Journal: Am J Cardiol

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Abstract

Degrees of Cross-Sectional-Area Luminal Narrowing of the Four Major Epicardial Coronary Arteries in Patients With Otherwise Functionally and Anatomically Normal Hearts.

Arnett EN, Roberts WC
Described herein are necropsy findings in the 4 major (left main, left anterior descending, left circumflex, and right) epicardial coronary arteries in 86 patients aged 10-70 years who never had symptoms of myocardial ischemia, and at autopsy had otherwise anatomically normal hearts. All 86 died of a non-cardiovascular condition. In each of these patients all 4 major epicardial coronary arteries were excised intact from the heart, divided into 5-mm segments, and each segment prepared for histologic examination. The degrees of cross-sectional area (CSA) narrowingwere determined from histologic examination of each 5-mm segment. The degree of narrowing in each 5 mm segment was divided into 4 categories: 0% to 25%, 26% to 50%, 51% to 75%, and 76% to 100%. Twelve patients (14%) had ≥1 artery narrowed >75% in CSA, a single artery in 9 patients, and 2 arteries in each of 3 patients. In contrast to the relative infrequency of narrowing >75%, narrowing 51-75% was common, and was present in 36 (42%) of the 86 patients. Of the 258 major coronary arteries (excludes the left main) studied in the 86 patients, 15 (6%) were narrowed >75%, and 70 (24%) were narrowed 51% to 75% in CSA. Even mild narrowing (26% to 50%) of the left main coronary artery (66 patients) was generally accompanied by 51% to 75% or greater narrowing of at least one of the other major coronary arteries. In conclusion, even hearts which have functioned normally and are otherwise anatomically normal, usually have some degree of atherosclerotic plaque in the major epicardial coronary arteries.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:39-43
Arnett EN, Roberts WC
Am J Cardiol: 14 May 2021; 147:39-43 | PMID: 33647269
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Abstract

Racial and Socioeconomic Disparities in Cardiotoxicity Among Women With HER2-Positive Breast Cancer.

Al-Sadawi M, Hussain Y, Copeland-Halperin RS, Tobin JN, ... Johnson MN, Yu AF
Breast cancer and cardiovascular-specific mortality are higher among blacks compared with whites, but disparities in cancer therapy-related adverse cardiovascular outcomes have not been well studied. We assessed for the contribution of race and socioeconomic status on cardiotoxicity among women with HER2-positive breast cancer. This retrospective cohort analysis studied women diagnosed with stage I-III HER2-positive breast cancer from 2004-2013. All underwent left ventricular ejection fraction assessment at baseline and at least one follow-up after beginning trastuzumab. Multivariable logistic regression was used to assess the association between race and socioeconomic status (SES) on cardiotoxicity, defined by clinical heart failure (New York Heart Association class III or IV) or asymptomatic left ventricular ejection fraction decline (absolute decrease ≥ 10% to < 53%, or ≥ 16%). Blacks had the highest prevalence of hypertension, diabetes, and increased BMI. Neighborhood-level SES measures including household income and educational attainment were lower for blacks compared with whites and others. The unadjusted cardiotoxicity risk was significantly higher in black compared with white women (OR, 2.10; 95% CI, 1.42 to 3.10). In a multivariable analysis, this disparity persisted after controlling for relevant cardiovascular risk factors (adjusted OR, 1.88; 95% CI, 1.25 to 2.84). Additional models adjusting for SES factors of income, educational attainment, and insurance status did not significantly alter the association between race and cardiotoxicity. In conclusion, black women are at increased risk of cardiotoxicity during HER2-targeted breast cancer therapy. Future etiologic analyses, particularly studies exploring biologic or genetic mechanisms, are needed to further elucidate and reduce racial disparities in cardiotoxicity.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:116-121
Al-Sadawi M, Hussain Y, Copeland-Halperin RS, Tobin JN, ... Johnson MN, Yu AF
Am J Cardiol: 14 May 2021; 147:116-121 | PMID: 33617819
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Abstract

Usefulness of Rhythm Monitoring Following Acute Ischemic Stroke.

Khurshid S, Li X, Ashburner JM, Lipsanopoulos ATT, ... Trinquart L, Lubitz SA
We characterized monitor utilization in stroke survivors and assessed associations with underlying clinical atrial fibrillation (AF) risk. We retrospectively analyzed consecutive patients with acute ischemic stroke 10/2018-6/2019 without prevalent AF and assessed the 6-month incidence of monitor utilization (Holter/ECG, event/patch, implantable loop recorder [ILR]) using Fine-Gray models accounting for the competing risk of death. We assessed for predictors of monitor utilization using cause-specific hazards regression adjusted for the Cohorts for Heart and Aging Research in Genomic Epidemiology AF (CHARGE-AF) score, stroke subtype, and discharge disposition. Of 493 patients with acute ischemic stroke (age 65±16; 47% women), the 6-month incidence of monitor utilization was 36.5% (95% CI 31.7, 41.3), and 6-month mortality was 13.6% (10.4, 16.8). Monitoring was performed with Holter/event (n = 107; 72.3%), ILR (n = 34; 23.0%) or both (n = 7; 4.7%). Monitoring was more likely after cryptogenic (hazard ratio [HR] 4.53 [3.22, 6.39]; 6-month monitor incidence 70.6%) and cardioembolic (HR 2.43 [1.28, 4.62]; incidence 47.7%) stroke, versus other/undocumented (incidence 22.7%). Among patients with cryptogenic stroke, the 6-month incidence of ILR was 27.5% [18.5, 36.5]. Monitoring was more likely after discharge home (HR 1.80 [1.29, 2.52]; incidence 46.1%) versus facility (incidence 24.9%). Monitoring was not associated with CHARGE-AF score (HR 1.08 per 1-SD increase [0.91, 1.27]), even though CHARGE-AF was associated with incident AF (HR 1.56 [1.03, 2.35]). In conclusion, rhythm monitors are utilized after one-third of ischemic strokes. Monitoring is more frequent after cryptogenic strokes, though ILR use is low. Monitor utilization is not associated with AF risk.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:44-51
Khurshid S, Li X, Ashburner JM, Lipsanopoulos ATT, ... Trinquart L, Lubitz SA
Am J Cardiol: 14 May 2021; 147:44-51 | PMID: 33617814
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Abstract

Relation of Decongestion and Time to Diuretics to Biomarker Changes and Outcomes in Acute Heart Failure.

Horiuchi Y, Wettersten N, van Veldhuisen DJ, Mueller C, ... Maisel A, Murray PT
Prompt treatment may mitigate the adverse effects of congestion in the early phase of heart failure (HF) hospitalization, which may lead to improved outcomes. We analyzed 814 acute HF patients for the relationships between time to first intravenous loop diuretics, changes in biomarkers of congestion and multiorgan dysfunction, and 1-year composite end point of death or HF hospitalization. B-type natriuretic peptide (BNP), high sensitivity cardiac troponin I (hscTnI), urine and serum neutrophil gelatinase-associated lipocalin, and galectin 3 were measured at hospital admission, hospital day 1, 2, 3 and discharge. Time to diuretics was not correlated with the timing of decongestion defined as BNP decrease ≥ 30% compared with admission. Earlier BNP decreases but not time to diuretics were associated with earlier and greater decreases in hscTnI and urine neutrophil gelatinase-associated lipocalin, and lower incidence of the composite end point. After adjustment for confounders, only no BNP decrease at discharge was significantly associated with mortality but not the composite end point (p = 0.006 and p = 0.062, respectively). In conclusion, earlier time to decongestion but not the time to diuretics was associated with better biomarker trajectories. Residual congestion at discharge rather than the timing of decongestion predicted a worse prognosis.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:70-79
Horiuchi Y, Wettersten N, van Veldhuisen DJ, Mueller C, ... Maisel A, Murray PT
Am J Cardiol: 14 May 2021; 147:70-79 | PMID: 33617811
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Abstract

Blood Coagulation Changes With or Without Direct Oral Anticoagulant Therapy Following Transcatheter Aortic Valve Implantation.

Katayama T, Yokoyama N, Watanabe Y, Takahashi S, ... Kawasugi K, Kozuma K
Thromboembolic events remain clinically unresolved after transcatheter aortic valve implantation (TAVI). The use of direct oral anticoagulant (DOAC) to reduce thrombosis associated with TAVI remains controversial. This study aimed at investigating the periprocedural change in blood coagulation and thrombolysis parameters in 199 patients undergoing transfemoral TAVI. Prothrombin activation fragment 1 + 2 (F1 + 2), thrombin-antithrombin complex (TAT), soluble fibrin monomer complex (SFMC), and fibrin/fibrinogen degradation product (FDP) levels were measured before and 1 hour after TAVI and 1, 2, and 7 days postoperatively. Of the 199 patients, 49 were treated with DOAC (apixaban in 32, edoxaban in 10, and rivaroxaban in 7). The F1 + 2 and TAT levels immediately increased 1 hour after TAVI and then gradually decreased in both groups. The SFMC level also significantly increased with a peak on day 1. The FDP level gradually increased, peaking on day 2. The values of F1 + 2, TAT, SFMC, and FDP in patients who used DOAC were significantly lower than those who did not use DOAC at 1 hour after TAVI in F1 + 2 (600 [452 to 765] vs 1055 [812 to 1340] pmol/L; p < 0.001), TAT (21.4 [16.2 to 37.0] vs 38.7 [26.4 to 58.7] μg/mL; p < 0.001) and on day 1 in SFMC (18.2 [9.4 to 57.9] vs 113.4 [70.9 to 157.3] μg/mL; p < 0.001) and day 2 in FDP (6.0 [4.7 to 10.0] vs 12.6 [8.2 to 17.4] μg/mL; p < 0.001). Ischemic stroke within 30 days after TAVI occurred in 3 patients (1.5%), who were not treated with DOAC. Coagulation cascade activation was observed after TAVI. DOAC could reduce transient hypercoagulation following TAVI.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:88-93
Katayama T, Yokoyama N, Watanabe Y, Takahashi S, ... Kawasugi K, Kozuma K
Am J Cardiol: 14 May 2021; 147:88-93 | PMID: 33617810
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Abstract

Economic Evaluation of an N-terminal Pro B-type Natriuretic Peptide-Supported Diagnostic Strategy Among Dyspneic Patients Suspected of Acute Heart Failure in the Emergency Department.

Siebert U, Milev S, Zou D, Litkiewicz M, ... Masson S, Januzzi JL
Our objective was to perform an economic evaluation of an N-terminal pro B-type natriuretic peptide (NT-proBNP)-supported diagnostic strategy in dyspneic patients suspected of acute heart failure in the emergency department (ED). A decision-tree model was developed to evaluate clinical outcomes and costs for NT-proBNP-supported assessment compared with clinical assessment alone over 6 months from the United States (US) Medicare perspective. The model considered rule-in/rule-out cutoffs identified in the ICON and ICON-RELOADED studies. Acute heart failure prevalence, diagnostic accuracies, and medical resource use conditional on disease status and test results were derived from ICON-RELOADED. Several assumptions based on previous studies of NT-proBNP acute dyspnea and verified with clinicians were applied to medical resource use and assessed in sensitivity analyses. Compared with clinical assessment alone, NT-proBNP-supported assessment improved overall probability of correct diagnosis by a relative 7% (18% for true-positive and 5% for true-negative). This led to relative reductions in medical resource use in ED and hospital, including fewer initial hospitalizations (-14%), required echocardiograms (-31%), cardiology admissions (-16%), intensive care unit admissions (-12%), ED readmissions (-3%), and hospital readmissions (-22%). NT-proBNP use decreased average inpatient management costs by a relative 10%, yielding cost savings of US$2,337 per patient ED visit. These findings were robust in sensitivity analyses. In conclusion, based on a contemporary trial of patients with acute dyspnea, this analysis reaffirmed that using NT-proBNP as a diagnostic tool may improve the management of patients with dyspnea presenting to EDs and is likely to be cost-saving from the US Medicare perspective.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:61-69
Siebert U, Milev S, Zou D, Litkiewicz M, ... Masson S, Januzzi JL
Am J Cardiol: 14 May 2021; 147:61-69 | PMID: 33617809
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Abstract

Coronary Artery Disease as the Cause of Sudden Cardiac Death Among Victims < 50 Years of Age.

Vähätalo J, Holmström L, Pakanen L, Kaikkonen K, ... Huikuri H, Junttila J
Coronary artery disease (CAD) is the most common cause of sudden cardiac death (SCD). Atherosclerosis increases with age, but also many victims of SCD in young and middle-aged population have CAD at autopsy. The purpose of this study was to determine the characteristics and autopsy findings of SCD due to CAD among victims of SCD under the age of 50. Fingesture is a population-based study consisting of consecutive series of victims of autopsy verified SCD in Northern Finland between the years 1998 to 2017 (n = 5,869). Histological examinations were part of all autopsies and a toxicology investigation was performed if needed. Analyses included information accumulated from death certificates, medical records, autopsy data, standardized questionnaire to the closest family members of the victims of SCD and police reports of the conditions of the death. Overall, 10.4% of all SCDs occurred among victims under the age of 50 years (610 victims). Most common underlying cause of SCD among these younger SCD victims was CAD (43.6%). The prevalence of CAD as the cause of SCD became more common in young SCD victims after the age of 35 years. The mean age of ischemic SCD victims was 44±5 years and most were men (89.5%). Most victims (90.2%) had no clinical diagnosis of CAD, however 33.8% had an autopsy evidence of silent myocardial infarction. SCD occurred during physical activity in 24.1%. Three-vessel disease was detected in 44.4% of the study victims. Cardiac hypertrophy (58.3%) and myocardial fibrosis (82.6%) were also common. At least 1 cardiovascular risk factor was present in 64.7% of SCD victims. In conclusion, most SCDs among victims < 50 years of age are due to CAD.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:33-38
Vähätalo J, Holmström L, Pakanen L, Kaikkonen K, ... Huikuri H, Junttila J
Am J Cardiol: 14 May 2021; 147:33-38 | PMID: 33621522
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Abstract

Impact of Ventricular Stroke Work Indices on Mortality in Heart Failure Patients After Percutaneous Mitral Valve Repair.

