Journal: Am J Cardiol

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Abstract

Lonuigitudinal Strain and Strain Rate for Estimating Left Ventricular Filling Pressure in Heart Transplant Recipients.

Colak A, Muderrisoglu H, Pirat B, Eroglu S, ... Sezgin A, Sade LE

Traditional parameters have limited value to estimate left ventricular filling pressure (LVFP) in orthotopic heart transplant (OHT) recipients. We hypothesized that global longitudinal strain (GLS), diastolic and systolic strain rate (SR) would be depressed in OHT recipients with elevated LVFP and could overcome the limitations of traditional parameters. We studied consecutively OHT patients at the time of endomyocardial biopsies and retrospectively pre-transplantation studies conforming to the same protocol. Comprehensive echocardiography with strain measurements was performed. Results were compared to pulmonary capillary wedge pressure (PCWP) obtained from right heart catheterization that was performed just after the echocardiography study. In all, 74 studies were performed in 50 OHT recipients. Mean PWCP was 11.8±4.3 mmHg (range: 4-25 mmHg). Several parameters, but not left atrial volume index, mitral inflow velocities, annular velocities, and their ratio (E/e\'), were different between studies with normal (n=47) and elevated PCWP (n=27). Area Under Curve (AUC) for GLS (0.932*), E/e\' (0.849*), and systolic SR (0.848*) (*p<0.0001) were more accurate than traditional parameters for predicting PCWP>12 mmHg. GLS, systolic SR and E/e\' remained accurate regardless of LV ejection fraction and allograft vasculopathy. Meanwhile, E/e\' was accurate to predict PWCP in native failing hearts before transplantation. Changes in GLS and E/e\' tracked accurately changes in PCWP. In conclusion, traditional indices of diastolic function perform poorly in OHT recipients, whereas GLS and E/e\' provide reliable means of LVFP, irrespective of ejection fraction and allograft vasculopathy. These parameters also track reasonably well the changes in LVFP.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 26 Sep 2020; epub ahead of print
Colak A, Muderrisoglu H, Pirat B, Eroglu S, ... Sezgin A, Sade LE
Am J Cardiol: 26 Sep 2020; epub ahead of print | PMID: 32998008
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Abstract

Cardiovascular Events and Mortality in Patients With Atrial Fibrillation and Anemia (from the Fushimi AF Registry).

An Y, Ogawa H, Esato M, Ishii M, ... Akao M,

Data regarding the associations of anemia (hemoglobin level <13.0 g/dl in men and <12.0 g/dl in women) with clinical outcomes in patients with atrial fibrillation (AF) remains scarce. This study sought to investigate the associations of anemia with the incidences of stroke or systemic embolism, major bleeding, heart failure (HF) hospitalization, and all-cause mortality including its causes, using the data from a Japanese community-based survey, the Fushimi AF Registry. A total of 4,169 AF patients were divided into the 3 groups, based on the baseline hemoglobin level: no (n = 2,622), mild (11.0 to <13.0 g/dl for men and <12.0 g/dl for women; n = 880), and moderate/severe anemia (<11.0 g/dl; n = 667). During a median follow-up of 1,464 days, the incidences of major bleeding, HF hospitalization, and mortality increased with higher rates of cardiac death, in accordance with anemic severity. On multivariate analyses, the higher risk of moderate/severe anemia, relative to no anemia, for major bleeding remained statistically significant (hazard ratio [HR]: 2.00, 95% confidential interval [CI]: 1.48 to 2.72). The risks of those with anemia, relative to no anemia, for HF hospitalization (mild; HR: 1.87, 95% CI: 1.51 to 2.31, and moderate/severe; HR: 2.02, 95% CI: 1.59 to 2.57) as well as for mortality (mild; HR: 1.80, 95% CI: 1.50 to 2.16, and moderate/severe; HR: 2.95, 95% CI: 2.45 to 3.55) were also higher, but not for stroke/systemic embolism. These relations were consistent, regardless of the use of oral anticoagulants. In conclusion, anemia was associated with higher risks of HF hospitalization, mortality, and major bleeding in AF patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:74-82
An Y, Ogawa H, Esato M, Ishii M, ... Akao M,
Am J Cardiol: 31 Oct 2020; 134:74-82 | PMID: 32900468
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Abstract

Predictors and In-Hospital Outcomes Among Patients Using a Single Versus Bilateral Mammary Arteries in Coronary Artery Bypass Grafting.

Sareh S, Hadaya J, Sanaiha Y, Aguayo E, ... Omari B, Benharash P

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:41-47
Sareh S, Hadaya J, Sanaiha Y, Aguayo E, ... Omari B, Benharash P
Am J Cardiol: 31 Oct 2020; 134:41-47 | PMID: 32900469
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Abstract

Cryoballoon Ablation and Bipolar Voltage Mapping in Patients With Left Atrial Appendage Occlusion Devices.

Huang HD, Krishnan K, Sharma PS, Kavinsky CJ, ... Larsen TR, Trohman RG

Left atrial appendage occlusion is utilized as a second line therapy to long-term oral anticoagulation in appropriately selected patients with atrial fibrillation (AF). We examined the feasibility of cryoballoon (CB) pulmonary vein isolation (PVI) subsequent to Watchman device implantation. The study prospectively identified patients with Watchman devices (>90 days old) who underwent CB-PVI ablation between 2018 and 2019. Twelve consecutive patients (male 50%; mean age 71 ± 9 years; CHADS-VASc score 3.4 ± 1.1) underwent CB-PVI procedures after Watchman device implantation (mean 182 ± 82 days). Acute PVI was achieved in 100% of patients. All patients had evidence of complete (n = 9) or partial (n = 3) endothelialization of the surface of the Watchman device with conductive tissue properties demonstrated during electrophysiologic testing. There were no major procedure-related complications including death, stroke, pericardial effusion, device dislodgment, device thrombus, or new or increasing peri-device leak. Mean peri-device leak size (45-day postimplant: 0.06 ± 0.09 mm vs Post-PVI: 0.04 ± 0.06 mm; p = 0.61) remained unchanged. Two patients had recurrence of AF after the 90-day blanking period (13.2 ± 6.6 months). One patient underwent a redo ablation procedure for recurrent AF. This pilot study suggests the potential feasibility of CB-PVI ablation in patients with chronic Watchman left atrial appendage occlusion devices. Larger prospective studies are needed to confirm the clinical efficacy and safety of this approach.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:99-104
Huang HD, Krishnan K, Sharma PS, Kavinsky CJ, ... Larsen TR, Trohman RG
Am J Cardiol: 14 Nov 2020; 135:99-104 | PMID: 32866447
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Abstract

Safety and Efficacy of Single Versus Dual Antiplatelet Therapy After Left Atrial Appendage Occlusion.

Patti G, Sticchi A, Verolino G, Pasceri V, ... Colombo A,

The optimal antiplatelet strategy after left atrial appendage (LAA) occlusion able to protect from device-related thrombosis, paying the lowest price in terms of bleeding increase, is unclear. In a real-world, observational study we performed a head-to-head comparison of single versus dual antiplatelet therapy (SAPT vs DAPT) in patients who underwent LAA occlusion. We included 610 consecutive patients, stratified according to the type of post-procedural antiplatelet therapy (280 on SAPT and 330 on DAPT). Primary outcome measure was the incidence of the net composite end point including Bleeding Academic Research Consortium classification 3-5 bleeding, major adverse cardiovascular events or device-related thrombosis at 1-year follow-up. The use of SAPT compared with DAPT was associated with similar incidence of the primary net composite end point (9.3% vs 12.7% p = 0.22), with an adjusted hazard ratio (HR) of 0.69, 95% confidence interval 0.41 to 1.15; p = 0.15) at multivariate analysis. However, SAPT significantly reduced Bleeding Academic Research Consortium classification 3-5 bleeding (2.9% vs 6.7%, p = 0.038; adjusted HR 0.37, 0.16 to 0.88; p = 0.024). The occurrence of ischemic events (major adverse cardiovascular events or device-related thrombosis) was not significantly different between the 2treatment strategies (7.8% vs 7.4%; adjusted HR 1.34, 0.70 to 2.55; p = 0.38). In patients who underwent LAA occlusion, post-procedural use of SAPT instead of DAPT was associated with reduction of bleeding complications, with no significant increase in the risk of thrombotic events. These hypothesis-generating findings should be confirmed in a specific, randomized study.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:83-90
Patti G, Sticchi A, Verolino G, Pasceri V, ... Colombo A,
Am J Cardiol: 31 Oct 2020; 134:83-90 | PMID: 32892987
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Abstract

Incidence and Impact of Thrombocytopenia in Patients Undergoing Percutaneous Coronary Intervention With Drug-Eluting Stents.

Park S, Ahn JM, Kim TO, Park H, ... Park SJ,

Platelets are crucial in the pathophysiology of coronary artery disease and are a major target of antithrombotic agents in patients receiving percutaneous coronary intervention (PCI). We sought to evaluate the incidence and prognostic impact of thrombocytopenia on clinical outcomes in patients undergoing PCI with drug-eluting stents (DES). We evaluated consecutive patients who received PCI with DES in the IRIS-DES registry between April 2008 and December 2017. Patients were divided into 2 groups based on the presence of thrombocytopenia (platelet count <150 × 10/L) at baseline. The primary outcome was all-cause mortality, and secondary outcomes included the composite outcome of death, myocardial infarction (MI), and stroke, and major bleeding. Complete follow-up data were available for 1 to 5 years (median, 3.1). Among 26,553 eligible patients, 1,823 (6.9%) had thrombocytopenia at baseline. At 5 years, the incidences of all-cause mortality (15.6% vs 8.1%, p <0.001), composite outcome (23.2% vs 15.6%, p <0.001), and major bleeding (3.7% vs 2.2%, p <0.001) were significantly higher in patients with thrombocytopenia than in those without thrombocytopenia. In multivariable Cox proportional-hazards models, thrombocytopenia was significantly associated with increased risks of all-cause mortality (hazard ratio 1.26, 95% confidence interval 1.07 to 1.48, p = 0.01) and major bleeding (hazard ratio 1.41, 95% confidence interval 1.04 to 1.91, P=0.03). In conclusion, among who patients underwent PCI with DES, the incidence of thrombocytopenia was 6.9%. Baseline thrombocytopenia was significantly associated with increased risks of mortality and major bleeding.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:55-61
Park S, Ahn JM, Kim TO, Park H, ... Park SJ,
Am J Cardiol: 31 Oct 2020; 134:55-61 | PMID: 32891400
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Abstract

Trends in Utilization and Safety of In-Hospital Coronary Artery Bypass Grafting During a Non-ST-Segment Elevation Myocardial Infarction.

Elbaz-Greener G, Rozen G, Kusniec F, Marai I, ... Planer D, Amir O

Up to 10% of non-ST-segment elevation myocardial infarction (NSTEMI) patients require coronary artery bypass graft (CABG) surgery during their hospitalization. Contemporary, real-world, data regarding CABG utilization and safety in NSTEMI patients are lacking. Our objectives were to investigate the contemporary trends in utilization and outcomes of CABG in patients admitted for NSTEMI. Using the 2003 to 2015 National Inpatient Sample data, we identified hospitalizations for NSTEMI, during which a CABG was performed. Patients\' sociodemographic and clinical characteristics, incidence of surgical complications, length of stay, and mortality were analyzed. Multivariate analyses were performed to identify predictors of in-hospital complications and mortality. An estimated total of 440,371 CABG surgeries, during a hospitalization for NSTEMI, were analyzed. The utilization of CABG was steady over the years. The data show increasing prevalence of individual co-morbidities as well as cases with Deyo Co-morbidity Index ≥2 (p <0.001). High, 26.4%, complication rate was driven mainly by cardiac and pulmonary complications. The mortality rate declined from 3.6% in 2003 to an average of 2.4% during 2010 to 2015. Older age, female gender, heart failure, and delayed CABG timing were independent predictors of adverse outcomes. In conclusion, utilization of in-hospital CABG as the primary revascularization strategy in patients with NSTEMI remained steady over the years. These data reveal the raising prevalence of co-morbidities during the study. High complication rate was recorded; however, the mortality declined over the years to about 2.4%. Delaying CABG was associated with small but statistically significant worsening in outcomes.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:32-40
Elbaz-Greener G, Rozen G, Kusniec F, Marai I, ... Planer D, Amir O
Am J Cardiol: 31 Oct 2020; 134:32-40 | PMID: 32919619
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Abstract

Effect of Progression of Valvular Calcification on Left Ventricular Structure and Frequency of Incident Heart Failure (from the Multiethnic Study of Atherosclerosis).

Fashanu OE, Upadhrasta S, Zhao D, Budoff MJ, ... Lima JAC, Michos ED

Heart failure (HF) is a leading cause of morbidity. Strategies for preventing HF are paramount. Prevalent extracoronary calcification is associated with HF risk but less is known about progression of mitral annular (MAC) and aortic valve calcification (AVC) and HF risk. Progression of valvular calcification (VC) [interval change of >0 units/yr] was assessed by 2 cardiac computed tomography scans over a median of 2.4 years. We used Cox regression to determine the risk of adjudicated HF and linear mixed effects models to determine 10-year change in left ventricular (LV) parameters measured by cardiac magnetic resonance imaging associated with VC progression. We studied 5,591 MESA participants free of baseline cardiovascular disease. Mean ± SD age was 62 ± 10 years; 53% women; 83% had no VC progression, 15% progressed at 1 site (AVC or MAC) and 3% at both sites. There were 251 incident HF over 15 years. After adjusting for cardiovascular risk factors, the hazard ratios (95% confidence interval) of HF associated with VC progression at 1 and 2 sites were 1.62 (1.21 to 2.17) and 1.88 (1.14 to 3.09), respectively, compared with no progression (p-for-trend <0.001). Hazard ratios were higher for HFpEF (2.52 [1.63 to 3.90] and 2.49 [1.19 to 5.25]) but nonsignificant for HFrEF. Both AVC (1.61 [1.19 to 2.19]) and MAC (1.50 [1.09 to 2.07]) progression were associated with HF. VC was associated with worsening of some LV parameters over 10 years. In conclusion, VC progression was associated with increased risk of HF and change in LV function. Interventions targeted at reducing VC progression may also impact HF risk, particularly HFpEF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:99-107
Fashanu OE, Upadhrasta S, Zhao D, Budoff MJ, ... Lima JAC, Michos ED
Am J Cardiol: 31 Oct 2020; 134:99-107 | PMID: 32917344
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Abstract

Balloon Filling Algorithm for Optimal Size of Balloon Expandable Prosthesis During Transcatheter Aortic Valve Replacement.

Schymik G, Radakovic M, Bramlage P, Schmitt C, Tzamalis P

Aim is to report on the results of an optimized balloon filling algorithm and suggest a refinement of the implantation approach to maximize safety. Appropriate sizing of balloon expandable valves during transcatheter aortic valve implantation is crucial. Study comprised 370 consecutive patients receiving SAPIEN 3 valve between 2015 and 2018. Valve expansion/recoil measurement in the inflow area, annular area, and outflow area was performed previously and postimplantation. Nominal balloon filling resulted in underexpansion-23 mm (20.96 mm), 26 mm (23.88 mm), and 29 mm (27.56 mm) SAPIEN 3 valves at the annular level. Increased balloon filling by 2 cc resulted in a gradual increase in valve diameter reaching 97.35% (23 mm), 96.50% (26 mm), and 96.11% (29 mm) of the nominal valve diameter. Final diameters were usually higher in the valvular inflow and outflow tracts. The 29 mm valve did not reach its nominal diameter with 2 cc overfilling and in none of inflow area (95.48%), annular area (96.11%), or outflow area (96.86%). Device success (by VARC II) was 96.2%. No root or septal rupture, device migration, mitral valve injury, coronary obstruction, or dissection occurred. Rate of new permanent pacemaker implantation was 8.3%. Paravalvular leakage was none or trace in most patients. Mean valve gradient was 10.77 mm Hg postprocedure. 1.9% of the patients had a maximum gradient of >40 mm Hg, 2.2% >20 mm Hg. In conclusion, an optimized balloon filling algorithm resulted in appropriate valve gradients, low levels of paravalvular leakage, low rates of permanent pacemaker implantation and no annular rupture.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 31 Oct 2020; 134:108-115
Schymik G, Radakovic M, Bramlage P, Schmitt C, Tzamalis P
Am J Cardiol: 31 Oct 2020; 134:108-115 | PMID: 32933756
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Abstract

Admissions Rate and Timing of Revascularization in the United States in Patients With Non-ST-Elevation Myocardial Infarction.

Case BC, Yerasi C, Wang Y, Forrestal BJ, ... Weintraub WS, Waksman R

Clinical trials have shown improved outcomes with an early invasive approach for non-ST-elevation myocardial infarction (NSTEMI). However, real-world data on clinical characteristics and outcomes based on time to revascularization are lacking. We aimed to analyze NSTEMI rates, revascularization timing, and mortality using the 2016 Nationwide Readmissions Database. We identify patients who underwent diagnostic angiography and subsequently received either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Finally, revascularization timing and mortality rates (in-hospital and 30-day) were extracted. Our analysis included 748,463 weighted NSTEMI hospitalizations in 2016. Of these hospitalizations, 50.3% (376,695) involved diagnostic angiography, with 34.1% (255,199) revascularized. Of revascularized patients, 77.6% (197,945) underwent PCI and 22.4% (57,254) underwent CABG. Patients with more comorbidities tended to have more delayed revascularization. PCI was most commonly performed on the day of admission (32.9%; 65,155). This differs from CABG, which was most commonly performed on day 3 after admission (13.7%; 7,823). The in-hospital mortality rate increased after day 1 for PCI patients and after day 4 for CABG patients, whereas 30-day in-hospital mortality for both populations increased as revascularization was delayed. Our study shows that patients undergoing early revascularization differ from those undergoing later revascularization. Mortality is generally high with delayed revascularization, as these are sicker patients. Randomized clinical trials are needed to evaluate whether very early revascularization (<90 minutes) is associated with improved long-term outcomes in high-risk patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:24-31
Case BC, Yerasi C, Wang Y, Forrestal BJ, ... Weintraub WS, Waksman R
Am J Cardiol: 31 Oct 2020; 134:24-31 | PMID: 32892989
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Abstract

Implementation of a Comprehensive ST-Elevation Myocardial Infarction Protocol Improves Mortality Among Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock.

Kumar A, Huded CP, Zhou L, Krittanawong C, ... Kapadia SR, Khot UN

Mortality in patients with STEMI-associated cardiogenic shock (CS) is increasing. Whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) can improve their care delivery and mortality is unknown. We evaluated the impact of a CSP on incidence and outcomes in patients with STEMI-associated CS. We implemented a 4-step CSP including: (1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). We studied 1,272 consecutive STEMI patients who underwent PCI and assessed for CS incidence per National Cardiovascular Data Registry definitions within 24-hours of PCI, care delivery, and mortality before (January 1, 2011, to July 14, 2014; n = 723) and after (July 15, 2014, to December 31, 2016; n = 549) CSP implementation. Following CSP implementation, CS incidence was reduced (13.0% vs 7.8%, p = 0.003). Of 137 CS patients, 43 (31.4%) were in the CSP group. CSP patients had greater IABP-Shock II risk scores (1.9 ± 1.8 vs 2.8 ± 2.2, p = 0.014) with otherwise similar hemodynamic and baseline characteristics, cardiac arrest incidence, and mechanical circulatory support use. Administration of guideline-directed medical therapy was similar (89.4% vs 97.7%, p = 0.172) with significant improvements in trans-radial PCI (9.6% vs 44.2%, p < 0.001) and door-to-balloon time (129.0 [89:160] vs 95.0 [81:116] minutes, p = 0.001) in the CSP group, translating to improvements in infarct size (CK-MB 220.9 ± 156.0 vs 151.5 ± 98.5 ng/ml, p = 0.005), ejection fraction (40.8 ± 14.5% vs 46.7 ± 14.6%, p = 0.037), and in-hospital mortality (30.9% vs 14.0%, p = 0.037). In conclusion, CSP implementation was associated with improvements in CS incidence, infarct size, ejection fraction, and in-hospital mortality in patients with STEMI-associated CS. This strategy offers a potential solution to bridging the historically elusive gap in their care.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:1-7
Kumar A, Huded CP, Zhou L, Krittanawong C, ... Kapadia SR, Khot UN
Am J Cardiol: 31 Oct 2020; 134:1-7 | PMID: 32933753
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Abstract

Comparison of Frequency of Atrial Fibrillation in Blacks Versus Whites and the Utilization of Race in a Novel Risk Score.

