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In This Issue of JAMA Cardiology
September 2016


JAMA Cardiol. 2016;1(6):625. doi:10.1001/jamacardio.2015.0032

In 2006, New York began excluding patients with cardiogenic shock from the publicly reported percutaneous coronary intervention risk-adjusted mortality analyses. To investigate the effect of this policy change, McCabe and coauthors examine statewide hospitalizations for patients with acute myocardial infarction and shock from 2002 through 2012 in New York and compare data with 4 comparable states. After 2006, there was a significant increase in percutaneous coronary interventions for patients with cardiogenic shock in New York and a concomitant decrease in in-hospital mortality, exceeding simultaneously observed trends in the comparative states. The findings suggest that alterations in public reporting policies may have significant implications for physician behavior and public health. In an editorial, Kirtane and coauthors emphasize the potential adverse consequences of indiscriminant public reporting of percutaneous coronary intervention mortality.


Author Audio Interview

Cost is a factor that may influence the use of sacubitril/valsartan in patients with heart failure with reduced ejection fraction in the United States. Using a 2-state Markov simulation model, Gaziano and coauthors perform a nationwide cost-effectiveness analysis of sacubitril/valsartan therapy for eligible adult patients (mean [SD] age, 63.8 [11.5] years), which estimated mortality and hospitalization over a 30-year period. The model predicted that sacubitril/valsartan therapy would increase life expectancy at an incremental cost-effectiveness ratio consistent with other accepted high-value cardiovascular interventions. Compared with enalapril, sacubitril/valsartan would remain cost-effective while resulting in approximately 220 fewer hospital admissions per 1000 patients with heart failure.

The standard dose of apixaban is 5 mg twice daily. Dose reduction is recommended in patients with atrial fibrillation and 2 or more of the following criteria: age older than 80 years, a weight of 60 kg or less, and a creatine level of 1.5 mg/dL or greater. However, in practice, patients with only 1 criterion often receive dose reduction. Using data from 17 322 patients in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial, Alexander and coauthors report that the benefit of standard-dose apixaban compared with warfarin on patients after stroke or systemic embolism was similar between patients with 1 dose-reduction criterion and no dose-reduction criteria, as was the benefit compared with warfarin on major bleeding. In an editorial, Weitz and Eikelboom emphasize that a 5-mg dose twice a day is safe, efficacious, and appropriate for such patients.


The Affordable Care Act facilitates health care access for underinsured and uninsured patients via Medicaid expansion and the insurance exchange market. Because heart transplantation in the United States has largely excluded uninsured patients, Oliveira and coauthors hypothesize that the Affordable Care Act would result in increased transplant listings. Using the United Network for Organ Sharing registry, they reported that heart transplants increased by 17% after the implementation of the Affordable Care Act, with a significantly greater increase in heart transplant listings in states that adopted Medicaid expansion than in those that did not (21% vs 12%; P = .02). However, longer transplant lists may exacerbate the shortage of donor organs.