Osteresch R, Diehl K, Dierks P, Schmucker J, ... Hambrecht R, Wienbergen H
Optimal patient selection for transcatheter mitral valve repair (TMVR) remains challenging. The aim of the study was to assess the impact of left and right ventricular stroke work index (LVSWi, RVSWi) on mortality in patients with chronic heart failure (CHF) undergoing TMVR. One hundred-forty patients (median age 74 ± 9.9 years, 67.9% male) with CHF who underwent successful TMVR were included. Primary end point was defined as all-cause mortality after 16 ± 9 months of follow-up. LVSWi was calculated as: Stroke volume index (SVi) * (mean arterial pressure - postcapillary wedge pressure) * 0.0136 = g/m-1/m2. RVSWi was calculated as: SVi * (mean pulmonary artery pressure - right atrial pressure) * 0.0136 = g/m-1/m2. Receiver operating characteristic (ROC) analysis determined an optimal threshold of 24.8 g/m-1/m2 for LVSWi (sensitivity 80.4%, specificity 40.2%, area under the curve (AUC) 0.71 [0.60 to 0.81]; p = 0.001) and 8.3 g/m-1/m2 for RVSWi (sensitivity 67.4%, specificity 57.0%, AUC 0.67 [0.56 to 0.78]; p = 0.006), respectively. Kaplan-Meier analysis showed significantly lower survival in patients with LVSWi ≤24.8 g/m-1/m2 (20.0% vs 39.4%; log-rank p = 0.038) and in patients with RVSWi ≤8.3 g/m-1/m2 (22.1% vs 43.7%; log-rank p = 0.026), respectively. LVSWi of ≤24.8 g/m-1/m2 and RVSWi of ≤8.3 g/m-1/m2 were independent predictors for all-cause mortality (hazard ratio (HR) 2.83; 95% confidence interval (CI) 1.1 to 7.6; p = 0.04; HR 2.52; 95% CI 1.04 to 6.1; p = 0.041). A risk-score incorporating LVSWi and RVSWi cut-off values from ROC analysis powerfully predicts long-term survival after successful TMVR (log-rank p = 0.02). In conclusion, LVSWi and RVSWi independently predict mortality in patients with CHF undergoing TMVR and might be useful in risk stratification of TMVR candidates.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:101-108
Osteresch R, Diehl K, Dierks P, Schmucker J, ... Hambrecht R, Wienbergen H
Am J Cardiol: 14 May 2021; 147:101-108 | PMID: 33647268
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Abstract

Sex-Specific Differences in Etiology and Prognosis in Patients With Significant Tricuspid Regurgitation.

Dietz MF, Prihadi EA, van der Bijl P, Fortuni F, ... Bax JJ, Delgado V
The aim of this study was to assess differences in etiology, comorbidities, echocardiographic parameters, and prognosis between men and women with significant tricuspid regurgitation (TR). Clinical and echocardiographic characteristics of 1569 patients (age 71 [62 to 78] years) at first diagnosis of significant TR were compared between men and women. Patients with congenital heart disease or previous tricuspid valve surgery were excluded. TR etiologies were defined as primary, left valvular disease related, left ventricular (LV) dysfunction related, pulmonary hypertension related, or isolated. The primary endpoint was all-cause mortality. Sex-specific differences in outcomes were compared in the total population and after propensity score matching. There were 798 (51%) women and 771 (49%) men in the study population. Women were diagnosed with significant TR at an older age compared with men (72 [62 to 79] years vs. 70 [61 to 77] years; p = 0.003). The TR etiology in women was more often left valvular disease related and isolated whereas men more often had LV dysfunction related TR. In the total population women had better 10-year survival compared with men (49% vs. 39%; p=0.001). After propensity score matching, the influence of sex on survival was neutralized (p = 0.228) but the TR etiologies remained significantly associated with all-cause mortality. Patients with left valvular disease or LV dysfunction related TR had lower survival compared with patients with primary TR (p = 0.004 and p = 0.019, respectively). In conclusion, long-term survival of patients with significant TR was similar between men and women after propensity score matching, while the etiology of TR remained significantly associated with all-cause mortality.

Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:109-115
Dietz MF, Prihadi EA, van der Bijl P, Fortuni F, ... Bax JJ, Delgado V
Am J Cardiol: 14 May 2021; 147:109-115 | PMID: 33640367
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Abstract

Meta-Analysis of Gender Disparities in In-hospital Care and Outcomes in Patients with ST-Segment Elevation Myocardial Infarction.

Shah T, Haimi I, Yang Y, Gaston S, ... Lansky A, Tirziu D
Gender disparities in ST-segment elevation myocardial infarction (STEMI) outcomes continue to be reported worldwide; however, the magnitude of this gap remains unknown. To evaluate gender-based discrepancies in clinical outcomes and identify the primary driving factors a global meta-analysis was performed. Studies were selected if they included all comers with STEMI, reported gender specific patient characteristics, treatments, and outcomes, according to the registered PROSPERO protocol: CRD42020161469. A total of 56 studies (705,098 patients, 31% females) were included. Females were older, had more comorbidities and received less antiplatelet therapy and primary percutaneous coronary intervention (PCI). Females experienced significantly longer delays to first medical contact (mean difference 42.5 min) and door-to-balloon time (mean difference 4.9 min). In-hospital, females had increased rates of mortality (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.84 to 1.99, p <0.00001), repeat myocardial infarction (MI) (OR 1.25, 95% CI 1.00 to 1.56, p=0.05), stroke (OR 1.67, 95% CI 1.27 to 2.20, p <0.001), and major bleeding (OR 1.82, 95% CI 1.56 to 2.12, p <0.00001) compared with males. Older age at presentation was the primary driver of excess mortality in females, although other factors including lower rates of primary PCI and aspirin usage, and longer door-to-balloon times contributed. In contrast, excess rates of repeat MI and stroke in females appeared to be driven, at least in part, by lower use of primary PCI and P2Y12 inhibitors, respectively. In conclusion, despite improvements in STEMI care, women continue to have in-hospital rates of mortality, repeat MI, stroke, and major bleeding up to 2-fold higher than men. Gender disparities in in-hospital outcomes can largely be explained by age differences at presentation but comorbidities, delays to care and suboptimal treatment experienced by women may contribute to the gender gap.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:23-32
Shah T, Haimi I, Yang Y, Gaston S, ... Lansky A, Tirziu D
Am J Cardiol: 14 May 2021; 147:23-32 | PMID: 33640366
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Abstract

Relation of Institutional Mitral Valve Surgical Volume to Surgical and Transcatheter Outcomes in Medicare Patients.

Barker CM, Reynolds MR, Reardon MJ, Van Houten JL, ... Mollenkopf SA, Feldman TE
There are limited data to support proposed increases to the minimum institutional mitral valve (MV) surgery volume required to begin a transcatheter mitral valve repair (TMVr) program. The current study examined the association between institutional MV procedure volumes and outcomes. All 2017 Medicare fee-for-service patients who received a TMVr or MV surgery procedure were included and analyzed separately. The exposure was institutional MV surgery volume: low (1 to 24), medium (25 to 39) or high (40+). Outcomes were in-hospital mortality and 1-year postdischarge mortality and cardiovascular rehospitalization. For MV surgery patients, in-hospital mortality rates were 6.4% at low-volume, 8.7% at medium-volume and 9.8% at high-volume facilities. Rates were significantly higher for low-volume [OR = 1.50, 95% CI (1.23 to 1.84)] and medium-volume [OR = 1.33, 95% CI (1.06 to 1.67)] compared with high-volume facilities. There was no statistically significant relationship between institutional MV surgery volume and in-hospital mortality for TMVr patients, either at low-volume [OR = 1.52, 95% CI (0.56, 4.13)] or medium-volume [OR = 1.58, 95% CI (0.82, 3.02)] facilities, compared with high-volume facilities. Across all volume categories, in-hospital mortality rates for TMVr patients were relatively low (2.3% on average). For both cohorts, the rates of 1-year mortality and cardiovascular rehospitalizations were not significantly higher at low- or medium-volume MV surgery facilities, as compared with high-volume. In conclusion, among Medicare patients, there was a relation between institutional MV surgery volume and in-hospital mortality for MV surgery patients, but not for TMVr patients.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 May 2021; 147:94-100
Barker CM, Reynolds MR, Reardon MJ, Van Houten JL, ... Mollenkopf SA, Feldman TE
Am J Cardiol: 14 May 2021; 147:94-100 | PMID: 33662328
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Abstract

Transcatheter Closure of Atrial Septal Defect Associated With Pulmonary Artery Hypertension using Fenestrated Devices.

Wang JK, Chiu SN, Lin MT, Chen CA, Lu CW, Wu MH
In patients with pulmonary artery hypertension (PAH) associated with atrial septal defect (ASD), closure of ASD may carry significant risks. We aimed to evaluate the safety and efficacy of transcatheter closure of ASD in selected patients with PAH using a fenestrated device followed by pulmonary vasodilator therapy. During the 14.8-year period, 51 ASD patients (10 males, age 46 ± 18 years) with a mean pulmonary artery pressure (PAP) ≥ 35 mm Hg and/or systolic PAP ≥ 60 mm Hg, underwent closure with a fenestrated device. Of them, mean Qp/Qs ratio, systolic PAP and mean PAP were 2.6 ± 1.2, 73 ± 14 mm Hg, and 44 ± 8 mm Hg, respectively. A total of 35 patients received pulmonary vasodilator therapy. The New York Heart Association (NYHA) functional class improved at 3 to 6 months follow-up. (p < 0.001) Nineteen patients underwent repeated catheterization. A comparison of the hemodynamic parameters between baseline and repeated catheterization revealed significant decreases in both systolic and mean PAP (77 ± 11 vs 55 ± 14 mm Hg, p < 0.0001 & 48 ± 7 vs 37 ± 8 mm Hg, p = 0.001, respectively), pulmonary vascular resistance (PVR) (5.1 ± 2.3 vs 4.0 ± 1.7 WU, p = 0.011) and PVRi (7.7 ± 3.3 vs 6.2 ± 2.4 WU*m2, p = 0.024). After a follow-up period of 84 ± 45 months, 6 mortalities were noted in which 2 were due to cardiac causes. In conclusion, catheter closure of ASD in patients with PAH using a fenestrated device followed by vasodilator therapy is safe and effective.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 14 May 2021; 147:122-128
Wang JK, Chiu SN, Lin MT, Chen CA, Lu CW, Wu MH
Am J Cardiol: 14 May 2021; 147:122-128 | PMID: 33667439
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Abstract

The Mechanism of Balloon Impact in Percutaneous Transluminal Coronary Angioplasty in Eccentric Coronary Artery Narrowings.

Saner H, Saner B, Meier B
In the early days of percutaneous transluminal coronary angioplasty (PTCA) and in particular before the stent era, the selection of the appropriate balloon diameter was crucial for risk and success of the intervention. With larger balloon diameters the risk of vessel wall dissection was increased but the rate of restenosis was much higher when smaller balloons were used. In retrospect, it is surprising how few histopathological studies have been performed during this time period to study the mechanism of PTCA. A main reason for this may have been that PTCA has been working well in most cases and was very effective for the relief of angina symptoms. This lack of basic research led even to the erroneous assumption by the PTCA pioneer Andreas Gruentzig, that the angioplasty procedure be characterized \"by a concentric expansion of the vessel over a suitable portion of its length.\" This view has been challenged by Professor Jesse E. Edwards, a distinguished cardiovascular pathologist from Minneapolis, MN/USA, with a world-wide reputation. The disagreement was based on the finding that 70% of coronary stenoses have been found to be eccentric and only 30% to be concentric narrowings. Jesse E. Edwards therefore initiated a histopathological study about the mechanism of balloon angioplasty in coronary arteries of freshly autopsied hearts. The study was performed in 1982 by one of the authors (HS), then a young cardiology fellow in the laboratories of Professor Kurt A. Amplatz. Kurt A. Amplatz was in an early stage of his career to later become a world famous pioneer for the development of a variety of catheters, wires, instruments, and devices for the closure of the patent foramen ovale, atrial and ventricular septal defects, and the left atrial appendage. The study documents were unavailable for almost 40 years but have recently been made accessible again. Conclusion: This manuscript discusses the main findings of the histopathological study on the mechanism of coronary balloon dilatation and is dedicated to 2 giants of cardiovascular research, Jesse E. Edwards and Kurt A. Amplatz.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:128-131
Saner H, Saner B, Meier B
Am J Cardiol: 30 Apr 2021; 146:128-131 | PMID: 33548188
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Abstract

Site of Deep Venous Thrombosis and Age in the Selection of Patients in the Emergency Department for Hospitalization Versus Home Treatment.

