搜索结果：Circulation. Cardiovascular quality and outcomes

Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.

Cancer is a leading cause of death globally. Accurate cancer burden information is crucial for policy planning, but many countries do not have up-to-date cancer surveillance data. To inform global cancer-control efforts, we used the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 framework to generate and analyse estimates of cancer burden for 47 cancer types or groupings by age, sex, and 204 countries and territories from 1990 to 2023, cancer burden attributable to selected risk factors from 1990 to 2023, and forecasted cancer burden up to 2050. Cancer estimation in GBD 2023 used data from population-based cancer registration systems, vital registration systems, and verbal autopsies. Cancer mortality was estimated using ensemble models, with incidence informed by mortality estimates and mortality-to-incidence ratios (MIRs). Prevalence estimates were generated from modelled survival estimates, then multiplied by disability weights to estimate years lived with disability (YLDs). Years of life lost (YLLs) were estimated by multiplying age-specific cancer deaths by the GBD standard life expectancy at the age of death. Disability-adjusted life-years (DALYs) were calculated as the sum of YLLs and YLDs. We used the GBD 2023 comparative risk assessment framework to estimate cancer burden attributable to 44 behavioural, environmental and occupational, and metabolic risk factors. To forecast cancer burden from 2024 to 2050, we used the GBD 2023 forecasting framework, which included forecasts of relevant risk factor exposures and used Socio-demographic Index as a covariate for forecasting the proportion of each cancer not affected by these risk factors. Progress towards the UN Sustainable Development Goal (SDG) target 3.4 aim to reduce non-communicable disease mortality by a third between 2015 and 2030 was estimated for cancer. In 2023, excluding non-melanoma skin cancers, there were 18·5 million (95% uncertainty interval 16·4 to 20·7) incident cases of cancer and 10·4 million (9·65 to 10·9) deaths, contributing to 271 million (255 to 285) DALYs globally. Of these, 57·9% (56·1 to 59·8) of incident cases and 65·8% (64·3 to 67·6) of cancer deaths occurred in low-income to upper-middle-income countries based on World Bank income group classifications. Cancer was the second leading cause of deaths globally in 2023 after cardiovascular diseases. There were 4·33 million (3·85 to 4·78) risk-attributable cancer deaths globally in 2023, comprising 41·7% (37·8 to 45·4) of all cancer deaths. Risk-attributable cancer deaths increased by 72·3% (57·1 to 86·8) from 1990 to 2023, whereas overall global cancer deaths increased by 74·3% (62·2 to 86·2) over the same period. The reference forecasts (the most likely future) estimate that in 2050 there will be 30·5 million (22·9 to 38·9) cases and 18·6 million (15·6 to 21·5) deaths from cancer globally, 60·7% (41·9 to 80·6) and 74·5% (50·1 to 104·2) increases from 2024, respectively. These forecasted increases in deaths are greater in low-income and middle-income countries (90·6% [61·0 to 127·0]) compared with high-income countries (42·8% [28·3 to 58·6]). Most of these increases are likely due to demographic changes, as age-standardised death rates are forecast to change by -5·6% (-12·8 to 4·6) between 2024 and 2050 globally. Between 2015 and 2030, the probability of dying due to cancer between the ages of 30 years and 70 years was forecasted to have a relative decrease of 6·5% (3·2 to 10·3). Cancer is a major contributor to global disease burden, with increasing numbers of cases and deaths forecasted up to 2050 and a disproportionate growth in burden in countries with scarce resources. The decline in age-standardised mortality rates from cancer is encouraging but insufficient to meet the SDG target set for 2030. Effectively and sustainably addressing cancer burden globally will require comprehensive national and international efforts that consider health systems and context in the development and implementation of cancer-control strategies across the continuum of prevention, diagnosis, and treatment. Gates Foundation, St Jude Children's Research Hospital, and St Baldrick's Foundation.

