Trends are shown for the overall pulseless ventricular tachycardia or ventricular fibrillation (VT/VF) out-of-hospital cardiac arrest (OHCA) cohort, the VT/VF OHCA with ST-segment elevation (STE) cohort, and the VT/VF OHCA without STE cohort (P for trend < .001).
eTable 1. Deyo Modification of Charlson Comorbidity Index
eTable 2. Baseline Characteristics of VT/VF OHCA Patients With STE Stratified by the Use of Coronary Angiography
eTable 3. Baseline Characteristics of VT/VF OHCA Patients Without STE Stratified by the Use of Coronary Angiography
eTable 4. Independent Patient and Hospital Factors Associated With Coronary Angiography and PCI in VT/VF OHCA Patients With STE Cohort
eTable 5. Independent Patient and Hospital Factors Associated With Coronary Angiography and PCI in VT/VF OHCA Patients Without STE Cohort
eTable 6. Independent Patient and Hospital Factors Associated With Survival to Discharge in VT/VF OHCA Patients With STE Cohort
eTable 7. Independent Patient and Hospital Factors Associated With Survival to Discharge in VT/VF OHCA Patients Without STE Cohort
eFigure 1. Flowchart of Study Population
eFigure 2. Trends of Survival to Discharge Home
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Patel N, Patel NJ, Macon CJ, et al. Trends and Outcomes of Coronary Angiography and Percutaneous Coronary Intervention After Out-of-Hospital Cardiac Arrest Associated With Ventricular Fibrillation or Pulseless Ventricular Tachycardia. JAMA Cardiol. 2016;1(8):890–899. doi:10.1001/jamacardio.2016.2860
What are the rates of use of coronary angiography and percutaneous coronary intervention (PCI) in out-of-hospital cardiac arrest (OHCA) associated with ventricular tachycardia or pulseless ventricular fibrillation (VT/VF)?
In this study of 407 974 adult patients hospitalized with VT/VF OHCA from 2000 to 2012, the use of coronary angiography and PCI progressively increased in patients with and without ST-segment elevation. An association was found with increased survival to discharge and survival to discharge home in the overall population of patients with VT/VF OHCA regardless of the presence of ST-segment elevation on the initial electrocardiogram.
Prospective randomized clinical trials are necessary to address the potential value of broader coronary angiography and PCI use as part of postresuscitation care in adults with VT/VF OHCA.
The 2015 cardiopulmonary resuscitation and emergency cardiovascular care guidelines recommend performing coronary angiography in resuscitated patients after cardiac arrest with or without ST-segment elevation (STE).
To assess the temporal trends, predictors, and outcomes of performing coronary angiography and percutaneous coronary intervention (PCI) in patients resuscitated after out-of-hospital cardiac arrest (OHCA) with initial rhythms of ventricular tachycardia or pulseless ventricular fibrillation (VT/VF).
Design, Setting, and Participants
An observational analysis of the use of coronary angiography and PCI in 407 974 patients hospitalized after VT/VF OHCA from January 1, 2000, through December 31, 2012, from the Nationwide Inpatient Sample database. Multivariable analysis was used to assess factors associated with coronary angiography and PCI use. Data analysis was performed from December 12, 2015, to January 5, 2016.
Main Outcomes and Measures
Temporal trends of coronary angiography, PCI, and survival to discharge in patients with VT/VF OHCA.
Among the 407 974 patients hospitalized after VT/VF OHCA, 143 688 (35.2%) were selected to undergo coronary angiography. The mean (SD) age of the total population was 65.7 (14.9) years, 37.9% were female, and 74.1% were white, 13.4% black, 6.8% Hispanic, and 5.7% other race. Use of coronary angiography increased from 27.2% in 2000 to 43.9% in 2012 (odds ratio, 2.47; 95% CI, 2.25-2.71; P for trend < .001), and PCI increased from 9.5% in 2000 to 24.1% in 2012 (odds ratio, 4.80; 95% CI, 4.21-5.66; P for trend < .001). From 2000 to 2012, coronary angiography and PCI after VT/VF OHCA increased in patients with STE (53.7% to 87.2%, P for trend < .001, and 29.7% to 77.3%, P for trend < .001, respectively) and those without STE (19.3% to 33.9%, P for trend < .001, and 3.5% to 11.8%, P for trend < .001, respectively). There was an associated increasing trend in survival to discharge in the overall population of patients with VT/VF OHCA (46.9% to 60.1%, P for trend < .001) in those with STE (59.2% to 74.3%, P for trend < .001) or without STE (43.3% to 56.8%, P for trend < .001).