Stein PD, Matta F, Hughes MJ
Despite apparent advantages of home treatment of deep venous thrombosis (DVT) based upon results of randomized controlled trials, physicians maintain a conservative approach, and a large proportion of patients with DVT are hospitalized. In the present investigation we assess whether selection of patients for hospitalization for acute DVT was related to the site of the DVT or to age. This was a retrospective cohort study based on administrative data from the Nationwide Emergency Department Sample, 2016. Patients were identified by International Classification of Diseases-10-Clinical Modification codes. Most, 87,436 of 133,414 (66%), had proximal DVT. A minority of patients with isolated distal DVT were hospitalized, 10,621 of 37,592 (28%). However, hospitalization was selected for 47,459 of 87,436 (54%) with proximal DVT; 4,867 of 7,599 (64%) with pelvic vein DVT; and 611 of 788 (78%) with DVT involving the inferior vena cava. Hospitalization for patients with distal DVT, proximal DVT, and pelvic vein DVT was age-dependent. In conclusion, both the site of acute DVT and age were factors affecting the clinical decision of emergency department physicians to select patients for hospital treatment.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:95-98
Stein PD, Matta F, Hughes MJ
Am J Cardiol: 30 Apr 2021; 146:95-98 | PMID: 33529621
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Abstract

Effect of Obesity on Response to Spironolactone in Patients With Heart Failure With Preserved Ejection Fraction.

Elkholey K, Papadimitriou L, Butler J, Thadani U, Stavrakis S
Obesity is common in heart failure with preserved ejection fraction (HFpEF). Whether obesity modifies the response to spironolactone in patients with HFpEF remains unclear. We aimed to investigate the effect of obesity, defined by body mass index (BMI) and waist circumference (WC), on response to spironolactone in patients with HFpEF enrolled in Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial. This was a post-hoc, exploratory analysis of the Americas cohort of Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial. BMI≥30 kg/m2 was used to define the obese group and WC≥102 cm in men and ≥88 cm in women were defined as high WC. In separate analyses, BMI and WC were treated as continuous variables. The effect of spironolactone versus placebo on outcomes was calculated by BMI and WC using Cox proportional hazard models. Obese patients were younger and had more co-morbidities. In multivariate analysis, spironolactone use was associated with a significant reduction in the primary end point, compared with placebo in obese [hazard ratio (HR = 0.618, 95% CI 0.460 to 0.831, p = 0.001), but not in nonobese subjects (HR = 0.946, 95% CI 0.623 to 1.437, p = 0.796; p for interaction = 0.056). There was a linear association between continuous BMI and the effect of spironolactone, with the effect becoming significant at 33kg/m2. Similar results were obtained for the WC-based analysis. In conclusion, use of spironolactone in obese patients with HFpEF was associated with a decreased risk of the primary end point, cardiovascular death and HF hospitalizations, compared with placebo. Further prospective randomized studies in obese subjects are required.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:36-47
Elkholey K, Papadimitriou L, Butler J, Thadani U, Stavrakis S
Am J Cardiol: 30 Apr 2021; 146:36-47 | PMID: 33529620
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Abstract

Effect of Transaortic Valve Intervention for Aortic Stenosis on Myocardial Mechanics.

Harrington CM, Sorour N, Gottbrecht M, Nagy A, ... Chung ES, Aurigemma GP
Chronic afterload excess in aortic stenosis results in compensatory concentric hypertrophy which mitigates the increased systolic load. Surgical aortic valve replacement has been shown to decrease afterload and improve left ventricular (LV) ejection fraction (EF). The extent to which these changes take place in patients undergoing TAVI (transcatheter aortic valve intervention) may be different than what has been observed in the surgical aortic valve replacement patients who were generally younger with few co-morbidities. Accordingly, we analyzed indices of LV structure and ventricular mechanics pre- and 1-year after TAVI in 397 patients (mean age 81±9, 46% women) with severe symptomatic aortic stenosis, complete echocardiographic data was available in 156 patients and these patients compromised our study population. Our principal findings are: (1) LV remodeling occurs after TAVI; (2) afterload decreases significantly; (3) LV chamber and myocardial function, assessed by left ventricular ejection fraction and midwall fractional shortening, and stroke volume, respectively, remain unchanged or decrease. In conclusion, TAVI effects LV remodeling despite significant co-morbidities. Thus, TAVI reduces afterload and leads to LV remodeling. Surprisingly, however, systolic function does not improve. These data run counter to the paradigm that afterload reduction improves systolic function and suggest that the response to afterload reduction is complex in the TAVI population.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 30 Apr 2021; 146:56-61
Harrington CM, Sorour N, Gottbrecht M, Nagy A, ... Chung ES, Aurigemma GP
Am J Cardiol: 30 Apr 2021; 146:56-61 | PMID: 33529618
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Abstract

Electrocardiogram Criteria to Diagnose Cardiac Amyloidosis in Men With a Bundle Branch Block.

Sharma S, Labib SB, Shah SP
Diagnosing cardiac amyloidosis is challenging and requires a high index of suspicion in patients with an increased left ventricular wall thickness (LVWT). Low QRS voltage on electrocardiogram (ECG) has been regarded as the hallmark ECG finding in cardiac amyloidosis; however, the presence of low voltage can range from 20-74% and the voltage/mass ratio carries a greater diagnostic accuracy than QRS voltage alone. Patients with cardiac amyloidosis can have conduction system infiltration and this may result in a BBB. Therefore, the ECG or mass/voltage criteria established for patients with a narrow QRS in the diagnosis of cardiac amyloidosis may not be applicable in patients with a BBB. We sought to identify criteria to aid in the diagnosis of cardiac amyloidosis in patients with increased LVWT on echocardiogram and with a BBB on ECG. We calculated the total QRS score/LVWT, limb lead QRS score/LVWT, R in lead aVL/LVWT, R in lead I/LVWT, and Sokolow index/LVWT. In patients with an increase in LVWT and BBB, total QRS voltage that is indexed to wall thickness can help distinguish between patients with increased wall thickness who have cardiac amyloidosis from those who have LVH related to a pressure overload state. A unique index of Total QRS Score/LVWT is the best predictor of cardiac amyloidosis with a cutoff value of 92.5 mV/cm which is 100% sensitive and 83% specific for the diagnosis of cardiac amyloidosis. This may be a useful screening tool in patients with an increased wall thickness to raise diagnostic suspicion for cardiac amyloidosis.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:89-94
Sharma S, Labib SB, Shah SP
Am J Cardiol: 30 Apr 2021; 146:89-94 | PMID: 33529617
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Abstract

Frequency, Trend, Predictors, and Impact of Gastrointestinal Bleeding in Atrial Fibrillation Hospitalizations.

Dave M, Kumar A, Majmundar M, Adalja D, ... Gullapalli N, Doshi R
Anticoagulation alone or in combination with other treatment strategies are implemented to reduce the risk of stroke in patients with atrial fibrillation (AF). Gastrointestinal bleeding (GIB) is a common complication of oral anticoagulation with a prevalence of 1% to 3% in patients on long term oral anticoagulation. We analyzed the national inpatient sample database from the year 2005 to 2015 to report evidence on the frequency, trends, predictors, clinical outcomes, and economic burden of GIB among AF hospitalizations. A total of 34,260,000 AF hospitalizations without GIB and 1,846,259 hospitalizations with GIB (5.39%) were included. The trend of AF hospitalizations with GIB per 100 AF hospitalizations remained stable from the year 2005 to 2015 (p value = 0.0562). AF hospitalizations with GIB had a higher frequency of congestive heart failure, long term kidney disease, long term liver disease, anemia, and alcohol abuse compared with AF hospitalizations without GIB. AF hospitalizations with GIB had a higher odds of in-hospital mortality (Odds ratio (OR) 1.47; 95% Confidence interval (CI): 1.46 to 1.48, p-value <0.0001), mechanical ventilation (OR 1.69; 95% CI: 1.68 to 1.70, p-value <0.0001), and blood transfusion (OR 7.2; 95% CI: 7.17 to 7.22, P-value <0.0001) compared with AF hospitalizations without GIB. AF hospitalizations with GIB had a lower odds of stroke (OR 0.51; 95% CI: 0.51 to 0.52, p-value <0.0001) compared with AF hospitalizations without GIB. Further, AF hospitalizations with GIB had a higher median length of stay and cost of hospitalization compared with AF hospitalizations without GIB. In conclusion, the frequency of GIB is 5.4% in AF hospitalizations and the frequency of GIB remained stable in the last decade as shown in this analysis. When GIB occurs, it is associated with higher resource utilization. This study addresses a significant knowledge gap highlighting national temporal trends of GIB and associated outcomes in AF hospitalizations.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:29-35
Dave M, Kumar A, Majmundar M, Adalja D, ... Gullapalli N, Doshi R
Am J Cardiol: 30 Apr 2021; 146:29-35 | PMID: 33529616
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Abstract

Meta-Analysis of Valve-in-Valve Transcatheter Aortic Valve Implantation Versus Redo-surgical Aortic Valve Replacement in Failed Bioprosthetic Aortic Valve.

Al-Abcha A, Saleh Y, Boumegouas M, Prasad R, ... Rayamajhi S, Abela GS
This meta-analysis was conducted to compare clinical outcomes of valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) versus redo-surgical aortic valve replacement (Redo-SAVR) in failed bioprosthetic aortic valves. We conducted a comprehensive review of previous publications of all relevant studies through August 2020. Twelve observational studies were included with a total of 8,430 patients, and a median-weighted follow-up period of 1.74 years. A pooled analysis of the data showed no significant difference in all-cause mortality (OR 1.15; 95% CI 0.93 to 1.43; p = 0.21), cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, and the rate of moderate to severe paravalvular leakage between ViV-TAVI and Redo-SAVR groups. The rate of major bleeding (OR 0.36; 95% CI 0.16 to 0.83, p = 0.02), procedural mortality (OR 0.41; 95% CI 0.18 to 0.96, p = 0.04), 30-day mortality (OR 0.58; 95% CI 0.45 to 0.74, p <0.0001), and the rate of stroke (OR 0.65; 95% CI 0.52 to 0.81, p = 0.0001) were significantly lower in the ViV- TAVI arm when compared with Redo-SAVR arm. The mean transvalvular pressure gradient was significantly higher post-implantation in the ViV-TAVI group when compared with the Redo-SAVR arm (Mean difference 3.92; 95% CI 1.97 to 5.88, p < 0.0001). In conclusion, compared with Redo-SAVR, ViV-TAVI is associated with a similar risk of all-cause mortality, cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, and the rate of moderate to severe paravalvular leakage. However, the rate of major bleeding, stroke, procedural mortality and 30-day mortality were significantly lower in the ViV-TAVI group when compared with Redo-SAVR.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:74-81
Al-Abcha A, Saleh Y, Boumegouas M, Prasad R, ... Rayamajhi S, Abela GS
Am J Cardiol: 30 Apr 2021; 146:74-81 | PMID: 33529615
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Abstract

Effect of High-Density Lipoprotein Cholesterol Levels on Overall Survival and Major Adverse Cardiovascular and Cerebrovascular Events.

Kaur M, Ahuja KR, Khubber S, Zhou L, ... Puri R, Kapadia S
Several studies designed to augment high density lipoprotein (HDL) levels have so far been unsuccessful in reducing rates of major adverse cardiovascular and cerebrovascular events (MACCE). In this study, we report the effect of HDL-C levels on overall survival outcomes and rates of MACCE following percutaneous coronary intervention (PCI). We reviewed patients who underwent PCI at the Cleveland Clinic from 2005 to 2017 and followed them through the end of 2018. Restricted cubic splines incorporated into Cox proportional hazard regression models were used to assess the outcomes. The HDL-C level associated with the lowest mortality was used as a reference value.15,633 patients underwent PCI during the study period, of which 70% were male, 81% were white, and 73% were on statins. The mean age at the time of procedure was 65.8 ± 11.8 years. After adjusting for demographics, co-morbidities, lipid profile, statin use, and date of procedure, our model demonstrated a U-shaped association between HDL-C and overall mortality, with HDL-C levels of 30-50 mg/dl associated with the most favorable outcomes, and HDL-C levels < 30 mg/dl or > 50 mg/dl associated with worse outcomes. A sensitivity analysis in men yielded a similar U-shaped association. In conclusion, our study shows that both low and high levels of HDL-C are associated with worse overall survival, with no effect on rates of MACCE in PCI patients. Further studies are required to understand the mechanism of this association between elevated HDL-C levels with increased overall mortality in patients with atherosclerotic cardiovascular disease (ASCVD).

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:8-14
Kaur M, Ahuja KR, Khubber S, Zhou L, ... Puri R, Kapadia S
Am J Cardiol: 30 Apr 2021; 146:8-14 | PMID: 33535058
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Abstract

Long-term Implications of Post-Procedural Left Ventricular End-Diastolic Pressure in Patients Undergoing Transcatheter Aortic Valve Implantation.

