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In This Issue of JAMA Cardiology
December 2016


JAMA Cardiol. 2016;1(9):969. doi:10.1001/jamacardio.2015.0050


To examine whether participation in cardiac rehabilitation (CR) is associated with health status after acute myocardial infarction (AMI), Kureshi and coauthors studied 4929 patients in the PREMIER and TRIUMPH study registries. Health status was assessed with the Seattle Angina Questionnaire and the 12-Item Short-Form Health Survey at 6 and 12 months after AMI. Those who did and did not participate in CR had similar reported health status during the year following AMI; however, participation in CR did confer a significant survival benefit (hazard ratio, 0.59; 95% CI, 0.46-0.75). These findings underscore the need for increased use of validated patient-reported outcome measures to further examine if and how health status can be maximized for patients who participate in CR. In an editorial, Jneid points out that only 41% of patients in this study were referred for CR, highlighting the need for more research to identify and overcome barriers leading to underuse of CR.


It is uncertain whether cardiac biomarkers improve assessment of cardiovascular risk in patients with type 2 diabetes. Scirica and coauthors studied biomarker profiles in 12 310 outpatients with diabetes with overt cardiovascular disease or multiple risk factors enrolled in the SAVOR–TIMI 53 trial, with a median follow-up of 2.1 years. Elevated levels of high-sensitivity troponin T, N-terminal pro–B-type natriuretic peptide, and high-sensitivity C-reactive protein levels were each associated with increased risk for all cardiovascular end points. When added to clinical variables, biomarkers significantly improved the discrimination and appropriate reclassification of risk. These data suggest that incorporation of biomarker data into standard risk algorithms may enhance risk stratification in patients with type 2 diabetes.

The CHA2DS2-VASc score is widely used for risk assessment in patients with atrial fibrillation but has only moderate discrimination. Ruff and coauthors investigated whether biomarkers could improve the risk of stroke, systemic embolic events, or death by measuring cardiac troponin I, N-terminal pro–B-type natriuretic peptide, and D-dimer levels in 4880 patients enrolled in the ENGAGE AF-TIMI 48 trial. After adjusting for the CHA2DS2-VASc score, each biomarker was associated with a significant gradient of risk; a multimarker risk score identified a more than 15-fold gradient of risk, with an increase in the C statistic from 0.586 to 0.708 and a net reclassification improvement of 59.4%. These results support consideration of biomarkers in clinical decision making in patients with atrial fibrillation.

To determine the characteristics of pulmonary arterial hypertension (PAH)–related hospitalizations in the United States, Anand and coauthors analyzed the National Inpatient Sample Database for adult patients with PAH. Between 2001 and 2012, there was a significant decrease in PAH-related hospitalizations, but hospital charges increased substantially and were increasingly borne by Medicare. Although in-hospital mortality was unchanged, complexity of care and length of stay increased. In a commentary, Mathai and McLaughlin emphasize that further research is essential to address persistent knowledge gaps in our understanding of the characteristics, cost, and effect of hospitalizations on outcomes in patients with PAH.

Invited Commentary and Review

Author Audio Interview