Conclusions and Relevance
Coronary angiography, PCI, and survival to discharge have increased in VT/VF OHCA survivors from event to hospitalization. However, a significant proportion of patients with VT/VF OHCA, especially those without STE, do not undergo coronary angiography and revascularization. Prospective studies are needed to determine whether this limitation has a survival effect.
Out-of-hospital cardiac arrest (OHCA) is estimated to affect approximately 325 000 people in the United States annually.1 Pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) is the initial rhythm in 23% to 54% of patients with OHCA, with the median values at the lower end of this range.1-5 Coronary artery disease is thought to be responsible for up to 60% to 80% of these OHCA cases.3,6-9 Survival after OHCA remains very low at approximately 10%.1 Overall patient survival after cardiac arrest depends on all components of the chain of survival, ranging from time to 911 contact and bystander responses to appropriate postresuscitation care. It has been suggested that urgent coronary intervention in unconscious patients after cardiac arrest may improve survival.2-9 In addition to therapeutic hypothermia in the comatose patient after cardiac arrest, early coronary angiography and revascularization are now considered other key components of postresuscitation care. In the 2015 American Heart Association (AHA) guidelines, coronary angiography is recommended in patients with OHCA with a suspected cardiac cause and ST-segment elevation (STE) on electrocardiography (ECG) (class of recommendation I, level of evidence B), and it should be considered in patients after cardiac arrest who present without STE but with a suspected cardiac cause of cardiac arrest (class of recommendation IIa, level of evidence B).10 However, there is a paucity of information about the use of coronary angiography and percutaneous coronary intervention (PCI) and its potential benefit for the population of patients with VT/VF OHCA. We reviewed the Nationwide Inpatient Sample (NIS) to examine temporal trends of coronary angiography and PCI in VT/VF OHCA in the United States for patients with and without STE. We also studied the temporal trends of survival to discharge in these patient populations.
We conducted an observational analysis of the use of coronary angiography and PCI in patients hospitalized after VT/VF OHCA from January 1, 2000, through December 31, 2012, from the NIS database. On multivariable analysis, we also assessed factors associated with coronary angiography and PCI use. Data analysis was performed from December 12, 2015, to January 5, 2016.
The NIS is the largest publicly available all-payer hospital discharge database. It is a part of the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality. The NIS contains the data to approximate a 20% stratified sample of US community hospitals. The data in the NIS are drawn from the states participating in HCUP, which make up 97% of the US population. Each hospitalization is deidentified and maintained in the NIS as a unique entry with 1 primary discharge diagnosis and fewer than 24 secondary diagnoses during that hospitalization. Each entry also carries information on demographic details, insurance status, comorbidities, primary and secondary procedures, and hospitalization outcome. The NIS variables are used to identify a patient’s demographic information. We defined the severity of comorbid conditions using the Deyo modification of the Charlson Comorbidity Index. This index contains 17 comorbidity variables with differential weights. The score ranges from 0 to 33, with higher scores corresponding to a greater burden of comorbid conditions (eTable 1 in the Supplement).
This study was deemed exempt from approval by the University of Miami Miller School of Medicine Institutional Review Board because the HCUP is a publicly available database that contains deidentified patient information. Therefore, no patient consent was required.