Szekely Y, Borohovitz A, Hochstadt A, Topilsky Y, ... Finkelstein A, Arbel Y
Current risk models have only limited accuracy in predicting transcatheter aortic valve Implantation (TAVI) outcomes and there is a paucity of clinical variables to guide patient management after the procedure. The prognostic impact of elevated left ventricular end-diastolic pressure (LVEDP) in TAVI patients is unknown. The aim of the present study was to evaluate the prognostic value of after-procedural LVEDP in patients who undewent TAVI. Consecutive patients with severe symptomatic aortic stenosis who undewent TAVI were divided into 2 groups according to after-procedural LVEDP above and below or equal 12 mm Hg. Collected data included baseline clinical, laboratory and echocardiographic variables. We evaluated the impact of elevated vs. normal LVEDP on in-hospital outcomes, short- and long-term mortality. Eight hundred forty-five patients were included in the study with complete in-hospital and late mortality data available for all survivors (median follow-up 29.5 months [IQR 16.5 to 48.0]). The mean age (±SD) was 82.3±6.2 years and mean Society of Thoracic Surgery score was 4.0%±3.0%. Patients with LVEDP>12 mm Hg (n = 591, 70%) and LVEDP≤12 mm Hg (n = 254, 30%) had a 6-months mortality rate of 6.8% and 2%, respectively (P=0.004) and a 1-year mortality rate of 10.1% vs 4.9%, respectively (p = 0.017). By multivariable analysis, after-procedural LVEDP>12 mm Hg was independently associated with all-cause mortality (HR 2.45, 95% CI 1.58 to 3.76, p <0.001) during long-term follow-up. In conclusion, elevated after-procedural LVEDP in patients who undewent TAVI is an independent predictor of mortality following TAVI. Further research regarding the use of LVEDP as a tool for after-procedural medical management is warranted.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:62-68
Szekely Y, Borohovitz A, Hochstadt A, Topilsky Y, ... Finkelstein A, Arbel Y
Am J Cardiol: 30 Apr 2021; 146:62-68 | PMID: 33539862
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Abstract

Soluble Angiotensin-Converting Enzyme 2, Cardiac Biomarkers, Structure, and Function, and Cardiovascular Events (from the Atherosclerosis Risk in Communities Study).

Hussain A, Tang O, Sun C, Jia X, ... Hoogeveen RC, Ballantyne CM
Membrane-bound angiotensin-converting enzyme 2 is important in regulation of the renin-angiotensin-aldosterone system, but the association of cleaved soluble ACE2 (sACE2) with cardiovascular disease (CVD) is unclear. We evaluated the association of sACE2 with cardiac biomarkers, structure, and function and cardiovascular events in the Atherosclerosis Risk in Communities Study. sACE2 was measured in a subset of 497 participants (mean age 78±5.4 years, 53% men, 27% black); Cox regression analyses assessed prospective associations of sACE2 with time to first CVD event at median 6.1-year follow-up. sACE2 was higher in men, blacks, and participants with prevalent CVD, diabetes, or hypertension. Higher sACE2 levels were associated with significantly higher biomarkers of cardiac injury (high-sensitivity cardiac troponin I and T, N-terminal pro-B-type natriuretic peptide), greater left ventricular mass index, and impaired diastolic function in linear regression analyses, and with increased risk for heart failure hospitalization (adjusted hazard ratio per natural log unit increase [HR] 1.32, 95% confidence interval [CI] 1.10 to 1.58), CVD events (HR 1.34, 95% CI 1.13 to 1.60), and all-cause death (HR 1.26, 95% CI 1.01 to 1.57). In an elderly biracial cohort, sACE2 was positively associated with biomarkers reflecting myocardial injury and neurohormonal activation, left ventricular mass index, impaired diastolic function, CVD, events and all-cause death.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:15-21
Hussain A, Tang O, Sun C, Jia X, ... Hoogeveen RC, Ballantyne CM
Am J Cardiol: 30 Apr 2021; 146:15-21 | PMID: 33539861
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Abstract

Meta-Analysis of Population Characteristics and Outcomes of Patients Undergoing Pericardiectomy for Constrictive Pericarditis.

Tzani A, Doulamis IP, Tzoumas A, Avgerinos DV, ... Klein A, Kampaktsis PN
We sought to systematically describe the epidemiology, etiology, clinical and operative characteristics as well as outcomes of patients who underwent pericardiectomy for constrictive pericarditis in the contemporary era. We conducted a systematic search of the MEDLINE, Embase, and Cochrane databases from their inception to April 1, 2020 for studies assessing the outcomes of pericardiectomy in patients with constrictive pericarditis. Studies with patients enrolled before 1985, pediatric patients or studies including >10% tuberculous pericarditis were excluded. The impact of pericarditis etiology on outcomes was evaluated with a meta-analysis. We analyzed 27 eligible studies and 2,114 patients. Etiology was most commonly idiopathic (50.2%), followed by after-cardiac surgery (26.2%) and radiation (6.9%). Patients were mostly men (76%), mean age 58 and with advanced symptoms (NYHA III/IV 70.1%). Total pericardiectomy was preferred (85.8%) and concomitant cardiac surgery was relatively common (23.8%). Operative mortality was 6.9% and 5-year mortality was 32.7%. Radiation and after-cardiac surgery patients had 3 and 2 times higher long-term risk for mortality respectively compared with idiopathic. A sensitivity analysis did not result in changes in the results. Thirty percent of included studies had more than low bias primarily originating from follow up and selection. Pericardiectomy is therefore performed mostly in middle-aged men with advanced symptoms and low co-morbidity burden and still caries significant operative mortality. Radiation and after-cardiac surgery patients have a significantly higher mortality risk compared with idiopathic. Several methodological issues and significant heterogeneity limit the generalization of these data and randomized controlled trials may have to be considered.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:120-127
Tzani A, Doulamis IP, Tzoumas A, Avgerinos DV, ... Klein A, Kampaktsis PN
Am J Cardiol: 30 Apr 2021; 146:120-127 | PMID: 33539860
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Abstract

Usefulness of the Duke Activity Status Index to Select an Optimal Cardiovascular Exercise Stress Test Protocol.

Canada JM, Reynolds MA, Myers R, West J, ... Arena R, Hundley WG
Exercise testing represents the preferred stress modality for individuals undergoing evaluation of suspected myocardial ischemia. Patients with limited functional status may be unable to achieve an adequate exercise stress, thus influencing the diagnostic sensitivity of the results. The Duke Activity Status Index (DASI) is a clinically applicable tool to estimate exercise capacity. The purpose of the current study was to assess the utility of the DASI to identify patients unable to achieve an adequate exercise stress result. Patients referred for exercise stress testing were administered the DASI pre-exercise. Baseline characteristics and exercise variables were evaluated including DASI-metabolic equivalents (DASI-METs), peak METs, exercise time (ET), and %-predicted maximal heart rate (%PMHR). Criteria for determining adequate exercise stress was defined as ≥85%PMHR or ≥ 5-METs at peak exercise. In 608 cardiovascular stress tests performed during the study period; 314 were exercise stress. The median DASI-METs (8.4 [interquartile range; 6.7 to 9.9]) was associated with estimated peak exercise METs (R=0.50, p <0.001), ET (R=0.29, p <0.001), and %PMHR (R=0.19, p = 0.003). DASI-METs were different between those with < or ≥85%PMHR (7.9 [6.6-9.0] vs. 8.9 [7.1-9.9], P=0.025) and those with < or ≥5-METs (5.8 [4.6 to 6.6] versus 8.9 [7.3-9.9], p <0.001). Receiver operating characteristic curve analysis identified a DASI-MET threshold of ≤/>7.4 to optimally predict adequate exercise stress (sensitivity=93%, specificity=71%). In conclusion, the DASI correlates with peak METs, ET, and %PMHR among patients referred for exercise testing and can be used to identify patients with an increased likelihood of an inadequate stress test result.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:107-114
Canada JM, Reynolds MA, Myers R, West J, ... Arena R, Hundley WG
Am J Cardiol: 30 Apr 2021; 146:107-114 | PMID: 33539859
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Abstract

Comparison of Patients With Nonobstructive Coronary Artery Disease With Versus Without Myocardial Infarction (from the VA Clinical Assessment Reporting and Tracking [CART] Program).

Kovach CP, Hebbe A, O\'Donnell CI, Plomondon ME, ... Waldo SW, Valle JA
Comparisons of the outcomes of patients with myocardial infarction with nonobstructive coronary artery disease (MINOCA) and patients with nonobstructive coronary artery disease (CAD) without myocardial infarction (MI) are limited. Here we compare the outcomes of patients with MINOCA and patients with nonobstructive CAD without MI and assess the influence of medical therapy on outcomes in these patients. Veterans who underwent coronary angiography between 2008 to 2017 with nonobstructive CAD were divided into those with or without pre-procedural troponin elevation. Patients with prior revascularization, heart failure, or who presented with cardiogenic shock, STEMI, or unstable angina were excluded. After propensity matching, outcomes were compared between groups. The primary outcome was major adverse cardiovascular events (MACE: mortality, myocardial infarction, and revascularization) within one year: 3,924 patients with nonobstructive CAD and a troponin obtained prior to angiography were identified (n=1,986 with elevated troponin) and restricted to 1,904 patients after propensity-matching. There was a significantly higher risk of MACE among troponin-positive patients compared with those with a negative troponin (HR 2.37; 95% CI, 1.67 to 3.34). Statin (HR 0.32; 95% CI, 0.22 to 0.49) and ACE inhibitor (HR 0.49; 95% CI, 0.32 to 0.75) therapy after angiography was associated with decreased MACE, while P2Y12 inhibitor, calcium-channel and beta-blocker therapy were not associated with outcomes. In conclusion, Veterans with MINOCA are at increased risk for MACE compared with those with nonobstructive CAD and negative troponin at the time of angiography. Specific medications were associated with a reduction in MACE, suggesting an opportunity to explore novel approaches for secondary prevention in this population.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:1-7
Kovach CP, Hebbe A, O'Donnell CI, Plomondon ME, ... Waldo SW, Valle JA
Am J Cardiol: 30 Apr 2021; 146:1-7 | PMID: 33539858
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Abstract

Usefulness of Beta-Blockers to Control Symptoms in Patients With Pericarditis.

Imazio M, Andreis A, Agosti A, Piroli F, ... Giustetto C, De Ferrari GM
Exercise restriction is a nonpharmacological treatment of pericarditis that could reduce symptoms by slowing heart rate (HR). Beta-blockers allow pharmacological control of HR. Aim of this paper is to explore the possible efficacy of beta-blockers to improve control of symptoms in patients with pericarditis. We analyzed consecutive cases with pericarditis referred to our center. Beta-blockers were prescribed on top of standard anti-inflammatory therapy in symptomatic patients (chest pain and palpitations) with rest HR>75 beats/min. The primary end point was the persistence of pericardial pain at 3 weeks. The secondary end point was the occurrence of recurrent pericarditis at 18 months. Propensity score matching was used to generate 2 cohorts of 101 patients with and without beta-blockers with balanced baseline features. A clinical and echocardiographic follow-up was performed at 3 weeks, 1, 3, 6 months and then every 12 months. A total of 347 patients (mean age 53 years, 58% females, 48% with a recurrence, 81% with idiopathic/viral etiology) were included. Among them, 128 patients (36.9%) were treated with beta-blockers. Peak C-reactive protein values were correlated with heart rate on first observation (r=0.48, p<0.001). Using propensity-score matched cohorts, patients treated with beta-blockers had a lower frequency of symptoms persistence at 3 weeks (respectively 4% vs. 14%; p = 0.024) and a trend towards a reduction of recurrences at 18 months (p = 0.069). In conclusion the use of beta-blockers on top of standard anti-inflammatory therapies was associated with improved symptom control.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:115-119
Imazio M, Andreis A, Agosti A, Piroli F, ... Giustetto C, De Ferrari GM
Am J Cardiol: 30 Apr 2021; 146:115-119 | PMID: 33539856
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Abstract

Acute Chylopericardium With Tamponade and Cardiac Arrest With Pseudomyxoma Peritonei.

Milandt N, Birkelund T, Engholm M
A 51-year-old woman with pseudomyxoma peritonei developed cardiac arrest 5 days after surgery. Acute echocardiography demonstrated pericardial tamponade. Emergency pericardiocentesis evacuated milky fluid and circulation was re-established. Analysis of the pericardial fluid suggested chylopericardium. In conclusion, this case demonstrates that chylopericardium may be life-threatening and underlines the importance of acute echocardiography in critical management of patients with unexplained shock.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:134-136
Milandt N, Birkelund T, Engholm M
Am J Cardiol: 30 Apr 2021; 146:134-136 | PMID: 33548186
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Abstract

Comparison of Outcomes and Mortality in Patients Having Left Ventricular Assist Device Implanted Early -vs- Late After Diagnosis of Cardiomyopathy.

