Of the 562 operators, 549 performed 1-25 cases, 230 performed 26-50 cases and 116 performed more than 50 cases during the study period. Researchers found that procedural success improved across categories of operator experience while procedural time and complications decreased.

Optimal success, defined as ≤1+ residual mitral regurgitation without death or cardiac surgery, increased across the categories of operator experience (63.9 percent, 68.4 percent and 75.1 percent; p<0.001). Likewise, there was an increase for acceptable procedural success, defined as residual ≤2+ mitral regurgitation without death or cardiac surgery, with more operator experience (91.4 percent, 92.4 percent, and 93.8 percent, p<0.001).

Regarding the learning curve, at about 50 cases there was an evident improvement, with continuous improvement up to 200 cases.

"Increasing operator case experience was associated with improvements in procedural outcomes, including procedural success, procedure time and procedural complications," concluded the researchers "These findings suggest that a relatively greater attention to case selection may be important during the early operator experience. Further research is needed to understand the specific factors associated with operator and site experience that impact long-term clinical outcomes."

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Patients with STEMI with cognitive impairment were less frequently treated with cardiac medical therapies, including aspirin or a P2Y12 receptor inhibitor, within 24 hours or parenteral anticoagulation in-hospital compared with patients without cognitive impairment. There was a numerically small difference in the use of PCI among STEMI patients without cognitive impairment, mild impairment and moderate/severe impairment, respectively: 92.1 percent, 92.8 percent and 90.4 percent (p=0.003).

The use of thrombolytic therapy (excluding those treated with PCI or ineligible) was lower in STEMI patients with mild or moderate/severe cognitive impairment (27.4 percent and 24.3 percent) compared with those without (40.9 percent). The results also showed in STEMI patients a slightly longer time from first medical contact to device and a lower use of CABG, and a difference in discharge medications with a lower use of P2Y12 receptor inhibitors, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins.

Focusing on patients presenting with NSTEMI, patients with cognitive impairment, compared with those without, were less likely to receive cardiac medical therapy within 24 hours, cardiac catheterization, or PCI and CABG procedures. In patients without, mild or moderate/severe cognitive impairment, the rates of catheterization were 84.7 percent, 50.3 percent and 24.6 percent (p<0.001) and the rates of PCI were 49.4 percent, 27.3 percent and 12.7 percent. The use of all discharge medications was lower for those with cognitive impairment.

Cognitive impairment was associated with higher in-hospital mortality for STEMI and NSTEMI patients. For patients with mild cognitive impairment, compared with those without, the adjusted odds ratio for in-hospital mortality was 2.2 for STEMI and 1.7 for NSTEMI. For those with moderate/severe cognitive impairment, the odds ratio was 1.3 for both STEMI and NSTEMI.

The authors note that one in 13 patients older than 65 years in the U.S. have cognitive impairment documented in their medical records. Cognitive impairment without dementia is more prevalent and varies from a spectrum of age-related cognitive issues to mild cognitive impairment. After MI, even mild cognitive impairment was associated with less invasive care and less referral to and participation in cardiac rehabilitation, with moderate to severe cognitive impairment associated with worse risk-adjusted one-year survival.

"Improving outcomes of this patient population requires understanding the MI presentation in context of other medical conditions and patient goals of care," researchers concluded. "It also requires addressing noncardiac risk for mortality during and after hospitalization. Additional studies are needed to determine an optimal approach to inform clinical decision-making for older patients with MI with cognitive impairment.

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The independent factors associated with prescribing ticagrelor rather than clopidogrel included younger age, white race, home ticagrelor use, invasive management, and inhospital reinfarction and stroke (p<0.0001 for all). For prescribing ticagrelor over prasugrel, the independent factors included older age, female sex, prior stroke, home ticagrelor use and inhospital stroke (p<0.0001 for all).

Among the 21,262 patients discharged on ticagrelor plus aspirin, high-dose aspirin was prescribed for 3.1 percent. Independent factors associated with prescribing high-dose aspirin were home aspirin use, diabetes, previous MI, previous CABG, STEMI, cardiogenic shock and geographic region (p=0.01).

"Our contemporary report shows a modest but significant increase in the use of ticagrelor early and at discharge, with simultaneous decline in the use of clopidogrel and prasugrel in patients presenting with AMI," the authors concluded. In addition, an increased use of low-dose aspirin at discharge in patients treated with ticagrelor was demonstrated. Yet, the significant regional and hospital variability in ticagrelor prescription and aspirin dose at discharge "represent[s] important opportunities for future improvements in care of patients with AMI."

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The authors developed hierarchical proportional models to predict LOS and hierarchical logistic regression models to predict discharge to postacute care (extended care, transitional care unit or rehabilitation).

After multivariable adjustment and stepwise elimination, factors independently associated with a longer LOS included: older age and at admission heart failure, higher heart rate, systolic blood pressure <150 mm Hg or >150 mm Hg, shock, diabetes, lower glomerular filtration rate, and lower hemoglobin.

After multivariable adjustment and stepwise elimination, factors independently associated with greater odds of discharge to a postacute facility included: older age and at admission heart failure, higher heart rate, shock, prior cerebrovascular disease and lower hemoglobin.

The authors write, "We have demonstrated that with clinical characteristics known at the time of initial hospitalization for AMI, both LOS and postacute utilization can be predicted with moderate and strong predictive accuracy, respectively."

They add, "We think that these models may substantially improve the ability of health care providers and health delivery organizations to improve performance in [episode payment models] and other types of payment mechanisms that incentivize judicious use of resources and costs, although further research into how best to use these models is needed."

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Results showed that TAVR patients who required surgical bailout had poor outcomes. Researchers found 50 percent of these patients had died within 30 days – more than 10-fold higher than patients who did not require surgical bailout during TAVR. Certain patients were at higher risk of requiring surgical bailout, including those undergoing emergency instead of elective TAVR procedures, and those whose catheter was not inserted through the femoral artery. Women and those with a higher ejection fraction were also at increased risk. The incidence of surgical bailout decreased over time – from 1.25 percent at the beginning of the study to 1.04 percent at the end.

"This excellent study reminds us… that we should thoroughly discuss the option of surgical bailout with every patient and the next of kin upfront before going into the procedure to avoid futile surgical bailout procedures prone to result in a disastrous outcome and therefore adds only further harm to the patients and their families," write Fabian Nietlispach, MD, PhD, and Osmund Bertel, MD, in an accompanying editorial comment. "Thoughtful patient selection is an issue not only for TAVR itself but also for surgical bailout when complications are met."

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