Kowlgi GN, Gunda S, Padala SK, Koneru JN, Deshmukh AJ, Ellenbogen KA

Blacks have a lower prevalence of atrial fibrillation (AF) compared with Whites. We sought to confirm previously reported ethnic trends in AF in Blacks and Whites in a large database, and develop a prediction score for AF. Over 330 million hospital discharges between the years 2003 to 2013 from the National Inpatient Sample database were analyzed. All hospitalizations with a diagnosis of AF formed the study cohort. Traditional risk factors for the development of AF were compared between Blacks and Whites. Univariate and multiple logistic regression analyses were used to formulate a risk score to predict AF-CHADSAVES (Congestive heart failure, Hypertension, Age>65 years, Diabetes Mellitus, prior Stroke, Age>75 years, Vascular disease, White Ethnicity, and previous cardiothoracic Surgery). AF prevalence in Whites was 11.3% vs 4.6% in Blacks (p < 0.001). Blacks were younger (33.8% vs 14.4% patients <65 years, p < 0.01) and had less males (46.3% vs 49.4%, p < 0.01). Blacks had more hypertension (71.3% vs 64.1%, p < 0.01), congestive heart failure (24.8% vs 22.6%, p < 0.01), diabetes mellitus with (7.5% vs 4.7%, p < 0.01) or without complications (30.3% vs 23.1%, p < 0.01), renal failure (29.7% vs 17.1%, p < 0.01), and obesity (13.1% vs 8.7%, p < 0.01). CHADSAVES predicted AF in the study population (NIS 2003 to 2013) with an AUC of 0.82 and verified in a validation cohort (NIS 2014) with an AUC of 0.85. In conclusion, our data confirm a significant AF ethnicity paradox. Despite a higher prevalence of traditional risk factors for AF, Blacks had >2-fold lower prevalence of AF compared with Whites. CHADSAVES can be used effectively to predict AF in inpatients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:68-76
Kowlgi GN, Gunda S, Padala SK, Koneru JN, Deshmukh AJ, Ellenbogen KA
Am J Cardiol: 14 Nov 2020; 135:68-76 | PMID: 32866451
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Abstract

Prognostic Implications of Significant Isolated Tricuspid Regurgitation in Patients With Atrial Fibrillation Without Left-Sided Heart Disease or Pulmonary Hypertension.

Dietz MF, Goedemans L, Vo NM, Prihadi EA, ... Delgado V, Bax JJ

The prognostic impact of isolated tricuspid regurgitation (TR) in patients with atrial fibrillation (AF) has not been investigated. The purpose of this study was to investigate the prognostic implications of significant isolated TR in AF patients without left-sided heart disease, pulmonary hypertension, or primary structural abnormalities of the tricuspid valve. A total of 63 AF patients with moderate and severe TR were matched for age and gender to 116 AF patients without significant TR. Patients were followed for the occurrence of all-cause mortality, hospitalization for heart failure and stroke. Patients with significant isolated TR (mean age 71 ± 8 years, 57% men) more often had paroxysmal AF as compared with patients without TR (mean age 71 ± 7 years, 60% men) (60% vs 43%, p = 0.028). In addition, right atrial size and tricuspid annular diameter were significantly larger in patients with significant isolated TR compared with their counterparts. During follow-up (median 62 [34 to 95] months), 53 events for the combined endpoint occurred. One- and 5-year event-free survival rates for patients with significant isolated TR were 76% and 56%, compared with 92% and 85% for patients without significant TR, respectively (Log rank Chi-Square p <0.001). The presence of significant isolated TR was independently associated with the combined endpoint (hazard ratio, 2.853; 95% confidence interval, 1.458 to 5.584; p = 0.002). In conclusion, in the absence of left-sided heart disease and pulmonary hypertension, significant isolated TR is independently associated with worse event-free survival in patients with AF.

Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:84-90
Dietz MF, Goedemans L, Vo NM, Prihadi EA, ... Delgado V, Bax JJ
Am J Cardiol: 14 Nov 2020; 135:84-90 | PMID: 32866441
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Abstract

Ventricular Fibrillation Storm in Coronavirus 2019.

Elsaid O, McCullough PA, Tecson KM, Williams RS, Yoon A

Cardiac arrhythmia is a known manifestation of novel coronavirus 2019 (COVID-19) infection. Herein, we describe the clinical course of an otherwise healthy patient who experienced persistent ventricular tachycardia and fibrillation which is believed to be directly related to inflammation, as opposed to acute myocardial injury or medications that can prolong the QT interval.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:177-180
Elsaid O, McCullough PA, Tecson KM, Williams RS, Yoon A
Am J Cardiol: 14 Nov 2020; 135:177-180 | PMID: 32871109
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Abstract

Optimizing Monotherapy Selection, Aspirin Versus P2Y12 Inhibitors, Following Percutaneous Coronary Intervention.

Yerasi C, Case BC, Forrestal BJ, Torguson R, ... Garcia-Garcia HM, Waksman R

Dual antiplatelet therapy (DAPT) reduces ischemic and thrombotic events after percutaneous coronary intervention (PCI). Initial reports of higher myocardial infarction and mortality rates prompted guideline committees to choose 12-month duration of DAPT after PCI. However, higher bleeding rates with DAPT remain a major concern. Since these guidelines were published, there have been improvements in stent design, deployment techniques, and antiplatelet therapies, which have reduced ischemic events. To address bleeding concerns, trials were performed to evaluate the effectiveness of short-duration DAPT. Two main strategies were employed: (1) aspirin monotherapy after a short-duration DAPT, and (2) P2Y12 inhibitor monotherapy after a short-duration DAPT. In this review, we outline all the major trials on short-duration DAPT that have examined the previously mentioned strategies and propose a new individualized treatment algorithm for which monotherapy to choose or remove after PCI. In conclusion, while removing the P2Y12 inhibitor after a short DAPT appears to be safe in the low-risk population, removing aspirin and continuing the P2Y12 inhibitor as monotherapy would be the preferred strategy in intermediate- to high-risk patients to mitigate the bleeding risk.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:154-165
Yerasi C, Case BC, Forrestal BJ, Torguson R, ... Garcia-Garcia HM, Waksman R
Am J Cardiol: 14 Nov 2020; 135:154-165 | PMID: 32962804
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Abstract

Characteristics and Long-Term Outcomes of Patients With Prior Coronary Artery Bypass Grafting Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

Gharacholou SM, Del-Carpio Munoz F, Motiei A, Sandhu GS, ... Pham SM, Singh M

Limited data are available on characteristics and long-term outcomes of patients with coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). Between January 2000 to December 2014, we identified STEMI patients with prior CABG undergoing primary percutaneous coronary intervention from 3 sites. Kaplan-Meier methods to estimate survival and major adverse cardiac events (MACE) were employed and compared to a propensity matched cohort of non-CABG STEMI patients. Independent predictors of outcomes were analyzed with Cox modeling. Of the 3,212 STEMI patients identified, there were 296 (9.2%) CABG STEMI patients, having nearly similar frequencies of culprit graft (47.6%) versus culprit native (52.4%) as the infarct-related artery (IRA). At 10 years, the adjusted survival was 44% in CABG STEMI versus 55% in non-CABG STEMI (HR 1.26; 95%CI 0.86 to 1.87; p = 0.72). Survival free of MACE was lower for CABG STEMI (graft IRA, 37%; native IRA, 46%) as compared to non-CABG STEMI controls (63%) (p = 0.02). Neither CABG history nor IRA (native vs graft) was independently associated with death or MACE in multivariable analysis. Temporal trends showed no significant change in death or MACE rates of CABG STEMI patients over time. In conclusion, long term survival of CABG STEMI patients is not significantly different than matched STEMI patients without prior CABG; however, CABG STEMI patients were at significantly higher risk for MACE events.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:1-8
Gharacholou SM, Del-Carpio Munoz F, Motiei A, Sandhu GS, ... Pham SM, Singh M
Am J Cardiol: 14 Nov 2020; 135:1-8 | PMID: 32866446
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Abstract

Impact of Prior Coronary Artery Bypass Grafting in Patients ≥75 Years Old Presenting With Acute Myocardial Infarction (From the National Readmission Database).

Lemor A, Hernandez GA, Basir MB, Patel S, ... Alaswad K, O\'Neill W

Patients ≥75 years old presenting with acute myocardial infarction (AMI) have complex coronary anatomy in part due to prior coronary artery bypass grafting (CABG), percutaneous coronary interventions (PCI), calcific and valvular disease. Using the National Readmission Database from January 2016 to November 2017, we identified hospital admissions for acute myocardial infarction in patients ≥75 years old and divided them based on a history of CABG. We evaluated in-hospital outcomes, 30-day mortality, 30-day readmission and predictors of PCI in cohorts. Out of a total of 296,062 patients ≥75 years old presenting with an AMI, 42,147 (14%) had history of previous CABG. Most presented with a non-ST segment elevation myocardial infarction, and those with previous CABG had higher burden of co-morbidities and were more commonly man. The in-hospital mortality was significantly lower in those with previous CABG (6.7% vs 8.8%, adjusted odds ratio, 0.88, 95% confidence interval, 0.82 to 0.94). Medical therapy was more common in those with previous CABG and 30-day readmission rates were seen more frequently in those with prior CABG. Predictors of not undergoing PCI included previous PCI, female, older ager groups, heart failure, dementia, malignancy, and higher number of co-morbidities. In conclusion, in patients ≥75 years old with AMI the presence of prior CABG was associated with lower odds of in-hospital and 30-day mortality, as well as lower complications rates, and a decreased use of invasive strategies (PCI, CABG, and MCS). However, 30-day MACE readmission was higher in those with previous CABG.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:9-16
Lemor A, Hernandez GA, Basir MB, Patel S, ... Alaswad K, O'Neill W
Am J Cardiol: 14 Nov 2020; 135:9-16 | PMID: 32866445
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Abstract

Procedural Characteristics and Outcomes of Patients Undergoing Percutaneous Coronary Intervention During Normal Work Hours Versus Non-work Hours.

Case BC, Yerasi CT, Forrestal BJ, Musallam A, ... Weintraub WS, Waksman R

Percutaneous coronary intervention (PCI) performed during non-work hours is believed to have inferior outcomes because of operator fatigue, differences in baseline patient characteristics, and fewer on-call catheterization laboratory staff. We aimed to analyze a cohort of patients who underwent PCI (all comers) at our tertiary-care center between January 1, 2006, and December 31, 2018, and compare procedural and in-hospital outcomes between 2 groups defined by whether PCI was performed during normal work hours (7:00 A.M. to 7:00 PM) versus non-work hours (7:01 P.M. to 6:59 A.M. weekdays; all hours weekends and holidays). Finally, we examined temporal changes throughout the 24-hour weekday. Primary outcomes were unadjusted in-hospital adverse outcomes (composite death, recurrent myocardial infarction, emergent coronary artery bypass grafting, and target lesion revascularization). We identified 21,848 patients who underwent PCI at our institution. The proportions of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) were higher during non-work hours. Overall, unadjusted in-hospital adverse outcomes were higher during non-work hours than during normal work hours (8.80% vs 2.00%; p <0.001). These findings were consistent based on the patient\'s clinical presentation (STEMI, NSTEMI, unstable angina, and stable angina). Despite confounding variables in the patients\' presentations preventing definite causal attribution, our analysis demonstrates that in-hospital adverse outcomes were higher for those patients who underwent PCI (all comers) who had their procedures during non-work hours than during normal work hours.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:32-39
Case BC, Yerasi CT, Forrestal BJ, Musallam A, ... Weintraub WS, Waksman R
Am J Cardiol: 14 Nov 2020; 135:32-39 | PMID: 32866443
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Abstract

Meta-Analysis of Complete versus Culprit-Only Revascularization in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease.

Levett JY, Windle SB, Filion KB, Cabaussel J, Eisenberg MJ

Approximately half of patients with ST-segment elevation myocardial infarction (STEMI) present with noninfarct related multivessel coronary artery disease (CAD) during primary percutaneous coronary intervention (PCI). However, questions remain concerning whether patients with STEMI and multivessel CAD should routinely undergo complete revascularization. Our objective was to compare the risks of major cardiovascular outcomes and procedural complications in patients with STEMI and multivessel CAD randomized to complete revascularization versus culprit-only PCI. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing complete revascularization to culprit-only PCI. RCTs were identified via a systematic search of MEDLINE, Embase, and Cochrane CENTRAL. Count data were pooled using DerSimonian and Laird random-effects models with inverse variance weighting to obtain relative risks (RRs) and 95% confidence intervals (CIs). A total of 9 RCTs (n = 6,751) were included, with mean/median follow-up times ranging from 6 to 36 months. Compared with culprit-only PCI, complete revascularization was associated with a substantial reduction in major adverse cardiovascular events (13.1% vs 22.1%; RR: 0.54; 95%CI: 0.43 to 0.66), repeat myocardial infarction (4.9% vs 6.8%; RR: 0.64; 95%CI: 0.48 to 0.84), and repeat revascularization (3.7% vs 12.3%; RR: 0.33; 95%CI: 0.25 to 0.44). Complete revascularization may have beneficial effects on all-cause and cardiovascular mortality, but 95%CIs were wide. Findings for stroke, major bleeding, and contrast-induced acute kidney injury were inconclusive. In conclusion, complete coronary artery revascularization appears to confer benefit over culprit-only PCI in patients with STEMI and multivessel CAD, and should be considered a first-line strategy in these patients.

Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:40-49
Levett JY, Windle SB, Filion KB, Cabaussel J, Eisenberg MJ
Am J Cardiol: 14 Nov 2020; 135:40-49 | PMID: 32871112
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Abstract

Outcomes After ST-Segment Versus Non-ST-Segment Elevation Myocardial Infarction Revascularized by Coronary Artery Bypass Grafting.

Malmberg M, Sipilä J, Rautava P, Gunn J, Kytö V

The objectives of this study were to investigate the outcome differences between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients treated with coronary artery bypass grafting surgery (CABG). We conducted a multicenter, retrospective cohort follow-up study of consecutive patients with STEMI (surgery ≤48 hours of admission; n = 348) or NSTEMI (n = 1,160) revascularized with first-time isolated CABG in Finland using nationwide registries (median age 68 years, 24% women). The short- and long-term (10-year) outcomes were studied with inverse propensity probability weight adjustment for baseline features. The median follow-up was 5.2 years. In-hospital mortality (11.4% vs 5.3%; adj. odds ratio [OR] 2.27; confidence interval [CI] 1.41 to 3.66; p = 0.001) and re-sternotomy rates (6.9% vs 3.5%; adj. OR 2.07; CI 1.22 to 3.51; p = 0.007) were higher in STEMI patients. Long-term all-cause mortality did not differ between STEMI and NSTEMI patients among all operated patients (30.2% vs 28.3%; adj. HR 1.30; CI 0.97 to 1.75; p = 0.080) or hospital survivors (21.6 vs 24.3%; HR 0.93; CI 0.64 to 1.36; p = 0.713). Occurrence of major adverse cardiovascular event in hospital survivors within 10 years was 34.7% in STEMI versus 29.6% in NSTEMI (adj. HR 1.24; CI 0.88 to 1.76; p = 0.220). Occurrences of cardiovascular death (14.6% vs 14.4%; p = 0.773), myocardial infarction (MI; 15.2% vs 10.3%; p = 0.203), and stroke (10.8% vs 14.8%; p = 0.242) were also comparable. In conclusion, patients with STEMI have poorer short-term outcome compared to NSTEMI patients after revascularization by CABG, but the long-term outcomes are comparable regardless of MI type. Thus, both short- and long-term risks should be considered when evaluating patient´s for CABG eligibility by MI type.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:17-23
Malmberg M, Sipilä J, Rautava P, Gunn J, Kytö V
Am J Cardiol: 14 Nov 2020; 135:17-23 | PMID: 32871111
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Abstract

Outcomes of Patients With Acute Myocardial Infarction Who Recovered From Severe In-hospital Complications.

Sawano S, Sakakura K, Taniguchi Y, Yamamoto K, ... Wada H, Fujita H

Acute myocardial infarction (AMI) would sometimes raise severe in-hospital complications such as cardiopulmonary arrest, shock, stroke, atrioventricular block, and respiratory failure. The purpose of this retrospective study was to compare the clinical outcomes of AMI patients who recovered from severe in-hospital complications with those who did not have in-hospital complications. We included 494 AMI patients, and divided those into the in-hospital complications group (n = 166) and noncomplications group (n = 328). The primary end point was the major adverse cardiovascular events (MACE) defined as the composite of all cause death, nonfatal myocardial infarction (MI), and readmission for heart failure within 1 year after the hospital discharge. A total of 50 postdischarge MACE were observed during the study period. MACE was more frequently observed in the in-hospital complications group (14.5%) than in the noncomplications group (7.9%) (p = 0.023). The presence of in-hospital complications was significantly associated with the MACE (Odds Ratio 1.889, 95% Confidence Interval 1.077 to 3.313, p = 0.026) after controlling age, gender, ST-elevation MI, and culprit of AMI. In conclusion, the MACE was significantly frequent in AMI patients who recovered from severe in-hospital complications and discharged to home, as compared with those who did not have in-hospital complications. AMI patients who recovered from complications could be recognized as a high risk group, and should be carefully managed after discharge to prevent cardiovascular events.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:24-31
Sawano S, Sakakura K, Taniguchi Y, Yamamoto K, ... Wada H, Fujita H
Am J Cardiol: 14 Nov 2020; 135:24-31 | PMID: 32871110
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Abstract

Comparison of Outcomes After Ablation of Atrial Fibrillation in Patients With Heart Failure With Preserved Versus Reduced Ejection Fraction.

Aldaas OM, Malladi CL, Mylavarapu PS, Lupercio F, ... Feld GK, Hsu JC

Catheter ablation improves outcomes in atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). We sought to evaluate the efficacy and safety of catheter ablation of AF in HF patients with a preserved ejection fraction (HFpEF). We performed a retrospective study of all patients who underwent de novo radiofrequency catheter ablation enrolled in the UC San Diego AF Ablation Registry. The primary outcome was recurrence of all atrial arrhythmias on or off antiarrhythmic drugs (AAD). Of 547 total patients, 51 (9.3%) had HFpEF, 40 (7.3%) had HFrEF, and 456 (83.4%) were without HF. There was no difference in recurrence of atrial arrhythmias on or off AAD (Adjusted Hazard Ratio [AHR] 1.92 [95% CI 0.97 to 3.83] for HFpEF vs HFrEF and AHR 0.90 [95% CI 0.59 to 1.39] for HFpEF vs no HF) or off AAD (AHR 1.96 [95% CI 0.99 to 3.90] for HFpEF vs HFrEF and AHR 1.14 [95% CI 0.74 to 1.77] for HFpEF vs no HF). There was also no difference in rates of all-cause hospitalizations (AHR 1.80 [95% CI 0.97 to 3.33] for HFpEF vs HFrEF and AHR 2.05 [95% CI 1.30 to 3.23] for HFpEF vs no HF) or rates of all-cause mortality (AHR 0.53 [95% CI 0.05 to 6.11] for HFpEF vs HFrEF and AHR 2.46 [95% CI 0.34 to 17.92] for HFpEF vs no HF). There were no significant differences in AAD use (p = 0.176) or procedural complications between groups (p = 0.980). In conclusion, there were no significant differences in arrhythmia-free survival between patients with HFpEF and HFrEF that underwent catheter ablation of AF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:62-70
Aldaas OM, Malladi CL, Mylavarapu PS, Lupercio F, ... Feld GK, Hsu JC
Am J Cardiol: 30 Nov 2020; 136:62-70 | PMID: 32941815
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Abstract

Relation of Atrial Fibrillation to Angiographic Characteristics and Coronary Artery Disease Severity in Patients Undergoing Percutaneous Coronary Intervention.

Pastori D, Biccirè FG, Lip GYH, Menichelli D, ... Gaudio C, Tanzilli G

Patients with atrial fibrillation (AF) have an increased risk of coronary artery disease (CAD) compared to patients without. Angiographic characteristics, clinical presentation and severity of CAD according to the presence of AF have been poorly described. We performed a retrospective study of 303 consecutive patients (mean age 69.6±10.8 years; 23.1% women) with and without AF undergoing percutaneous coronary intervention. Data on 1) type of CAD presentation, 2) coronary involvement and 3) number of diseased coronary vessels (≥70%/luminal narrowing) were collected. CHADS-VASc and 2MACE scores were calculated. Presentation of CAD was STEMI in 37.6% of patients, NSTEMI-UA in 55.1%, and other in 7.3%. NSTEMI-UA was more common in AF (69.6% vs. 46.6%, p<0.001), while STEMI was more in the non-AF (22.3% vs. 46.6%, p<0.001) group. Left anterior descending artery (LAD) was the most common diseased vessel (70.6%) followed by right coronary artery (RCA, 56.4%) and obtuse marginal artery (36.6%). Patients with AF had a significantly lower RCA involvement (47.3% vs. 61.8%, p=0.016), with a trend for LAD (64.3% vs. 74.3%, p=0.069). At multivariable logistic regression analysis, AF remained inversely associated with RCA involvement (Odds Ratio [OR] 0.541, 95% Confidence Interval [CI] 0.335-0.874, p=0.012) and with ≥3 vessel CAD (OR 0.470, 95%CI 0.272-0.810, p=0.007). The 2 MACE score was associated with diseased LAD (OR 1.301, 95%CI 1.103-1.535, p=0.002) and with ≥3 vessel CAD (OR 1.330, 95%CI 1.330-1.140, p<0.001). In conclusion, patients with AF show lower RCA involvement and generally less severe CAD compared to non-AF ones. 2MACE score was higher in LAD obstruction and identified patients with severe CAD.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 17 Nov 2020; epub ahead of print
Pastori D, Biccirè FG, Lip GYH, Menichelli D, ... Gaudio C, Tanzilli G
Am J Cardiol: 17 Nov 2020; epub ahead of print | PMID: 33220321
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Abstract

Outcomes Associated with Dronedarone Use in Patients with Atrial Fibrillation.