Chen E, Nesseler N, Martins RP, Goéminne C, ... Flécher E, Galand V
LVAD implantation in patients with a recently diagnosed cardiomyopathy has been poorly investigated. This work aims at describing the characteristics and outcomes of patients receiving a LVAD within 30 days following the diagnosis of cardiomyopathy. Patients from the ASSIST-ICD study was divided into recently and remotely diagnosed cardiomyopathy based on the time from initial diagnosis of cardiomyopathy to LVAD implantation using the cut point of 30 days. The primary end point of the study was all-cause mortality at 30-day and during follow-up. A total of 652 patients were included and followed during a median time of 9.1 (2.5 to 22.1) months. In this population, 117 (17.9%) had a recently diagnosed cardiomyopathy and had LVAD implantation after a median time of 15.0 (9.0 to 24.0) days following the diagnosis. This group of patients was significantly younger, with more ischemic cardiomyopathy, more sudden cardiac arrest (SCA) events at the time of the diagnosis and were more likely to receive temporary mechanical support before LVAD compared with the remotely diagnosed group. Postoperative in-hospital survival was similar in groups, but recently diagnosed patients had a better long-term survival after hospital discharge. SCA before LVAD and any cardiac surgery combined with LVAD implantation were identified as 2 independent predictors of postoperative mortality in recently diagnosed patients. In conclusion, rescue LVAD implantation for recently diagnosed severe cardiomyopathy is common in clinical practice. Such patients experience a relatively low postoperative mortality and have a better long-term survival compared with remotely diagnosed patients.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Apr 2021; 146:82-88
Chen E, Nesseler N, Martins RP, Goéminne C, ... Flécher E, Galand V
Am J Cardiol: 30 Apr 2021; 146:82-88 | PMID: 33549526
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Abstract

The Impact of Environmental Factors on the Mortality of Patients With Chronic Heart Failure.

Lopez PD, Cativo-Calderon EH, Otero D, Rashid M, Atlas S, Rosendorff C
Outcomes of acute heart failure hospitalizations are worse during the winter than the rest of the year. Seasonality data are more limited for outcomes in chronic heart failure and the effect of environmental variables is unknown. In this population-level study, we merged 20-year data for 555,324 patients with heart failure from the national Veterans Administration database with data on climate from the National Oceanic and Atmospheric Administration and air pollutants by the Environmental Protection Agency. The outcome was the all-cause mortality rate, stratified by geographical location and each month. The impact of environmental factors was assessed through Pearson\'s correlation and multiple regression with a family-wise α = 0.05. The monthly all-cause mortality was 13.9% higher in the winter than the summer, regardless of gender, age group, and heart failure etiology. Winter season, lower temperatures, and higher concentrations of nitrogen dioxide were associated with a higher mortality rate in multivariate analysis of the overall population. Different environmental factors were associated in regions with similar patterns of temperature and precipitation. The only environmental factor associated with the mortality rate of patients dwelling in large urban centers was the air quality index. In conclusion, the mortality in chronic heart failure exhibits a seasonal pattern, regardless of latitude or climate. In this group of patients, particularly those of male gender, a higher mortality was associated with environmental factors and incorporating these factors in treatment plans and recommendations could have a favorable cost-benefit ratio.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 30 Apr 2021; 146:48-55
Lopez PD, Cativo-Calderon EH, Otero D, Rashid M, Atlas S, Rosendorff C
Am J Cardiol: 30 Apr 2021; 146:48-55 | PMID: 33577810
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Abstract

Relation between Retinopathy and Progression of Coronary Artery Calcium in Individuals with Versus Without Diabetes Mellitus (From the Multi-Ethnic Study of Atherosclerosis).

Khazai B, Adabifirouzjaei F, Guo M, Ipp E, ... Hendel R, Budoff MJ
Retinopathy is a microvascular complication of diabetes mellitus (DM); however, it is also increasingly recognized in persons without DM. The microvascular diseases may play a prominent role in coronary heart disease (CHD) development in individuals with DM. We performed the study to evaluate the relation between non-DM retinopathy and CHD and also the association between baseline retinopathy and incidence and progression of CHD in individuals with and without DM. We included 5709 subjects with and without DM from the Multi-Ethnic Study of Atherosclerosis, who had retinal photos and coronary artery calcium score (CACS) available. We studied the association between baseline retinopathy and incidence and progression of coronary artery calcification (CAC) in subjects with and without DM. In DM group, the presence of retinopathy was significantly associated with an increased rate of CAC (RR 1.3 (95% CI [1.02, 1.66]) after adjusting for age, sex, race, follow-up time, and CHD risk factors. In non-DM group, the presence of retinopathy was not significantly associated with increased risk of CAC, however, the interaction between presence of retinopathy and DM status was not statistically significant. Within the DM group with CAC present at baseline, the presence of retinopathy was significantly associated with greater CAC progression (113 Agatson units (AU) greater, (95% CI [51-174]). In the non-DM group with present CAC at baseline; the presence of retinopathy was associated with 24 (95% CI [-0.69, 48.76]) AU higher CAC progression. All findings were adjusted for CHD risk factors. In conclusion, after adjustment for major CHD risk factors, retinopathy was associated with progression of CAC in both DM and non-DM individuals. However, the association was stronger in those with DM.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 19 Apr 2021; epub ahead of print
Khazai B, Adabifirouzjaei F, Guo M, Ipp E, ... Hendel R, Budoff MJ
Am J Cardiol: 19 Apr 2021; epub ahead of print | PMID: 33892913
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Abstract

Comparison of Hospitalization Trends and Outcomes in Acute Myocardial Infarction Patients With Versus Without Opioid Use Disorder.

Ranka S, Dalia T, Acharya P, Taduru SS, ... Shah Z, Gupta K
Discrepancies in medical care are well known to adversely affect patients with opioid abuse disorders (OUD), including management and outcomes of acute myocardial infarction (AMI) in patients with OUD. We used the National Inpatient Sample was queried from January 2006 to September 2015 to identify all patients ≥18 years admitted with a primary diagnosis of AMI (weighted N = 13,030; unweighted N = 2,670) and concomitant OUD. Patients using other nonopiate illicit drugs were excluded. Propensity matching (1:1) yielded 2,253 well-matched pairs in which intergroup comparison of invasive revascularization strategies and cardiac outcomes were performed. The prevalence of OUD patients with AMI over the last decade has doubled, from 163 (2006) to 326 cases (2015) per 100,000 admissions for AMI. The OUD group underwent less cardiac catheterization (63.2% vs 72.2%; p <0.001), percutaneous coronary intervention (37.0% vs 48.5%; p <0.001) and drug-eluting stent placement (32.3% vs 19.5%; p <0.001) compared with non-OUD. No differences in in-hospital mortality/cardiogenic shock were noted. Among subgroup of ST-elevation myocardial infarction patients (26.2% of overall cohort), the OUD patients were less likely to receive percutaneous coronary intervention (67.9% vs 75.5%; p = 0.002), drug-eluting stent (31.4% vs 47.9%; p <0.001) with a significantly higher mortality (7.4% vs 4.3%), and cardiogenic shock (11.7% vs 7.9%). No differences in the frequency of coronary bypass grafting were noted in AMI or its subgroups. In conclusion, OUD patients presenting with AMI receive less invasive treatment compared with those without OUD. OUD patients presenting with ST-elevation myocardial infarction have worse in-hospital outcomes with increased mortality and cardiogenic shock.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:18-24
Ranka S, Dalia T, Acharya P, Taduru SS, ... Shah Z, Gupta K
Am J Cardiol: 14 Apr 2021; 145:18-24 | PMID: 33454349
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Abstract

Meta-Analysis Comparing the Safety and Efficacy of Single vs Dual Antiplatelet Therapy in Post Transcatheter Aortic Valve Implantation Patients.

Ullah W, Zghouzi M, Ahmad B, Biswas S, ... Prasad A, Alraies MC
The relative safety and efficacy of aspirin versus dual antiplatelet therapy (DAPT; aspirin+clopidogrel) in patients who underwent transcatheter aortic valve implantation (TAVI) and did not have a long-term indication for oral anticoagulation remains controversial. Digital databases were searched to identify relevant articles. The major safety end point was bleeding, while the efficacy end points included after-TAVI ischemic and thrombotic events. Data were analyzed using a random effect model to calculate the pooled unadjusted odds ratio (OR) for dichotomous outcomes. Eleven studies comprising 4805 patients (aspirin 2258, DAPT 2547) were included in the quantitative analysis. Patients receiving aspirin-alone had significantly lower odds of all cause bleeding (OR 0.41, 95% CI 0.29 to .057, p <0.00001), major vascular bleeding (OR 0.51, 95% CI 0.34 to 0.77, p = 0.001), Valve Academic Research Consortium 2 (VARC-2) major bleeding (OR 0.50, 95% CI 0.30 to 0.83 p = 0.008), VARC-2 minor bleeding (OR 0.55, 95% CI 0.31 to 0.97, p = 0.04), transfusion requirement (OR 0.39, 95%CI 0.15 to 0.0.98, p = 0.05) and major vascular complications (OR0.41, 95% CI 0.26 to 0.66, p = 0.0002) compared with after-TAVI patients receiving both aspirin and clopidogrel. These was no significant difference in the odds of VARC-2 life threatening bleeding (OR 0.52, 95% CI 0.25 to 1.07, p = 0.08), prosthetic valve thrombosis (OR 1.17, 95% CI 0.22 to 6.30, p = 0.85), cardiac tamponade (OR 0.77, 95% CI 0.20 to 2.98, p = 0.70), conversion to open procedure (OR 1.99, 95 % CI 0.42 to 9.44, p = 0.39), MI (OR 0.79 95% CI 0.38 to 1.64, p = 0.52), transient ischemic attack (TIA) (OR 0.89, 95% CI 0.12 to 6.44, p = 0.91), major stroke (OR 0.68 95 % CI 0.43 to 1.08, p = 0.10), disabling stroke (0R 1.01, 95% CI 0.41 to 2.48, p = 0.99), cardiovascular mortality (OR 0.81 95% CI 0.38 to 1.74, p = 0.59) and all-cause mortality (OR 0.86, 95% CI 0.63 to 1.16, p = 0.31) between the 2 groups. In conclusion, after-TAVI patients who received aspirin alone had lower bleeding events with no significant differences in mortality and stroke rate compared with those who received DAPT.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:111-118
Ullah W, Zghouzi M, Ahmad B, Biswas S, ... Prasad A, Alraies MC
Am J Cardiol: 14 Apr 2021; 145:111-118 | PMID: 33454348
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Abstract

Effect of Mitral Regurgitation on Thrombotic Risk in Patients With Nonrheumatic Atrial Fibrillation: A New CHADS-VASc Score Risk Modifier?

Van Laer SL, Verreyen S, Winkler KM, Miljoen H, ... Heidbuchel H, Claeys MJ
The current study assessed the effect of mitral regurgitation (MR) on thrombotic risk in nonrheumatic atrial fibrillation (AF). AF carries a thrombotic risk related to left atrial blood stasis. The prevalence of atrial thrombosis, defined as the presence of left atrial appendage thrombus and/or left atrial spontaneous echo contrast grade >2, was determined in 686 consecutive nonrheumatic AF patients without (adequate) anticoagulation scheduled for transesophageal echocardiography before electrical cardioversion and was related to the severity of MR adjusted for the CHA2DS2-VASc score. A total of 103 (15%) patients had severe MR, 210 (31%) had moderate MR, and 373 (54%) had no-mild MR; the median CHA2DS2-VASc score was 3.0 (interquartile range 2.0 to 4.0). Atrial thrombosis was observed in 118 patients (17%). The prevalence of atrial thrombosis decreased with increasing MR severity: 19.9% versus 15.2% versus 11.6% for no-mild, moderate, and severe MR, respectively (p value for trend = 0.03). Patients with moderate and severe MR had a lower risk of atrial thrombosis than patients with no-mild MR, with adjusted odds ratios of 0.51 (95% confidence interval 0.31 to 0.84) and 0.24 (95% confidence interval 0.11 to 0.49), respectively. The protective effect of MR was present across all levels of the CHA2DS2-VASc risk score and the presence of moderate-severe MR in patients with an intermediate CHA2DS2-VASc score (2 to 3) lowered the atrial thrombotic risk to the level of patients with a low CHA2DS2-VASc score (0 to 1). In conclusion, our data show that the presence of MR attenuated the atrial thrombotic risk by more than 50% in patients with nonrheumatic AF.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:69-76
Van Laer SL, Verreyen S, Winkler KM, Miljoen H, ... Heidbuchel H, Claeys MJ
Am J Cardiol: 14 Apr 2021; 145:69-76 | PMID: 33454347
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Abstract

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Versus Without Chronic Kidney Disease.

Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, ... Nakagawa Y, Kimura T
Chronic kidney disease (CKD) might be an important determinant in choosing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). However, there is a scarcity of studies evaluating the effect of CKD on long-term outcomes after PCI relative to CABG in the population including severe CKD. Among 30257 consecutive patients patients who underwent first coronary revascularization with PCI or isolated CABG in the CREDO-Kyoto PCI/CABG registry Cohort-2 (n = 15330) and Cohort-3 (n = 14,927), we identified the current study population of 12,878 patients with multivessel or left main disease, and compared long-term clinical outcomes between PCI and CABG stratified by the subgroups based on the stages of CKD (no CKD: eGFR >=60 ml/min/1.73m2, moderate CKD: 60> eGFR >=30 ml/min/1.73m2, and severe CKD: eGFR <30 ml/min/1.73m2 or dialysis). There were 6,999 patients without CKD (PCI: n = 5,268, and CABG: n = 1,731), 4,427 patients with moderate CKD (PCI: n = 3,226, and CABG: n = 1,201), and 1,452 patients with severe CKD (PCI: n = 989, and CABG: n = 463). During median 5.6 years of follow-up, the excess mortality risk of PCI relative to CABG was significant regardless of the stages of CKD without interaction (no CKD: HR, 1.36; 95%CI, 1.12 to 1.65; p = 0.002, moderate CKD: HR, 1.40; 95%CI, 1.17 to 1.67; p <0.001, and severe CKD: HR, 1.33; 95%CI, 1.09 to 1.62; p = 0.004, Interaction p = 0.83). There were no significant interactions between CKD and the effect of PCI relative to CABG for all the outcome measures evaluated. In conclusion, PCI compared with CABG was associated with significantly higher risk for all-cause death regardless of the stages of CKD without any significant interaction.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:37-46
Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, ... Nakagawa Y, Kimura T
Am J Cardiol: 14 Apr 2021; 145:37-46 | PMID: 33454346
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Abstract

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graftinge Among Patients with Unprotected Left Main Coronary Artery Disease in the New-Generation Drug-Eluting Stents Era (From the CREDO-Kyoto PCI/CABG Registry Cohort-3).

