78 384 patients (median age, 82 years; 45.6% female), 17.4% experienced the composite outcome, including death (10.9%), ≥2 HF readmissions (1.6%), and 1 HF readmission (4.9%). The model demonstrated good discrimination (C statistic, 0.753 derivation and 0.747 validation) and excellent calibration. Among 1-year survivors, performance in predicting HF readmission as an isolated outcome was similar (C statistic, 0.753). A simplified model, including the top 12 variables from the full model, maintained comparable performance (C statistics, 0.74–0.75). CONCLUSIONS: This prediction model effectively stratifies post-transcatheter aortic valve replacement patients by risk of death or HF readmission, supporting its use to guide clinical surveillance and clinical trial enrollment for adjunctive medical therapies aimed at mitigating this risk.

Background: The relationship between body size and cardiovascular events is complex. This study utilized the ADVANCE (Assessing Diagnostic Value of Noninvasive FFR _CT in Coronary Care) Registry to investigate the association between body mass index (BMI), coronary artery disease (CAD), and clinical outcomes. Methods: The ADVANCE registry enrolled patients undergoing evaluation for clinically suspected CAD who had >30% stenosis on cardiac computed tomography angiography. Patients were stratified by BMI: normal 2 , overweight 25–29.9 kg/m ² , and obese ≥30 kg/m ² . Baseline characteristics, cardiac computed tomography angiography and computed tomography fractional flow reserve (FFR _CT ), were compared across BMI groups. Adjusted Cox proportional hazards models assessed the association between BMI and outcomes. Results: Among 5014 patients, 2166 (43.2%) had a normal BMI, 1883 (37.6%) were overweight, and 965 (19.2%) were obese. Patients with obesity were younger and more likely to have comorbidities, including diabetes and hypertension (all P P CT , was similar across BMI categories (63.4% obese, 66.1% overweight, and 67.8% normal BMI; P =0.07). Additionally, patients with obesity had a lower coronary volume-to-myocardial mass ratio compared with patients who were overweight or had normal BMI (obese BMI, 23.7; overweight BMI, 24.8; and normal BMI, 26.3; P 0.05). Conclusions: Patients with obesity in the ADVANCE registry were less likely to have anatomically obstructive CAD by cardiac computed tomography angiography but had a similar degree of physiologically significant CAD by FFR _CT and similar rates of adverse events. An exclusively anatomic assessment of CAD in patients with obesity may underestimate the burden of physiologically significant disease that is potentially due to a significantly lower volume-to-myocardial mass ratio.

Background: Patients evaluated for coronary artery disease have a range of symptoms and underlying risk. The relationships between patient-described symptoms, clinician conclusions, and subsequent clinical management and outcomes remain incompletely described. Methods: In this secondary analysis, we examined the association between 4 types of presenting symptoms (substernal/left-sided chest pain, other chest/neck/arm pain, dyspnea, and other symptoms) and patient risk, noninvasive test results, clinical management, and outcomes for stable outpatients randomized in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Multivariable regression models were used to evaluate differences in noninvasive test result, all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/myocardial infarction by symptom type. Results: Among 9996 patients, most presented with chest pain (47.2% substernal, 29.2% other), followed by dyspnea (14.9%), and other symptoms (8.7%). Patients with dyspnea were older (median age 63 versus 60, P ≤0.02) with higher baseline risk (78.2% with atherosclerotic cardiovascular disease >7.5% versus 67.6%, P ≤0.02). Using patients with substernal chest pain as a reference, there was no difference in noninvasive test positivity across symptom groups (all P >0.05), but test-positive patients with dyspnea (adjusted odds ratio, 0.66 [95% CI, 0.51–0.85]) or other symptoms (adjusted odds ratio, 0.65 [95% CI, 0.47–0.90]) were less likely to be referred for cardiac catheterization. While symptom type alone was not associated with outcomes, symptom presentation with chest pain or dyspnea did modify the association between a positive noninvasive test and clinical outcome (interaction P =0.025 for both all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/MI). Conclusions: Among low-risk outpatients evaluated for coronary artery disease, typicality of symptoms was not closely associated with higher baseline risk but was related to differences in processes of care and the prognostic value of a positive test. Adverse events were not associated with clinician risk estimates or symptoms alone. These unexpected findings highlight the limitation of relying solely on symptom presentation or clinician risk estimation to evaluate patients for suspected coronary artery disease. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01174550.

