Adoption of the 2013 ACC/AHA Cholesterol Management Guideline in cardiology practices was modest. Timely interventions are needed to improve guideline-concordant practice to reduce the burden of ASCVD.

Approximately 1 in 10 patients in the United States have received TAVR for an off-label indication. After adjustment, 1-year mortality was similar in these patients to that in patients who received TAVR for an on-label indication. These results reinforce the need for additional research on the efficacy of off-label TAVR use.

Summary Background To determine use of any and at least moderate intensity statin therapy in a national sample of patients with diabetes. Hypothesis Nationwide frequency and facility-level variation in statin therapy is suboptimal. Methods We sampled 40–75 years old patients with diabetes receiving primary care between October 1, 2012 to September 30, 2013 at 130 parent facilities and associated community based outpatient clinics in the Veterans Affairs Health Care System. We examined frequency and facility-level variation in use of any or at least moderate intensity statin therapy (mean daily dose associated with ≥30% low-density lipoprotein cholesterol lowering). Results In 911,444 patients with diabetes, 68.3% and 58.4% were receiving any and moderate to high intensity statin therapy, respectively. Patients receiving statin had higher burden of cardiovascular disease, were more likely to be on non-statin lipid lowering therapy and to receive care at a teaching facility, and had more frequent primary care visits. The median facility-level use of any and at least moderate intensity statin therapy were 68.7% (IQR, 65.9–70.8%) and 58.6% (55.8–61.4%), respectively. After adjusting for several patient and some facility related characteristics, the median rate ratios for any and moderate to high intensity statin therapy were 1.20 (95% CI, 1.18–1.22) and 1.29 (1.24–1.33) respectively, indicating 20–29% variation in statin use between 2 identical patients receiving care at 2 random facilities. Conclusion Statin use was sub-optimal in a national sample of patients with diabetes with modest facility-level variation, likely indicating differences in statin prescribing patterns.

Background Patient selection and outcomes for percutaneous coronary intervention ( PCI ) and coronary artery bypass grafting ( CABG ) have changed over the past decade. However, there is limited information on outcomes for both revascularization strategies in the same population. The study evaluated temporal changes in risk profile, procedural characteristics, and clinical outcomes for PCI‐ and CABG ‐treated patients. Methods and Results We analyzed all PCI and isolated CABG between 2005 and 2017 in nonfederal hospitals in Washington State. Descriptive analysis was performed to evaluate temporal changes in risk profile and, risk‐adjusted in‐hospital mortality. Over the study period, 178 474 PCI and 36 592 CABG procedures were performed. PCI and CABG volume decreased by 2.9% and 22.6%, respectively. Compared with 2005–2009, patients receiving either form of revascularization between 2014 and 2017 had a higher prevalence of comorbidities including diabetes mellitus and hypertension and dialysis. Presentation with ST‐segment–elevation myocardial infarction (17% versus 20%) and cardiogenic shock (2.4% versus 3.4%) increased for patients with PCI compared with CABG. Conversely, clinical acuity decreased for patients receiving CABG over the study period. From 2005 to 2017, mean National Cardiovascular Data Registry Cath PCI mortality score increased for patients treated with PCI (20.1 versus 22.4, P <0.0001) and decreased for patients treated with CABG (18.8 versus 17.8, P <0.0001). Adjusted observed/expected in‐hospital mortality ratio increased for PCI (0.98 versus 1.19, P <0.0001) but decreased for CABG (1.21 versus 0.74, P <0.0001) over the study period. Conclusions Clinical acuity increased for patients treated with PCI rather than CABG . This resulted in an increase in adjusted observed/expected mortality ratio for patients undergoing PCI and a decrease for CABG . These shifts may reflect an increased use of PCI instead of CABG for patients considered to be at high surgical risk.

More than 1 in 10 patients in this national registry were receiving inappropriate aspirin therapy for primary prevention, with significant practice-level variations. Our findings suggest that there are important opportunities to improve evidence-based aspirin use for the primary prevention of CVD.