Breast cancer is a leading cause of mortality and morbidity among females worldwide. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we provided an updated comprehensive assessment of the epidemiological trends, disease burden, and risk factors associated with breast cancer globally, regionally, and nationally from 1990 to 2023. Breast cancer incidence, mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) were estimated by age and sex for 204 countries and territories from 1990 to 2023. Mortality estimates were generated using GBD Cause of Death Ensemble models, leveraging data from population-based cancer registration systems, vital registration systems, and verbal autopsies. Mortality-to-incidence ratios were calculated to derive both mortality and incidence estimates. Prevalence was calculated by combining incidence and modelled survival estimates. YLLs were established by multiplying age-specific deaths with the GBD standard life expectancy at the age of death. YLDs were estimated by applying disability weights to prevalence estimates. The sum of YLLs and YLDs equalled the number of DALYs. Breast cancer burden attributable to seven risk factors was examined through the comparative risk assessment framework. The GBD forecasting framework was used to forecast breast cancer incidence and mortality from 2024 to 2050. Age-standardised rates were calculated for each metric using the GBD 2023 world standard population. In 2023, there were an estimated 2·30 million (95% uncertainty interval [UI] 2·01 to 2·61) breast cancer incident cases, 764 000 deaths (672 000 to 854 000), and 24·1 million (21·3 to 27·5) DALYs among females globally. In the World Bank low-income group, where a low age-standardised incidence rate (ASIR) was estimated (44·2 per 100 000 person-years [31·2 to 58·4]), the age-standardised mortality rate (ASMR) was the highest (24·1 per 100 000 [16·8 to 31·9]). The highest ASIR was in the high-income group (75·7 per 100 000 [67·1 to 84·0]), and the lowest ASMR was in the upper-middle-income group (11·2 per 100 000 [10·2 to 12·3]). Between 1990 and 2023, the ASIR in the low-income group increased by 147·2% (38·1 to 271·7), compared with a 1·2% (-11·5 to 17·2) change in the high-income group. The ASMR decreased in the high-income group, changing by -29·9% (-33·6 to -25·9), but increased by 99·3% (12·5 to 202·9) in the low-income group. The increase in age-standardised DALY rates followed that of ASMRs. Risk factors such as dietary risks, tobacco use, and high fasting plasma glucose contributed to 28·3% (16·6 to 38·9) of breast cancer DALYs in 2023. The risk factors with a decrease in attributable DALYs between 1990 and 2023 were high alcohol use and tobacco. By 2050, the global incident cases of breast cancer among females were forecast to reach 3·56 million (2·29 to 4·83), with 1·37 million (0·841 to 2·02) deaths. The stable incidence and declining mortality rates of female breast cancer in high-income nations reflect success in screening, diagnosis, and treatment. In contrast, the concurrent rise in incidence and mortality in other regions signals health system deficits. Without effective interventions, many countries will fall short of the WHO Global Breast Cancer Initiative's ambitious target of achieving an annual reduction of 2·5% in age-standardised mortality rates by 2040. The mounting breast cancer burden, disproportionately affecting some of the world's most vulnerable populations, will further exacerbate health inequalities across the globe without decisive immediate action. Gates Foundation, St Jude Children's Research Hospital.

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality, near-misses and morbidity in Uganda and globally. Kawempe National Referral Hospital (KNRH), Uganda's largest obstetric referral hospital, receives many obstetric emergencies, including PPH, from lower-level health facilities. Little is known about the outcomes and management of severe PPH at KNRH. This study aimed to map the occurrence, profile and management challenges of severe PPH at KNRH. A prospective hospital-based observational pilot study was conducted between 5th April and 30th May 2023 at KNRH. Sixty women with severe PPH, both in-house and referrals, were enrolled. Data collection was done by research assistants on day 0-3 and 42 of inclusion, capturing characteristics, management and outcomes of the participants. Descriptive statistics were used for analysis. Of the 60 participants, 47 were referrals. There were 3 maternal deaths, 56 maternal near-misses (hysterectomy, cardiovascular dysfunction, uterine rupture or massive blood loss, and 46 underwent critical interventions (intensive care, laparotomy or blood transfusions). All the participants with uterine ruptures and 12 out of the 13 participants with stillbirths and hysterectomies, respectively, were among referrals. Only referrals had an initial systolic blood pressure ≤ 60 mm Hg and received ≥ 5 units of blood. In both groups approximately two thirds received tranexamic acid and oxytocin/misoprostol while few of the participants (23.3%) received uterine massage. Nine women had surgical site infections (8 were referrals), and 15 had suboptimal (fair/poor) wellbeing at 6 weeks postpartum (13 were referrals). None of the comparisons were statistically significant due to too few observations. Referrals were more critically ill and disproportionally affected by adverse outcomes and substandard care. While drugs and fluids were often timely administered according to national guidelines and did not differ greatly between the groups, gaps remained particularly non-pharmaceutical interventions. Bettered implementation of evidence-based PPH management and strengthening of the referral system could improve quality of care and maternal outcomes.

Atrial secondary mitral regurgitation (aSMR) is a distinct subtype of SMR characterized by normal leaflets, annular dilatation, left atrial (LA) enlargement, and preserved left ventricular function. Treatment pathways for aSMR are undefined, and limited data exist regarding outcomes following mitral transcatheter edge-to-edge repair (MTEER). The analysis aimed to evaluate outcomes in patients with aSMR treated with MTEER from the EXPANDed (Evaluation of the MitraClip X System Post-MArket Real-World CliNical Outcomes Database ) studies. One-year outcomes were assessed in patients from the EXPANDed studies (EXPAND and EXPAND G4 [Evaluation of the MitraClip X System Post-MArket Real-World CliNical Outcomes Database Generation 4 ]) who met criteria for aSMR. aSMR was defined by the presence of atrial fibrillation, left ventricular ejection fraction ≥45%, and at least 1 dilated LA parameter per echocardiographic core laboratory assessment: LA volume index, LA diameter, or LA diameter index. Of the 967 patients with SMR treated with MTEER in the EXPANDed data set, 160 (17%) met criteria for aSMR. Patients with aSMR were elderly (78±8 years), symptomatic (Kansas City Cardiomyopathy Questionnaire Overall Summary score, 48±27 pts), and had small left ventricular and large LA dimensions at baseline. Acute procedural success was achieved in 97.5% of patients with aSMR, with MR reduction to ≤1+ in 95.2% at 1 year. There were significant 1-year improvements in quality of life (+19 pt Kansas City Cardiomyopathy Questionnaire Overall Summary) and functional capacity (New York Heart Association I/II 80%). The 1-year all-cause mortality rate was 9%, with patients experiencing a 56% reduction in 1-year heart failure hospitalization rates from pre- to post-MTEER. In the largest population of patients with aSMR assessed by an echocardiographic core laboratory, MTEER safely and significantly reduced MR with improvements in quality of life and reduction in heart failure hospitalization through 1 year.