Yamamoto K, Shiomi H, Morimoto T, Kadota K, ... Kimura T, CREDO-Kyoto PCI/CABG Registry Cohort-3 investigators
Long-term safety of percutaneous coronary intervention (PCI) as compared with coronary artery bypass grafting (CABG) is still controversial in patients with unprotected left main coronary artery disease (ULMCAD), and there is a scarcity of real-world data on the comparative long-term clinical outcomes between PCI and CABG for ULMCAD in new-generation drug-eluting stents era. The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013, and we identified 855 patients with ULMCAD (PCI: N = 383 [45%], and CABG: N = 472 [55%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.5 (interquartile range: 3.9 to 6.6) years. The cumulative 5-year incidence of all-cause death was not significantly different between the PCI and CABG groups (21.9% vs 17.6%, Log-rank p = 0.13). After adjusting confounders, the excess risk of PCI relative to CABG remained insignificant for all-cause death (HR, 1.00; 95% CI, 0.68 to 1.47; p = 0.99). There were significant excess risks of PCI relative to CABG for myocardial infarction and any coronary revascularization (HR, 2.07; 95% CI, 1.30 to 3.37; p = 0.002, and HR, 2.96; 95% CI, 1.96 to 4.46; p < 0.001), whereas there was no significant excess risk of PCI relative to CABG for stroke (HR, 0.85; 95% CI, 0.50 to 1.41; p = 0.52). In conclusion, there was no excess long-term mortality risk of PCI relative to CABG, while the excess risks of PCI relative to CABG were significant for myocardial infarction and any coronary revascularization in the present study population reflecting real-world clinical practice in Japan.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:47-57
Yamamoto K, Shiomi H, Morimoto T, Kadota K, ... Kimura T, CREDO-Kyoto PCI/CABG Registry Cohort-3 investigators
Am J Cardiol: 14 Apr 2021; 145:47-57 | PMID: 33454345
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Abstract

Supravalvular Aortic Stenosis and the Risk of Premature Death Among Patients With Homozygous Familial Hypercholesterolemia.

Zhang R, Xie J, Zhou J, Xu L, ... Wang L, Yang Y
Patients with homozygous familial hypercholesterolemia (HoFH) have a high risk for premature death. Supravalvular aortic stenosis (SVAS) is a common and the feature lesion of the aortic root in HoFH. The relation between SVAS and the risk of premature death in patients with HoFH has not been fully investigated. The present study analysis included 97 HoFH patients with mean age of 14.7 (years) from the Genetic and Imaging of Familial Hypercholesterolemia in Han Nationality Study. During the median (±SD) follow-up 4.0 (±4.0) years, 40 (41.2%) participants had SVAS and 17 (17.5%) participants experienced death. The proportion of premature death in the non-SVAS and SVAS group was 7.0% and 32.5%, respectively. Compared with the non-SVAS group, SVAS group cumulative survival was lower in the HoFH (log-rank test, p <0.001). This result was further confirmed in the multivariable Cox regression models. After adjusting for age, sex, low density lipoprotein cholesterol (LDL_C)-year-score, lipid-lowering drugs, cardiovascular disease, and carotid artery plaque, SVAS was an independent risk factor of premature death in HoFH on the multivariate analysis (hazard ratio 4.45; 95% confidence interval, 1.10 to 18.12; p = 0.037). In conclusion, a significantly increased risk of premature death was observed in HoFH patients with SVAS. Our study emphasized the importance of careful and aggressive management in these patients when appropriate.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:58-63
Zhang R, Xie J, Zhou J, Xu L, ... Wang L, Yang Y
Am J Cardiol: 14 Apr 2021; 145:58-63 | PMID: 33454344
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Abstract

Closing Gaps in Lifestyle Adherence for Secondary Prevention of Coronary Heart Disease.

Aggarwal M, Ornish D, Josephson R, Brown TM, ... Freeman AM, Aspry K
The secondary prevention (SP) of coronary heart disease (CHD) has become a major public health and economic burden worldwide. In the United States, the prevalence of CHD has risen to 18 million, the incidence of recurrent myocardial infarctions (MI) remains high, and related healthcare costs are projected to double by 2035. In the last decade, practice guidelines and performance measures for the SP of CHD have increasingly emphasized evidence-based lifestyle (LS) interventions, including healthy dietary patterns, regular exercise, smoking cessation, weight management, depression screening, and enrollment in cardiac rehabilitation. However, data show large gaps in adherence to healthy LS behaviors and low rates of enrollment in cardiac rehabilitation in patients with established CHD. These gaps may be related, since behavior change interventions have not been well integrated into traditional ambulatory care models in the United States. The chronic care model, an evidence-based practice framework that incorporates clinical decision support, self-management support, team-care delivery and other strategies for delivering chronic care is well suited for both chronic CHD management and prevention interventions, including those related to behavior change. This article reviews the evidence base for LS interventions for the SP of CHD, discusses current gaps in adherence, and presents strategies for closing these gaps via evidence-based and emerging interventions that are conceptually aligned with the elements of the chronic care model.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 14 Apr 2021; 145:1-11
Aggarwal M, Ornish D, Josephson R, Brown TM, ... Freeman AM, Aspry K
Am J Cardiol: 14 Apr 2021; 145:1-11 | PMID: 33454343
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Abstract

Comparison of Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Among Patients With Three-Vessel Coronary Artery Disease in the New-Generation Drug-Eluting Stents Era (From CREDO-Kyoto PCI/CABG Registry Cohort-3).

Matsumura-Nakano Y, Shiomi H, Morimoto T, Yamaji K, ... Kimura T, On behalf the CREDO-Kyoto PCI/CABG Registry Cohort-3 Investigators
There is a scarcity of data comparing long-term clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel coronary artery disease (3VD) in the new-generation drug-eluting stents era. CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who had undergone first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. We identified 2525 patients with 3VD (PCI: n = 1747 [69%], and CABG: n = 778 [31%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.7 (interquartile range: 4.4 to 6.6) years. The cumulative 5-year incidence of all-cause death was significantly higher in the PCI group than in the CABG group (19.8% vs 13.2%, log-rank p = 0.001). After adjusting confounders, the excess risk of PCI relative to CABG for all-cause death remained significant (HR, 1.45; 95% CI, 1.14 to 1.86; p = 0.003), which was mainly driven by the excess risk for non-cardiovascular death (HR, 1.88; 95% CI, 1.30 to 2.79; p = 0.001), while there was no excess risk for cardiovascular death between PCI and CABG (HR, 1.19; 95% CI, 0.87 to 1.64; p = 0.29). There was significant excess risk of PCI relative to CABG for myocardial infarction (HR, 1.77; 95% CI, 1.19 to 2.69; p = 0.006), whereas there was no excess risk of PCI relative to CABG for stroke (HR, 1.24; 95% CI, 0.83 to 1.88; p = 0.30). In conclusion, in the present study population reflecting real-world clinical practice in Japan, PCI compared with CABG was associated with significantly higher risk for all-cause death, while there was no excess risk for cardiovascular death between PCI and CABG.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:25-36
Matsumura-Nakano Y, Shiomi H, Morimoto T, Yamaji K, ... Kimura T, On behalf the CREDO-Kyoto PCI/CABG Registry Cohort-3 Investigators
Am J Cardiol: 14 Apr 2021; 145:25-36 | PMID: 33454340
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Abstract

Relation of First and Total Recurrent Atherosclerotic Cardiovascular Disease Events to Increased Lipoprotein(a) Levels Among Statin Treated Adults With Cardiovascular Disease.

Wong ND, Zhao Y, Sung J, Browne A
The relation between elevated lipoprotein(a) and total atherosclerotic cardiovascular disease (ASCVD) residual risk in persons with known cardiovascular disease on statin therapy is not well-established. We examined first and total recurrent ASCVD event risk in statin-treated adults with prior ASCVD. We studied 3,359 adults (mean age 63.6 years, 85.1% male) with prior ASCVD on statin therapy from the AIM-HIGH clinical trial cohort. The first and total ASCVD event rates were calculated by lipoprotein(a) [Lp(a)] categories. Cox regression and Prentice, Williams and Peterson (PWP) models provided hazard ratios (HRs) for ASCVD events over a mean follow-up of 3.3 years, adjusted for age, gender, trial treatment, LDL-C, and other risk factors. A total of 747 events occurred during follow-up, among which 544 were first events. First and total ASCVD event rates were greater with higher Lp(a) levels. Compared with Lp(a)<15 mg/dL, HRs (95% CIs) for subsequent total ASCVD events among Lp(a) levels of 15-<30, 30-<50, 50-<70, and ≥70 mg/dL were 1.04 (0.82 to 1.32), 1.15 (0.88 to 1.49), 1.27 (1.00 to 1.63) and 1.51 (1.25 to 1.84). Moreover, a continuous relation for total events was observed (HR=1.08 [1.04 to 1.12] per 20 mg/dL greater Lp(a). Findings for first ASCVD events and in those with LDL-C ≥70 mg/dL versus <70 mg/dL and with and without diabetes were similar. The risk of first and total ASCVD events is increased with Lp(a) levels of ≥70 mg/dL and ≥50 mg/dL, respectively, among adults with known CVD on statin therapy.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:12-17
Wong ND, Zhao Y, Sung J, Browne A
Am J Cardiol: 14 Apr 2021; 145:12-17 | PMID: 33454339
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Abstract

Center-Level Variations in Maximum Recipient Body Mass Index in Heart Transplantation.

Fisher BW, Huckaby LV, Sultan I, Hickey G, Kilic A
This study explored center-level variations in maximum recipient body mass index (BMI) and the associated impact of morbid obesity on outcomes of orthotopic heart transplantation (OHT). Using the United Network for Organ Sharing (UNOS) database, we examined adults (≥18 years) who underwent OHT between 2010 and 2018. Centers performing <10 OHTs per year were excluded. Recipients were stratified by BMI: <35, 35-38, 38 to 40, >40 kg/m2. Kaplan-Meier analysis was utilized to model survival and Cox regression analysis was utilized for adjusted analysis of 1-year mortality. A total of 17,821 candidates underwent OHT with 1,330 having a BMI >35kg/m2. Among 84 centers, a mean of 92.06% of recipients per center had a BMI<35 with 5.87%, 1.01%, and 1.06% of recipients having BMIs of 35 to 38, 38 to 40, and >40 at each center, respectively. A total of 5, 54, 17, and 8 centers had maximum recipient BMIs of <35, 35 to 38, 38 to 40, and >40 kg/m2, respectively. Centers performing OHT on recipients with higher BMIs displayed higher overall OHT volume (p = 0.002). Rates of post-transplant dialysis (p <0.001) and stroke (p = 0.008) were higher with increased BMI and length of stay was significantly longer (p <0.001). Following risk-adjustment, BMI 35 to 38 (HR 1.19) was not associated with increased risk of 1-year mortality although BMI 38 to 40 (HR 1.80, p = 0.007) and >40 (HR 2.85, p <0.001) were associated. In conclusion, most centers in the United States have a maximum recipient BMI of 35 to 38 for OHT, which appears justified as the risk of 1-year mortality increases with BMI >38.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 14 Apr 2021; 145:91-96
Fisher BW, Huckaby LV, Sultan I, Hickey G, Kilic A
Am J Cardiol: 14 Apr 2021; 145:91-96 | PMID: 33454338
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Abstract

In-Hospital Outcomes and Trends of Endovascular Intervention vs Surgical Revascularization in Octogenarians With Peripheral Artery Disease.

Pacha HM, Al-Khadra Y, Darmoch F, Soud M, ... Shishehbor MH, Alraies MC
It is unknown whether endovascular intervention (EVI) is associated with superior outcomes when compared with surgical revascularization in octogenarian. National Inpatient Sample (NIS) database was used to compare the outcomes of limb revascularization in octogenarians who had surgical revascularization versus EVI. The NIS database\'s information on PAD patients ≥80-year-old who underwent limb revascularization between 2002 and 2014 included 394,504 octogenarian patients, of which 184,926 underwent surgical revascularization (46.9%) and 209,578 underwent EVI (53.1%). Multivariate analysis was performed to examine in-hospital outcomes. Trend over time in limb revascularization utilization was examined using Cochrane-Armitage test. EVI group had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.61 [95% CI: 0.58 to 0.63], myocardial infarction (aOR: 0.84 [95% CI: 0.81 to 0.87]), stroke (aOR: 0.93 [95% CI: 0.89 to 0.96]), acute kidney injury (aOR: 0.79 [95% CI: 0.77 to 0.81]), and limb amputation (aOR: 0.77 [95% CI: 0.74 to 0.79]) compared with surgical group (p < 0.001 for all). EVI group had higher risk of bleeding (aOR: 1.20 [95% CI: 1.18 to 1.23]) and vascular complications (3.2% vs 2.7%, aOR: 1.25 [95% CI: 1.19 to 1.30]) compared with surgical group (p < 0.001 for all). Within study period, EVI utilization increased in octogenarian patients from 2.6% to 8.9% (ptrend < 0.001); whereas use of surgical revascularization decreased from 11.6% to 5.2% (ptrend < 0.001). In conclusion, the utilization of EVI in octogenarians is increasing, and associated with lower risk of in-hospital mortality and adverse cardiovascular and limb outcomes as compared with surgical revascularization.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 14 Apr 2021; 145:143-150
Pacha HM, Al-Khadra Y, Darmoch F, Soud M, ... Shishehbor MH, Alraies MC
Am J Cardiol: 14 Apr 2021; 145:143-150 | PMID: 33460607
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Abstract

Arrhythmogenic Right Ventricular Cardiomyopathy Presenting as Clinical Myocarditis in Women.