We used the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) code 427.5 as a principal diagnosis to identify all patients 18 years or older with OHCA. The positive predictive value of this code is 78% to 94%.11-13 This approach has also been used in prior studies11-18 using administrative databases to identify patients with OHCA. We did not use ICD-9-CM code 99.60 (cardiopulmonary resuscitation) or 99.63 (closed chest cardiac massage) to avoid inclusion of in-hospital cardiac arrest (IHCA). This approach of identifying IHCA has been used in prior studies16,19-21 that used the NIS database. We excluded patients with do-not-resuscitate orders (n = 10 956) or records with missing data on age, sex, survival and/or discharge disposition, or type of admission as pregnancy or trauma related (n = 457). Patients with VT or VF were identified using ICD-9-CM codes 427.1, 427.41, or 427.42 as a secondary diagnosis. Therefore, our final study sample included 407 974 patients with VT/VF (eFigure 1 in the Supplement). Patients with STE myocardial infarction (STEMI) were then identified using ICD-9-CM codes 410.11 to 410.61, 410.81, and 410.91. Sensitivity and specificity of hospitalization data for identifying STEMI are 86% or higher, and the positive predictive value is 93% or higher.22,23 Patients without either of these codes were considered to have no STE. The ICD-9-CM codes were also used to identify patients who underwent coronary angiography (88.54, 88.55, 88.56, 88.57, 00.24, 00.59, 37.22, and 37.23) or PCI (36.06, 36.07, 00.40, 00.41, 00.42, 00.43, 00.44, 00.45, 00.46, 00.47, 00.48, and 00.66).
The primary measure of interest was the use of coronary angiography and PCI in populations of patients with VT/VF OHCA. We also assessed the factors associated with coronary angiography and PCI use along with temporal trends in their use from 2000 to 2012. Trends and factors associated with survival to discharge were also assessed. In addition, we analyzed these same trends according to the presence or absence of post–cardiac arrest STE.
Weighted data were used for all statistical analyses. Differences in baseline characteristics were examined using the Pearson χ2 test for categorical variables (reported as percentage); the unpaired, 2-tailed t test for normally distributed continuous variables (reported as mean [SD or SE]); and the Wilcoxon signed rank test if continuous variables were not normally distributed in the study population. For trend analysis, we used the Cochrane-Armitage test for categorical variables and linear regression for continuous variables. P < .05 was considered significant. No adjustments were made for multiple comparisons. STATA statistical software, version 11.0 (StataCorp), and SAS statistical software, version 9.4 (SAS Institute Inc), were used for analysis, which accounted for the complex survey design and clustering. Hierarchical mixed-effects models were generated to identify independent multivariable predictors of coronary angiography and survival to discharge. Hierarchical modeling is designed to analyze data with nested observations and is more appropriate than simple regression modeling for an available data set.
The NIS data set is inherently hierarchical because the data have the group (ie, hospital)–specific attributes, and within each group there are patients who contribute specific patient attributes to the data. Hierarchical models take into consideration the effect of nesting. Two-level hierarchical models (with patient-level factors nested within hospital-level factors) were created with the unique hospital identification number incorporated as random effects within the model (meaning that patients treated at the same hospital may experience similar outcomes as a result of other processes of care).
In all multivariable models, we included hospital-level variables, such as hospital region (Midwest, South, amd West, with Northeast as the reference category), location (urban vs rural), hospital bed size, teaching vs nonteaching hospital, and patient-level variables, such as age, sex, race, Deyo modification of the Charlson Comorbidity Index, STEMI, mechanical circulatory support use, admission during a weekend, median household income, and primary expected payer. Model discrimination was assessed using the C index. Data were complete for all covariates except race (19.8% missing), hospital location (0.4% missing), hospital bed size (0.4% missing), and primary expected payer (0.2% missing). We performed multiple imputations to impute missing values using the fully conditional specification method (an iterative Markov Chain Monte Carlo algorithm) in STATA statistical software, version 11.0 (StataCorp). Results with and without multiple imputation were not meaningfully different; therefore, only the former are presented.