Goehring EL, Bohn RL, Pezzullo J, Tave AK, ... Sicignano N, Naccarelli GV

The antiarrhythmic drug dronedarone was designed to reduce the extra-cardiac adverse effects associated with amiodarone use in treatment of patients with atrial fibrillation / atrial flutter (AF/AFL). This epidemiological study used a retrospective cohort design to compare risk of cardiovascular-related hospitalizations and death in AF/AFL patients treated with dronedarone versus other antiarrhythmic drugs (AADs). AF/AFL patients with incident dronedarone fills were matched by propensity score (PS) to incident users of other AADs. The primary study outcome was hospitalization for cardiovascular (CV) causes within 24 months after the first study drug fill. A secondary composite outcome comprised hospitalization for CV causes or all-cause mortality during follow-up. In the AF/AFL patient cohort meeting eligibility criteria, 6,964 incident users of dronedarone and 25 607 incident users of other AADs were identified. The PS-matched cohort comprised 6,349 Dronedarone users (91.2% of all eligible) and 12,698 other AAD users. Dronedarone patients had a significantly lower risk of hospitalization for a CV event compared to Other AAD users (hazard ratio = 0.87; 95% confidence interval = 0.79 to 0.96). This was consistent with results for the composite outcome (hazard ratio=0.86; 95% confidence interval = 0.78 to 0.95). In conclusion, AF/AFL patients initiated on dronedarone versus other AADs had significantly lower risk of CV hospitalizations as well as the composite CV hospitalization / death from any cause.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:77-83
Goehring EL, Bohn RL, Pezzullo J, Tave AK, ... Sicignano N, Naccarelli GV
Am J Cardiol: 14 Nov 2020; 135:77-83 | PMID: 32861738
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Abstract

Procedural Outcomes of Patients Undergoing Percutaneous Coronary Intervention for De Novo Lesions in the Ostial and Proximal Left Circumflex Coronary Artery.

Musallam A, Chezar-Azerrad C, Torguson R, Case BC, ... Mintz GS, Waksman R

Ostial coronary artery lesions can be challenging during percutaneous coronary intervention (PCI) because of elastic fiber content, calcium burden, and angulation. We assessed procedural and clinical major adverse cardiac events (MACE) associated with PCI for ostial lesions, focusing on ostial left circumflex (LC) lesions compared with ostial left anterior descending artery (LAD) and right coronary artery lesions. All patients with ostial or very proximal coronary artery lesions treated with PCI at MedStar Washington Hospital Center (Washington, DC) from 2003 to 2018 were included. The primary end point was target lesion revascularization (TLR)-MACE, defined as the composite of all-cause mortality, Q-wave myocardial infarction (MI), and TLR at 1 year. A total of 4,759 patients with available 1-year follow-up were included: 2,236 ostial/very proximal LAD, 980 ostial/very proximal LC, and 1,543 ostial/very proximal right. The presenting clinical syndrome for the LC group was mainly stable or unstable angina, whereas MI was more common in the LAD. At 1 year, the TLR-MACE rate was 16.7% in the LC group versus 12.5% in the LAD and 11.8% in the right group (p = 0.001). Mortality rates were 11.2% in the LC group versus 8.4% in the LAD and 6% in the right group (p <0.001). A Cox model showed that dialysis had the highest impact on TLR-MACE. In conclusion, compared with PCI of ostial or very proximal LAD or right lesions, PCI of ostial or very proximal LC lesions was associated with higher rates of TLR-MACE.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 14 Nov 2020; 135:62-67
Musallam A, Chezar-Azerrad C, Torguson R, Case BC, ... Mintz GS, Waksman R
Am J Cardiol: 14 Nov 2020; 135:62-67 | PMID: 32958219
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Abstract

Familial LEOPARD Syndrome With Hypertrophic Cardiomyopathy.

Galazka P, Jain R, Muthukumar L, Sanders H, ... Khandheria BK, Tajik AJ

Multiple lentigines syndrome is an autosomal dominant inherited condition with variable expressivity that is also known as LEOPARD syndrome. LEOPARD stands for lentigines, electrocardiographic conduction defects, ocular hypertelorism, pulmonary valve stenosis, abnormalities of genitalia, retardation of growth, and deafness. LEOPARD syndrome most frequently develops secondary to a missense mutation of protein-tyrosine phosphatase nonreceptor type 11 gene, which encodes tyrosine phosphatase. The missense mutation p.Tyr279Cys can either occur as a de novo mutation or affect multiple family members. Although hypertrophic cardiomyopathy is not part of the LEOPARD acronym, it is the most frequent cardiac anomaly observed in this syndrome. The recognition of increased left or right ventricular wall thickness in patients with LEOPARD syndrome may have significant impact on their clinical course similar to classic hypertrophic cardiomyopathy, which may require septal reduction procedures for relief of left or right ventricular outflow tract obstruction or implantable cardioverter-defibrillator placement for sudden cardiac death prevention. We describe a case series of a family with diffuse lentigines and hypertrophic cardiomyopathy in which the son carries the protein-tyrosine phosphatase nonreceptor type 11 (p.Tyr279Cys) gene mutation and both the son and daughter underwent left ventricular myectomy at an early age. In conclusion, our case series of a family with LEOPARD syndrome illustrates the importance of recognizing hypertrophic cardiomyopathy as part of this syndrome.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:168-173
Galazka P, Jain R, Muthukumar L, Sanders H, ... Khandheria BK, Tajik AJ
Am J Cardiol: 14 Nov 2020; 135:168-173 | PMID: 32866449
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Abstract

Cardiac Computed Tomography-Derived Left Atrial Volume Index as a Predictor of Long-Term Success of Cryo-Ablation in Patients with Atrial Fibrillation.

Maier J, Blessberger H, Nahler A, Hrncic D, ... Lambert T, Steinwender C

Patients with symptomatic, drug-refractory atrial fibrillation (AF) are frequently treated with catheter ablation. Cryo-ablation has been established as an alternative to radiofrequency ablation but long-term outcome data are still limited. This study aimed at elucidating the influence of the left atrial volume index (LAVI), derived from cardiac computed tomography (cCT) data, on the long-term outcome of ablation-naïve AF patients, after their first cryo-ablation. 415 patients (n=290[69.90%] male, 60.00[IQR:53.00-68.00] years old) undergoing a cCT and subsequent cryo-ablation index procedure were included in this single centre retrospective data analysis. A composite endpoint was defined (AF on electrocardiogram and/or electric cardioversion and/or re-do). Patients were closely followed for a year and then contacted for long-term follow-up after a median of 53.00 months (IQR:34.50-73.00). Statistical analyses of the outcome and predictors of AF recurrence were conducted. In 224 patients (53.98%) no evidence of AF recurrence could be found. LAVI differed significantly between the positive and adverse (AF recurrence) outcome group (49.96 vs. 56.07mL/m, p<0.001). Cox regression analyses revealed cCT LAVI (HR:1.022, 95%CI:1.013-1.031, p<0.001), BMI (HR:1.044, 95%CI:1.005-1.084, p<0.05) and the type of AF (HR:1.838 for non-paroxysmal AF, 95%CI:1.214-2.781, p<0.01) to be effective predictors of AF recurrence. A prognostic cCT LAVI cut-off value of 51.99mL/m was calculated and must be validated in future prospective studies. In conclusion, LAVI is an accurate, yet underutilized predictor of AF recurrence after pulmonary vein isolation with cryo-energy and scores for calculating AF recurrence or progression risks might underemphasize the importance of CT-derived LAVI as a predictive factor.

Copyright © 2020 Elsevier Ltd. All rights reserved.

Am J Cardiol: 01 Nov 2020; epub ahead of print
Maier J, Blessberger H, Nahler A, Hrncic D, ... Lambert T, Steinwender C
Am J Cardiol: 01 Nov 2020; epub ahead of print | PMID: 33152317
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Abstract

Comparison of Prevalence, Presentation and Prognosis of Acute Coronary Syndromes in ≤35 years, 36 - 54 years, and ≥ 55 years Patients.

Qureshi WT, Kakouros N, Fahed J, Rade JJ

Whether very young patients (≤35-year-old) differ in the prevalence, presentation and prognosis of ACS is not well known. Out of 43,446 patients who were referred to a tertiary care cardiac catheterization laboratory between 1/1/2006 and 6/30/2017, 26,545 patients were ACS (defined as ST Elevation MI (STEMI), Non-ST Elevation MI (NSTEMI) or unstable angina pectoris). Detailed chart review was performed and characteristics at baseline were compared for ages ≤35 years, ages 36-54 years and ages ≥55 years. A total of 291 (1.1%) were ≤35-year-old, 7649 (28.8) were 36-54-year-old and 18605 (70.1%) were ≥55-year-old. ACS patients aged ≤35-year-old, were more likely to be men, Caucasian white, smoker, obese and have family history of coronary artery disease and less likely to have comorbidities such as hypertension, diabetes mellitus, hyperlipidemia compared with older patients. They were also more likely to present with elevated troponin levels than other groups. They also tended to present with late ST elevation myocardial infarction and were more likely to receive bare metal stents than older individuals. The prevalence of 2- and 3-vessel disease was lower compared with older individuals. They also had higher prevalence of cardiogenic shock. Compared with 36-54-year-old patients, ≤35-year-old were at significant higher risk of 30-day mortality in a multivariable adjusted regression model (Odds ratio 5.65, 95% confidence interval 2.49 - 12.82, p <0.001). Very young patients comprised ∼1% of all ACS cases but had much more prevalence of modifiable risk factors and significantly worse mortality. Modifying these risk factors may mitigate the risk in these patients and should be studied in the future.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 05 Nov 2020; epub ahead of print
Qureshi WT, Kakouros N, Fahed J, Rade JJ
Am J Cardiol: 05 Nov 2020; epub ahead of print | PMID: 33166493
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Abstract

Worth Remembering: Cardiac Memory Presenting as Deep Anterior T-Wave Inversions Explained by Intermittent Left Bundle Branch Block.

Pierce JB, Rosenthal J, Stone NJ

Cardiac memory is a common cause of deep T-wave inversions (TWI) in the anterior precordial leads and can be difficult to distinguish from alternative causes of TWI such as myocardial ischemia. Cardiac memory is generally a benign condition except in the setting of prolonged QT when it can contribute to the precipitation of torsades de pointes. Herein, we describe the presentation and clinical course of a case of cardiac memory due to intermittent left bundle branch block (LBBB) that presented asymptomatically to our outpatient cardiology clinic with deep anterior TWI. We discuss common causes of and mechanisms underlying cardiac memory and how to distinguish it from alternative causes of TWI based on 12-lead electrocardiogram. In conclusion, intermittent LBBB is an under-recognized cause of cardiac memory that can present as deep anterior TWI mimicking cardiac ischemia, and awareness of this clinical entity may help prevent unnecessary invasive and expensive testing on otherwise healthy patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:174-176
Pierce JB, Rosenthal J, Stone NJ
Am J Cardiol: 14 Nov 2020; 135:174-176 | PMID: 32866450
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Abstract

\"Pill In The Pocket\" Antiarrhythmic Drugs For Orally Administered Pharmacologic Cardioversion Of Atrial Fibrillation.

Reiffel JA, Capucci A

The therapy of atrial fibrillation (AF) often involves the use of a rhythm control strategy, in which one or more antiarrhythmic drugs (AAD), ablative procedures, and/or hybrid approaches involving both of these options are utilized in an attempt to restore and maintain sinus rhythm. For chronic therapy, an AAD is taken daily. However, for patients with symptomatic but infrequent, acute, but non-destabilizing episodes, the use of an AAD only at the time of an episode that can quickly restore sinus rhythm, generally as an out-patient, without the burden of a daily drug regimen, may be better. This is called \"pill-in-the-pocket\" (PITP) therapy. This manuscript reviews the PITP concept, traces its development from its origins using quinidine, to its expansion using class IC AADs, to the more recent investigation of ranolazine for this purpose. Who should get it, what it involves, its efficacy rates and concerns are all discussed.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Reiffel JA, Capucci A
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144165
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Abstract

Incidental Thoracic Aortic Dilation On Chest Computed Tomography In Patients With Atrial Fibrillation.

Ramchand J, Bansal A, Saeedan MB, Wang TKM, ... Popović ZB, Kalahasti V

Individuals with atrial fibrillation (AF) have risk factors that predispose to thoracic aneurysmal disease (TAD) and atherosclerosis. In this study in individuals with AF, we assessed the occurrence of incidental TAD and assessed if a validated predictive score used to predict AF, the CHARGE-AF score, was associated with greater aortic dimensions. We also assessed the prevalence of coronary calcification. We conducted a cross-sectional study of 1,000 consecutive individuals with AF undergoing chest multidetector CT during evaluation for pulmonary vein isolation. A dilated aortic root (AR) or ascending aorta (AA, dimension/ body surface area >2.05cm/m) were found in 195 (20%). A total of 12 (1%) had significant aortic aneurysmal enlargement of > 5.0cm. Advancing age, a bicuspid aortic valve, hypertension and male gender were associated with increased aortic dimensions. Aortic root dimensions increased linearly (P<0.001) and ascending aortic dimensions increased non-linearly across CHARGE-AF deciles (P<0.001). Nearly two-thirds (63%) had coronary calcification, 38% of whom were not on lipid-lowering therapy. In conclusion, in individuals with AF undergoing gated chest CT, 1 in 5 had previously undetected TAD, with a small proportion having significantly aneurysmal dimensions approaching surgical thresholds. Risk factors previously established to increase the propensity to develop AF are also associated with increased TAD. These findings raise the need to consider a surveillance strategy for TAD in patients with AF, particularly in those with other risk factors for aortic disease. A high prevalence of coronary calcium was also detected, representing an opportunity to optimize statin therapy in patients with AF.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Ramchand J, Bansal A, Saeedan MB, Wang TKM, ... Popović ZB, Kalahasti V
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144160
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Usefulness of Lipoprotein (a) for Predicting Outcomes After Percutaneous Coronary Intervention for Stable Angina Pectoris in Patients on Hemodialysis.

Hishikari K, Hikita H, Yoshikawa H, Abe F, ... Yonetsu T, Sasano T

Serum lipoprotein (a) level is genetically determined and remains consistent during a person\'s life. Previous studies have reported that people with high lipoprotein (a) level are at a high risk of cardiac events. We investigated the association between lipoprotein (a) levels and clinical outcomes after percutaneous coronary intervention (PCI) for stable angina pectoris (SAP) in hemodialysis (HD) patients. Serum lipoprotein (a) levels were measured on admission in 410 consecutive HD patients who underwent successful PCI for SAP. Patients were divided into 2 groups: low and high group having lipoprotein (a) level <40 mg/dL (n = 297) and ≧40 mg/dL (n = 113) respectively. After PCI, the incidence of major adverse cardiac event (MACE) including cardiac death, nonfatal myocardial infarction, necessity of a new coronary revascularization procedure (coronary bypass surgery, repeat target lesion PCI, PCI for a new non-target lesion) was analyzed. At a median follow-up of 24 months (12 to 37 months), MACE occurred in 188 patients (45.6%). The rate of MACE rate was significantly higher in the high lipoprotein (a) group than in the low lipoprotein (a) group (59.2% vs 40.7%, long-rank test chi-square = 12.3; p < 0.001). Cox analysis showed that high lipoprotein (a) level (Hazard Ratio, 1.62; 95% Confidence Interval, 1.19 to 2.20; p = 0.002) was an independent predictor for MACE after PCI. In conclusion, high lipoprotein (a) level was associated with a higher incidence of MACE after PCI for SAP in HD patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:32-37
Hishikari K, Hikita H, Yoshikawa H, Abe F, ... Yonetsu T, Sasano T
Am J Cardiol: 30 Nov 2020; 136:32-37 | PMID: 32941820
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Abstract

Safety and Efficacy of Oral Anticoagulants for Atrial Fibrillation in Patients After Bariatric Surgery.

Hendricks AK, Zieminski JJ, Yao X, Dunlay SM, ... Herrin TR, Nei SD

Anticoagulation management is challenging in bariatric surgery patients, due to altered gastrointestinal anatomy and potentially reduced absorption. Few studies have evaluated clinical outcomes in this population. The objective of this study was to compare the efficacy and safety of oral anticoagulants in patients with and without a history of bariatric surgery. A retrospective, matched cohort study was conducted, utilizing data from the OptumLabs Data Warehouse. Patients ≥18 years old, with nonvalvular atrial fibrillation (NVAF), and treated with an oral anticoagulant between January 1, 2010 and December 31, 2018 were included. Outcomes were compared between bariatric and nonbariatric surgery patients. Secondary analysis compared warfarin to the direct oral anticoagulants (DOAC) in the bariatric cohort. The primary efficacy outcome was the rate of ischemic stroke and systemic embolism and the primary safety outcome was major bleeding. A total of 1,673 bariatric surgery and 155,619 nonbariatric surgery patients were identified. There was no significant difference in the rate of ischemic stroke or systemic embolism (0.83 vs 1.32 per 100 person years; Hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.31 to 1.22; p = 0.17) or major bleeding (5.30 vs 4.87 per 100 person years; HR 1.05, 95% CI 0.80 to 1.37; p = 0.73) between bariatric and nonbariatric surgery patients. In bariatric surgery patients alone, efficacy and safety were similar with warfarin compared with the DOACs. Results of this study suggest that bariatric surgery patients are not at an increased thrombotic or bleeding risk when using oral anticoagulants for NVAF. DOACs may be a reasonable alternative to warfarin.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:76-80
Hendricks AK, Zieminski JJ, Yao X, Dunlay SM, ... Herrin TR, Nei SD
Am J Cardiol: 30 Nov 2020; 136:76-80 | PMID: 32941819
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Abstract

Relevance of Functional Mitral Regurgitation in Aortic Valve Stenosis.

Benfari G, Setti M, Nistri S, Fanti D, ... Ribichini FL, Rossi A

The clinical relevance of functional-mitral-regurgitation (FMR) in patients with aortic valve stenosis (AS) has been poorly studied using a quantitative approach. In addition, FMR prognostic value has mostly been analyzed after aortic valve replacement. Between 2010 and 2014 the echocardiograms of consecutive AS patients were retrospectively reviewed. Inclusion criteria were calcified aortic valve with transaortic-velocity >2.5 m/s and calculated mitral effective regurgitant orifice area (ERO) in the presence of mitral regurgitation. Organic mitral valve disease was an exclusion-criteria. Primary endpoint was heart failure or death under medical management. Secondary endpoint was heart failure or death. Eligible patients were 189, age 79 ± 8 years, 61% NYHA I/II, indexed aortic valve area (AVA) 0.55 ± 0.17 cm/m. Mitral ERO was 7.6 ± 4.2 mm (>10 mm in 30% of patients). Longitudinal function (by S\'-TDI) was associated with mitral ERO independently of ejection fraction and ventricular volumes (p = 0.01). Mitral ERO greater than 10 mm (threshold identified by spline survival-modeling) was associated with severe symptoms (Odds ratio [OR] 3.1 [1.6 to 6.0]; p = 0.0006) and higher pulmonary-arterial-pressure (OR 3.0 [1.4 to 5.9]; p = 0.002). Follow-up was completed for 175 patients. After 4.7 [1.4 to 7.2] years, 87 (50%) patients underwent AVR, 66 (38%) had heart-failure, 64 (37%) died. No procedure on FMR was required. Mitral ERO was independently associated with primary and secondary endpoints both as continuous variable (Hazard ratio [HR] 1.15 [1.00 to 1.30]; p = 0.04 and HR 1.23 [1.05 to 1.43]; p = 0.01 per 5 mm ERO increase) or as ERO> versus ≤10 mm. Adjustment for S\'-TDI or subgroup-analysis did not affect results. The analysis by AVA revealed the incremental prognostic role of mitral ERO over AS severity. In conclusion, AS patients with concomitant FMR >10 mm holds a higher risk during medical follow-up. FMR quantitation, even for volumetrically modest regurgitation, provides incremental prognostic information over AS severity.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:115-121
Benfari G, Setti M, Nistri S, Fanti D, ... Ribichini FL, Rossi A
Am J Cardiol: 30 Nov 2020; 136:115-121 | PMID: 32941813
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Abstract

Comparison of Outcomes in Patients With Takotsubo Syndrome With-vs-Without Cardiogenic Shock.

Syed M, Khan MZ, Osman M, Alharbi A, ... Munir MB, Balla S

There is limited data on the in-hospital outcomes of cardiogenic shock (CS) secondary to takotsubo syndrome (TS). We aimed to assess the incidence, predictors, and outcomes of CS in hospitalized patients with TS. All patients with TS were identified from the National Inpatient Sample database from September 2006 to December 2017. The cohort was divided into those with versus without CS and logistic regression analysis was used to identify predictors of CS and mortality in patients admitted with TS. A total of 260,144 patients with TS were included in our study, of whom 14,703 (6%) were diagnosed with CS. In-hospital mortality in patients with CS was approximately six-fold higher compared with those without CS (23% vs 4%, p <0.01). TS patients with CS had a higher incidence of malignant arrhythmias like ventricular tachycardia or ventricular fibrillation (15.0% vs 4%, p <0.01) and non-shockable cardiac arrests (12% vs 2%, p <0.01). Independent predictors of CS were male gender, Asian and Hispanic ethnicity, increased burden of co-morbidities including congestive heart failure, chronic pulmonary disease, and chronic diabetes. Independent predictors of mortality were male gender, advanced age, history of congestive heart failure, chronic renal failure, and chronic liver disease. In conclusion, CS occurs in approximately 6% of patients admitted with TS, in-hospital mortality in TS patients with CS was approximately six-fold higher compared with those without CS (23% vs 4%, p <0.01), male gender and increased burden of co-morbidities at baseline were independent predictors of CS and mortality.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:24-31
Syed M, Khan MZ, Osman M, Alharbi A, ... Munir MB, Balla S
Am J Cardiol: 30 Nov 2020; 136:24-31 | PMID: 32941812
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Abstract

Relationship Between Anemia and Sudden Cardiac Death in Patients With Severe Aortic Stenosis.