Although cardiovascular disease is the leading cause of death in the United States among Medicare beneficiaries, management of modifiable risk factors remains suboptimal. Medicare Advantage (MA) enrollment has increased substantially; therefore, understanding the quality of cardiovascular risk factor management in MA is critical. In this study, we evaluated whether cardiovascular risk factor management was better among MA compared with traditional Medicare (TM) beneficiaries. We linked physical examination and laboratory data from the National Health and Nutrition Examination Survey (2015-2018) to Medicare enrollment data. We calculated age- and sex-standardized differences for treatment and control rates of hypertension, diabetes, and hyperlipidemia among adults &#x2265;65 years enrolled in MA compared with TM. National Health and Nutrition Examination Survey weights were used to calculate nationally representative estimates. The weighted study population included 45&#x2009;426&#x2009;712 adults (34.4% MA, 65.6% TM). The mean age was 72.9 years and 55.3% were female. MA beneficiaries were more likely to be female (58.5% versus 53.5%), less likely to be White (71.7% versus 81.7%), and more likely to have household incomes <100% poverty (11.4% versus 7.0%). Treatment rates for hypertension (82.3% versus 79.1%; SD, 3.4 percentage points [pp]; [95% CI, -1.1 to 7.9]), hyperlipidemia (56.4% versus 56.0%; SD, 0.5 pp [95% CI, -5.7 to 6.8]), and diabetes (76.3% versus 82.5%; SD, -5.0 pp [95% CI, -13.1 to 3.1]) did not significantly differ between MA and TM beneficiaries. There were also no differences in control rates for hypertension (43.6% versus 46.1%; SD, -1.2 pp [95% CI, -8.8 to 6.4]), hyperlipidemia (51.5% versus 48.0%; SD, 4.0 pp [95% CI, -1.7 to 9.7]), and diabetes (61.5% versus 55.3%; SD, 4.4 pp [95% CI, -6.3 to 15.1]). Despite the rapid rise in MA enrollment among individuals with cardiovascular risk factors and disease over the past decade, treatment and control rates for hypertension, diabetes, and hyperlipidemia were similar between MA and TM beneficiaries.

Bile acid sequestrants have been reported to reduce serum thyroid hormone levels by binding T4 and T3 excreted into the intestinal lumen, preventing their reabsorption into the systemic circulation and interrupting the enterohepatic circulation of these hormones. This meta-analysis evaluates whether adjunctive bile acid sequestrants accelerate reductions in serum iodothyronine when added to standard hyperthyroidism therapy. A systematic review and meta-analysis were conducted and registered in PROSPERO (CRD42025643217). MEDLINE, Embase, Web of Science, and Cochrane databases were searched from March 1971 to September 2025 for randomized controlled trials (RCTs) assessing adult non-critically ill patients with hyperthyroidism treated with standard therapy (thionamides and beta-blocker) plus adjunctive bile acid sequestrants (cholestyramine or colestipol) versus standard therapy alone. Primary outcomes included a reduction in serum-free T4 and total T3. The secondary outcome was adverse effect frequency. Initial search yielded 705 results. After removal of duplicates and title/abstract screening, 17 full-text articles were reviewed, and five RCTs met the inclusion criteria, totaling 173 adult patients: 93 (53.75%) received adjunctive therapy, and 80 (46.25%) were controls. Causes for thyrotoxicosis included Graves' disease, toxic adenoma, and multinodular goiter. Doses ranged from cholestyramine 1 g twice a day to 4 g four times a day, and colestipol 20 g daily. At 2 weeks of treatment, bile acid sequestrants showed a non-significant reduction in serum total T3 (mean difference [MD] -0.44 nmol/L, 95% confidence interval [CI]: -1.2 to +0.32) and free T4 level (MD -0.55 ng/dL, CI: -1.15 to +0.04). At 4 weeks, there was a statistically significant reduction in total T3 (MD -1.59 nmol/L, CI: -2.90 to -0.27) and free T4 level (MD -1 ng/dL, CI: -1.74 to -0.25). Adjunctive bile acid sequestrants with standard hyperthyroidism therapy appear to enhance reductions in serum total T3 and free T4 at the mark of four weeks and were well tolerated. However, due to considerable heterogeneity and low quality of evidence, our results should be interpreted with caution. Larger, high-quality RCTs are needed to strengthen the evidence regarding the efficacy of adjunctive bile acid sequestrant therapy.

