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New England Journal of Medicine

Advancing Safety and Equity Together
New England Journal of Medicine, Volume 382, Issue 4, Page 301-303, January 2020.
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Payment for Services Rendered — Updating Medicare’s Valuation of Procedures
New England Journal of Medicine, Volume 382, Issue 4, Page 303-306, January 2020.
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Healing as a Servant Instead of a Prophet
New England Journal of Medicine, Volume 382, Issue 4, Page 306-307, January 2020.
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Vaccination of Infants with Meningococcal Group B Vaccine (4CMenB) in England
New England Journal of Medicine, Volume 382, Issue 4, Page 309-317, January 2020.
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Correction: Renal resistive index reflects Fontan pathophysiology and predicts mortality
Ohuchi H, Negishi J, Hayama Y, et al. Renal resistive index reflects Fontan pathophysiology and predicts mortality. Heart 2017;103:1631–7. doi: 10.1136/heartjnl-2016-310812. It was reported in this paper that "Informed consent was obtained from all patients and/or their parents and the Ethics Committee of the National Cardiovascular Centre approved the study protocol". The study was approved in advance by our institutional ethics committee (National Cerebral and Cardiovascular Centre, Suita, Japan; approval number M23-002; received 18 April 2011) on the understanding that it would be performed under the ethical guidelines for clinical studies. It was believed that an opt-out policy was in place for patients that were approached to participate in this study. However, it became apparent later that the appropriate information about this study had not been posted online and patients were not in fact offered the right to refuse participation. Our institutional ethics committee considered this error to be...
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Heartbeat: When should patients consider implantable cardiac defibrillator deactivation?
The use of implantable cardiac defibrillators (ICDs) has dramatically improved outcomes for patients with many types of heart disease. Yet, the patient with an ICD faces a difficult decision near the end of life—should the ICD be deactivated and, if so, when? Evidence to support a specific approach to this clinical dilemma is not amenable to standard research approaches because the outcomes are qualitative, not quantitative. Thus, carefully designed and implemented qualitative research studies are needed to inform clinical practice. In this issue of Heart, Stoevelaar and colleagues1 performed a focus group study using a constant comparative method for analysis of transcriptions from group sessions with 41 participants. Patients reported that few physicians discussed deactivation of ICDs. Patients also expressed a desire for more information about deactivation and advance care planning, depending on disease stage and patient preferences. The online version of this article also features a...
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JACC Instructions for Authors
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Prior Heart Failure Hospitalization, Clinical Outcomes, and Response to Sacubitril/Valsartan Compared With Valsartan in HFpEF
AbstractBackground The period shortly after hospitalization for heart failure (HF) represents a high-risk window for recurrent clinical events, including rehospitalization or death. Objectives This study sought to determine whether the efficacy and safety of sacubitril/valsartan varies in relation to the proximity to hospitalization for HF among patients with HF with preserved ejection fraction (HFpEF). Methods In this post hoc analysis of PARAGON-HF (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ARB [Angiotensin Receptor Blocker] Global Outcomes in HFpEF), we assessed the risk of clinical events and response to sacubitril/valsartan in relation to time from last HF hospitalization among patients with HFpEF (≥45%). The primary outcome was composite total HF hospitalizations and cardiovascular death, analyzed by using a semiparametric proportional rates method, stratified by geographic region. Results Of 4,796 validly randomized patients in PARAGON-HF, 622 (13%) were screened during hospitalization or within 30 days of prior hospitalization, 555 (12%) within 31 to 90 days, 435 (9%) within 91 to 180 days, and 694 (14%) after 180 days; 2,490 (52%) were never previously hospitalized. Over a median follow-up of 35 months, risk of total HF hospitalizations and cardiovascular death was inversely and nonlinearly associated with timing from prior HF hospitalization (p < 0.001). There was a gradient in relative risk reduction in primary events with sacubitril/valsartan from patients hospitalized within 30 days (rate ratio: 0.73; 95% confidence interval: 0.53 to 0.99) to patients never hospitalized (rate ratio: 1.00; 95% confidence interval: 0.80 to 1.24; trend in relative risk reduction: pinteraction = 0.15). With valsartan alone, the rate of total primary events was 26.7 (≤30 days), 24.2 (31 to 90 days), 20.7 (91 to 180 days), 15.7 (>180 days), and 7.9 (not previously hospitalized) per 100 patient-years. Compared with valsartan, absolute risk reductions with sacubitril/valsartan were more prominent in patients enrolled early after hospitalization: 6.4% (≤30 days), 4.6% (31 to 90 days), and 3.4% (91 to 180 days), whereas no risk reduction was observed in patients screened >180 days or who were never hospitalized (trend in absolute risk reduction: pinteraction = 0.050). Conclusions Recent hospitalization for HFpEF identifies patients at high risk for near-term clinical progression. In the PARAGON-HF trial, the relative and absolute benefits of sacubitril/valsartan compared with valsartan in HFpEF appear to be amplified when initiated in the high-risk window after hospitalization and warrant prospective validation. (PARAGON-HF; NCT01920711)
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Heart Failure With Preserved Ejection Fraction: Separating the Wheat From the Chaff
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Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting
AbstractBackground The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting. Objectives This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting. Methods From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important: >75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality. Results A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p < 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target—77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival. Conclusions In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.
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Heart Rhythm