Ducharme-Smith A, Chahal CAA, Sawatari H, Podboy A, ... Nkomo VT, Pellikka PA

Aortic stenosis (AS) is associated with significant morbidity and mortality, including sudden cardiac death (SCD). Anemia is a known risk factor for mortality in patients with AS. We sought to understand the prognostic implications between anemia and SCD in severe AS. The Mayo Clinic AS database includes 8,357 adults with severe AS (mean gradient ≥40 mm Hg, aortic valve area ≤1 cm, or peak aortic jet velocity ≥4 m/s) enrolled between January 1, 1995 and April 30, 2015. Survival and cause of death were ascertained from the National Death Index and SCD from medical records. We excluded patients with multiple valvular abnormalities, leaving 7,292 subjects. The median (interquartile range, [IQR]) age was 76 (68, 82) years with 56% male, and median (IQR) hemoglobin level was 12.9 (11.6, 14.1) g/dl. The frequency of anemia (hemoglobin <13.0g/dl for men, <12.0 g/dL for women) was 40%. During median (IQR) follow up of 4.4 (1.8, 8.1) years, 4,056 died (10-year survival 38%) including 225 with SCD (10-year cumulative incidence 5%). In a multivariate model including age, sex, body-mass index, hypertension, diabetes mellitus, myocardial infarction, estimated glomerular filtration rate, and time dependent aortic valve replacement, anemia was associated with increased all-cause mortality (hazard ratios 1.75, 95%CI 1.64, 1.87; p < 0.001) and increased SCD mortality (hazard ratios 1.42, 95%CI 1.07, 1.86; p = 0.01). In conclusions, anemia is a frequent finding in patients with severe AS and independently associated with increased all-cause mortality and SCD. Anemia may be a useful prognostic marker and a modifiable therapeutic target in managing patients with severe AS.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Nov 2020; 136:107-114
Ducharme-Smith A, Chahal CAA, Sawatari H, Podboy A, ... Nkomo VT, Pellikka PA
Am J Cardiol: 30 Nov 2020; 136:107-114 | PMID: 32946861
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Abstract

Comparison in Patients < 75 Years of Age - Versus - Those > 75 Years on One-year-Events With Atrial Fibrillation and Left Atrial Appendage Occluder (From the Prospective Multicenter German LAARGE Registry).

Nasasra AE, Brachmann J, Lewalter T, Akin I, ... Senges J, Zeymer U

Left atrial appendage closure (LAAC) is an alternative to oral anticoagulation therapy in patients with non-valvular atrial fibrillation for the prevention of embolic stroke and systemic embolism. Although elderly patients (>75 years) have both higher ischemic and bleeding risk as compared with younger patients, they benefit from optimal anticoagulation. The subanalysis aimed to assess the indications, the safety, efficacy, and 1-year outcomes of interventional LAAC in elderly patients (≥ 75 years) compared with younger (< 75 years) patients in clinical practice. We analyzed data from the prospective Left-Atrium-Appendage Occluder Registry Germany. A total of 638 patients were included in the registry, 402 (63%) were aged ≥ 75 years. Compared with younger subjects, patients aged ≥75 were more likely to have higher CHA2DS2-VASC and HAS-BLED scores. Procedural success rate was high und similar in both groups (97.6%). Periprocedural adverse events were not statistically significant in groups (11.9% in <75 years vs 12.9% in ≥75 years; p = 0.80). At 1 year follow-up, all-cause mortality was higher in patients aged ≥75 compared withwith younger group (13.0% vs 7.8 %,p = 0.04), mainly due to non-cardiovascular causes (10.6% vs 6.0%). No significant differences in major bleeding, stroke, systemic embolism were observed. In conclusion, LAAC is feasible and safe in patients with AF at high stroke risk and with contraindications for OAC and should be considered as candidates for LAA closure. Elderly patients often present these characteristics and could benefit from this novel therapy.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Nov 2020; 136:81-86
Nasasra AE, Brachmann J, Lewalter T, Akin I, ... Senges J, Zeymer U
Am J Cardiol: 30 Nov 2020; 136:81-86 | PMID: 32946860
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Abstract

Cardiac Stress Testing After Coronary Revascularization.

Dhoot A, Liu S, Savu A, Cheema ZM, ... Kaul P, Bagai A

Unless prompted by symptoms or change in clinical status, the appropriate use criteria consider cardiac stress testing (CST) within 2 years of percutaneous coronary intervention (PCI) and 5 years of coronary artery bypass grafting (CABG) to be rarely appropriate. Little is known regarding use and yield of CST after PCI or CABG. We studied 39,648 patients treated with coronary revascularization (29,497 PCI; 10,151 CABG) between April 2004 and March 2012 in Alberta, Canada. Frequency of CST between 60 days and 2 years after revascularization was determined from linked provincial databases. Yield was defined as subsequent rates of coronary angiography and revascularization after CST. Post PCI, 14,195 (48.1%) patients underwent CST between 60 days and 2 years, while post CABG, 4,469 (44.0%) patients underwent CST. Compared with patients not undergoing CST, patients undergoing CST were more likely to be of younger age, reside in an urban area, have higher neighborhood median household income, but less medical comorbidities. Among PCI patients undergoing CST, 5.2% underwent subsequent coronary angiography, and 2.6% underwent repeat revascularization within 60 days of CST. Rates of coronary angiography and repeat revascularization post-CST among CABG patients were 3.6% and 1.1%, respectively. Approximately one-half of patients undergo CST within 2 years of PCI or CABG in Alberta, Canada. Yield of CST is low, with only 1 out of 38 tested post-PCI patients and 1 out of 91 tested post-CABG patients undergoing further revascularization. In conclusion, additional research is required to determine patients most likely to benefit from CST after revascularization.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:9-14
Dhoot A, Liu S, Savu A, Cheema ZM, ... Kaul P, Bagai A
Am J Cardiol: 30 Nov 2020; 136:9-14 | PMID: 32946857
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Abstract

Comparisons of Edoxaban Versus Warfarin on Levels of Plasma Prothrombin Fragment in Patients With Nonvalvular Atrial Fibrillation.

Tamura A, Yamamoto E, Kawano Y

The effect of edoxaban on plasma prothrombin fragment 1+2 (PTF1+2), a sensitive maker of in vivo thrombin generation, has not been fully investigated in nonvalvular atrial fibrillation (NVAF). We compared plasma PTF1+2 levels between 25 NVAF patients receiving warfarin and 100 NVAF patients receiving edoxaban and additionally analyzed the association between plasma PTF1+2 levels and the dose of edoxaban. Plasma PTF1+2 levels were significantly higher in patients receiving edoxaban than in those receiving warfarin (141.5 ± 50.0 pmol/l vs 93.1 ± 55.7 pmol/l, p < 0.001). The prevalence of plasma PF1+2 levels above the upper limit (229 pmol/l) of the normal range did not differ between the 2 groups (4% vs 4%), whereas the prevalence of plasma PTF1+2 levels below the lower limit (69 pmol/l) of the normal range was significantly lower in patients receiving edoxaban than in those receiving warfarin (1% vs 48%, p < 0.001). Multiple linear regression analysis identified age and warfarin treatment as independent variables associated with the plasma PTF1+2 level. In a subgroup analysis, plasma PTF1+2 levels were significantly higher in 58 receiving edoxaban of 30 mg/day than in 42 receiving edoxaban of 60 mg/day (157.6 ± 50.8 pmol/l vs 121.6 ± 39.8 pmol/l, p = 0.01); however, after adjusting for confounding factors, the dose of edoxaban was not independently associated with the plasma PTF1+2 level. In conclusion, edoxaban sufficiently inhibits thrombin generation unrelated to its dose in NVAF, although its inhibitory effect is weaker compared with warfarin.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:71-75
Tamura A, Yamamoto E, Kawano Y
Am J Cardiol: 30 Nov 2020; 136:71-75 | PMID: 32946856
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Abstract

Relation of Timing of Percutaneous Coronary Intervention on Outcomes in Patients With Non-ST Segment Elevation Myocardial Infarction.

Batchelor RJ, Dinh D, Brennan A, Wong N, ... Stub D,

International guidelines suggest revascularization within 24 hours in non-ST segment elevation myocardial infarction (NSTEMI). Within a large population cohort study, we aimed to explore clinical practice regarding timing targets for percutaneous coronary intervention (PCI) in NSTEMI. The Victorian Cardiac Outcomes Registry was established in 2013 as a state-wide clinical quality registry, pooling data from public and private PCI capable centers. Data were collected on 11,852 PCIs performed for NSTEMI from 2014 to 2018. Patients were divided into 3 groups by time of symptom onset to PCI (<24 hours; 24 to 72 hours; >72 hours). We performed multivariable logistic regression analysis conditional on several baseline covariates in investigating the impact of timing of PCI in NSTEMI on clinical outcomes. Patients who underwent PCI within 24 hours represented 18.4% (n = 2,178); 24 to 72 hours 45.8% (n = 5,434); >72 hours 35.8% (n = 4,240). Patients waiting longer for PCI were older (62.6 ± 12.2 vs 64.8 ± 12.6 vs 67.0 ± 12.7, p <0.001), more likely to be female (23.1% vs 24.2% vs 26.4%, p = 0.007), and have diabetes (18.6% vs 21.1% vs 27.1%, p <0.001). Multivariate logistic regression found that as compared with PCI <24 hours, PCI 24 to 72 hours and PCI >72 hours of symptom onset were associated with a decreased risk of 30-day mortality (odds ratio 0.55; 95% confidence interval 0.35 to 0.86, p = 0.008 and odds ratio 0.64; 95% confidence interval 0.35 to 1.01, p = 0.053, respectively). There was no significant difference in 30-day mortality between groups following exclusion of patients presenting with cardiogenic shock or out of hospital cardiac arrest requiring intubation. In conclusion, many registry patients undergo PCI outside the 24-hour window following NSTEMI. This delay is at odds with current guideline recommendations but does not appear to be associated with an increased mortality risk.

Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:15-23
Batchelor RJ, Dinh D, Brennan A, Wong N, ... Stub D,
Am J Cardiol: 30 Nov 2020; 136:15-23 | PMID: 32946855
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Abstract

Predictors and Mechanisms of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy.

Raphael CE, Liew AC, Mitchell F, Kanaganayagam GS, ... Pennell DJ, Prasad SK

Atrial fibrillation (AF) in hypertrophic cardiomyopathy (HC) is associated with significant symptomatic deterioration, heart failure, and thromboembolic disease. There is a need for better mechanistic insight and improved identification of at risk patients. We used cardiovascular magnetic resonance (CMR) to assess predictors of AF in HC, in particular the role of myocardial fibrosis. Consecutive patients with HC referred for CMR 2003 to 2013 were prospectively enrolled. CMR parameters including left ventricular volumes, presence and percentage of late gadolinium enhancement in the left ventricle (%LGE) and left atrial volume index (LAVi) were measured. Overall, 377 patients were recruited (age 62 ± 14 years, 73% men). Sixty-two patients (16%) developed new-onset AF during a median follow up of 4.5 (interquartile range 2.9 to 6.0) years. Multivariable analysis revealed %LGE (hazard ratio [HR] 1.3 per 10% (confidence interval: 1.0 to 1.5; p = 0.02), LAVi (HR 1.4 per 10 mL/m[1.2 to 1.5; p < 0.001]), age at HC diagnosis, nonsustained ventricular tachycardia and diabetes to be independent predictors of AF. We constructed a simple risk prediction score for future AF based on the multivariable model with a Harrell\'s C-statistic of 0.73. In conclusion, the extent of ventricular fibrosis and LA volume independently predicted AF in patients with HC. This finding suggests a mechanistic relation between fibrosis and future AF in HC. CMR with quantification of fibrosis has incremental value over LV and LA measurements in risk stratification for AF. A risk prediction score may be used to identify patients at high risk of future AF who may benefit from more intensive rhythm monitoring and a lower threshold for oral anticoagulation.

Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:140-148
Raphael CE, Liew AC, Mitchell F, Kanaganayagam GS, ... Pennell DJ, Prasad SK
Am J Cardiol: 30 Nov 2020; 136:140-148 | PMID: 32950468
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Comparison of the Usefulness of Strain Imaging by Echocardiography Versus Computed Tomography to Detect Right Ventricular Systolic Dysfunction in Patients With Significant Secondary Tricuspid Regurgitation.

Hirasawa K, van Rosendael PJ, Dietz MF, Ajmone Marsan N, Delgado V, Bax JJ

Assessment of right ventricular (RV) systolic function in patients with significant secondary tricuspid regurgitation (STR) remains challenging. In patients with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI), STR and RV enlargement have been associated with poor outcomes. In these patients, speckle tracking echocardiography (STE) may detect RV systolic dysfunction better than 3-dimensional (3D) RV ejection fraction (EF). The purpose of this study was to investigate the prevalence of RV dysfunction when assessed with STE in patients with significant STR (≥3+) compared with patients without significant STR (<3+) matched for 3D RV dimensions and RVEF on dynamic computed tomography (CT). Patients with dynamic CT data before TAVI were evaluated retrospectively. To assess the performance of RV-free wall strain (RVFWS) for identifying patients with impaired RV systolic function, patients were subsequently matched 1:1 based on age, gender, indexed RV end-diastolic volume (RVEDVi), indexed RV end-systolic volume (RVESVi), RVEF, and left ventricular ejection fraction (LVEF). In a total 267 patients (80 ± 8 years, 48% male), significant STR (≥3+) was observed in 67 patients. Patients with STR≥3+ had larger RVEDVi, larger RVESVi, lower LVEF, and more impaired RVFWS compared with patients with STR<3+ (n = 200). After propensity score matching, patients with STR≥3+ (n = 53) had significantly more impaired RVFWS compared with patients with STR<3+ (n = 53): -18.2 ± 5.0% versus -21.1 ± 3.7%, p = 0.001. In conclusion, patients with significant STR have more pronounced RV systolic dysfunction as assessed with STE than the patients without significant STR despite having similar 3D RV dimensions and RVEF on dynamic CT.

Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:116-122
Hirasawa K, van Rosendael PJ, Dietz MF, Ajmone Marsan N, Delgado V, Bax JJ
Am J Cardiol: 31 Oct 2020; 134:116-122 | PMID: 32891401
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Abstract

Utility of Cardiac Magnetic Resonance Imaging Versus Cardiac Positron Emission Tomography for Risk Stratification for Ventricular Arrhythmias in Patients With Cardiac Sarcoidosis.

Gowani Z, Habibi M, Okada DR, Smith J, ... Tandri H, Chrispin J

Abnormalities on cardiac magnetic resonance imaging (CMR) and positron emission tomography (PET) predict ventricular arrhythmias (VA) in patients with cardiac sarcoidosis (CS). Little is known whether concurrent abnormalities on CMR and PET increases the risk of developing VA. Our aim was to compare the additive utility of CMR and PET in predicting VA in patients with CS. We included all patients treated at our institution from 2000 to 2018 who (1) had probable or definite CS and (2) had undergone both CMR and PET. The primary endpoint was VA at follow up, which was defined as sustained ventricular tachycardia, sudden cardiac death, or any appropriate device tachytherapy. Fifty patients were included, 88% of whom had a left ventricular ejection fraction >35%. During a mean follow-up 4.1 years, 7/50 (14%) patients had VA. The negative predictive value of LGE for VA was 100% and the negative predictive value of FDG for VA was 79%. Among groups, VA occurred in 4/21 (19%) subjects in the LGE+/FDG+ group, 3/14 (21%) in the LGE+/FDG- group, and 0/15 (0%) in the FDG+/LGE- group. There were no LGE-/FDG- patients. In conclusion, CMR may be the preferred initial clinical risk stratification tool in patients with CS. FDG uptake without LGE on initial imaging may not add additional prognostic information regarding VA risk.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 31 Oct 2020; 134:123-129
Gowani Z, Habibi M, Okada DR, Smith J, ... Tandri H, Chrispin J
Am J Cardiol: 31 Oct 2020; 134:123-129 | PMID: 32950203
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Meta-analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients with ST Elevation Myocardial Infarction.

Jhand A, Atti V, Gwon Y, Dhawan R, ... Bhatt D, Velagapudi P

Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared to TFA in STEMI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov and recent major scientific conference sessions from inception to October 15, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infraction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N=12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (RR: 0.71, 95%CI: 0.57 - 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 - 0.77) and vascular complications (RR: 0.42, 95%CI: 0.32 - 0.56) compared with TFA. There was no difference in the incidence of MI, stroke, or procedure duration between the two groups. The difference in all-cause mortality between TRA and TFA was statistically non-significant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 17 Nov 2020; epub ahead of print
Jhand A, Atti V, Gwon Y, Dhawan R, ... Bhatt D, Velagapudi P
Am J Cardiol: 17 Nov 2020; epub ahead of print | PMID: 33220324
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Long Term Outcomes of Patients treated with Transcatheter Aortic Valve Implantation.

Pravda NS, Codner P, Assa HV, Witberg G, ... Sagie A, Kornowski R

Transcatheter aortic-valve implantation (TAVI) is an established treatment option in patients with severe symptomatic aortic stenosis. Intermediate and long-term follow up data of these patients is limited. Data was taken from a large all-comer single centre prospective registry (2008-2019). The primary end point was all-cause mortality. The secondary endpoints were long-term valve hemodynamic performance; paravalvular leak (PVL) at 5-year follow-up. We also report on temporal trends in this cohort. Our cohort included 998 patients with a mean age of 82.3 ± 7.2 years and 52.2% females. TAVI was performed via the transfemoral, trans-apical, subclavian and other access routes in 93.9%, 3.6%, 2.5% and 0.6% of patients, respectively. A self-expandable device was used in 69.4% of cases, balloon expandable device in 28.1% and in 2.5% other devices. The cumulative risk for all-cause mortality at 5 years was 43.4% (95% CI 39.1- 47.7). The immediate and long-term valve gradients were low and maintained. On durability analysis at 5 years, severe structural valve deterioration (SVD) was present in 1.6% of cases. At 5-year follow-up, PVL was moderate in 3.3% and no patients has severe PVL. On temporal trends analysis, we found that the procedural aspects of TAVI improved over time with lower rates of significant PVL and significantly lower procedural mortality. In conclusion, TAVI patients have a favourable long-term outcome, with excellent valve hemodynamic parameters and good clinical outcomes. Over time and with increasing experience, procedural and patient outcomes have improved.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 16 Nov 2020; epub ahead of print
Pravda NS, Codner P, Assa HV, Witberg G, ... Sagie A, Kornowski R
Am J Cardiol: 16 Nov 2020; epub ahead of print | PMID: 33217350
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Abstract

Anatomic and Flow Characteristics of Left Anterior Descending Coronary Artery Angiographic Stenoses Predisposing to Myocardial Infarction.

Katritsis DG, Pantos I, Zografos T, Spahillari A, ... Kastrati A, Cutlip D

The impact of the anatomic characteristics of coronary stenoses on the development of future coronary thrombosis has been controversial. This study aimed at identifying the anatomic and flow characteristics of left anterior descending (LAD) coronary artery stenoses that predispose to myocardial infarction, by examining angiograms obtained before the index event. We identified 90 patients with anterior ST-elevation myocardial infarction (STEMI) for whom coronary angiograms and their reconstruction in the three-dimensional (3D) space were available at 6 to 12 months before the STEMI, and at the revascularization procedure. The majority of culprit lesions responsible for STEMI occurred between 20 and 40 mm from the LAD ostium, whereas the majority of stable lesions not associated with STEMI were found in distances >60 mm (p<0.001). Culprit lesions were significantly more stenosed (diameter stenosis 68.6±14.2% vs 44.0±10.4%, p<0.001), and significantly longer than stable ones (15.3±5.4 mm vs 9.2±2.5 mm, p<0.001). Bifurcations at culprit lesions were significantly more frequent (88.8%) compared to stable lesions (34.4%, p<0.001). Computational fluid dynamics simulations demonstrated that hemodynamic conditions in the vicinity of culprit lesions promote coronary thrombosis due to flow recirculation. A multiple logistic regression model with diameter stenosis, lesion length, distance from the LAD ostium, distance from bifurcation, and lesion symmetry, showed excellent accuracy in predicting the development of a culprit lesion [AUC: 0.993 (95% CI: 0.969-1.000), p<0.0001]. In conclusion, specific anatomic and hemodynamic characteristics of LAD stenoses identified on coronary angiograms may assist risk stratification of patients by predicting sites of future myocardial infarction.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 17 Nov 2020; epub ahead of print
Katritsis DG, Pantos I, Zografos T, Spahillari A, ... Kastrati A, Cutlip D
Am J Cardiol: 17 Nov 2020; epub ahead of print | PMID: 33220322
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Abstract

The Impact of Baseline Thrombocytopenia on Late Bleeding and Mortality After Transcatheter Aortic Valve Implantation (from the Japanese Multicenter OCEAN-TAVI Registry).