Chronic kidney disease (CKD) is common and ranks among the leading causes of mortality and morbidity. This analysis aimed to present global CKD estimates using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 to inform evidence-based policies for CKD identification and treatment. This analysis focused on adults aged 20 years and older over the period 1990 to 2023, from 204 countries and territories. Data sources used were published literature, vital registration systems, kidney failure treatment registries, and household surveys. Estimates of CKD burden, including deaths, incidence, prevalence, and disability-adjusted life-years (DALYs), were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool. A comparative risk assessment approach estimated the proportion of cardiovascular deaths attributable to impaired kidney function and estimated risk factors for CKD. Globally, in 2023, 788 million (95% uncertainty interval 743-843) people aged 20 years and older were estimated to have CKD, up from 378 million (354-407) in 1990. The global age-standardised prevalence of CKD in adults was 14&#xb7;2% (13&#xb7;4-15&#xb7;2), a relative rise of 3&#xb7;5% (2&#xb7;7-4&#xb7;1) from 1990. The region with the highest age-standardised prevalence was north Africa and the Middle East (18&#xb7;0%; 16&#xb7;9-19&#xb7;4). Most people had stage 1-3 CKD, with a combined prevalence of 13&#xb7;9% (13&#xb7;1-15&#xb7;0). In 2023, CKD was the ninth leading cause of death globally, accounting for 1&#xb7;48 million (1&#xb7;30-1&#xb7;65) deaths, and the 12th leading cause of DALYs, with an age-standardised DALY rate of 769&#xb7;2 (691&#xb7;8-857&#xb7;4) per 100&#x2009;000. Impaired kidney function as a risk factor accounted for 11&#xb7;5% (8&#xb7;4-14&#xb7;5) of cardiovascular deaths. High fasting plasma glucose, body-mass index, and systolic blood pressure were all leading risk factors for CKD DALYs. CKD is a major global health issue, with rising prevalence and increasing importance as a cause of death and as a risk factor for cardiovascular death. A better understating of aetiology, appropriate screening, and implementation programmes are needed to translate advances in CKD treatment into improved patient outcomes. Gates Foundation, Wellcome, US National Kidney Foundation, and US National Institute of Diabetes and Digestive and Kidney Diseases.

Type 2 myocardial infarction (MI) is common among older adults and is associated with adverse outcomes in single-center studies. We aimed to examine temporal trends and compare outcomes between type 1 and type 2 MI in Medicare beneficiaries. Medicare beneficiaries with type 1 or type 2 MI were identified using International Classification of Diseases, Tenth Revision codes from Medicare Provider Analysis and Review 100% inpatient files. Temporal trends were assessed from 2018 to 2021. Patients with type 2 MI were matched 1:1 to type 1 MI by age, sex, race, and year. Outcomes included all-cause mortality, recurrent MI, heart failure hospitalization (HFH), and stroke. Time-to-event analyses used Cox models for mortality and Fine-Gray models for hospitalization outcomes, with short-term (&#x2264;30 days) and long-term (>30 days) outcomes assessed using landmark analysis. Among 1&#x2009;816&#x2009;926 Medicare beneficiaries, the proportion of type 2 MI increased from 19.4% in 2018 to 26.8% in 2021 (Ptrend<0.001). In propensity-matched analyses of 94&#x2009;132 patients (mean age 77.3&#xb1;11 years, 53.3% male), patients with type 2 (versus type 1) MI had lower short-term all-cause mortality (hazard ratio, 0.61 [95% CI, 0.59-0.63]), recurrent MI (subdistribution hazard ratio [sHR], 0.56 [95% CI, 0.54-0.59]), HFH (sHR, 0.56 [95% CI, 0.47-0.67]), and similar risk of stroke (sHR, 1.04 [95% CI, 0.90-1.21]). In long-term, patients with type 2 (versus type 1) MI had higher risk of all-cause mortality (hazard ratio, 1.23 [95% CI, 1.20-1.26]) and stroke (sHR, 1.20 [95% CI, 1.10-1.31]). The risk of recurrent MI and HFH associated with type 2 (versus type 1) MI in long-term follow-up was lower but considerably attenuated in magnitude compared with short-term risk (recurrent MI: sHR, 0.89 [95% CI, 0.86-0.94]; HFH; sHR, 0.73 [95% CI, 0.66-0.81]). Type 2 MI now accounts for over one-quarter of all MIs and is increasingly diagnosed. While patients with type 1 MI had higher short-term all-cause mortality risk, those with type 2 MI demonstrated higher long-term all-cause mortality and stroke risk, with lower risk of recurrent MI and HFH. These results highlight an urgent need for evidence-based strategies in this high-risk population.