Of 407 974 patients with VT/VF OHCA, 143 688 (35.2%) underwent coronary angiography. Of these, 71 273 (49.6% of patients selected to undergo coronary angiography and 17.5% of all patients with VT/VF OHCA) underwent PCI. The mean (SD) age of the total population was 65.7 (14.9) years, 37.9% were female, and 74.1% were white, 13.4% black, 6.8% Hispanic, and 5.7% other race. Baseline patient and hospital characteristics stratified by coronary angiography use are given in Table 1. A medical history of the following conditions led to an increase in the use of coronary angiography: STEMI, lower Deyo modification of the Charlson Comorbidity Index, obesity, and hypertension. Patients selected to undergo coronary angiography had higher mechanical circulatory support use. On the other hand, diabetes, history of heart failure, chronic obstructive pulmonary disease, chronic kidney disease, anemia, history of neurologic disorder, and coagulopathy were associated with lower use of coronary angiography. Large urban, teaching hospitals and hospitals located in the Midwest, South, and West used coronary angiography more often, whereas smaller rural, nonteaching hospitals and those located in the Northeast used coronary angiography less often (Table 1). Baseline characteristics of patients with VT/VF OHCA with or without STE stratified by coronary angiography use are given in eTable 2 and eTable 3 in the Supplement, respectively.
From 2000 to 2012, there was an increasing trend toward the use of coronary angiography and PCI in the overall population of patients with VT/VF OHCA (coronary angiography, 27.2% to 43.9%; P for trend < .001; PCI, 9.5% to 24.1%; P for trend < .001). Among the subgroup with STE, coronary angiography use increased from 53.7% to 87.2% (P for trend < .001), and PCI use increased from 29.7% to 77.3% (P for trend < .001). For those without STE, the coronary angiography use increased from 19.3% to 33.9% (P for trend < .001), and PCI use increased from 3.5% to 11.8% (P for trend < .001) (Figure 1). After adjustment, the odds ratios (ORs) for coronary angiography and PCI were 2.5 times and 5 times higher in 2012 compared with 2000 for patients with VT/VF OHCA (OR, 2.47; 95% CI, 2.25-2.71; and OR, 4.80; 95% CI, 4.21-5.66, respectively, in 2012 vs 2000). Similarly, the OR of coronary angiography and PCI increased for patients with VT/VF OHCA with STE and without STE (OR, 5.12; 95% CI, 4.09-6.42, and OR, 7.35; 95% CI, 6.04-8.95, and OR, 1.98; 95%, CI 1.79-2.21, and OR, 3.30; 95% CI, 2.69-4.02, respectively, in 2012 vs 2000).
After adjustment, patients more likely to undergo coronary angiography and PCI were younger, more likely to be male, more likely to have STEMI and mechanical circulatory support use, more likely to have private insurance or self-pay, and more often presented to larger urban, teaching hospitals located in the Midwest, South, and West (Table 2). eTable 4 and eTable 5 in the Supplement give the independent patient and hospital factors associated with coronary angiography use in patients with VT/VF OHCA with and without STE, respectively.
Patients selected to undergo coronary angiography had higher associated survival to discharge compared with those who did not undergo coronary angiography in the overall population of patients with VT/VF OHCA (77.3% vs 38.9%; OR, 6.26; 95% CI, 5.93-6.61; P < .001). Similarly, patients selected to undergo coronary angiography had higher survival to discharge compared with those who did not undergo coronary angiography in patients with VT/VF OHCA with and without STE (75.5% vs 43.4%; OR, 3.71; 95% CI, 3.27-4.22; P < .001, and 78.5% vs 38.5%; OR, 7.02; 95% CI, 6.6-7.46; P < .001, respectively). From 2000 to 2012, there was an increasing trend of survival to discharge in the overall VT/VF OHCA population (46.9% to 60.1%, P for trend < .001). Among the subgroup with STE, survival to discharge increased from 59.2% to 74.3% (P for trend < .001). For those without STE, the increase in survival to discharge was 43.3% to 56.8% (P for trend < .001) (Figure 2). Similarly, there was an increasing trend of survival to discharge home in the overall group with VT/VF OHCA with or without STE (eFigure 2 in the Supplement). After adjustment, the OR of survival to discharge increased during the study duration for the overall study population in those with and without STE (OR, 1.49; 95% CI, 1.37-1.62; P < .001; OR, 1.29; 95% CI, 1.07-1.58; P < .001; and OR, 1.52; 95% CI, 1.39-1.67; P < .001, respectively, in 2012 vs 2000).
