Despite no objective definition, hyperacute T waves (HATW) are recommended by the American College of Cardiology as a STEMI equivalent finding, requiring emergent reperfusion. We sought to derive and validate a quantitative definition of HATW. We retrospectively evaluated adults with possible ACS across five PCI centers. Exclusions were: lack of pre-angiogram ECG, QRS duration ≥110 ms, and elevated troponin without angiogram. The outcome definition was: myocardial infarction with TIMI 0-1 flow culprit lesion. ECG measures included T wave magnitude (T wave area relative to QRS amplitude) and symmetry (T wave peak-to-end time relative to onset-to-peak time). The HATW score was derived and evaluated on separate groups. The primary analysis was HATW score performance for acute coronary occlusion in patients without STEMI criteria. 3,274 patients were reviewed, and 618 were excluded. 1,261 and 1,395 patients were allocated to derivation and validation groups. In derivation the optimal HATW score threshold for ≥ 98% specificity was: 2 consecutive leads with mean HATW score ≥ 0.7. In validation the performance for acute coronary occlusion in the subset without STEMI criteria (N = 1300) was: 98.4% specificity, 20.7% sensitivity, 47.4% PPV, 12.54 LR+. Among patients without STEMI criteria but positive HATW score, 84% had a culprit lesion causing AMI. The HATW score is the first objective definition of hyperacute T waves showing significant clinical utility as an ECG finding of acute coronary occlusion in potential ACS patients.

Background: Despite the known benefits for individuals with heart failure (HF), incomplete data suggest a low use of palliative care (PC) for HF in the United States. We aimed to investigate the national PC use for adults with HF by determining when they received their first PC consultation (PCC) and the associations with clinical factors following diagnosis of HF. Methods and Results: We conducted a retrospective cohort study in a national all‐payer electronic health record database to identify adults (aged ≥18 years) with newly diagnosed HF between 2011 and 2018. The proportion of those who received PCC within 5 years following a diagnosis of HF, and associations of time to first PCC with patient characteristics and HF‐specific clinical markers were determined. We followed 127 712 patients for a median of 792 days, of whom 18.3% received PCC in 5 years. Shorter time to receive PCC was associated with diagnoses of HF in 2016 to 2018 (compared with 2010–2015: adjusted hazard ratio [aHR], 1.421 [95% CI, 1.370–1.475]), advanced HF (aHR, 2.065 [95% CI, 1.940–2.198]), cardiogenic shock (aHR, 2.587 [95% CI, 2.414–2.773]), implantable cardioverter‐defibrillator (aHR, 5.718 [95% CI, 5.327–6.138]), and visits at academic medical centers (aHR, 1.439 [95% CI, 1.381–1.500]). Conclusions: Despite an expanded definition of PC and recommendations by professional societies, PC for HF remains low in the United States. Racial and geographic variations in access and use of PC exist for patients with HF. Future studies should interrogate the mechanisms of PC underusage, especially before advanced stages, and address barriers to PC services across the health care system.

Background: The STEMI/NSTEMI classification guides management and quality metrics for acute myocardial infarction (AMI). We examined whether the final cath-lab diagnosis of STEMI versus NSTEMI correlates more closely with door-to-balloon (D2B) time than with either ST-segment elevation (STE) on pre-angiogram ECG or a culprit lesion with TIMI 0-1 flow. Methods: This retrospective study analyzed 410 patients with AMI from the DOMI-ARIGATO database who underwent coronary angiography. For each patient, we recorded FDx coded by the interventional cardiologist, D2B < 120 min versus > 120 min, STE criteria (Fourth Universal Definition), and angiographic TIMI 0-1 culprit. Predictors of FDx-STE discordance were evaluated with multivariable logistic regression. Results: Among 410 angiographed AMI patients (mean age 63 ± 13; 71% male), 165 (40.2%) received an FDx-STEMI and 245 (59.8%) an FDx-NSTEMI. D2B time showed 94% agreement with FDx (160/165 FDx-STEMI treated < 120 min; 225/245 FDx-NSTEMI treated > 120 min), exceeding concordance for STE (82%; p < 0.001) and TIMI 0-1 flow (75%; p < 0.001). FDx and STE diverged in 75 patients (18%): 60 rapidly treated STE-negative cases were labelled STEMI, whereas 15 delayed STE-positive cases were labelled NSTEMI. In regression analysis, D2B < 120 min remained the sole independent predictor of discordance (adjusted OR 6.7, 95% CI 3.5–13.8). Conclusions: In this registry, the cath-lab label “STEMI” showed the strongest correlation with meeting a 120 min benchmark, exceeding correlations for STE or angiographic occlusion. These findings suggest that quality-metric compliance, rather than electrocardiographic or anatomic criteria, predominantly drives final diagnosis.

The commercial use of percutaneous left atrial appendage occlusion with the Watchman device is increasing in the United States. The purpose of this study was to evaluate center-related variation in total hospital costs for Watchman device implantation and identify factors associated with high hospital costs at a national level. All adults undergoing elective left atrial appendage occlusion with Watchman were identified in the 2016-2018 National Inpatient Database. Mixed models were used to evaluate the impact of center on total hospital costs, adjusting for patient and center characteristics and length of stay. A total of 30,175 patients underwent Watchman device implantation at a median cost of $24,500 and demonstrated significant variability across admissions (interdecile range, $13,900-37,000). Nearly 13% of the variability in patient-level costs was related to the center performing the procedure rather than patient factors. Higher-volume centers had lower total costs and demonstrated lesser total cost variation. Centers with low procedural volume, occurrence of procedural complications, congestive heart failure, and length of stay were independent predictors of a high-cost hospitalization. Though complications were associated with increased expenditure, they did not explain the observed cost variation related to the center. A significant proportion of variation in total hospital cost was attributable to the center performing the procedure. Addressing variability of Watchman-related costs is necessary to achieve high-quality value-based care.