Scheel PJ, Murray B, Tichnell C, James CA, ... Chelko SP, Gilotra NA
Patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) classically initially present with ventricular arrhythmias or, less commonly, heart failure. Myocardial inflammation has been implicated in pathogenesis, but clinical myocarditis in ARVC is less described. We therefore studied clinical myocarditis as an initial ARVC presentation, and hypothesized that these patients have distinct clinical and genetic characteristics. Using the Johns Hopkins ARVC Registry, we identified 12 patients (all female, median age 20) referred between 2014 and 2019 diagnosed with myocarditis at presentation who were subsequently diagnosed with ARVC by Task Force Criteria. Majority presented with chest pain (n = 7, 58%) or ventricular arrhythmia (n = 3, 25%). All patients had troponin elevations and left ventricular (LV) function was reduced in 5 (42%). Magnetic resonance imaging demonstrated LV delayed gadolinium enhancement and/or pericardial enhancement in 10 (83%); only 3 (25%) patients had right ventricular abnormalities. Pathogenic genetic variants were identified in 11 (92%) patients: 10 desmoplakin (DSP) and 1 desmoglein-2 (DSG2). Thus, nearly 1/3 (10/32, 31%) of overall DSP ARVC patients were originally diagnosed with myocarditis. Patients were diagnosed with ARVC 1.8 years (IQR 2.7 years) after presentation and 8 (75%) patients did not meet Task Force Criteria without genetic testing. ARVC diagnosis led to an additional 5 (42%) patients referred for implantable cardiac defibrillator and 17 family member diagnoses. In conclusion, ARVC may initially present as myocarditis and these patients have distinct characteristics including female gender, LV involvement and DSP gene variants. Genetic testing is key to ARVC diagnosis and should be considered in select myocarditis patients.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:128-134
Scheel PJ, Murray B, Tichnell C, James CA, ... Chelko SP, Gilotra NA
Am J Cardiol: 14 Apr 2021; 145:128-134 | PMID: 33460606
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Abstract

Patient-Reported Outcomes in Adults With Congenital Heart Disease Following Hospitalization (from APPROACH-IS).

Moons P, Luyckx K, Thomet C, Budts W, ... Kovacs AH, APPROACH-IS consortium and the International Society for Adult Congenital Heart Disease (ISACHD)
In this international study, we (1) compared patient-reported outcomes (PROs) in adults with congenital heart disease (CHD) who had versus had not been hospitalized during the previous 12 month, (2) contrasted PROs in patients who had been hospitalized for cardiac surgery versus nonsurgical reasons, (3) assessed the magnitude of differences between the groups (i.e., effect sizes), and (4) explored differential effect sizes between countries. APPROACH-IS was a cross-sectional, observational study that enrolled 4,028 patients from 15 countries (median age 32 years; 53% females). Self-report questionnaires were administered to measure PROs: health status; anxiety and depression; and quality of life. Overall, 668 patients (17%) had been hospitalized in the previous 12 months. These patients reported poorer outcomes on all PROs, with the exception of anxiety. Patients who underwent cardiac surgery demonstrated a better quality of life compared with those who were hospitalized for nonsurgical reasons. For significant differences, the effect sizes were small, whereas they were negligible in nonsignificant comparisons. Substantial intercountry differences were observed. For various PROs, moderate to large effect sizes were found comparing different countries. In conclusion, adults with CHD who had undergone hospitalization in the previous year had poorer PROs than those who were medically stable. Researchers ought to account for the timing of recruitment when conducting PRO research as hospitalization can impact results.

Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:135-142
Moons P, Luyckx K, Thomet C, Budts W, ... Kovacs AH, APPROACH-IS consortium and the International Society for Adult Congenital Heart Disease (ISACHD)
Am J Cardiol: 14 Apr 2021; 145:135-142 | PMID: 33460605
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Abstract

Meta-Analysis of Transcatheter Aortic Valve Implantation in Patients With Stenotic Bicuspid Versus Tricuspid Aortic Valve.

Majmundar M, Kumar A, Doshi R, Shah P, ... Kalra A, Panaich SS
Most of the trials investigating the role of transcatheter aortic valve implantation (TAVI) across various strata of risk categories have excluded patients with bicuspid aortic stenosis (BAS) due to its anatomical complexities. The aim of this study was to perform a meta-analysis with meta-regression of studies comparing clinical, procedural, and after-procedural echocardiographic outcomes in BAS versus tricuspid aortic stenosis (TAS) patients who underwent TAVI. We searched the PubMed and Cochrane databases for relevant articles from the inception of the database to October 2019. Continuous and categorical variables were pooled using inverse variance and Mantel-Haenszel method, respectively, using the random-effect model. To rate the certainty of evidence for each outcome, we used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. Nineteen articles were included in the final analysis. There was no difference in the risk of 30-day mortality, 1-year mortality, 30-day cardiovascular mortality, major and/or life-threatening bleeding, major vascular complications, acute kidney injury, permanent pacemaker implantation, device success, annular rupture, after-procedural aortic valve area, and mean pressure gradient between the 2 groups. BAS patients who underwent TAVI had a higher risk of 30-day stroke, conversion to surgery, need for second valve implantation, and moderate to severe paravalvular leak. In conclusion, the present meta-analysis supports the feasibility of TAVI in surgically ineligible patients with BAS. However, the incidence of certain procedural complications such as stroke, conversion to surgery, second valve implantation, and paravalvular leak is higher among BAS patients compared with TAS patients, which must be discussed with the patient during the decision-making process.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:102-110
Majmundar M, Kumar A, Doshi R, Shah P, ... Kalra A, Panaich SS
Am J Cardiol: 14 Apr 2021; 145:102-110 | PMID: 33460604
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Abstract

Pericardial Involvement in Cancer.

Chahine J, Shekhar S, Mahalwar G, Imazio M, Collier P, Klein A
Despite the monumental advances in the diagnoses and therapeutics of malignancy, several cancer patients have presented with pericardial involvement, including acute pericarditis, constrictive pericarditis, and pericardial effusion. Multiple factors can contribute to acute pericarditis, including direct metastasis to the heart, pericardial hemorrhage, infections due to immunosuppression, and cancer therapies that include chemotherapy, immunotherapy, and radiation. Pericardial effusion, either due to cancer invasion or cancer treatment, is one of the most common incidental findings in cancer patients, which significantly worsens morbidity and mortality. If left untreated, pericardial effusion is known to cause complications such as pericardial tamponade. Constrictive pericarditis can be due to radiation exposure, chemotherapy, or is a sequela of a previous episode of acute pericarditis. In conclusion, early detection, prompt treatment, and understanding of pericardial diseases are necessary to help improve the quality of life of cancer patients, and we aim to summarize the knowledge of pericardial involvement in patients with cancer.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:151-159
Chahine J, Shekhar S, Mahalwar G, Imazio M, Collier P, Klein A
Am J Cardiol: 14 Apr 2021; 145:151-159 | PMID: 33460602
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Abstract

Standardized Measurement of Femoral Artery Depth by Computed Tomography to Predict Vascular Complications After Transcatheter Aortic Valve Implantation.

Durand E, Penso M, Hemery T, Levesque T, ... Dacher JN, Eltchaninoff H
Vascular complications (VCs) are difficult to predict and remain an important issue after transfemoral (TF) transcatheter aortic valve implantation (TAVI) although their incidence has decreased with size reduction of introducers. We aimed to evaluate a standardized measurement of femoral artery depth (FAD) using computed tomography (CT) to predict VCs after TAVI. We performed a retrospective study of 679 TF TAVI patients. We evaluated a standardized CT method to measure FAD immediately above the bifurcation. Sheath-to-femoral-artery ratio (SFAR), calcification, and tortuosity were also evaluated. VCs were defined by the Valve Academic Research Consortium (VARC)-2. Receiver operating characteristic (ROC) curves were used to predict major VCs and the need for a stent-graft. The median values of FAD and SFAR were 49.0 (36.2 to 66.7) mm and 0.95 (0.81 to 1.18), respectively. Major VCs occurred in 37 (5.4%) patients and a stent-graft was required in 49 (7.1%) patients. FAD predicted the need for a stent-graft [0.61 (0.51 to 0.70), p = 0.04] but not major VCs [0.52 (0.40 to 0.63), p = 0.76]. In contrast, SFAR did not predict the need for a stent-graft [0.53 (0.43 to 0.62), p = 0.61] but predicted major VCs [0.70 (0.58 to 0.81), p = 0.001]. Calcification and tortuosity predicted neither major VCs nor the need for a stent-graft. In conclusion, the results of our study suggest that CT measurements of FAD and SFAR provide additional information to predict major VCs and the need for a femoral stent-graft after TF TAVI.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:119-127
Durand E, Penso M, Hemery T, Levesque T, ... Dacher JN, Eltchaninoff H
Am J Cardiol: 14 Apr 2021; 145:119-127 | PMID: 33460601
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Abstract

Relation of Antecedent Symptoms to the Likelihood of Detecting Subclinical Atrial Fibrillation With Inserted Cardiac Monitors.

Reiffel JA, Verma A, Kowey PR, Halperin JL, ... Ziegler PD, REVEAL AF Investigators
Atrial fibrillation (AF) comes to attention clinically during an evaluation of symptoms, an evaluation of its adverse outcomes, or because of incidental detection during a routine examination or electrocardiogram. However, a notable number of additional individuals have AF that has not yet been clinically apparent or suspect-subclinical AF (SCAF). SCAF has been recognized during interrogation of pacemakers and defibrillators. More recently, SCAF has been demonstrated in prospective studies with long-term monitors-both external and implanted. The REVEAL AF trial enrolled a demographically \"enriched\" population that underwent monitoring for up to 3 years with an insertable cardiac monitor. SCAF was noted in 40% by 30 months. None of these patients had AF known before the study; however, some had nonspecific symptoms common to patients with known AF. The current study assessed whether patients with versus without such symptoms were more likely to have SCAF detected. We found that only palpitations had an association with AF detection when controlling for other baseline symptoms (hazard ratio 1.61 (95% confidence interval 1.12 to 2.32; p = 0.011). No other prescreening symptoms evaluated were associated with an increased likelihood of SCAF detection although patients without detected SCAF had an even higher frequency of symptoms than those with detected SCAF. Thus, REVEAL AF demonstrated that the presence of palpitations is associated with an increased likelihood of SCAF whereas other common symptoms are not; and, symptoms, per se, may more likely be consequent to associated disorders than they are a direct consequence of SCAF.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:64-68
Reiffel JA, Verma A, Kowey PR, Halperin JL, ... Ziegler PD, REVEAL AF Investigators
Am J Cardiol: 14 Apr 2021; 145:64-68 | PMID: 33497655
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Abstract

Effect of Glomerular Filtration Rates on Outcomes Following Percutaneous Left Atrial Appendage Closure.