After adjustment, patients more likely to survive to discharge were those treated from 2007 to 2012, those selected to undergo coronary angiography and/or PCI, those who were younger, those who were male, those who had STEMI, those who had lower Deyo modification of the Charlson Comorbidity Index, and those with private insurance, including health maintenance organization (Table 3). On the other hand, black race, Hispanic ethnicity, requirement for mechanical circulatory support, higher Deyo modification of the Charlson Comorbidity Index, lack of insurance, and treatment at large, urban, teaching hospitals located in the Midwest, South, and West were less likely to survive to discharge (Table 3). eTable 6 and eTable 7 in the Supplement give the independent patient and hospital factors associated with survival to discharge in patients with VT/VF OHCA with and without STE, respectively.
This analysis of a large inpatient registry reveals that coronary angiography and PCI after VT/VF OHCA has substantially increased in the United States since the year 2000 regardless of the presence of STE on their presenting ECG. Even after controlling for patient and hospital characteristics, the trend of increased use over time remained significant. This increasing use of coronary angiography and PCI after OHCA was associated with improved survival to hospital discharge and discharge home in the overall cohort, as well as in those with and without STE.
Even though this is one of the largest studies to find a change in practice over time with regard to post–cardiac arrest angiography, several smaller studies3,24-26 have found similar trends. A French retrospective study24 of 111 consecutive survivors of OHCA found that 82% underwent angiography and 33% underwent PCI. The Cardiac Arrest Registry to Enhance Survival,3 a registry of 4029 individuals between 2010 and 2013, found that early angiography was performed in 1953 individuals (48.5%), of whom 1253 (64.2%) underwent revascularization. Other much smaller retrospective studies25,26 found ranges of 40% to 81%. Our study found a somewhat lower incidence of post–VT/VF OHCA angiography of 35.2%. The increased use of coronary angiography in these smaller studies is most likely because these procedures were performed at centers that specialized in post–cardiac arrest care. Therefore, the lower rates of coronary angiography observed in our study are likely to be a true reflection of real-world clinical practice in the United States.
There has been a shift in the paradigm of the treatment of OHCA that started with a French study6 of 84 individuals undergoing coronary angiography after cardiac arrest. That study6 found that the incidence of coronary artery disease in these patients was approximately 70% and that more than 50% had acutely occluded coronary arteries. Coronary angiography was performed on all individuals without any obvious noncardiac causes of the OHCA. Those who underwent successful angioplasty had an association with significantly improved survival rates.6 Since that publication, several studies8,27,28 have found that 37.5% to 86% of cardiac arrest survivors have an acute coronary syndrome on coronary angiography. Thus, it seems that the most likely cause of cardiac arrests is acute coronary syndromes. Multiple small retrospective studies2,3,8,9,26,29-34 found that coronary angiography after OHCA regardless of ECG findings is associated with lower mortality and other outcomes, such as improved neurologic functioning.