Effective risk communication is essential in managing cardiovascular disease, the leading cause of global mortality. Clear communication between patients and physicians supports informed decision-making, yet comprehension gaps persist. We aimed to assess the quality of risk communication during hospital admissions for cardiovascular events, from patient and physician perspectives, and identify discrepancies in risk perception and associated factors. The HARIPA study (Heart Risk Perception and Communication Inpatient) by the Spanish Society of Cardiology was a multicenter, cross-sectional analysis conducted in 28 hospitals across Spain from October 2022 to March 2023. It included consecutive cardiology inpatients (urgent or scheduled), aged &#x2265;18 years, who could complete structured questionnaires. Participating physicians also completed parallel questionnaires. These assessed admission diagnosis, perceptions of future cardiovascular risk, and communication about potential procedural complications. Agreement between responses was evaluated using kappa indices (weighted for ordinal variables), and multivariable logistic regression was used to examine the impact of demographic and clinical factors (odds ratios with 95% CIs). We included 943 patients (mean age, 68.2 years; 29.4% women). The most frequent reason for admission was ischemic heart disease (41.3%). Responses resulted in a substantial agreement, with a kappa index of 0.72. Concordance between patients and physicians regarding future cardiovascular risk was low (weighted kappa: 0.29), with patients often underestimating their risk. And for assessment about procedural potential complications was moderate (kappa: 0.34). Although 76.9% of patients reported feeling adequately informed about procedural risks, 69.3% of those who experienced complications (n=208) stated they had not been warned about them. This study reveals significant gaps in risk communication in cardiovascular care, particularly regarding future risks and complications. As well-informed patients are more likely to adhere to preventive therapies, tailoring communication strategies to individual patient characteristics could improve understanding and align perceptions with clinical realities, enhancing health outcomes.

The Get With The Guidelines-Heart Failure program is a national quality improvement initiative that was established in 2005 with the goal of improving the quality of care for patients hospitalized with heart failure. We examined patient characteristics, adherence to achievement and quality measures, and in-hospital outcomes in patients hospitalized with heart failure among Get With The Guidelines-Heart Failure fully participating hospitals between 2005 and 2024. Measures were applied to eligible patients without documented contraindications. Multivariable regression analysis, adjusting for patient and hospital characteristics, was performed to assess temporal changes in individual measures and outcomes. Over the first 20 years, the Get With The Guidelines-Heart Failure program has grown to include 1 561 093 patient records (median age 73 [62-83], 47.4% women, median ejection fraction 45% [28%-58%]) and 819 participating hospitals. There was significant and sustained improvement in an all-or-none composite achievement metric, with an increase from 76.1% to 88.7% between 2005 and 2024 (adjusted odds ratio, 3.7 [95% CI, 3.5-4.0]; P<0.001). Rates of mineralocorticoid receptor antagonist prescriptions among eligible patients also increased substantially from 27.4% to 80.9% (adjusted odds ratio, 22.3 [95% CI, 20.2-24.6]; P<0.001). Meanwhile, prescriptions of new therapies such as angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors reached rates of 67.3% and 78.2% in 2024, respectively. Sustained improvements were also seen for other achievement and quality measures, including postdischarge follow-up and prescription of anticoagulation for patients with atrial fibrillation or atrial flutter. Equity of care by social vulnerability index also improved over time for guideline-based therapies such as evidence-based &#x3b2;-blockers and mineralocorticoid receptor antagonists. In contrast, vaccination rates and use of implantable cardioverter defibrillators saw recent decreases. The Get With The Guidelines-Heart Failure program was associated with sustained improvements in key achievement and quality measures for patients hospitalized with heart failure during its initial 2 decades, with a notable rise in the prescription of guideline-directed medical therapies and rapid implementation of new medications.

Equitable, timely, and evidence-based care remains a central goal across health care ecosystems, yet significant quality gaps, care variability, and health disparities persist. Professional societies, including the American Heart Association, have long developed clinical practice guidelines to provide standardized, evidence-based recommendations across the cardiovascular care continuum. These guidelines are operationalized into quality measures to monitor care, identify gaps, and guide improvement. Professional societies, agencies, and health systems have applied implementation science strategies, such as education, data sharing, and evaluation, to improve care quality and achieve quality measures defined in the clinical practice guidelines. American Heart Association's Get With The Guidelines programs target inpatient quality measures for stroke, heart failure, atrial fibrillation, resuscitation, and coronary artery disease, complemented by ambulatory quality improvement programs to support seamless care transitions. Decades of Get With The Guidelines implementation have enabled American Heart Association teams and volunteers to refine these programs, improving guideline adherence at local, regional, and national levels. Lessons learned informed the development of the Observe, Uncover, Trial, Personalize, Accelerate, Check, Expand Framework, designed to guide successful quality improvement initiatives. While existing quality improvement frameworks provide structured approaches, many are costly, slow, or siloed, limiting rapid-cycle, data-driven innovation across diverse health systems. The Observe, Uncover, Trial, Personalize, Accelerate, Check, Expand framework addresses these limitations as an adaptable model, applicable across care settings, disease areas, patient populations, system size, budgets, and target end points. Here, we illustrate the Observe, Uncover, Trial, Personalize, Accelerate, Check, Expand framework through 2 recent American Heart Association programs: Target: Aortic Stenosis and the IMPLEMENT-HF initiative, demonstrating its utility in guiding effective, scalable quality improvement.

Invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI) are common procedures for the diagnosis and treatment of coronary artery disease (CAD). These procedures are typically performed within the parameters of insurance coverage, but little is known about how insurance policies align with guidelines and landmark randomized clinical trials. We developed 6 use cases (3 each for ICA and PCI) of clinical scenarios for stable CAD commonly encountered in clinical practice and compared policies of the largest US public and private payers (based on total revenue and number of beneficiaries) to the 2012 and 2023 professional society guidelines as well as the ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) and ISCHEMIA (Initial Invasive or Conservative Strategy for Stable Coronary Disease) trials. We classified policies as more restrictive, equal, or less restrictive than the guidelines and published randomized clinical trials by evaluating them on parameters of optimal medical therapy (OMT) and noninvasive imaging for ICA policies; and OMT, anatomic severity of CAD, and ability to proceed with PCI for PCI policies. We summarized findings with descriptive statistics. Among 33 payers, 18 (55%) ICA and 14 (42%) PCI policies were publicly available. When comparing requirements for OMT among symptomatic patients before ICA, 22% of policies were less restrictive, 75% were equivalent, and 3% were more restrictive than the 2012 and 2023 professional society guidelines. For the number of OMT medications among symptomatic patients before ICA, 44% were less restrictive and 56% were equivalent compared with the ORBITA trial. When comparing requirements for OMT for symptomatic patients before PCI, 21% of policies were less restrictive, 75% were equivalent, and 4% were more restrictive than the 2012 and 2023 guidelines. ICA and PCI coverage policies were only publicly available for approximately half of the largest US insurers, indicating need for greater transparency. When available, policies were variable in their alignment with clinical practice guidelines.

Achieving adequate blood pressure control is challenging for patients and clinicians. Digital hypertension management solutions that use push notifications to promote lifestyle management have been proposed as an approach, but their effectiveness remains unknown. This analysis was designed to interrogate the independent and short-term effects of push notifications, tailored to participant and environmental factors, and on physical activity levels and sodium intake among individuals with hypertension. The myBPmyLife study was a 6-month randomized controlled trial of participants with self-reported hypertension recruited from an academic medical center and federally qualified health centers. A core component of the intervention consisted of microrandomized push notifications promoting lifestyle modifications that were randomly delivered at 4 daily time points and focused on physical activity and dietary sodium intake. Our primary outcome for this secondary analysis was the step count 60 minutes after a physical activity notification and lower-sodium food choices 24 hours after a dietary notification. This analysis focuses on the results of the microrandomized trial and used a centered and weighted least squares method adapted for 2 or more treatments. A total of 298 participants were randomized to the intervention arm, of whom 287 had data available for analysis. Participants' mean age was 59.5 (SD 13.1) years, 138 (48.1%) were women, and 206 (71.8%) were White. Participants were randomized at 187,517 time points over 6 months, which led to 0.96 (SD 0.86) push notifications per day divided between activity (50.4%; SD 0.4) and dietary (49.8%; SD 0.4) notifications. Activity notifications did not increase step count in the 60 minutes after a notification (estimate 1.01, 95% CI 0.98-1.04; P=.40). Similarly, dietary notifications did not impact the number of lower-sodium food choices in the subsequent 24 hours (estimate 0.93, 95% CI 0.83-1.04; P=.23), but in exploratory post hoc analyses, did increase mobile app use by 95.5% (95% CI 1.81-2.10; P<.001), mobile app clicks or searches by 93.7% (95% CI 1.72%-2.16%; P<.001), and low sodium searches by 113.0% (95% CI 1.73-2.53; P<.001), all within 60 minutes. In patients with hypertension, push notifications did not impact short-term physical activity levels or dietary sodium intake but did improve intervention engagement.

The dissemination of novel procedures should attempt to strike a balance between access and procedure quality. This study aimed to evaluate the temporal trends and geographic dispersion of mitral transcatheter edge-to-edge repair (M-TEER) sites and to examine the associations of site volume and site-to-population density with patient outcomes. We used the Medicare administrative databases in the United States to identify sites performing M-TEER in patients aged 65 to 99 years from 2017 to 2020 and examined the annualized volume and site-to-population density (per million beneficiaries in each corresponding hospital referral region). A hierarchical Cox regression analysis accounting for site-level clustering was performed to assess the association of site volume and density with 30-day and 1-year all-cause mortality. We identified 456 sites performing M-TEER in 16&#x2009;810 patients (median [interquartile range] age, 81 [75-86] years; female, 47%). The case number of M-TEER increased by 54% from 3125 in 2017 to 4820 in 2020, while sites performing M-TEER increased by 71% from 252 in 2017 to 432 in 2020, corresponding to a decline in the median patient-to-site distances from 37.1 kilometers (interquartile range, 14.4-105.0) to 28.6 kilometers (interquartile range, 12.8-74.9). Higher site volume (every 10 cases/y) was associated with lower 30-day (adjusted hazard ratio, 0.94 [95% CI, 0.91-0.99]) and 1 year (adjusted hazard ratio, 0.98 [95% CI, 0.96-1.00]) mortality, while there was insufficient evidence to determine the association between higher site density (every 1 site/million-beneficiaries) and 30-day (adjusted hazard ratio, 1.00 [95% CI, 0.99-1.02]) and 1-year (adjusted hazard ratio, 1.00 [95% CI, 0.99-1.01]) mortality. Although sites performing M-TEER have been rapidly expanding, we did not find associations between higher regional site density and patient mortality. Continuous careful planning in disseminating M-TEER while ensuring adequate procedure volume per site may optimize patient outcomes.