Ito S, Taniguchi T, Shirai S, Ando K, ... Yashima F, Hayashida K

Baseline thrombocytopenia was reported as a risk factor for bleeding or mortality in several medical areas, particularly in the cardiovascular field. This study aimed to assess the prognostic value of baseline thrombocytopenia in patients who had transcatheter aortic valve implantation (TAVI). This study included 2,588 patients from the Optimized CathEter vAlvular iNtervention (OCEAN) Japanese multicenter registry. Thrombocytopenia was defined as platelet count of <150 × 10/L and was classified into moderate/severe (<100 × 10/L) and mild (≧100-<150 × 10/L). At 3 years after index procedure, the moderate/severe thrombocytopenia group had a significantly higher cumulative composite late bleeding than the no thrombocytopenia group (log-rank test, p < 0.0001). Moreover, the moderate/severe thrombocytopenia group had a significantly higher cumulative all-cause, cardiovascular, and non-cardiovascular mortality rates than the no thrombocytopenia group (log-rank test, p < 0.0001, p = 0.0014, p < 0.0001, respectively). After adjusting for confounders, the excess risk of moderate/severe and mild thrombocytopenia relative to no thrombocytopenia for the composite bleeding remained significant (hazard ratio 2.66: [95% confidence interval: 1.35-4.88], P = 0.006 and hazard ratio 2.10: [95% confidence interval: 1.36-3.21], P = 0.001, respectively). In conclusion, baseline thrombocytopenia was associated with an increased risk of late bleeding and poor prognosis. Baseline platelet level could be a prognostic marker for risk stratification.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 17 Nov 2020; epub ahead of print
Ito S, Taniguchi T, Shirai S, Ando K, ... Yashima F, Hayashida K
Am J Cardiol: 17 Nov 2020; epub ahead of print | PMID: 33220320
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Abstract

Continuous Thermodilution Method to Assess Coronary Flow Reserve.

Gutiérrez-Barrios A, Izaga-Torralba E, Crespo FR, Gheorghe L, ... Vázquez-García R, Alfonso F

Coronary flow reserve (CFR) is a well-validated flow-based physiological parameter that has shown value in clinical risk stratification. CFR can be invasively assessed, classically by Doppler and, more recently, by thermodilution with saline boluses (CFR). Alternatively, continuous thermodilution is a novel operator-independent, highly-reproducible technique to invasively quantify maximum absolute coronary flow (AF). This study aimed to assess the feasibility of this method to quantify resting AF and to determine CFR (CFR as compared with CFR. Sixty-two consecutive patients with suspicion of coronary disease and absence of significant epicardial lesions were prospectively investigated. AF at maximal hyperemia (20mL/min) and at lower infusion rates (6-8-10-12 mL/min) were systematically measured using a dedicated catheter and a temperature/pressure guidewire. The absence of baseline Pd/Pa decrease at 6 (0.15±0.2%), 8 (0.17±0.18%) and 10mL/min (0.2±0.12%) demonstrated absence of hyperemia at ≤10mL/min (all p=NS). However, at 12mL/min hyperemia was confirmed by a significant decrease in Pd/Pa (1.3±1.5%,p<0.01) and increase in AF from 10mL/min to 12mL/min (31.4±28.1mL,p<0.05). All curve tracings at 10mL/min (129/129, 100%) were adequate vs only (7/15, 53%) and (15/18, 17%) at 6ml/min and 8mL/min, respectively, and this infusion-rate was considered to determine resting-AF. CFR was determined as the ratio of hyperemic-AF (20mL/min) by resting-AF (10mL/min). Mean CFR was 2.56±0.9 and CFR 2.49±1. Both parameters showed a good correlation (r=0.76;p< 0.001) and intra-class agreement (ICC=0.76;p< 0.001).The continuous thermodilution method enables to quantify resting-AF providing a novel clinical tool to determine CRF. CFR shows a good correlation with CFR.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 17 Nov 2020; epub ahead of print
Gutiérrez-Barrios A, Izaga-Torralba E, Crespo FR, Gheorghe L, ... Vázquez-García R, Alfonso F
Am J Cardiol: 17 Nov 2020; epub ahead of print | PMID: 33220317
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Abstract

Prognostic Impact of Heart Failure History in Patients with Secondary Mitral Regurgitation Treated by MitraClip.

Adamo M, Gavazzoni M, Castiello A, Estevez-Loureiro R, ... Maisano F, Metra M

The aim of this study was to investigate the prognostic role of heart failure (HF) history in patients with secondary mitral regurgitation (SMR) underwent MitraClip. We retrospectively analyzed 186 patients with SMR undergoing MitraClip at 4 centres. HF history was defined as number or days of HF hospitalizations in the 12-month before MitraClip, or as time from last HF hospitalization to MitraClip, or time between first SMR diagnosis and MitraClip. More severe symptoms were observed in patients with >1 HF hospitalization compared with those with ≤1 HF hospitalizations, in those with ≥10 days versus <10 days of HF hospitalization and in those with shortest time from the last HF hospitalization. No significant differences were observed for procedural data in the population stratified according to the different definitions. In variables related with HF history, only the number of HF hospitalizations before MitraClip was associated with an increased risk of clinical events (hazard ratio 1.59; 95% confidence interval [1.09 to 2.12]; p = 0.015), whereas days of previous HF hospitalization, time from last HF hospitalization and from first diagnosis of SMR do not impact on prognosis. A significant decrease in the number and days of HF hospitalizations was observed in the 12-month after MitraClip compared with the 12-month before. In conclusion, in variables related with HF history, recurrence (>1) of HF hospitalizations before MitraClip was the most powerful predictor of prognosis. Latency of intervention did not affect outcomes.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:120-127
Adamo M, Gavazzoni M, Castiello A, Estevez-Loureiro R, ... Maisano F, Metra M
Am J Cardiol: 14 Nov 2020; 135:120-127 | PMID: 32861737
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Abstract

Meta-analysis Evaluating the Utility of Colchicine in Secondary Prevention of Coronary Artery Disease.

Xia M, Yang X, Qian C

Colchicine has shown potential therapeutic benefits in cardiovascular conditions owing to its broad anti-inflammatory properties. Here, we performed a meta-analysis to determine the efficacy and safety of colchicine in patients with coronary artery disease (CAD). A systematical search in electronic databases of PubMed, The Cochrane Library and Scopus were carried out to identify eligible studies. Only randomized controlled trials (RCTs) evaluating the cardiovascular effects of colchicine in CAD patients were included. Study-level data of cardiovascular outcomes or adverse events were pooled using random-effect models. We finally included 5 RCTs with follow-up duration ≥6 months, comprising a total of 11,790 patients with CAD. Compared with placebo or no treatment, colchicine administration was associated with a significantly lower incidence of major adverse cardiovascular events (relative risk [RR] 0.65, 95% confidence interval [CI] 0.52-0.82). Such a benefit was not modified by the clinical phenotype of CAD (P for interaction = 0.34). Colchicine treatment also decreased the risk of myocardial infarction (RR 0.73, 95% CI 0.55-0.98), coronary revascularization (RR 0.61, 95% CI 0.42-0.89) and stroke (RR 0.47, 95% CI 0.28-0.81) in CAD patients, but with no impact on cardiovascular mortality. In addition, the rates of common adverse events were generally similar between colchicine and control groups, including noncardiovascular deaths (RR 1.50, 95% CI 0.93-2.40) and gastrointestinal symptoms (RR 1.05, 95% CI 0.91-1.22). In conclusion, the results of our meta-analysis demonstrated that colchicine treatment may reduce the risk of future cardiovascular events in CAD patients.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 29 Oct 2020; epub ahead of print
Xia M, Yang X, Qian C
Am J Cardiol: 29 Oct 2020; epub ahead of print | PMID: 33137319
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Abstract

Optimal Medical Therapy Following Transcatheter Aortic Valve Implantation.

Kaewkes D, Ochiai T, Flint N, Patel V, ... Cheng W, Makkar R

Limited data exist on optimal medical therapy post-transcatheter aortic valve implantation (TAVI) for late cardiovascular events prevention. We aimed to evaluate the benefits of beta-blocker (BB), renin-angiotensin system inhibitor (RASi), and their combination on outcomes following successful TAVI. In a consecutive cohort of 1684 patients with severe aortic stenosis undergoing TAVI, the status of BB and RASi treatment at discharge was collected, and patients were classified into 4 groups: no-treatment, BB alone, RASi alone, and combination groups. The primary outcome was a composite of all-cause mortality and rehospitalization for heart failure (HHF) at 2-year. There were 415 (25%), 462 (27%), 349 (21%), and 458 (27%) patients in no-treatment, BB alone, RASi alone, and combination groups, respectively. The primary outcome was lower in RASi alone (21%; adjusted hazard ratio (HR): 0.58; 95% confidence interval (CI): 0.42-0.81) and combination (22%; HR: 0.53; 95% CI: 0.39-0.72) groups than in no-treatment group (34%) but no significant difference between RASi alone and combination groups (HR: 1.14; 95% CI: 0.80-1.62). The primary outcome results were maintained in a sensitivity analysis of patients with reduced left ventricular systolic function. Furthermore, RASi treatment was an independent predictor of 2-year all-cause mortality (HR: 0.68; 95% CI: 0.51-0.90), while that was not observed in BB therapy (HR: 0.94; 95% CI: 0.71-1.25). In conclusion, post-TAVI treatment with RASi, but not with BB, was associated with lower all-cause mortality and HHF at 2-year. The combination of RASi and BB did not add an incremental reduction in the primary outcome over RASi alone.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 18 Nov 2020; epub ahead of print
Kaewkes D, Ochiai T, Flint N, Patel V, ... Cheng W, Makkar R
Am J Cardiol: 18 Nov 2020; epub ahead of print | PMID: 33221263
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Abstract

Frequency and Impact of Hyponatremia on All-Cause Mortality in Patients with Aortic Stenosis.

Ramberg E, Greve AM, Berg RMG, Sajadieh A, ... Wachtell K, Nielsen OW

Asymptomatic aortic stenosis (AS) is a frequent condition that may cause hyponatremia due to neurohumoral activation. We examined if hyponatremia heralds poor prognosis in patients with asymptomatic AS, and whether AS in itself is associated with increased risk of hyponatremia. The study question was investigated in 1,677 individuals that had and annual plasma sodium measurements in the SEAS (Simvastatin and Ezetimibe in Aortic Stenosis) trial; 1,873 asymptomatic patients with mild-moderate AS (maximal transaortic velocity 2.5-4.0 m/s) randomized to simvastatin/ezetimibe combination vs. placebo. All-cause mortality was the primary endpoint and incident hyponatremia (P-Na <137 mmol/L) a secondary outcome. At baseline, 4% (n=67) had hyponatremia. After a median follow-up of 4.3 (IQR 4.1-4.6) years, 140 (9%) of those with initial normonatremia had developed hyponatremia, and 174 (10%) had died. In multiple regression Cox models, both baseline hyponatremia (HR 2.1, [95% confidence interval 1.1-3.8]) and incident hyponatremia (HR 1.9, [95% confidence interval 1.0-3.4], both p≤.03) was associated with higher all-cause mortality as compared to normonatremia. This association persisted after adjustment for diuretics as a time-varying covariate. Higher N-terminal pro b-type natriuretic peptide levels and lower sodium levels at baseline was associated with higher risk of incident hyponatremia. Conversely, assignment to simvastatin/ezetimibe protected against incident hyponatremia. In conclusion, both prevalent and incident hyponatremia associate with increased mortality in patients with AS. The prevalence of hyponatremia is around 4% and the incidence about 2% per year, which is comparable to that of older adults without AS.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 18 Nov 2020; epub ahead of print
Ramberg E, Greve AM, Berg RMG, Sajadieh A, ... Wachtell K, Nielsen OW
Am J Cardiol: 18 Nov 2020; epub ahead of print | PMID: 33221262
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Abstract

Comparative Assessments of Left and Right Ventricular Function by Two-Dimensional, Contrast Enhanced and Three-Dimensional Echocardiography with Gated Heart Pool Scans in Patients Following Myocardial Infarction.

Selvakumar D, Brown P, Geenty P, Barnett R, ... Altman M, Thomas L

Multiple noninvasive imaging modalities are available to measure biventricular function, although limited studies have assessed agreement between modalities in assessing left and right ventricular ejection fraction (LVEF & RVEF) in the same cohort of patients. In this study we prospectively compared the agreement of 2-dimensional echocardiography (2DE), contrast enhanced 2DE, 3-dimensional echocardiography (3DE), and gated heart pool scan (GHPS) measures of LVEF and RVEF in patients with acute ST-elevation myocardial infarction. We recruited 95 consecutive ST-elevation myocardial infarction patients (mean age 61.4 ± 12.0, male: 79.5%) admitted to a major tertiary hospital between July 2016 and May 2018. Despite minimal inter- and intra-observer variability (coefficient of variance < 5% in both categories), substantial discrepancies exist between modalities with Pearson\'s correlation coefficients ranging from 0.64 to 0.91 for LVEF measurements, and 0.27 to 0.86 for RVEF measurements. Bland-Altman plots demonstrated no systematic bias between modalities. GHPS and 3DE offered the closest agreement for both LVEF and RVEF, demonstrating the greatest correlation coefficient (r = 0.91 and 0.86 respectively), lowest mean absolute differences (4% and 3% respectively), and narrowest Bland-Altman limits of agreement (19% and 18% respectively). Greater than 10% of 2DE and contrast enhanced 2DE scans discordantly showed LVEF values >40% for patients whose LVEF was measured as ≤ 40% by 3DE or GHPS. In conclusion, substantial variation exists between modalities when assessing LVEF and RVEF, although we demonstrate that 3DE and GHPS have the closest agreement. This variability should be considered in clinical management of patients, and modalities should not be used interchangeably in sequential patient follow-up.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:14-23
Selvakumar D, Brown P, Geenty P, Barnett R, ... Altman M, Thomas L
Am J Cardiol: 31 Oct 2020; 134:14-23 | PMID: 32917345
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Abstract

Relation between Thyroid Function and Mortality in patients with Chronic Heart Failure.

Samuel NA, Cuthbert JJ, Brown OI, Kazmi S, ... Rigby AS, Clark AL

Thyroid dysfunction is common in patients with chronic heart failure (CHF), but there is conflicting evidence regarding its prognostic significance. We investigated the relation between thyroid function and prognosis in a large, well characterised cohort of ambulatory patients with CHF. Heart failure was defined as signs and symptoms of the disease and either left ventricular systolic dysfunction (LVSD) mild or worse (heart failure with reduced ejection fraction (HFrEF)), or no LVSD and raised amino-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (>125 ng/L) (heart failure with normal ejection fraction (HFnEF)). Euthyroid state was defined as a thyroid-stimulating hormone (TSH) level between 0.35-4.70 mIU/l, hypothyroidism as TSH >4.70 mIU/L, and hyperthyroidism as TSH <0.35 mIU/L. 2997 patients had HFrEF and 1995 patients had HFnEF. 4491 (90%) patients were euthyroid, 312 (6%) were hypothyroid, and 189 (4%) were hyperthyroid. In univariable analysis, both hypothyroid patients (hazard ratio (HR) 1.25, 95% confidence interval (CI) 1.08 to 1.45) and hyperthyroid patients (HR 1.21, 95% CI 1.01 to 1.46) had a greater risk of death compared to euthyroid patients. There was a U-shaped relation between TSH and outcome. Increasing TSH was a predictor of mortality in univariable analysis (HR 1.02, 95% CI 1.01 to 1.03), but the association disappeared in multivariable analysis. The three strongest predictors of adverse outcome were increasing age, increasing NT-proBNP, and higher NYHA class. In conclusion, although thyroid dysfunction is associated with worse survival in patients with CHF, it is not an independent predictor of mortality.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 24 Oct 2020; epub ahead of print
Samuel NA, Cuthbert JJ, Brown OI, Kazmi S, ... Rigby AS, Clark AL
Am J Cardiol: 24 Oct 2020; epub ahead of print | PMID: 33115640
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Abstract

Relation of Aspartate Aminotransferase to Alanine Aminotransferase Ratio to Nutritional Status and Prognosis in Patients with Acute Heart Failure.

Maeda D, Sakane K, Kanzaki Y, Okuno T, ... Sohmiya K, Hoshiga M

Elevated liver fibrosis markers are associated with worse prognosis in acute heart failure (AHF). The aspartate aminotransferase to alanine aminotransferase ratio (AAR) is one such fibrosis marker, and low ALT is a surrogate marker of malnutrition. Here, we evaluated the association between AAR and nutritional status and prognosis in patients with AHF. Consecutive 774 patients who were admitted due to AHF were divided into 3 groups according to AAR at discharge: first tertile, AAR<1.16 (n=262); second tertile, 1.16≤AAR<1.70 (n=257); and third tertile, AAR≥1.70 (n=255). Nutritional indices and a composite of all-cause death or HF rehospitalization were compared among the 3 tertiles. Patients in the third AAR tertile were older and had lower body mass index than patients in other AAR tertiles. A higher AAR was associated with worse nutritional indices (i.e., controlling nutritional status score, geriatric nutritional risk index and prognostic nutritional index). Clinical outcome rates significantly increased along AAR tertiles (first tertile, 28%; second tertile, 43%; third tertile, 58%, P<0.001). Cox proportional hazards models including potential prognostic factors revealed high AAR was an independent prognostic factor of AHF. In conclusion, AAR at discharge may be associated with nutritional status and worse clinical outcomes in patients with AHF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 24 Oct 2020; epub ahead of print
Maeda D, Sakane K, Kanzaki Y, Okuno T, ... Sohmiya K, Hoshiga M
Am J Cardiol: 24 Oct 2020; epub ahead of print | PMID: 33115639
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Abstract

Meta-analysis Comparing Outcomes of Percutaneous Coronary Intervention of Native Artery versus Bypass Graft in Patients with Prior Coronary Artery Bypass Grafting.

Farag M, Gue YX, Brilakis ES, Egred M

Percutaneous coronary intervention (PCI) is common in patients with prior coronary artery bypass graft surgery (CABG), however the data on the association between the PCI target-vessel and clinical outcomes are not clear. We aimed to investigate long-term clinical outcomes of patients with prior CABG who underwent PCI of either bypass graft or native artery. We performed a systematic review and meta-analysis of observational studies comparing PCI of either bypass graft or native artery in patients with prior CABG. Twenty-two studies comprising 40,984 patients were included. The median follow-up duration was 2 (1-3) years. Compared with bypass graft PCI, native artery PCI was frequent (61% vs. 39%) and was associated with lower major adverse cardiac events (MACE) (OR 0.51, 95%CI 0.45-0.57, P<0.001), lower all-cause death (OR 0.65, 95%CI 0.49-0.87, P=0.004), lower myocardial infarction (OR 0.56, 95%CI 0.45-0.69, P<0.001), and lower target vessel revascularization (TVR) (OR 0.62, 95%CI 0.51-0.76, P<0.001). There was no significant difference in the early incidence of major bleeding or stroke between the 2 cohorts. In 6 studies involving 2,919 patients with ST-elevation myocardial infarction, there was no significant differences between the 2 cohorts. The increase in TVR risk with bypass graft PCI was associated with MACE. In conclusion, in observational studies involving patients with prior CABG, native artery PCI was associated with lower MACE, all-cause death, myocardial infarction, and TVR compared with bypass graft PCI at a median follow-up of 2 years. Native artery PCI might be considered the preferred treatment for bypass graft failure.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Farag M, Gue YX, Brilakis ES, Egred M
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144169
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Abstract

Discharge Location and Outcomes after Transcatheter Aortic Valve Implantation.

Sweda R, Dobner S, Heg D, Lanz J, ... Windecker S, Stortecky S

The relationship between discharge location and outcomes after transcatheter aortic valve implantation (TAVI) is largely unknown. Thus, the objective of this study was to investigate the impact of discharge location on clinical outcomes after TAVI. Between August 2007 and December 2018, consecutive patients undergoing transfemoral TAVI at Bern University Hospital were grouped according to discharge location. Clinical adverse events were adjudicated according to VARC-2 endpoint definitions. Of 1,902 eligible patients, 520 (27.3%) were discharged home, 945 (49.7%) were discharged to a rehabilitation clinic and 437 (23.0%) were transferred to another institution. Compared with patients discharged to a rehabilitation facility or another institution, patients discharged home were younger (80.8±6.5 vs. 82.9±5.4 and 82.8±6.4 years), less likely female (37.3% vs. 59.7% and 54.2%) and at lower risk according to STS-PROM (4.5±3.0% vs. 5.5±3.8% and 6.6±4.4%). At 1 year follow-up, patients discharged home had similar rates of all-cause mortality (HR 0.82; 95%CI 0.54-1.24), cerebrovascular events (HR 1.04; 95%CI 0.52-2.08) and bleeding complications (HR 0.93; 95%CI 0.61-1.41) compared to patients discharged to a rehabilitation facility. Patients discharged home or to rehabilitation were at lower risk for death (HR 0.37; 95%CI 0.24-0.56 and HR 0.44; 95%CI 0.32-0.60) and bleeding (HR 0.48; 95%CI 0.30-0.76 and HR 0.66; 95%CI 0.45-0.96) during the first year after hospital discharge compared to patients transferred to another institution. In conclusion, discharge location is associated with outcomes after TAVI with patients discharged home or to a rehabilitation facility having better clinical outcomes than patients transferred to another institution. Clinical Trial registration: https://www.clinicaltrials.gov. NCT01368250.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Sweda R, Dobner S, Heg D, Lanz J, ... Windecker S, Stortecky S
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144166
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Abstract

Outcomes of Percutaneous Coronary Intervention in Patients with Rheumatoid Arthritis.