The upward trend in the use of coronary angiography after VT/VF OHCA is a reflection of changes in clinical practice during the past 15 years. A significant number of studies2-4,8,9,24-26 with relatively modest sample sizes, published between 2000 and 2015, have found improved outcomes with early coronary angiography after OHCA. One of these studies6 had a significant effect on the recommendations issued by major cardiovascular professional societies in 2006 on the use of coronary angiography in OHCA. In 2006, the American College of Cardiology, AHA, and European Society of Cardiology consensus guidelines on ventricular arrhythmias and prevention of sudden cardiac death recommended the use of coronary angiography in patients with life-threatening arrhythmias or survivors of sudden cardiac death who have intermediate to high probability of coronary artery disease (class of recommendation IIa, level of evidence C). They also strongly recommended early coronary angiography in those presenting with polymorphic VT when ischemia cannot be excluded (class of recommendation I, level of evidence C).35 Two years later, the AHA and the International Liaison Committee on Resuscitation (ILCOR) indicated that patients with OHCA should undergo immediate coronary angiography in the presence of STE or when an acute coronary syndrome is suspected.36 In 2010, the AHA and ILCOR again provided consensus guidelines with similar recommendations, stating that early coronary angiography and PCI should be considered in patients with STEMI or new left bundle branch block and that it was reasonable to perform early coronary angiography and PCI in selected patients despite the absence of STE.37 All these consistent statements by major cardiovascular societies most likely influenced the use of coronary angiography after VT/VF OHCA during our study. The most recent 2015 AHA guidelines continue to emphasize the use of coronary angiography in patients with OHCA with STE (class of recommendation I, level of evidence B) and patients without STE but with suspected cardiac origin as the cause of cardiac arrest (class of recommendation IIa, level of evidence B).10 This finding may lead to an even higher use of coronary angiography after OHCA.
Our study indicates that the use of coronary angiography after VT/VF OHCA has increased during the past several years and suggests its use has been associated with improved survival in a large nationwide study. Trend in survival to discharge is consistent with a study34 that evaluated mortality after OHCA using the same database in which the authors reported that survival to discharge after overall OHCA, including pulseless electrical activity, improved from 30.4% in 2001 to 42.2% in 2009. However, that study did not explore the use of coronary angiography and PCI in patients with VT/VF OHCA and its association with survival to discharge or to discharge home. A novel finding from our study is increased use of coronary angiography and PCI in VT/VF OHCA and its association with improved survival to discharge and to discharge home from 2000 to 2012. Although there is a strong correlation with early coronary angiography after OHCA and improved outcomes, causation has yet to be proven. Although almost every study to date evaluating this topic has suggested improved outcomes with increased use of coronary angiography, they have all been retrospective in nature. Part of the observed increase in survival rates may be attributable to selection bias. Patients undergoing early coronary angiography are usually less sick or more likely to benefit based on evidence of acute coronary syndrome as the mechanism of arrest. This finding is clearly reflected in our study, which revealed that lower Deyo modifications of the Charlson Comorbidity Index and other comorbidities, such as chronic kidney disease, known coronary artery disease, neurologic dysfunction, coagulopathy, heart failure, and diabetes, were associated with a lower incidence of coronary angiography. A large, multicenter randomized clinical trial is still needed to definitively prove that early coronary angiography after OHCA is truly beneficial.
Despite the trends and benefits of use discussed above, there has been a countercurrent to increased use.5 Some centers have discouraged the practice of coronary angiography in OHCA survivors, except for subgroups who have the most obvious potential benefits (eg, those with STEMI), and focused on excluding the highest-risk patients. This position is based on the requirement for public reporting of mortality and complication rates and its effect on the reputation and possibly the compensation in large interventional programs.38-40 A previous study5 suggested that this concern can be obviated by having a 2-tiered reporting system for cardiac catheterization laboratories: one for high-risk patients, such as patients after cardiac arrest, and another for less complex cases.