Background: Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results: Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011–2016). Multilevel, multivariable Fine‐Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1‐year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th–75th percentiles, 13.3%–47.0%]). The odds of receiving AVR varied >2‐fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14–2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1‐year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13–1.33). Conclusions: Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.

Background: Non‐statin lipid lowering therapies (LLTs) provide additional treatment options for patients. Use patterns and patient perceptions of non‐statin LLT remain incompletely described.Hypothesis: The guideline‐recommended statin intensity remains underutilized in patients treated with and without non‐statin LLT.Methods: The PALM Registry collected LLT information on patients with or at risk of ASCVD treated at 125 US clinics in 2015. We compared patient perceptions, lipid levels and statin use among patients treated with and without non‐statin LLT.Results: Among 7720 patients, 1930 (25.0%) were treated with a non‐statin LLT (1249 fish oil, 417 fibrates, 329 ezetimibe, 196 niacin). Concurrent statin treatment occurred in 73.7%, of which 45.4% were dosed under the guideline‐recommended intensity. Compared with patients on statin alone, patients receiving both a statin and non‐statin LLT (n = 1423) were more likely to be male, white race and to perceive themselves as higher risk of ASCVD compared with their peers (38.5% vs. 34.9%, p = .047). Only 27.4% of patients treated with non‐statin LLT alone perceived themselves at higher risk. Most (75.7%) patients treated with a non‐statin LLT alone reported never being treated with a statin, despite ASCVD in 30.8% of these patients. Among those previously treated with a statin, 59.3% reported being willing to try a statin again.Conclusions: Non‐statin LLT is used in one in four patients with or at risk for ASCVD; its use is frequently in place of statin therapy or in the absence of guideline‐recommended statin intensity. More work is needed to establish statins as first line therapy.

In Reply We thank the authors for their insightful comments regarding our substudy of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial.¹ The authors have made several important points, and we would like to provide the data and rationale to support our analyses and conclusions. We appreciate the intricacies of the data obtained from a coronary computed tomography angiography (CTA) evaluation. The authors correctly note that the prognostic information gained from a coronary CTA is not only from the presence or absence of obstructive coronary disease but also based on the plaque location and morphology. A separate substudy of the PROMISE trial examined the risk stratification of patients using high-risk coronary plaque detection.² In that analysis, the authors found that, among patients in the PROMISE trial, the presence of high-risk plaque conferred an independent risk of a major adverse cardiovascular event beyond that of cardiovascular risk factors and obstructive coronary artery disease. However, importantly, there was no significant difference in age between patients with or without high-risk plaque identified by coronary CTA (61.0 years vs 60.4 years; P = .07). When patients were stratified by age less than vs greater than the median, the study showed that the predictive value of high-risk plaque presence was stronger in younger patients (adjusted hazard ratio [HR], 2.33; 95% CI, 1.20-4.51) than in older patients (adjusted hazard ratio, 1.36; 95% CI, 0.77-2.39). This aligns with our study where CTA better stratified risk for cardiovascular death or myocardial infarction among patients younger than 65 years.

The incidence and prevalence of symptomatic coronary artery disease (CAD) increase with age.^1,2 Given the aging population, more older adults are presenting for evaluation of symptoms possibly related to CAD. However, identifying those who are at an increased risk for future cardiovascular (CV) events remains unclear. There are also unique considerations in the performance or interpretation of noninvasive testing for CAD among different age groups of patients. For example, noninvasive testing in older adults may present unique challenges owing to exercise limitations or uninterpretable electrocardiograms (ECGs). Further, the pretest probability of CAD varies with age and affects interpretation of both positive and negative test results.