Dawson LP, Dinh D, O\'Brien J, Duffy SJ, ... Ajani AE,

RA is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without rheumatoid arthritis (RA). The Melbourne Interventional Group PCI registry (2005-2018) was used to identify 756 patients with RA. Outcomes were compared to the remaining cohort (N=38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnoea, chronic lung disease, myocardial infarction, and renal impairment, while rates of dyslipidaemia and current smoking were lower, all p<0.05. Lesions in patients with RA were more frequently complex (ACC/AHA type B2/C), requiring longer stents, with higher rates of no reflow, all p<0.05. Risk of long-term mortality, adjusted for potential confounders, was higher for patients with RA (Hazard Ratio 1.53, 95%CI 1.30-1.80; median follow-up 5.0 years), while 30-day outcomes including mortality, major adverse cardiovascular events, bleeding, stroke, myocardial infarction, coronary artery bypass surgery and target vessel revascularisation were similar. In subgroup analysis, patients with RA and lower BMI (P<0.001) and/or acute coronary syndromes (P=0.05) had disproportionately higher risk of long-term mortality compared to patients without RA. In conclusion, patients with RA undergoing PCI had more comorbidities and longer, complex coronary lesions. Risk of short-term adverse outcomes were similar, while risk of long-term mortality was higher, especially among patients with acute coronary syndromes and lower BMI.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Dawson LP, Dinh D, O'Brien J, Duffy SJ, ... Ajani AE,
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144158
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Abstract

Relation of Adiponectin to Cardiovascular Events and Mortality in Patients with Acute Coronary Syndrome.

Nomura H, Arashi H, Yamaguchi J, Ogawa H, Hagiwara N

The association between serum adiponectin levels and cardiovascular events, particularly how adiponectin predicts the development of cardiovascular events and mortality in acute coronary syndrome (ACS) patients remains unresolved. Hence, we aimed to determine whether higher adiponectin levels predict cardiovascular events and mortality in these patients. Regression analyses were performed to clarify adiponectin\'s ability to predict cardiovascular events and mortality among 1641 ACS patients. Subgroup analyses were performed according to sex, age, and body mass index (BMI). The primary endpoint was a composite of the first all-cause death, non-fatal myocardial infarction, or non-fatal stroke event. The secondary endpoint was all-cause death. Hazard ratios (HRs) for the primary and secondary endpoints per 5-µg/ml increase in adiponectin levels were 1.31 [95% confidence interval (CI), 1.13-1.47; p=0.0007] and 1.32 [95% CI, 1.13-1.51; p=0.001], respectively. Higher adiponectin levels were associated with increased cardiovascular events in men, patients aged ≥65 years, and those with BMI <25 kg/m. In conclusion, higher adiponectin levels were associated with increased cardiovascular events and all-cause mortality in ACS patients. Its predictive ability might be limited in women, patients aged <65 years, and patients with BMI ≥25 kg/m.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Nomura H, Arashi H, Yamaguchi J, Ogawa H, Hagiwara N
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144157
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Abstract

Usefulness of Thoracic Aortic Calcium to Predict 1-Year Mortality after Transcatheter Aortic Valve Implantation.

Hamandi M, Amiens P, Grayburn PA, Al-Azizi K, ... Harbaoui B, Lantelme P

In patients undergoing transcatheter aortic valve implantation (TAVI), vascular disease is associated with increased risk of mortality. Thoracic aortic calcification (TAC), an objective surrogate of vascular disease, could be a predictor of mortality after TAVI. We aimed to analyze the association between TAC burden and 1-year all-cause mortality in patients undergoing TAVI in a US population. From July 2015 through July 2017, a retrospective review of TAVI procedures was performed at Baylor Scott & White-The Heart Hospital, Plano, Texas. Patients were analyzed for comorbidities, cardiac risk factors, and 30-day and 1-year all-cause mortality. Restricted cubic splines (RCS) analysis was used to define low, moderate, and high TAC categories. The association between TAC and survival was evaluated using unadjusted and adjusted Cox models. A total of 431 TAVI procedures were performed, of which TAC was measured in 374 (81%) patients. Median [IQR] age was 82 [77, 87] years, and 51% were male. Median [IQR] STS PROM was 5.6 [4.1, 8.2] %. Overall 30-day and 1-year all-cause mortality was 1% and 10%, respectively. TAC was categorized as low (<1.6 cm3), moderate (1.6 - 2.9 cm3), and high (>2.9 cm3). At 1 year, all-cause mortality was 16% in patients with high TAC compared to 6% in the low and moderate TAC categories (p = 0.008). Unadjusted and adjusted Cox regression analysis showed a significant increase in mortality for patients with high TAC compared with low TAC (HR 2.98, 95% CI [1.34-6.63]), but not significant compared with moderate TAC group. TAC is a predictor of late mortality after TAVI. In conclusion, adding TAC to pre-operative evaluation may provide an objective, reproducible, and potentially widely available tool that can help in shared-decision making.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Hamandi M, Amiens P, Grayburn PA, Al-Azizi K, ... Harbaoui B, Lantelme P
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144156
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Abstract

Meta-Analysis of Safety and Efficacy of Direct Oral Anticoagulants Versus Warfarin According to Time in Therapeutic Range in Atrial Fibrillation.

Lee JJ, Ha ACT, Dorian P, Verma M, Goodman SG, Friedrich JO

Among atrial fibrillation (AF) patients, it is unclear whether the efficacy and safety of direct oral anticoagulants (DOAC) relative to warfarin is consistent across various levels of international normalized ratio (INR) control. To determine the efficacy and safety of DOAC agents compared to warfarin for patients with various levels of anticoagulation control as reflected by their time in therapeutic range (TTR), we conducted a systematic review and meta-analysis of published randomized controlled trials of DOAC versus (vs.) warfarin which reported outcomes stratified by TTR. Based on reported center-based TTR (cTTR) ranges, degrees of INR control were categorized into 3 cTTR strata: low (<60%), intermediate (60-66%), and high (>66%). Pooled hazard ratios (HR) and 95% confidence intervals (CI) were determined for stroke or systemic embolism (SSE), major bleeding, and intracranial hemorrhage (ICH). Across all cTTR strata, DOAC-treated patients had lower risk of SSE vs. warfarin, with a HR of 0.73 (95% CI 0.61-0.88) for the low, 0.76 (95% CI 0.59-0.98) intermediate; and 0.78 (95% CI 0.63-0.96) high cTTR subgroups. Compared to warfarin, DOAC-treated patients had lower risk of major bleeding in the low and intermediate cTTR strata, and similar risk in the highest cTTR stratum (HR 1.00, 95% CI 0.80-1.26). Patients treated with DOAC had lower risk of ICH compared to warfarin (HR 0.55, 95% CI; 0.40-0.74) which was observed across all cTTR strata. In conclusion, regardless of the degree of INR control, DOAC agents are preferable over warfarin as stroke prevention therapy for patients with AF.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 11 Nov 2020; epub ahead of print
Lee JJ, Ha ACT, Dorian P, Verma M, Goodman SG, Friedrich JO
Am J Cardiol: 11 Nov 2020; epub ahead of print | PMID: 33189659
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Abstract

Novel Score to Predict Very Late Recurrences after Catheter Ablation of Atrial Fibrillation.

Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J

Various predictors of atrial fibrillation (AF) recurrence have been shown based on the baseline characteristics before catheter ablation (CA). This study aimed to develop a novel scoring system for predicting very late recurrences of AF (VLRAFs) after an initial CA, taking the post-procedural clinical data into account and reassessing VLRAFs in 12-month patients\' condition using previously known pre-procedural predictors of AF recurrences. We retrospectively studied 327 patients who underwent an initial CA with freedom from AF for over 12 months. We elucidated the predictors of VLRAFs and created a new score to predict VLRAFs in the discovery AF cohort (n=181). Thereafter, we investigated whether the new scoring system could accurately predict VLRAFs in the validation AF cohort (n=146). In the discovery AF cohort, VLRAFs were observed in fifty-three patients (29%) during the follow-up period (mean follow-up duration: 55 months). The univariate and multivariate Cox proportional-hazards model demonstrated that non-pulmonary vein (PV) foci, early recurrences of AF (ERAFs), atrial premature contraction (APC) burden ≥ 142/24hours, and minimum prematurity index of the APCs ≤ 48% were associated with VLRAFs after CA. We created a new scoring system to predict VLRAFs, the n-PReDCt score (non-PV: 1 point, ERAFs (Recurrences of AF in early phase after CA): 1 point, APC burDen ≥ 142/24hours: 1 point, and minimum prematurity index (=Coupling interval) of the APCs of ≤ 48%: 1 point). The n-PReDCt score was significantly associated with VLRAFs by a Kaplan-Meier analysis in the discovery AF and validation AF cohorts (p<0.0001 and p<0.0001, respectively).

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 16 Nov 2020; epub ahead of print
Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J
Am J Cardiol: 16 Nov 2020; epub ahead of print | PMID: 33217347
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Abstract

Effect of Diabetes Mellitus and Left Ventricular Perfusion on Frequency of Development of Heart Failure and/or All-cause Mortality Late After Acute Myocardial Infarction.

Tomasik A, Nabrdalik K, Kwiendacz H, Radzik E, ... Nowalany-Kozielska E, Lip GYH

Type 2 diabetes mellitus (DM) has a detrimental impact on cardiovascular outcomes, with implications for prognosis following ST elevation myocardial infarction (STEMI).The aim was to evaluate the impact of DM and myocardial perfusion on the long-term risk of heart failure (HF) and/or all-cause mortality following primary percutaneous coronary intervention (pPCI) for STEMI. A total of 406 STEMI patients (104 with DM) treated with pPCI were enrolled in this observational study. Myocardial perfusion was reassessed with the Quantitative Myocardial Blush Evaluator (QuBE). Follow-up data on HF (ICD10 (International Statistical Classification of Diseases) codes I50.0 - I50.9) and all-cause mortality were obtained from the National Health Fund. During a 6-year follow-up, 36 (35%) patients with DM died compared to 45 (15%) patients without DM (P<0.001). Also, 24 (23%) patients with DM developed HF compared to 51 (17%) patients without DM (P=0.20). Patients with DM and HF had the highest mortality rate (75%), and those with DM and a QuBE score below the median value (9.0 arb. units) had significantly higher risk of HF (hazard ratio HR=1.96, 95% CI 1.18-3.27, P=0.0099) and the composite of HF and/or all-cause mortality (HR=1.89, 95% CI 1.33-2.69, P=0.0004). In conclusion DM (type 2) and diminished myocardial perfusion increase the risk of HF and/or all-cause mortality during a 6-year follow-up following pPCI for STEMI.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Tomasik A, Nabrdalik K, Kwiendacz H, Radzik E, ... Nowalany-Kozielska E, Lip GYH
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144164
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Abstract

Relation of Neighborhood Disadvantage to Heart Failure Symptoms and Hospitalizations.

Shirey TE, Hu Y, Ko YA, Nayak A, ... Patel S, Morris AA

Residence in socioeconomically deprived neighborhoods may influence patient\'s health-related behaviors and overall health. We evaluated the association of neighborhood disadvantage on heart failure (HF) symptom burden and hospitalization rates. We characterized neighborhood deprivation in 359 HF subjects (age 56 ± 13 years, 52% black) in metropolitan Atlanta using the Area Deprivation Index (ADI). ANOVA was used to compare HF symptoms measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ), and HF Self-Care Index across ADI tertiles. Zero-inflated Poisson regression was used to compare rates of recurrent HF hospitalization (HFH) across ADI tertiles. Subjects living in more deprived neighborhoods were more likely to be black, have Medicare or Medicaid insurance, and have a lower ejection fraction than those living in less deprived neighborhoods (all P≤ 0.005). Subjects in more deprived neighborhoods had more severe HF symptoms (P< 0.001), but there was no difference in HF Self-Care Index scores across ADI tertiles. Subjects living in more deprived neighborhoods had a higher odds of being hospitalized for HF than subjects in less deprived neighborhoods. Once subjects had experienced a HFH, however, the association between ADI and the risk of recurrent HFH varied by racial group. Among whites, increasing ADI was associated with a marginally decreased risk of recurrent HFH, while there was no association between ADI and recurrent HFH among blacks. In conclusion, individuals with HF living in more deprived neighborhoods have greater symptom burden and are more likely to experience a HFH than those living in less deprived neighborhoods.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Oct 2020; epub ahead of print
Shirey TE, Hu Y, Ko YA, Nayak A, ... Patel S, Morris AA
Am J Cardiol: 30 Oct 2020; epub ahead of print | PMID: 33144159
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Abstract

Relation of Low Normal Left Ventricular Ejection Fraction to Heart Failure Hospitalization in Blacks (From the Jackson Heart Study).

Kamimura D, Valle KA, Blackshear C, Mentz RJ, ... Butler J, Hall ME

There is no clear consensus on a lower cutoff value for normal left ventricular ejection fraction (EF) and the prognostic implications of low normal EF (LNEF) are poorly understood, particularly in Blacks. Therefore, we investigated the association of LNEF and incident heart failure (HF) in a community-based cohort of Blacks. We studied 3,669 participants (mean age 54 years, 63% women) of the Jackson Heart Study without prevalent HF or coronary heart disease (CHD). Participants were divided into three groups: (1) Reduced EF (<50%), (2) LNEF (≥50%, <55%), and (3) Normal EF (≥55%). There were 197 cases of incident HF hospitalizations over a median follow-up of 10 years (interquartile range 9.4 to 10). After adjustment for conventional risk factors and incident CHD, the LNEF group had a higher rate of incident HF hospitalization than the Normal EF group (HR 1.58, 95% CI 1.04 to 2.38, p<0.05). Furthermore, this relation remained statistically significant after additionally adjusting for LV mass index but was not significant after adjusting for LV diastolic dysfunction grade. In participants with LNEF with incident HF, 63% developed HF with reduced EF and 37% developed HF with preserved EF. In conclusion, LNEF is associated with higher risk of incident HF hospitalization in comparison with normal EF in a community-based cohort of Blacks. In those with LNEF who went on to develop HF, most cases were HF with reduced EF. These findings suggest that strategies are needed for risk stratification and management to improve outcomes in patients with LNEF.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Nov 2020; 136:100-106
Kamimura D, Valle KA, Blackshear C, Mentz RJ, ... Butler J, Hall ME
Am J Cardiol: 30 Nov 2020; 136:100-106 | PMID: 32910930
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Abstract

Optimal Dose and Type of β-blockers in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention.

Park J, Han JK, Kang J, Chae IH, ... Koo BK, Kim HS

The clinical benefit of β-blockers in modern reperfusion era is not well determined. We investigated the impact of β-blockers in acute coronary syndrome (ACS) after percutaneous coronary intervention. From the Grand-DES registry, a patient-level pooled registry consisting of 5 Korean multicenter prospective drug-eluting stent registries, a total of 6,690 ACS patients were included. Prescription records of dose and type of β-blockers were investigated trimonthly from discharge. Patients were categorized by the mean value of doses during the follow-up (≥50% [high-dose], ≥25% to <50% [medium-dose], and <25% [low-dose] of the full dose that was used in each randomized clinical trial) and vasodilating property of β-blockers. Three-year cumulative risk of all-cause death, cardiac death, and myocardial infarction were assessed. Patients receiving β-blockers were associated with a lower risk of all-cause and cardiac death compared with those not receiving β-blockers (adjusted hazard ratio [aHR] 0.29, 95% confidence interval [CI] 0.24 to 0.35 for all-cause death; aHR 0.27, 95% CI 0.21 to 0.34 for cardiac death). Medium-dose β-blocker group was associated with a lower risk of cardiac death compared with high- and low-dose β-blocker groups (aHR 0.49, 95% CI 0.25 to 0.96, for high-dose; aHR 0.46, 95% CI 0.29 to 0.74, for low-dose). Patients receiving vasodilating β-blockers were associated with a lower risk of cardiac death compared with those receiving conventional β-blockers (aHR 0.58, 95% CI 0.40 to 0.84). In conclusion, β-blocker therapy was associated with better clinical outcomes in patients with ACS, especially with medium-dose and vasodilating β-blockers.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Dec 2020; 137:12-19
Park J, Han JK, Kang J, Chae IH, ... Koo BK, Kim HS
Am J Cardiol: 14 Dec 2020; 137:12-19 | PMID: 32998005
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Abstract

Incidence, Characteristics, and Outcomes of Emergent Isolated Coronary Artery Bypass Grafting.

Elsisy MF, Stulak JM, Alkhouli M

Data on emergency coronary artery bypass surgery (CABG) are limited. We studied patients who underwent isolated CABG at Mayo Clinic between 1993 and 2019. Baseline characteristics and in-hospital outcomes of emergent CABG were described in consecutive eras (1993 to 2000, 2001 to 2010, and 2011 to 2019). Cumulative survival was estimated by the Kaplan Meier method for the overall group, and stratified by the indication of surgery. In the 14,455 isolated CABG included, 427 (2.95%) were emergent. The number of emergent CABG decreased from 222 to 150 and 55 in the consecutive study eras. There was a temporal increase in the prevalence of heart failure, but no change in mean age, and prevalence of hypertension, diabetes, renal failure, or atrial fibrillation. The proportion of patients with failed/complicated percutaneous coronary intervention decreased from 38.2% in 1993 to 2000 to 22.7% in 2001 to 2010 and 25.5% in 2011 to 2019 (p = 0.003). In 2011 to 2019, 100% of patient received an internal mammary graft compared with 75.6% in 1993 to 2000 (p < 0.001). Operative mortality was 8.7% overall (8.6% in 1993 to 2000, 10.0% in 2001 to 2010, and 5.5% in 2011 to 2019, p = 0.56). There were no differences in postoperative complications except for the incidence of renal failure and new dialysis which increased over time. Predicted 10-year survival was 57.0% and was not different according to CABG indication (p = 0.12). In conclusion, we documented a temporal decrease in the incidence of emergent CABG between 1993 and 2019, especially those performed due to complications of coronary interventions. Despite the higher prevalence of left ventricular dysfunction and the more complete revascularization in more recent years, in-hospital mortality did not increase.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 14 Dec 2020; 137:20-24
Elsisy MF, Stulak JM, Alkhouli M
Am J Cardiol: 14 Dec 2020; 137:20-24 | PMID: 32998004
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Abstract

Long-Term Outcomes Stratified by Body Mass Index in Patients Undergoing Transcatheter Aortic Valve Implantation.

Quine EJ, Dagan M, William J, Nanayakkara S, ... Stub D, Walton AS

Transcatheter aortic valve implantation (TAVI) is emerging as the default strategy for older patients with severe, symptomatic, and trileaflet aortic stenosis. Increased body-mass index (BMI) is associated with a protective effect in patients undergoing percutaneous coronary intervention. We assessed whether elevated BMI was associated with a similar association in TAVI. We evaluated prospectively collected data from 634 patients who underwent TAVI at 2 centers from August 2008 to April 2019. Patients were stratified as normal weight (BMI 18.5 to 24.9 kg/m, n = 214), overweight (25 to 29.9 kg/m, n = 234), and obese (>30 kg/m, n = 185). Outcomes were reported according to VARC-2 criteria. Mortality was assessed using Cox proportional hazards regression analysis (median follow-up 2 years). Kaplan-Meier analysis was used to estimate cumulative mortality. Baseline differences were seen in age (85 vs 84 vs 82, p <0.001), STS-PROM score (4.3 vs 3.4 vs 3.6, p <0.001), sex (50% vs 36% vs 55% female, p <0.001), clinical frailty score (p = 0.02), diabetes (21% vs 29% vs 40%, p <0.001), and presence of chronic obstructive pulmonary disease (COPD) (13% vs 13% vs 23%, p = 0.009). On multivariable analysis there was no mortality difference between normal and obese patients (hazard ratio [HR] 0.70, confidence interval [CI] 0.46 to 1.1 p = 0.11), however overweight patients had significantly lower mortality (HR 0.56 CI 0.38 to 0.85, p = 0.006). Variables independently associated with increased mortality were increasing age, male sex, COPD, previous balloon valvuloplasty, and higher STS-PROM. In conclusion, overweight patients have lower long-term mortality when compared with normal weight and obese patients undergoing TAVI.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Dec 2020; 137:77-82
Quine EJ, Dagan M, William J, Nanayakkara S, ... Stub D, Walton AS
Am J Cardiol: 14 Dec 2020; 137:77-82 | PMID: 33017578
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Abstract

Prognostic Value of Baseline Sarcopenia on 1-year Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation.