Our study has some important limitations. It has inherent selection bias because of the retrospective observational nature of the study. We relied on ICD-9 codes among patients who survived to hospitalization for case identification. Although this method has been validated for OHCA in different cohorts, our data include hospitals not typically represented in registries and clinical trials; coding practices may vary according to hospital. Information on the location of cardiac arrest and the duration or quality of cardiopulmonary resuscitation is not collected in a large administrative database. Moreover, there is a possibility of ICD-9-CM codes used to identify secondary diagnosis representing medical history and not the event during the same admission. In addition, results of this study apply to survivors of an initial cardiac arrest who were successfully transported and hospitalized and are not representative of patients who died in the field, during transport, or on arrival to an emergency department. We made our best efforts to include only patients who exclusively experienced OHCA, but exclusion of IHCA cannot be ensured because of the possibility of coding errors. In this regard, a recent report5 on cardiac arrest from the Institute of Medicine suggests that future versions of the ICD should include specific codes for OHCA and IHCA. These, plus the existing codes for VT/VF, should obviate such problems in the future. In addition, survival bias and competing risks could have contributed to the favorable outcomes associated with coronary angiography because gravely ill patients die soon after admission and are less likely to receive further interventions. The NIS is an administrative database that lacks clinical details. As an example, timing of coronary angiography and angiographic data were not available. Therefore, the assessment of the timing and effect of the extent of revascularization on clinical outcomes was not possible. Among survivors to discharge, neurologic status could not be assessed because there were no data about the cerebral performance category scale. Despite these limitations, our study provides an estimate of trends of coronary angiography for populations of patients with VT/VF OHCA and associations with survival rates.
Among patients hospitalized with VT/VF OHCA from 2000 to 2012 in US hospitals participating in the NIS, the use of coronary angiography and PCI has progressively increased. These increases were observed in patients with VT/VF OHCA with and without STE. There was an association with increased survival to discharge and survival to discharge home in the overall population of patients with VT/VF OHCA regardless of the presence of STE on the initial ECG. Prospective randomized clinical trials will be necessary to address the potential value of broader coronary angiography and PCI use as a part of postresuscitation care in the population of patients with VT/VF OHCA.
Corresponding Author: Nish Patel, MD, Division of Cardiology, University of Miami Miller School of Medicine, 1120 NW 14th St, Clinical Research Bldg, Ste 1139, Miami, FL 33136 (email@example.com).
Accepted for Publication: June 26, 2016.
Published Online: September 14, 2016. doi:10.1001/jamacardio.2016.2860.
Author Contributions: Drs N. Patel and N. J. Patel contributed equally. Drs Patel and Cohen had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Patel, Patel, Rengifo-Moreno, Cohen.
Acquisition, analysis, or interpretation of data: Patel, Patel, Macon, Thakkar, Desai, Alfonso, Myerburg, Bhatt.
Drafting of the manuscript: Patel, Patel, Macon, Thakkar, Desai.
Critical revision of the manuscript for important intellectual content: Patel, Patel, Rengifo-Moreno, Alfonso, Myerburg, Bhatt, Cohen.
Statistical analysis: Patel, Patel, Thakkar, Desai.
Administrative, technical, or material support: Patel, Macon, Desai, Rengifo-Moreno.
Study supervision: Patel, Rengifo-Moreno, Alfonso, Cohen.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Myerburg is supported in part by the American Heart Association Chair in Cardiovascular Research and a grant from the Miami Heart Research Institute. Dr Bhatt reported being on the advisory boards of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; on the boards of directors for Boston Veterans Affairs Research Institute, Society of Cardiovascular Patient Care; chair of the American Heart Association Quality Oversight Committee; and on the data monitoring committees for Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Population Health Research Institute. He also reported receiving honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org), Belvoir Publications (editor in chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (editor in chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor; associate editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (chief medical editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), WebMD (CME steering committees); serving as deputy editor of Clinical Cardiology, vice chair of the NCDR-ACTION Registry Steering Committee, and chair of the Veterans Affairs Clinical Assessment Reporting and Tracking Research and Publications Committee; receiving research funding from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi Aventis, The Medicines Company; receiving royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); serving as a site coinvestigator for Biotronik, Boston Scientific, St Jude Medical; serving as a trustee for the American College of Cardiology; and conducting unfunded research for FlowCo, PLx Pharma, and Takeda. Dr Cohen reported receiving honoraria from Abiomed, Accumed, AstraZeneca, Medtronic, Merit Medical, and Terumo Medical and serving as a clinical trial enroller for Reprise III and Harmonee. No other disclosures were reported.
Funding/Support: Dr Myerburg is supported in part by the American Heart Association Chair in Cardiovascular Research and a grant from the Miami Heart Research Institute.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.