The COVID-19 pandemic disrupted health services, particularly affecting individuals with cardiometabolic diseases. This study compared health care use and mortality trends in adults with cardiometabolic diseases during the first pandemic year. It also examined associations between changes in outpatient visits and diagnostic tests with acute health care utilization and mortality. Using health administrative databases, we conducted a retrospective population-based study using an open-cohort sampling on adult (&#x2265;18 years of age) Ontario residents with a prior diagnosis of angina, congestive heart failure, hypertension, or diabetes between January 2016 and March 2021. During the pandemic's first year (March 2020-March 2021), observed (per 100&#x2009;000 at-risk) versus projected event rates were compared for all-cause outpatient visits, diagnostic testing, emergency department visits, hospitalizations and mortality across the 4 time periods. Auto-regressive integrated moving-average models were used to calculate projected rates from observed monthly rates from similar periods pre-COVID (January 2016-December 2019). Quasi-Poisson models examined interactions between care access and acute outcomes. In the first pandemic quarter, rates of outpatient visits, diagnostic testing, emergency department visits, and hospitalizations for adults with cardiometabolic diseases decreased. By year-end, outpatient visits exceeded projections for angina, congestive heart failure, and diabetes, while most diagnostic test rates remained below projections. Mortality was as projected, except in adults with hypertension during the first quarter (observed 54&#x2009;964 versus projected, 50&#x2009;134 [95% CI, 46&#x2009;686-53&#x2009;840]). In adults with diabetes and hypertension, fewer cardiac investigations and echocardiograms were associated with greater mortality than prepandemic (interaction P<0.01). Unlike other populations, diabetes and hypertension patients showed reduced emergency department visits, hospitalizations, and mortality during months with the highest virtual care use (P<0.02). The pandemic impacted health care utilization and mortality for adults with cardiometabolic diseases. Access to diagnostic testing is critical, particularly for those with diabetes and hypertension. Virtual care may benefit frequent health care users.

The Qiliqiangxin (QLQX) capsule is a prominent traditional Chinese medicine formulation developed based on the collateral disease theory, specifically for the treatment of heart failure (HF). Its composition includes 11 medicinal botanicals, such as Huang Qi, Ren Shen, and Dan Shen, and is designed to tonify qi, activate blood circulation, and promote diuresis. Supported by over 20 years of extensive clinical application, modern pharmacological research, and stringent quality control, QLQX has been incorporated into the national heart failure guidelines in China. This study evaluates the efficacy and safety of QLQX as adjunctive therapy for heart failure with reduced ejection fraction (HFrEF). We systematically searched seven databases until February 24, 2025, for randomized controlled trials (RCTs) evaluating QLQX in patients with HFrEF. Two independent researchers screened trials, extracted data, and assessed the risk of bias using the Cochrane RoB 2.0 tool. Meta-analyses were conducted for efficacy and safety outcomes, with evidence quality evaluated through the GRADE framework. Twenty-four RCTs (n&#xa0;=&#xa0;5580) were included. Compared with conventional treatments (CTs) alone, QLQX adjunctive therapy significantly reduced the risk of cardiovascular death (RR&#xa0;=&#xa0;0.82, 95&#xa0;%CI [0.69, 0.96], P&#xa0;=&#xa0;0.02), hospitalization for HF (RR&#xa0;=&#xa0;0.78, 95&#xa0;%CI [0.67, 0.91], P&#xa0;=&#xa0;0.001), and composite cardiovascular events by 18&#xa0;% (RR&#xa0;=&#xa0;0.82, 95&#xa0;%CI [0.73, 0.92], P&#xa0;=&#xa0;0.0005), with evidence quality rated as moderate. QLQX significantly improved cardiac function parameters compared to controls: increased left ventricular ejection fraction (MD&#xa0;=&#xa0;7.14, 95&#xa0;% CI [6.75, 7.54], P&#xa0;<&#xa0;0.05), reduced left ventricular end-diastolic diameter (MD&#xa0;=&#xa0;-5.25, 95&#xa0;% CI [-5.75, -4.75], P&#xa0;<&#xa0;0.05), improved NYHA class (RR&#xa0;=&#xa0;1.19, 95&#xa0;%CI [1.14, 1.25]), decreased NT-proBNP (SMD&#xa0;=&#xa0;-2.01, 95&#xa0;%CI [-2.26, -1.95], P&#xa0;<&#xa0;0.05), and increased 6-min walking distance (MD&#xa0;=&#xa0;44.80, 95&#xa0;%CI [42.37, 47.22], P&#xa0;<&#xa0;0.05). QLQX adjunct therapy effectively reduces cardiovascular death and HF hospitalization while improving cardiac function in HFrEF, with favorable safety. Large-scale multicenter RCTs with extended follow-up are required to confirm long-term benefits and address existing study limitations.