Yoon YH, Ko Y, Kim KW, Kang DY, ... Park DW, Park SJ

There is limited data regarding the association between sarcopenia and clinical outcomes in patients who underwent transcatheter aortic valve implantation (TAVI). From the prospective ASAN-TAVI registry, we evaluated a total of 522 patients with severe aortic stenosis who underwent TAVI between March 2010 and November 2018. Routine pre-TAVI computed tomography scan was used to calculate the skeletal muscle index (SMI), which was defined as skeletal muscle area at the L3 level divided by height squared; subject patients were classified into the gender-specific tertile groups of SMI. The patients\' mean age was 79 years and 49% were men. Mean SMI values were 41.3 ± 6.7 cm/m in men and 34.1 ± 6.5 cm/m in women. The Kaplan-Meier estimates of all-cause mortality at 12 months were higher in the low-tertile group than in the mid- and high-tertile groups (15.5%, 7.1%, and 6.2%, respectively; p = 0.036). In multivariate analysis, low-tertile of SMI was an independent predictor of mortality (vs high-tertile of SMI, hazard ratio 2.69; 95% confidence interval, 1.18 to 6.12; p = 0.019). The all-cause mortality was substantially higher in the groups with high-surgical risk plus low SMI tertile. The risk assessment with addition of SMI on conventional STS-PROM score was significantly improved by statistical measures of model reclassification and discrimination. In patients who underwent TAVI, sarcopenia measured by SMI was significantly associated with an increased risk of 1-year mortality. The prognostic impact of SMI-measured sarcopenia was more prominent in patients with high surgical risks.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 23 Oct 2020; epub ahead of print
Yoon YH, Ko Y, Kim KW, Kang DY, ... Park DW, Park SJ
Am J Cardiol: 23 Oct 2020; epub ahead of print | PMID: 33164764
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Abstract

Evaluation of a Low-Dose Radiation During Transcatheter Aortic Valve Implantation.

Michel JM, Hashorva D, Kretschmer A, Alvarez-Covarrubias HA, ... Joner M, Kasel AM

We aimed to evaluate the efficacy and safety of a low-dose imaging protocol to reduce intraprocedural radiation during transcatheter aortic valve implantation (TAVI). Observational analysis: 802 transfemoral TAVI patients receiving balloon-expandable devices ≥23 mm at a high-volume centre. After propensity score matching, a standard-dose group (SD, n = 333) treated between January 2014 and February 2016 was compared with a low-dose group (LD, n = 333) treated between August 2017 and March 2019 after departmental uptake of a low-dose imaging protocol (reduced field size, high table height, use of \"fluoro save,\" 3.75 frames/second acquisition, increased filtering). Primary end point was dose-area product (DAP). Secondary safety end points were VARC-2 device success and a composite of in-hospital complications. The LD protocol was associated with lower DAP (4.64 [2.93, 8.42] vs 22.73 [12.31, 34.58] Gy⋅cm, p <0.001) and fluoroscopy time (10.4 [8.1, 13.9] vs 11.5 [9.1, 15.3] minutes, p = 0.001). Contrast use was higher in the LD group (LD 110 [94, 130] vs SD 100 [80, 135] milliliters, p = 0.042). Device success (LD 88.3% vs SD 91.3%, p = 0.25), and the composite end point (LD 8.1% vs SD 11.4%, p = 0.19) were similar. In multivariate analysis, the low-dose protocol was associated with a 19.8 Gy⋅cm reduction in procedural DAP (p <0.001). In conclusion, compared with standard imaging, a low-dose protocol for TAVI significantly reduced radiation dose without compromising outcomes.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 23 Oct 2020; epub ahead of print
Michel JM, Hashorva D, Kretschmer A, Alvarez-Covarrubias HA, ... Joner M, Kasel AM
Am J Cardiol: 23 Oct 2020; epub ahead of print | PMID: 33190811
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Abstract

Meta-analysis Comparing Early Outcomes Following Transcatheter Aortic Valve Implantation With the Evolut Versus Sapien 3 Valves.

Alperi A, Faroux L, Muntané-Carol G, Rodés-Cabau J

We aimed to compare the early (in-hospital/30-day) outcomes (major periprocedural complications, device success/valve performance, and mortality) following transcatheter aortic valve implantation with the Sapien 3 versus Evolut transcatheter valve systems. This was a systematic review from PubMed and EMBASE databases for studies reporting raw data or estimates. The outcomes analyzed were (1) in-hospital/30-day major periprocedural complications, (2) device success and valve performance, and (3) mortality. The outcomes were defined according to VARC-2 criteria. A total of 24,628 transcatheter aortic valve implantation patients from 9 studies (1 randomized, 8 observational [5 case- or propensity-matched analyses]) were included: 12,411 and 12,217 patients had Sapien 3 and Evolut valve implantation, respectively. There were no differences between devices regarding in-hospital/30-day stroke (risk ratio [RR] 0.95, 95% confidence interval [CI] 0.34 to 2.66), major vascular complications (RR 1.03, 95% CI 0.63 to 1.68), acute kidney injury (RR 1.17, 95% CI 0.78 to 1.77), device success (RR 1.00, 95% CI 0.97 to 1.04) and moderate-severe residual aortic regurgitation (RR 0.49, 95% CI 0.20 to 1.17). Sapien 3 recipients exhibited lower risk of permanent pacemaker implantation (RR 0.66, 95% CI 0.55 to 0.80), a higher risk of life-threatening bleeding (RR 1.82, 95% CI 1.18 to 2.80), and higher residual transvalvular gradients (mean difference 3.95 mmHg, 95% CI 3.37 to 4.56). A lower risk of in-hospital/30-day mortality was observed for Sapien 3 (RR 0.79, 95% CI 0.69 to 0.90). In conclusion, the similarities in device success rate and major periprocedural complications (except for a higher and lower risk of permanent pacemaker implantation and life-threatening bleeding, respectively, with the Evolut system) support the lack of a valve type effect accounting for the increased mortality risk observed with the Evolut valve.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 23 Oct 2020; epub ahead of print
Alperi A, Faroux L, Muntané-Carol G, Rodés-Cabau J
Am J Cardiol: 23 Oct 2020; epub ahead of print | PMID: 33190806
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Abstract

Trends and Impact of the Use of Mechanical Circulatory Support for Cardiogenic Shock Secondary to Takotsubo Cardiomyopathy.

Napierkowski S, Banerjee U, Anderson HV, Charitakis K, ... Smalling RW, Dhoble A

Data on the trend and impact of mechanical circulatory support (MCS) in patients with Takotsubo cardiomyopathy (TC) are scarce. We evaluated the incidence and outcomes of cardiogenic shock (CS) in TC patients and the trend in use of MCS over time. The National Inpatient Sample from 2005 to 2014 was used to identify patients admitted with TC and those receiving MCS. Multivariate logistic regression was performed to identify predictors of mortality. The Cochran-Armitage test was used for the trend analysis across the years. Admissions for TC showed a linear increase for the study period. From 2005 to 2014 the proportion of TC managed with MCS remained stable, with some yearly fluctuations. Crude in-hospital mortality rate was 2.5% in the patients admitted with TC but was significantly higher in those with CS (15.81% vs 1.68%, p < 0.001). There was no difference in mortality in TC patients with CS, both with and without the use of MCS. However, patients managed with MCS were more likely to be discharged to a skilled nursing facility (31% vs 25.55, p = 0.015) compared with TC patients with CS who were medically managed. The cost of care for patients with TC and CS, managed with MCS was significantly higher than those managed medically ($171K vs $128K, p <0.001). In patients managed with MCS, only sepsis was associated with a higher likelihood of death using multivariate analysis (Odds Ratio 2.538, Confidence Interval 1.245 to 5.172; p = 0.011). In conclusion, the incidence of TC has increased over the years, but the proportion of patients requiring MCS has declined. Crude mortality rate for TC was 2.5%, but was 15.8% in the TC patients with CS. The use of MCS did not lead to improved mortality but was associated with higher cost and increased likelihood of skilled nursing facility discharge.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 05 Oct 2020; epub ahead of print
Napierkowski S, Banerjee U, Anderson HV, Charitakis K, ... Smalling RW, Dhoble A
Am J Cardiol: 05 Oct 2020; epub ahead of print | PMID: 33035466
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Abstract

Cardiovascular Risk Among Patients ≥65 Years of Age with Parkinson\'s Disease (From the National Inpatient Sample).

Abugroun A, Taha A, Abdel-Rahman M, Patel P, Ali I, Klein LW

In this study, we aimed to investigate the relationship between Parkinson\'s disease (PD) and vascular disease and risk factors using a nationally representative sample. The National Inpatient Sample was queried for all patients aged ≥65 who were diagnosed with PD during the year 2016. Patients were identified using the International Classification of Diseases-Tenth Revision (ICD-10) diagnosis code: \"G20.\" Each patient diagnosed with PD was frequency-matched to controls at a 1:4 ratio by age and gender. Study outcomes were hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, and stroke. Outcomes were modeled using logistic regression analysis and further validation was obtained using a propensity score-matched analysis. A total of 57,914 patients (weighted: 289,570) with PD were included. Most patients were of Caucasian race (80.8%). Females were 42.4% and the mean age was 79 years, standard error of the mean (0.03). PD correlated with lower odds for hyperlipidemia adjusted odd ratio (a-OR): 0.77 (95% confidence interval [CI]: 0.75 to 0.79) p <0.001, diabetes mellitus a-OR 0.73 (95% CI 0.71 to 0.75) p <0.001, hypertension a-OR 0.68 (95% CI: 0.67 to 0.70) p <0.001, coronary artery disease a-OR 0.64 (95% CI: 0.63 to 0.66) p <0.001 and higher odds for stroke a-OR: 1.27 (95% CI: 1.24 to 1.31) p <0.001. Following propensity score matching, identical findings were found. In conclusion, patients with PD have a distinct cardiovascular profile with higher rates of stroke and lower rates of coronary artery disease and vascular disease risk factors.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:56-61
Abugroun A, Taha A, Abdel-Rahman M, Patel P, Ali I, Klein LW
Am J Cardiol: 30 Nov 2020; 136:56-61 | PMID: 32941821
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Abstract

Relation of High-sensitivity Cardiac Troponin I Elevation With Exercise to Major Adverse Cardiovascular Events in Patients With Coronary Artery Disease.

Lima BB, Hammadah M, Kim JH, Uphoff I, ... Vaccarino V, Quyyumi AA

High sensitive cardiac troponin I (hs-cTnI) increases with inducible myocardial ischemia in patients with coronary artery disease (CAD). We aimed to assess if the change in hs-cTnI levels with exercise stress testing is associated with major adverse cardiac events (MACE). A cohort of 365 (age 62 ± 9 years, 77% men) patients with stable CAD underwent 99mTc sestamibi myocardial perfusion imaging with treadmill testing. Plasma hs-cTnI level was measured at rest and at 45 min after stress. Multivariable Fine & Gray\'s subdistribution hazards models were used to determine the association between the change in hs-cTnI and MACE, a composite end point of cardiovascular death, myocardial infarction, and unstable angina requiring revascularization. During a median follow-up of 3 years, 39 (11%) patients experienced MACE. After adjustment, for each two-fold increment in hs-cTnI with stress, there was a 2.2 (95% confidence interval 1.3-3.6)-fold increase in the hazard for MACE. Presence of both a high resting hs-cTnI level (>median) and ≥ 20% stress-induced hs-cTnI elevation was associated with the highest incidence of MACE (subdistribution hazards models 4.6, 95% confidence interval 1.6 to 13.0) compared with low levels of both. Risk discrimination statistics significantly improved after addition of resting and change in hs-cTnI levels to a model including traditional risk factors and inducible ischemia (0.67 to 0.71). Conversely, adding inducible ischemia by SPECT did not significantly improve the C-statistic from a model including traditional risk factors, baseline and change in hs-cTnI (0.70 to 0.71). In stable CAD patients, higher resting levels and elevation of hs-cTnI with exercise are predictors of adverse cardiovascular outcomes beyond traditional cardiovascular risk factors and presence of inducible ischemia.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:1-8
Lima BB, Hammadah M, Kim JH, Uphoff I, ... Vaccarino V, Quyyumi AA
Am J Cardiol: 30 Nov 2020; 136:1-8 | PMID: 32941818
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Abstract

Relation of Absence of Coronary Artery Calcium to Cardiovascular Disease Mortality Risk Among Individuals Meeting Criteria for Statin Therapy According to the 2018/2019 ACC/AHA Guidelines.

Rajan T, Rozanski A, Cainzos-Achirica M, Grandhi GR, ... Berman D, Nasir K

The 2013 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines resulted in broad recommendations for preventive statin therapy allocation in patients without known cardiovascular disease (CVD). Subsequent studies demonstrated significant heterogeneity of atherosclerotic cardiovascular disease risk across the primary prevention population. In 2018/2019, the guidelines were revised to optimize risk assessment and cholesterol management. We sought to evaluate the heterogeneity of risk in statin-recommended patients, using coronary artery calcium (CAC) according to 2018/2019 ACC/AHA guidelines in a primary prevention cohort. We evaluated 5,800 statin-naive patients aged 40 to 75 years without known coronary heart disease from the Cedars-Sinai Medical Center study cohort. All participants underwent clinical CAC scoring for risk stratification and were followed for all-cause and CVD-specific mortality. A total of 181 deaths occurred including 54 CVD deaths over a follow-up of 9.5 years. Overall, 1,939 participants would have been recommended statin therapy, 32% of whom had no detectable CAC. CAC = 0 participants had the lowest all-cause and CVD mortality rates in both statin-recommended and nonrecommended groups (0.2 and 0.4 CVD deaths per 1,000 person-years, respectively). Absence of CAC in statin-naive patients portends an approximately 12-fold lower CVD mortality (0.2% vs 2.4%) in those recommended for statin therapy compared with any CAC present. In conclusion, in a cohort of patients meeting the 2018/2019 ACC/AHA guidelines for statin therapy for primary prevention, there was a marked heterogeneity of CAC scores, with about one-third of the statin recommended population having no detectable CAC (CAC = 0) with a significantly lower CVD mortality compared with CAC>0.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:49-55
Rajan T, Rozanski A, Cainzos-Achirica M, Grandhi GR, ... Berman D, Nasir K
Am J Cardiol: 30 Nov 2020; 136:49-55 | PMID: 32941817
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Abstract

Prognostic Implications of Increased Right Ventricular Wall Tension in Secondary Tricuspid Regurgitation.

Fortuni F, Dietz MF, Butcher SC, Prihadi EA, ... Delgado V, Bax JJ

Secondary tricuspid regurgitation (TR) imposes a chronic volume overload on the right ventricle (RV) which can increase RV wall tension (RVWT). The aim of this study was to investigate the prognostic implications of increased RVWT in patients with significant secondary TR. A total of 1,142 patients with moderate-to-severe secondary TR were included. Based on the simplified Laplace-Young\'s law, RVWT was defined as the product between pulmonary artery systolic pressure (PASP) and RV base-to-apex length. The association between RVWT and risk of all-cause death was identified with spline curve analysis and patients were divided according to the cut-off of RVWT beyond which the hazard ratio (HR) and 95% confidence interval for all-cause mortality were above 1. Four hundred sixty-five (41%) patients had RVWT >3,300 mm Hg x mm and formed the group with increased RVWT. Patients with increased RVWT were more likely male, had more frequent heart failure symptoms and presented with more co-morbidities, larger RV and left ventricular (LV) dimensions, worse LV function, more severe secondary TR and higher PASP compared with patients with nonincreased RVWT. During a median follow-up of 51 (17 to 86) months, 586 (51%) patients died. The cumulative 5-year survival rate was significantly worse in patients with increased RVWT as compared with patients with nonincreased RVWT (38% vs 63% p <0.001). After correcting for potential confounders, increased RVWT retained an independent association with all-cause mortality (HR 1.555; 95% CI 1.268 to 1.907; p <0.001). In conclusion, increased RVWT is independently associated with worse prognosis and its evaluation may improve risk stratification in patients with significant secondary TR.

Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:131-139
Fortuni F, Dietz MF, Butcher SC, Prihadi EA, ... Delgado V, Bax JJ
Am J Cardiol: 30 Nov 2020; 136:131-139 | PMID: 32941816
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Abstract

Usefulness of Semisupervised Machine-Learning-Based Phenogrouping to Improve Risk Assessment for Patients Undergoing Transcatheter Aortic Valve Implantation.

Abdul Ghffar Y, Osman M, Shrestha S, Shaukat F, ... Badhwar V, Sengupta PP

Semisupervised machine-learning methods are able to learn from fewer labeled patient data. We illustrate the potential use of a semisupervised automated machine-learning (AutoML) pipeline for phenotyping patients who underwent transcatheter aortic valve implantation and identifying patient groups with similar clinical outcome. Using the Transcatheter Valve Therapy registry data, we divided 344 patients into 2 sequential cohorts (cohort 1, n = 211, cohort 2, n = 143). We investigated patient similarity analysis to identify unique phenogroups of patients in the first cohort. We subsequently applied the semisupervised AutoML to the second cohort for developing automatic phenogroup labels. The patient similarity network identified 5 patient phenogroups with substantial variations in clinical comorbidities and in-hospital and 30-day outcomes. Cumulative assessment of patients from both cohorts revealed lowest rates of procedural complications in Group 1. In comparison, Group 5 was associated with higher rates of in-hospital cardiovascular mortality (odds ratio [OR] 35, 95% confidence interval [CI] 4 to 309, p = 0.001), in-hospital all-cause mortality (OR 9, 95% CI 2 to 33, p = 0.002), 30-day cardiovascular mortality (OR 18, 95% CI 3 to 94, p <0.001), and 30-day all-cause mortality (OR 3, 95% CI 1.2 to 9, p = 0.02) . For 30-day cardiovascular mortality, using phenogroup data in conjunction with the Society of Thoracic Surgeon score improved the overall prediction of mortality versus using the Society of Thoracic Surgeon scores alone (AUC 0.96 vs AUC 0.8, p = 0.02). In conclusion, we illustrate that semisupervised AutoML platforms identifies unique patient phenogroups who have similar clinical characteristics and overall risk of adverse events post-transcatheter aortic valve implantation.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:122-130
Abdul Ghffar Y, Osman M, Shrestha S, Shaukat F, ... Badhwar V, Sengupta PP
Am J Cardiol: 30 Nov 2020; 136:122-130 | PMID: 32941814
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Abstract

Relation of Biomarkers of Cardiac Injury, Stress, and Fibrosis With Cardiac Mechanics in Patients ≥ 65 Years of Age.

Gottdiener JS, Seliger S, deFilippi C, Christenson R, ... Psaty BM, Shah SJ

High sensitivity cardiac troponin T (hscTnT), soluble ST2 (sST2), N-terminal B-type natriuretic peptide (NT-proBNP), and galectin-3 are biomarkers of cardiac injury, stress, myocardial stretch, and fibrosis. Elevated levels are associated with poor outcomes. However, their association with cardiac mechanics in older persons is unknown. Associations between these biomarkers and cardiac mechanics derived from speckle tracking echocardiography, including left ventricular longitudinal strain (LVLS), early diastolic strain, and left atrial reservoir strain (LARS) were evaluated using standardized beta coefficients () in a cross sectional analysis with cardiac biomarkers in older patients without cardiovascular disease, low ejection fraction, or wall motion abnormalities. Biomarker associations with strain were attenuated by demographics and risk factors. In adjusted models, LVLS was associated with continuous measures of hscTnT (β-0.06, p = 0.020), sST2 (β -0.05, p = 0.024) and NT-proBNP (β -0.06, p = 0.007). \"High\" levels (i.e., greater than prognostic cutpoint) of hscTnT (>13 ng/ml), sST2 (>35 ng/ml), and NT-proBNP (>190 pg/ml) were also associated with worse LVLS. In risk factor adjusted models, LARS was associated with hscTnT (β -0.08, p = 0.003) and NT-proBNP (β-0.18, p <0.0001). High hscTnT (>13 ng/ml) and high NT-proBNP (>190 pg/ml) were also both associated with worse LARS. Gal-3 was not associated with any strain measure. In conclusion, in persons ≥ 65 years of age, without cardiovascular disease, low ejection fraction, or wall motion abnormalities, hscTnT, sST2, and NT-proBNP are associated with worse LVLS. HscTnT and NT-proBNP are associated with worse LARS. In conclusion, these subclinical increases in blood biomarkers, and their associations with subtle diastolic and systolic dysfunction, may represent pre-clinical heart failure.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:156-163
Gottdiener JS, Seliger S, deFilippi C, Christenson R, ... Psaty BM, Shah SJ
Am J Cardiol: 30 Nov 2020; 136:156-163 | PMID: 32946864
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Abstract

Timing of Ablation and Prognosis of Patients With Electrical Storm and Scar-Related Left Ventricular Dysfunction.