Compared with the 2003 Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) guideline, the 2017 American College of Cardiology and American Heart Association guideline (ACC/AHA 2017) expanded hypertension diagnostic criteria to blood pressure (BP) &#x2265;130/80 mm&#x2009;Hg and intensified treatment goals to <130/80 mm&#x2009;Hg. The cost-effectiveness of ACC/AHA 2017 guideline treatment has not been quantified. We used the Cardiovascular Disease (CVD) Policy Model to simulate hypertension treatment according to ACC/AHA 2017 compared with JNC7 in untreated US adults aged 35 to 79 years. Outcomes were projected over 10 years and included CVD events and deaths, quality-adjusted life-years (QALYs), and total health care costs (ie, costs of antihypertensive treatment and costs of health care utilization for cardiovascular and noncardiovascular care, regardless of payer). Cost-effectiveness was calculated from a health care sector perspective as incremental health care costs divided by incremental QALYs. Under ACC/AHA 2017, 4.9 million more US adults are indicated for treatment and 14.9 million are recommended more intensive treatment goals compared with JNC7. Over 10 years, ACC/AHA 2017 versus JNC7 treatment would cost $48&#x2005;300 per QALY gained ($38&#x2005;300/QALY in men; $65&#x2005;200/QALY in women). Overall, 34% of CVD events prevented by ACC/AHA 2017 versus JNC7 would be from expanded diagnosis (at $120&#x2005;900/QALY gained), and 66% from intensified BP treatment goals (at $18&#x2005;900/QALY gained). Cost-effectiveness improved with a longer time horizon ($17&#x2005;600 per QALY gained at 30 years) and when generic drug costs were assumed in place of median US drug costs ($27&#x2005;900 per QALY gained in 10 years). ACC/AHA 2017 is cost-saving in adults with BP &#x2265;140/90 mm&#x2009;Hg and prior CVD or 10-year CVD risk &#x2265;10%. Initiating hypertension treatment according to the ACC/AHA 2017 guideline in untreated US adults is cost-effective compared with JNC7 at 10 years. Prioritizing low-cost generic medicines and intensive BP treatment of high-CVD-risk adults with BP &#x2265;140/90 mm&#x2009;Hg returns the most value.

Data comparing valve systems in the valve-in-valve transcatheter aortic valve replacement (TAVR) field have been obtained from retrospective studies. This prespecified secondary analysis of the LYTEN randomized trial (Comparison of the Balloon-Expandable Edwards Valve and Self-Expandable CoreValve Evolut R or Evolut PRO System for the Treatment of Small, Severely Dysfunctional Surgical Aortic Bioprostheses) aims to compare the 3-year hemodynamic performance and clinical outcomes between balloon-expandable valves (BEV) SAPIEN 3/ULTRA (Edwards Lifesciences) and self-expanding valves (SEV) Evolut R/PRO/PRO+ (Medtronic) in valve-in-valve TAVR. Patients with a failed small (&#x2264;23 mm) surgical valve undergoing valve-in-valve TAVR were randomized to receive a SEV or a BEV. Patients had a clinical and valve hemodynamic (Doppler echocardiography) evaluation at 3-year follow-up. Study outcomes were defined according to VARC (Valve Academic Research Consortium)-2/VARC-3 criteria. Intended performance of the valve was defined as mean gradient <20 mm&#x2009;Hg, peak velocity <3 m/s, Doppler velocity index &#x2265;0.25, and less than moderate aortic regurgitation. Ninety-eight patients underwent TAVR (46 BEV [SAPIEN 3/ULTRA], 52 SEV [Evolut R-PRO-PRO+]). At 3 years, patients receiving a SEV had a higher rate of intended valve performance (BEV: 27.6% versus SEV: 82.4%; P<0.001), with lower mean gradients (BEV: 20&#xb1;9 versus SEV: 13&#xb1;9 mm&#x2009;Hg; P=0.002), and larger indexed effective orifice area (BEV: 0.69&#xb1;0.27 versus SEV: 0.93&#xb1;0.32 cm2/m2; P=0.002). The rate of moderate aortic regurgitation was 0% in the BEV group versus 2.9% in the SEV group (P=0.582). Functional status and quality of life improved similarly in both groups. No differences were observed in the composite end point of death, stroke, or heart failure-related hospitalization (BEV: 32.6% versus SEV: 25.5%; P=0.489). Mortality was also not statistically different between groups (BEV: 23.3% versus SEV: 15.7%; P=0.375). No significant differences were observed in other adverse events. In patients undergoing valve-in-valve TAVR for failed small aortic bioprostheses, SEV demonstrated a superior valve hemodynamic performance at 3-year follow-up, with similar clinical outcomes and functional improvement compared with BEV. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03520101.