Jiménez Candil J, Castro JC, Hernández J, Fernández-Portales J, ... González-Juanatey C, Sánchez PL

Although radiofrequency catheter ablation (RFCA) is indicated in electrical storm (ES) refractory to antiarrhythmic drugs, its most appropriate timing has not been determined. Our objective is to analyse the impact of the timing of RFCA on 30-day mortality in patients with ES and previous scar-related systolic dysfunction. In this multi-centre study, we analysed 104 patients (age: 72 ± 10, left ventricular ejection fraction: 30 ± 6%) attended consecutively due to an ES caused by monomorphic ventricular tachycardia. Sixty-four subjects were treated with RFCA (mean time from admission = 83 ± 67 hours) and 40 were not. Upon admission 25 (24%) individuals had severe heart failure. Mortality rate at 30 days was 24 (23%) patients. RFCA was associated with a reduction of 30-day mortality (hazard ratio = 0.2; p = 0.008). After showing a positive correlation between the time of the RFCA (hours) and survival at 30 days (C-statistic = 0.77; p <0.001), we found that only subjects ablated >48 hours after admission had lower mortality at 30 days than those treated conservatively: 38% (no RFCA) versus 30% (RFCA ≤48 hours) versus 7% (RFCA >48 hours) (adjusted hazard ratio for RFCA >48 hours vs others = 0.2; p = 0.007). Among the patients ablated, those who were non-inducible had lower 30-day mortality: 8% versus 29% (p = 0.03). Extracorporeal membrane oxygenation was associated with a higher rate of non-inducibility in RFCA >48 hours (100% vs 76%; p = 0.03), but not in RFCA ≤48 hours (60% vs 60%; p = 1). In conclusion, among high-risk patients with ES, RFCA performed >48 hours after admission is associated with a reduction in 30-day mortality. In such subjects, the probability of successful RFCA increases when performed under extracorporeal membrane oxygenation support.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:87-93
Jiménez Candil J, Castro JC, Hernández J, Fernández-Portales J, ... González-Juanatey C, Sánchez PL
Am J Cardiol: 30 Nov 2020; 136:87-93 | PMID: 32946863
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Abstract

Cardiovascular Outcome of Pediatric Patients With Bi-Allelic (Homozygous) Familial Hypercholesterolemia Before and After Initiation of Multimodal Lipid Lowering Therapy Including Lipoprotein Apheresis.

Taylan C, Driemeyer J, Schmitt CP, Pape L, ... Weber LT, Klaus G

Twenty-four patients with bi-allelic familial hypercholesterolemia commencing chronic lipoprotein apheresis (LA) at a mean age of 8.5 ± 3.1 years were analysed retrospectively and in part prospectively with a mean follow-up of 17.2 ± 5.6 years. Mean age at diagnosis was 6.3 ± 3.4 years. Untreated mean LDL-C concentrations were 752 mg/dl ± 193 mg/dl (19.5 mmol/l ± 5.0 mmol/l). Multimodal lipid lowering therapy including LA resulted in a mean LDL-C concentration of 184 mg/dl (4.8 mmol/l), which represents a 75.5% mean reduction. Proprotein convertase subtilisin/kexin type 9-antibodies contributed in 3 patients to LDL-C lowering with 5 patients remaining to be tested. After commencing chronic LA, 16 patients (67%) remained clinically stable with only subclinical findings of atherosclerotic cardiovascular disease (ASCVD), and neither cardiovascular events, nor need for vascular interventions or surgery. In 19 patients (79%), pathologic findings were detected at the aortic valve (AV), which in the majority were mild. AV replacement was required in 2 patients. Mean Lipoprotein(a) concentration was 42.4 mg/dl, 38% had >50 mg/dl. There was no overt correlation of AV pathologies with other ASCVD complications, or Lipoprotein(a) concentration. Physicochemical elimination of LDL particles by LA appears indispensable for patients with bi-allelic familial hypercholesterolemia and severe hypercholesterolemia to maximize the reduction of LDL-C. In conclusion, in this rare patient group regular assessment of both the AV, as well as all arteries accessible by ultrasound should be performed to adjust the intensity of multimodal lipid lowering therapy with the goal to prevent ASCVD events and aortic surgery.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:38-48
Taylan C, Driemeyer J, Schmitt CP, Pape L, ... Weber LT, Klaus G
Am J Cardiol: 30 Nov 2020; 136:38-48 | PMID: 32946862
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Abstract

Relation of Interatrial Block to Cognitive Impairment in Patients ≥ 70 Years of Age (From the CAMBIAD Case-control Study).

Herrera C, Bruña V, Abizanda P, Díez-Villanueva P, ... Martínez-Sellés M,

The association between atrial fibrillation, stroke, and interatrial block (IAB) (P-wave duration ≥120 ms) is well recognized, particularly in the case of advanced IAB. We aimed to assess the association of IAB with mild cognitive impairment. Advanced Characterization of Cognitive Impairment in Elderly with Interatrial Block was a case-control multicenter study, conducted in subjects aged ≥70 years in sinus rhythm without significant structural heart disease. Diagnosis of mild cognitive impairment was performed by an expert geriatrician, internist, or neurologist in the presence of changes in cognitive function (Mini Mental State Examination score 20 to 25) without established dementia. A total of 265 subjects were included. Mean age was 79.6 ± 6.3 years and 174 (65.7%) were women; there were 143 cases with mild cognitive impairment and 122 controls with normal cognitive function. Compared with controls, cases had longer P-wave duration (116.2 ± 13.8 ms vs 112.5 ± 13.3 ms, p = 0.028), higher prevalence of IAB (73 [51.0%] vs 38 [31.1%], p = 0.001), higher prevalence of advanced IAB (28 [19.6%] vs 10 [8.2%], p = 0.002), and higher MVP ECG risk score (2.7 ± 1.4 vs 2.2 ± 1.3, p = 0.004). IAB was independently associated with mild cognitive impairment, both for partial (odds ratio 2.0, 95% CI: 1.1 to 3.9) and advanced IAB (odds ratio 2.8, 95% CI: 1.1 to 6.7). In conclusion, in subjects aged ≥70 years without significant structural heart disease, IAB is independently associated with mild cognitive impairment. This association is stronger in the case of advanced IAB.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:94-99
Herrera C, Bruña V, Abizanda P, Díez-Villanueva P, ... Martínez-Sellés M,
Am J Cardiol: 30 Nov 2020; 136:94-99 | PMID: 32946858
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Abstract

Mortality Risk Assessment Using CHA(2)DS(2)-VASc Scores in Patients Hospitalized With Coronavirus Disease 2019 Infection.

Ruocco G, McCullough PA, Tecson KM, Mancone M, ... Fedele F, Palazzuoli A

Early risk stratification for complications and death related to Coronavirus disease 2019 (COVID-19) infection is needed. Because many patients with COVID-19 who developed acute respiratory distress syndrome have diffuse alveolar inflammatory damage associated with microvessel thrombosis, we aimed to investigate a common clinical tool, the CHA(2)DS(2)-VASc, to aid in the prognostication of outcomes for COVID-19 patients. We analyzed consecutive patients from the multicenter observational CORACLE registry, which contains data of patients hospitalized for COVID-19 infection in 4 regions of Italy, according to data-driven tertiles of CHA(2)DS(2)-VASc score. The primary outcomes were inpatient death and a composite of inpatient death or invasive ventilation. Of 1045 patients in the registry, 864 (82.7%) had data available to calculate CHA(2)DS(2)-VASc score and were included in the analysis. Of these, 167 (19.3%) died, 123 (14.2%) received invasive ventilation, and 249 (28.8%) had the composite outcome. Stratification by CHA(2)DS(2)-VASc tertiles (T1: ≤1; T2: 2 to 3; T3: ≥4) revealed increases in both death (8.1%, 24.3%, 33.3%, respectively; p <0.001) and the composite end point (18.6%, 31.9%, 43.5%, respectively; p <0.001). The odds ratios for mortality and the composite end point for T2 patients versus T1 CHA(2)DS(2)-VASc score were 3.62 (95% CI:2.29 to 5.73,p <0.001) and 2.04 (95% CI:1.42 to 2.93, p <0.001), respectively. Similarly, the odds ratios for mortality and the composite end point for T3 patients versus T1 were 5.65 (95% CI:3.54 to 9.01, p <0.001) and 3.36 (95% CI:2.30 to 4.90,p <0.001), respectively. In conclusion, among Italian patients hospitalized for COVID-19 infection, the CHA(2)DS(2)-VASc risk score for thromboembolic events enhanced the ability to achieve risk stratification for complications and death.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Ruocco G, McCullough PA, Tecson KM, Mancone M, ... Fedele F, Palazzuoli A
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 32991860
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Abstract

Impact of High-Density Lipoprotein Levels on Cardiovascular Outcomes of Patients Undergoing Percutaneous Coronary Intervention With Drug-Eluting Stents.

Roumeliotis A, Claessen B, Dangas G, Torguson R, ... Kini A, Mehran R

Low levels of high-density lipoprotein (HDL) have been associated with adverse cardiovascular events in epidemiologic studies. Evidence regarding its role in patients who underwent percutaneous coronary intervention (PCI) is scarce. We evaluated consecutive patients who underwent PCI with drug-eluting stents from 2012 to 2017, excluding those with unavailable baseline HDL, age <18 years, presentation with ST-segment elevation myocardial infarction (MI) or shock, and coexisting neoplastic disease. The final population was stratified according to baseline HDL levels into reduced and nonreduced HDL cohorts, with cut-off value 40 mg/dl in males and 50 mg/dl in females. The primary end point was 1-year major adverse cardiovascular events (MACE), defined as the composite of death, MI, or target vessel revascularization (TVR). Among 10,843 patients included, 6,511 (60%) had reduced HDL, and 4,332 (40%) nonreduced HDL. The rate of 1-year MACE was similar between the 2 groups (7.5% vs 6.6%; p = 0.14). Although mortality and MI rates were comparable, reduced HDL was associated with significantly higher TVR 5.2% vs 4.0%; p = 0.02, a finding that attenuated after multivariable adjustment (adjusted hazard ratio 1.18, p = 0.14). Sex subgroup analysis included 7,718 (71.2%) males and 3,125 (28.8%) females. Among men, there was a trend toward higher MACE in those with reduced HDL (7.4% vs 6.0%; p = 0.08) mostly driven by TVR (5.4% vs 3.7%; p = 0.005). No association between HDL and 1-year outcomes was evident in females. Assessment for interaction between sex and reduced HDL did not reach statistical significance. In conclusion, reduced baseline HDL was not associated with increased risk of MACE in a contemporary PCI population.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Roumeliotis A, Claessen B, Dangas G, Torguson R, ... Kini A, Mehran R
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 33002465
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Abstract

Effect of Earlier Atrioventricular Valve Intervention on Survival After the Fontan Operation.

Stephens EH, Dearani JA, Niaz T, Arghami A, Phillips SD, Cetta F

Whereas the prevalence and impact of atrioventricular valve (AVV) regurgitation in patients with single ventricle physiology has become increasingly apparent, the optimal timing for valve intervention is unclear. To investigate this, we performed a retrospective review of all 1,167 patients from the Mayo Clinic Fontan database. Thirteen percent (153 patients) had AVV repair or replacement during their staged single ventricle palliation. We found that patients with right ventricular morphology and common AVV were at increased risk for AVV intervention. Patients who underwent AVV intervention had increased risk of death/transplant compared with those who did not (hazards ratio [HR] = 1.75, 95% CI 1.37 to 2.23, p <0.001). With respect to valve intervention timing, whereas AVV intervention before Fontan presented similar risk for death/transplant compared with no AVV intervention (HR = 0.85, 95% CI 0.32 to 2.27, p = 0.74), intervention at time of Fontan had a significantly higher risk (HR = 1.46, 95% CI 1.09 to 1.97, p = 0.01), and intervention after Fontan had a much more substantial risk (HR = 3.83, 95% CI 2.54 to 5.79, p <0.001). AVV repair failure occurred in 11% of patients. In terms of relative risk of valve repair versus replacement, in post-Fontan AVV intervention patients, AVV replacement carried a 2.9 fold risk of death/transplant compared with AVV repair. In conclusion, AVV disease remains a considerable challenge for durable Fontan physiology. This data demonstrates that earlier intervention on valve pathology improves survival with the Fontan circulation. Continued surveillance of single ventricle patients and prompt referral of those with valve pathology can improve outcomes in this challenging population.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Stephens EH, Dearani JA, Niaz T, Arghami A, Phillips SD, Cetta F
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 32991859
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Abstract

Temporal Trends of Cardiac Outcomes and Impact on Survival in Patients With Cancer.

Hussain M, Hou Y, Watson C, Moudgil R, ... Cheng F, Collier P

To evaluate the temporal relations of cardiovascular disease in oncology patients referred to cardio-oncology and describe the impact of cardiovascular disease and cardiovascular risk factors on outcomes. All adult oncology patients referred to the cardio-oncology service at the Cleveland Clinic from January 2011 to June 2018 were included in the study. Comprehensive clinical information were collected. The impact on survival of temporal trends of cardiovascular disease in oncology patients were assessed with a Cox proportional hazards model and time-varying covariate adjustment for confounders. In total, 6,754 patients were included in the study (median age, 57 years; [interquartile range, 47 to 65 years]; 3,898 women [58%]; oncology history [60% - breast cancer, lymphoma, and leukemia]). Mortality and diagnosis of clinical cardiac disease peaked around the time of chemotherapy. 2,293 patients (34%) were diagnosed with a new cardiovascular risk factor after chemotherapy, over half of which were identified in the first year after cancer diagnosis. Patients with preexisting and post-chemotherapy cardiovascular disease had significantly worse outcomes than patients that did not develop any cardiovascular disease (p < 0.0001). The highest 1-year hazard ratios (HR) of post-chemotherapy cardiovascular disease were significantly associated with male (HR 1.81; 95% confidence interval 1.55 to 2.11; p < 0.001] and diabetes [HR 1.51; 95% confidence interval 1.26 to 1.81; p < 0.001]. In conclusion, patients referred to cardio-oncology, first diagnosis of cardiac events peaked around the time of chemotherapy. Those with preexisting or post-chemotherapy cardiovascular disease had worse survival. In addition to a high rate of cardiovascular risk factors at baseline, risk factor profile worsened over course of follow-up.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Hussain M, Hou Y, Watson C, Moudgil R, ... Cheng F, Collier P
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 32991858
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Abstract

Virtually All Complications of Active Infective Endocarditis Occurring in a Single Patient.

Roberts WC, Kapoor D, Main ML

Described herein is a 49-year-old black man with advanced polycystic renal disease, on hemodialysis for 6 years, who during his last 12 days of life had his vegetations on the aortic valve extend to the mitral and tricuspid valves, through the aortic wall to produce diffuse pericarditis, to the atrioventricular node to produce complete heart block, and embolize to cerebral arteries producing multiple brain infarcts, to a branch on the left circumflex coronary artery producing acute myocardial infarction, and to mesenteric arteries producing bowel infarction.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Roberts WC, Kapoor D, Main ML
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 32991857
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Abstract

Outcomes of Transcatheter Aortic Valve Replacement With Percutaneous Coronary Intervention versus Surgical Aortic Valve Replacement With Coronary Artery Bypass Grafting.

Abugroun A, Osman M, Awadalla S, Klein LW

We aimed to compare the outcomes of combined surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG) to concurrent transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) in a large U.S. population sample. The National Inpatient Sample was queried for all patients diagnosed with aortic valve stenosis who underwent SAVR with CABG or TAVR with PCI during the years 2016 to 2017. Study outcomes included all-cause in-hospital mortality, acute stroke, pacemaker insertion, vascular complications, major bleeding, acute kidney injury, sepsis, non-home discharge, length of stay and cost. Outcomes of hospitalization were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes. Overall, 31,205 patients were included (TAVR + PCI = 2,185, SAVR + CABG = 29,020). In reference to SAVR + CABG, recipients of TAVR + PCI were older with mean age 82 versus 73 years, effect size (d) = 0.9, had higher proportions of females 47.6% versus 26.6%, d = 0.4 and higher prevalence of congestive heart failure and chronic renal failure. On multivariable analysis, TAVR + PCI was associated with lowers odds for mortality adjusted OR: 0.32 (95% CI: 0.17 to 0.62) p = 0.001, lower odds for acute kidney injury, sepsis, non-home discharge, shorter length of stay and higher odds for vascular complications, need for pacemaker insertion and higher cost. The occurrence of stroke was similar between both groups. In conclusion, results from real-world observational data shows less rates of mortality and periprocedural complications in TAVR + PCI compared to SAVR + CABG.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Abugroun A, Osman M, Awadalla S, Klein LW
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 32991856
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Abstract

Five-Year Residual Atherosclerotic Cardiovascular Disease Risk Prediction Model for Statin Treated Patients With Known Cardiovascular Disease.

Wong ND, Zhao Y, Xiang P, Coll B, López JAG

Despite statin therapy, many patients with atherosclerotic cardiovascular disease (ASCVD) still suffer from ASCVD events. Predictors of residual ASCVD risk are not well-delineated. We aimed to develop an ASCVD risk prediction model for patients with previous ASCVD on statin use. We utilized statin-treated patients with ASCVD from the AIM-HIGH trial cohort. A 5-year risk score for subsequent ASCVD events with known ASCVD was developed using Cox regression, including potential risk factors with age, sex, and race forced in the model. Internal discrimination and calibration were evaluated. We included 3,271 patients with ASCVD (85.4% male, mean age 63.6 years, 65% on moderate- and 24% on high-intensity statin) with complete risk factor data and mean follow-up of 4.18 years. Overall, the estimated 5-year ASCVD risk was 21.1%: 10.2% of patients had a 5-year risk of >30%, and 38.8% had risk of between 20% and 30%. In the model, male sex, hemoglobin A1c, alcohol use (inversely), family history of cardiovascular disease, homocysteine, history of carotid artery disease, and lipoprotein(a) best predicted residual ASCVD risk. Niacin treatment status did not enter the model. A C-statistic of 0.59 was obtained, with the Greenwood-Nam-D\'Agostino test showing excellent calibration. We developed a risk prediction risk model for predicting 5-year residual ASCVD risk in statin-treated patients with known ASCVD that may help in identifying such persons at the highest risk of recurrent events. Validation in larger samples with patients on high-intensity statin is needed.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Wong ND, Zhao Y, Xiang P, Coll B, López JAG
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 32991855
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Abstract

Trends in Costs and Risk Factors of 30-Day Readmissions for Transcatheter Aortic Valve Implantation.

Arora S, Hendrickson MJ, Strassle PD, Qamar A, ... Bhatt DL, Vavalle JP

As transcatheter aortic valve implantation (TAVI) continues its rapid growth as a treatment approach for aortic stenosis, costs associated with TAVI, and its burden to healthcare systems will assume greater importance. Patients undergoing TAVI between January 2012 and November 2017 in the Nationwide Readmission Database were identified. Trends in cause-specific readmissions were assessed using Poisson regression. Thirty-day TAVI cost burden (cost of index TAVI hospitalization plus total 30-day readmissions cost) was adjusted to 2017 U.S. dollars and trended over year from 2012 to 2017. Overall, 47,255 TAVI were included and 30-day readmissions declined from 20% to 12% (p <0.0001). Most common causes of readmission (heart failure, infection/sepsis, gastrointestinal causes, and respiratory) declined as well, except arrhythmia/heart block which increased (1.0% to 1.4%, p <0.0001). Cost of TAVI hospitalization ($52,024 to $44,110, p <0.0001) and 30-day cost burden ($54,122 to $45,252, p <0.0001) declined. Whereas costs of an average readmission did not change ($9,734 to $10,068, p = 0.06), cost burden of readmissions (per every TAVI performed) declined ($4,061 to $1,883, p <0.0001), including reductions in each of the top 5 causes except arrhythmia/heart block ($171 to $263, p = 0.04). Index TAVI hospitalizations complicated by acute kidney injury, length of stay ≥5 days, low hospital procedural volume, and skilled nursing facility discharge were associated with increased odds of 30-day readmissions. In conclusion, the costs of index hospitalizations and 30-day cost burden for TAVI in the U.S. significantly declined from 2012 to 2017. However, readmissions due to arrhythmia/heart block and their associated costs increased. Continued strategies to prevent readmissions, especially those for conduction disturbances, are crucial in the efforts to optimize outcomes and costs with the ongoing expansion of TAVI.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Arora S, Hendrickson MJ, Strassle PD, Qamar A, ... Bhatt DL, Vavalle JP
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 32991853
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Abstract

Estimating Aspirin Overuse for Primary Prevention of Atherosclerotic Cardiovascular Disease (from a Nationwide Healthcare System).

Ong SY, Chui P, Bhargava A, Justice A, Hauser RG

The American College of Cardiology and American Heart Association recently published guidelines narrowing the indications for low-dose aspirin use. The suitability of the electronic health record (EHR) to identify patients for low-dose aspirin deprescribing is unknown. To apply the 3 low-dose aspirin guidelines to EHR data, the guidelines were deconstructed into components from their narrative text and assigned computer-interpretable definitions based on electronic data interchange standards. These definitions were used to search EHR data to identify patients for aspirin deprescribing. To verify EHR records for low-dose aspirin, we then compared the records with a survey of patients\' self-reported use of low-dose aspirin. Of the 3 aspirin guidelines, only 1 had a definition suitable for EHR implementation. The other 2 contained difficult-to-implement phrases (e.g., \"higher ASCVD risk\", \"increased bleeding risk\"). An EHR search with the single implementable guideline identified 86,555 people for possible aspirin deprescribing (2% of 5,598,604). Only 676 of 1,135 (60%) patients who self-reported taking low-dose aspirin had an active EHR record for low-dose aspirin at that time. Limitations exist when using EHR data to identify patients for possible low-dose aspirin deprescribing such as incomplete EHR capture of and the interpretation of non-specific terminology when translating guidelines into an electronic equivalent. In conclusion, data show many people unnecessarily take low-dose aspirin.

Published by Elsevier Inc.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Ong SY, Chui P, Bhargava A, Justice A, Hauser RG
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 32991852
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