Faroux L, Cruz-González I, Arzamendi D, Freixa X, ... O\'Hara G, Rodés-Cabau J
Scarce data support the prescription of oral anticoagulation in patients with concomitant advanced chronic kidney disease (CKD) and atrial fibrillation, and left atrial appendage closure (LAAC) may provide a favorable risk-benefit ratio in this population. However, outcomes of LAAC in CKD patients are unknown. We aimed to investigate the impact of moderate-to-severe CKD on clinical outcomes following percutaneous LAAC. This was a multicenter study including 1094 patients who underwent LAAC. Moderate-to-severe CKD was defined as an eGFR<45 mL/min. Death, ischemic stroke, severe bleeding (≥BARC 3a) and serious adverse event (SAE; composite of death, stroke or severe bleeding) were recorded. A total of 300 patients (27.4%) had moderate-to-severe CKD. There were no differences between groups in periprocedural complications or device related thrombosis. At a median follow-up of 2 (1 to 3) years, patients with moderate-to-severe CKD did not present an increased risk of ischemic stroke (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.22 to 1.92; p = 0.435) but were at a higher risk of death (HR: 2.84; 95% CI: 2.22 to 3.64; p <0.001), severe bleeding (HR: 1.96; 95% CI: 1.36 to 2.81; p <0.001) and SAE (HR: 2.23; 95% CI: 1.80 to 2.77; p <0.001). By multivariable analysis, an eGFR<45 ml/min (HR: 1.92; 95% CI: 1.34 to 2.76; p <0.001) and previous bleeding (HR: 2.30; 95% CI: 1.27 to 4.17; p = 0.006) were associated with an increased risk of severe bleeding. In conclusion, patients with moderate-to-severe CKD who underwent LAAC had very high thrombotic and bleeding risks. Although the rates of device related thrombosis or ischemic stroke after-LAAC were not influenced by kidney dysfunction, patients with moderate-to-severe CKD remained at higher risk of severe bleeding events.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Apr 2021; 145:77-84
Faroux L, Cruz-González I, Arzamendi D, Freixa X, ... O'Hara G, Rodés-Cabau J
Am J Cardiol: 14 Apr 2021; 145:77-84 | PMID: 33508268
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Abstract

Prevalence and Determinants of Atrial Fibrillation-Associated In-Hospital Ischemic Stroke in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

Patil S, Gonuguntla K, Rojulpote C, Kumar M, ... Nardino RJ, Pickett C
Atrial fibrillation (AF) is an established risk factor ischemic stroke (IS) and is commonly encountered in patient hospitalized with acute myocardial infarction (AMI). Uncommonly, IS can occur as a complication resulting from percutaneous coronary intervention (PCI). There is limited real world data regarding AF-associated in-hospital IS (IH-IS) in patients admitted with AMI undergoing PCI. We queried the National Inpatient Sample database from January 2010 to December 2014 to identify patients admitted with AMI who underwent PCI. In this cohort, we determined the prevalence of AF associated IH-IS and compared risk factors for IH-IS between patients with AF and without AF using multivariable logistic regression models. IH-IS was present in 0.46% (n = 5,938) of the patients with AMI undergoing PCI (n = 1,282,829). Prevalence of IH-IS in patients with AF was higher compared with patients without AF (1.05% vs 0.4%; adjusted odds ratio: 1.634, 95% confidence interval: 1.527 to 1.748, p <0.001). Regardless of AF status, prevalence and risk of IH-IS was higher in females and increased with advancing age. There was significant overlap among risk-factors associated with increased risk of IH-IS in AF and non-AF cohorts, except for obesity in AF patients (adjusted odds ratio: 1.268, 95% confidence interval: 1.023 to 1.572, p = 0.03) in contrast to renal disease, malignancy, and peripheral vascular disease in non-AF patients. In conclusion, IH-IS is a rare complication affecting patients undergoing PCI for AMI and is more likely to occur in AF patients, females, and older adults, with heterogeneity among risk factors in patients with and without AF.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:1-7
Patil S, Gonuguntla K, Rojulpote C, Kumar M, ... Nardino RJ, Pickett C
Am J Cardiol: 31 Mar 2021; 144:1-7 | PMID: 33385356
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Abstract

Trends, Outcomes, and Predictive Score For Emergency Coronary Artery Bypass Graft Surgery After Elective Percutaneous Coronary Intervention (from a Nationwide Dataset).

Pancholy SB, Patel GA, Patel NR, Patel DD, ... Mamas MA, Patel TM
The temporal trends and preprocedural predictors of emergency coronary artery bypass graft surgery (ECABG) after elective percutaneous coronary intervention (PCI) in the contemporary era are largely unknown. From January 2003 to December 2014 elective hospitalizations with PCI as the primary procedure were extracted from the Nationwide Inpatient Sample. ECABG was identified as CABG within 24 hours of elective PCI. Temporal trends of elective PCI, ECABG, comorbidities, and in-hospital mortality were analyzed. Logistic regression model was used to identify preprocedural independent predictors of ECABG and post-PCI ECABG risk score was developed using the regression coefficients from the logistic regression model in the development cohort. The score was then validated in the validation cohort. Of 1,605,641 elective PCI procedures included in the final analysis, 5,561 (0.3%) patients underwent ECABG. The incidence of ECABG, co-morbidities and overall in-hospital mortality increased over the study period, whereas the in-hospital mortality after ECABG remained unchanged. An increasing trend of elective PCI performed at facilities without on-site CABG was noted, with a higher unadjusted in-hospital mortality in this cohort. ECABG risk score, performed well with a significantly higher risk of ECABG in those patients with a score in the highest tertile compared with those with lower ECABG score (0.6% vs 0.3%, p = 0.0005). In conclusion, an increasing trend of adverse outcomes after elective PCI is observed. We describe an easy-to-use predictive score using preprocedural variables that may allow the operator to triage the patient to an appropriate setting in an effort to improve outcomes.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:46-51
Pancholy SB, Patel GA, Patel NR, Patel DD, ... Mamas MA, Patel TM
Am J Cardiol: 31 Mar 2021; 144:46-51 | PMID: 33385353
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Abstract

Short-Term Outcomes of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Kidney Transplant Recipients (from the US Nationwide Representative Study).

Abdelfattah OM, Saad AM, Abushouk A, Hassanein M, ... Krishnaswamy A, Kapadia S
Kidney transplant recipients (KTRs) are considered high-risk patients for surgical interventions. Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) at high operative risk. However, the outcomes of TAVI compared with SAVR KTRs have not been well-studied in nationally representative data. Patients with prior history of functioning kidney transplant who were hospitalized for TAVI and SAVR between January 2012 and December 2017 were identified retrospectively in the Nationwide Readmissions Database. Our study included 762 TAVI and 1,278 SAVR KTRs. Compared with SAVR, TAVI patients generally had higher rates of co-morbidities with lower risk of in-hospital mortality (3.1% vs 6.3, p = 0.002), blood transfusion (11.5% vs 38.6%, p <0.001), acute myocardial infarction (3.9% vs 6.5%, p = 0.16), acute kidney injury (24.5% vs 42.1%, p <0.001), sepsis (3.9% vs 9.5%, p <0.001) and discharge with disability (42.6% vs 68.4%, p <0.001). However, the rate of permanent pacemaker implantation was significantly higher in TAVI group (11.4% vs 3.9%, p <0.001). Of note, in-hospital stroke and 30-day readmission were comparable between both groups. These findings were confirmed after adjusting for other co-morbidities. TAVI is growing as a valid and safe alternative for KTRs with severe AS.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:83-90
Abdelfattah OM, Saad AM, Abushouk A, Hassanein M, ... Krishnaswamy A, Kapadia S
Am J Cardiol: 31 Mar 2021; 144:83-90 | PMID: 33383014
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Abstract

Effect of Losartan or Atenolol on Children and Young Adults With Bicuspid Aortic Valve and Dilated Aorta.

Flyer JN, Sleeper LA, Colan SD, Singh MN, Lacro RV
Bicuspid aortic valve aortopathy is defined by dilation of the aortic root (AoRt) and/or ascending aorta (AsAo), and increases risk for aortic aneurysm and dissection. The effects of medical prophylaxis on aortic growth rates in moderate to severe bicuspid aortopathy have not yet been evaluated. This was a single-center retrospective study of young patients (1 day to 29 years) with bicuspid aortopathy (AoRt or AsAo z-score ≥ 4 SD, or absolute dimension ≥ 4 cm), treated with either losartan or atenolol. Maximal diameters and BSA-adjusted z-scores obtained from serial echocardiograms were utilized in a mixed linear effects regression model. The primary outcome was the annual rate of change in AoRt and AsAo z-scores during treatment, compared with before treatment. The mean ages (years) at treatment initiation were 14.2 ± 5.1 (losartan; n = 27) and 15.2 ± 4.9 (atenolol; n = 18). Median treatment duration (years) was 3.1 (IQR 2.4, 6.0) for losartan, and 3.7 (IQR 1.4, 6.6) for atenolol. Treatment was associated with decreases in AoRt and AsAo z-scores (SD/year), for both losartan and atenolol (pre- vs post-treatment): losartan/AoRt: +0.06 ± 0.02 vs -0.14 ± 0.03, p < 0.001; losartan/AsAo: +0.20 ± 0.03 vs -0.09 ± 0.05, p < 0.001; atenolol/AoRt: +0.07 ± 0.03 vs -0.02 ± 0.04, p = 0.04; atenolol/AsAo: +0.21 ± 0.04 vs -0.06 ± 0.06, p < 0.001. Treatment was also associated with decreases in absolute growth rates (cm/year) for all comparisons (p ≤ 0.02). Medical prophylaxis reduced proximal aortic growth rates in young patients with at least moderate and progressive bicuspid aortopathy.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:111-117
Flyer JN, Sleeper LA, Colan SD, Singh MN, Lacro RV
Am J Cardiol: 31 Mar 2021; 144:111-117 | PMID: 33383013
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Abstract

Rate of Incomplete Revascularization Following Coronary Artery Bypass Grafting at a Single Institution Between 2007 and 2017.

Soukup CR, Schmidt CW, Chan-Tram C, Garberich RF, Sun BC, Traverse JH
Incomplete revascularization following coronary artery bypass grafting (CABG) is associated with increased repeat revascularization, myocardial infarction and death. Whether the rate of incomplete revascularization is increasing over time has not been previously described. All patients with multivessel coronary artery disease who underwent isolated and elective CABG at our Institution in 2007 (n = 291) were compared to patients who underwent CABG in 2017 (n = 290). A Revascularization Index Score was created to compare rates of incomplete revascularization between the 2 years based on the coronary anatomy and degree of stenosis. Comparison of the 2 years disclose that the rate of incomplete revascularization increased from 17.9% in 2007 to 28.3% in 2017 (p = 0.003) and was accompanied by a decline in the Revascularization Index Score from 0.73 to 0.67 (p = 0.005). Left ventricular function improved in both groups following CABG. Two-year cardiovascular mortality was significantly higher in the 2017 cohort compared to the 2007 cohort. These differences may be attributable to patient factors including more severe coronary artery disease associated with older age, greater incidence of smoking and previous percutaneous coronary intervention. In conclusion, the rate of incomplete revascularization following CABG significantly increased in 2017 compared to 2007 and was associated with higher cardiovascular mortality.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:33-36
Soukup CR, Schmidt CW, Chan-Tram C, Garberich RF, Sun BC, Traverse JH
Am J Cardiol: 31 Mar 2021; 144:33-36 | PMID: 33383011
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Abstract

Assessing the Best Prognostic Score for Transcatheter Aortic Valve Implantation (from the RISPEVA Registry).

Pepe M, Corcione N, Petronio AS, Berti S, ... Biondi-Zoccai G, Giordano A
The ACC/TVT score is a specific predictive model of in-hospital mortality for patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to test its predictive accuracy in comparison with standard surgical risk models (Logistic Euroscore, Euroscore II, and STS-PROM) in the population of TAVI patients included in the multicenter RISPEVA (Registro Italiano GISE sull\'impianto di Valvola Aortica Percutanea) registry. The study cohort included 3293 patients who underwent TAVI between 2008 and 2019. The 4 risk scores were calculated for all patients. For all scores, the capability to predict 30-day mortality was assessed by means of several analyses testing calibration and discrimination. The ACC/TVT score showed moderate discrimination, with a C-statistics for 30-day mortality of 0.63, not significantly different from the standard surgical risk models. The ACC/TVT score demonstrated, in contrast, better calibration compared with the other scores, as proved by a greater correspondence between estimated probabilities and the actual observations. However, when the ACC/TVT score was tested in the subgroup of patients treated in a more contemporary period (from 2016 on), it revealed a slight tendency to lose discrimination and to overestimate mortality risk. In conclusion, in comparison with the standard surgical risk models, the ACC/TVT score demonstrated better prediction accuracy for estimation of 30-day mortality in terms of calibration. Nevertheless, its predictive reliability remained suboptimal and tended to worsen in patients treated more recently.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 31 Mar 2021; 144:91-99
Pepe M, Corcione N, Petronio AS, Berti S, ... Biondi-Zoccai G, Giordano A
Am J Cardiol: 31 Mar 2021; 144:91-99 | PMID: 33383010
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Abstract

Prognostic Value and Interplay Between Myocardial Tissue Velocities in Patients Undergoing Coronary Artery Bypass Grafting.

Olsen FJ, Lindberg S, Fritz-Hansen T, Modin D, ... Møgelvang R, Biering-Sørensen T
Early diastolic tissue velocity (e\') by tissue Doppler imaging represents an early marker of left ventricular (LV) dysfunction in ischemic heart disease. We assessed the value of e\' for predicting mortality in patients undergoing coronary artery bypass grafting (CABG). We retrospectively investigated patients treated with CABG between 2006-2011. Before surgery, all patients underwent an echocardiogram with tissue Doppler imaging to measure tissue velocities: systolic (s\'), e\', and late diastolic (a\'). The primary outcome was all-cause mortality. Survival analysis was applied. Improvement of EuroSCORE-II was assessed by net reclassification index. Of 660 patients, 72 (11%) died during a median follow-up time of 3.8 years. Mean age was 68 years, LVEF 50%, and 84% were men. All tissue velocities showed a significant negative association with outcome and e\' provided highest Harrell\'s C-statistics (c-stat=0.68). After multivariable adjustment for EuroSCORE-II, LV hypertrophy, LV internal diameter, and global longitudinal strain, declining e\' was associated with a higher risk of mortality (HR=1.35 (1.12 to 1.61), p = 0.001, per 1cm/s absolute decrease). LVEF≤40% modified the relationship between both s\' and e\' and outcome (p for interaction=0.021 and 0.024, respectively), such that neither predicted mortality when LVEF was ≤40%. In patients with LVEF>40%, only e\' remained a predictor after multivariable adjustments (HR=1.36 (1.10 to 1.69), p = 0.005, per 1cm/s absolute decrease). A net reclassification index improvement of 0.14 was observed when adding global e\' to the EuroSCORE-II. In conclusion, e\' is an independent predictor of all-cause mortality in patients undergoing CABG, especially in patients with LVEF>40%, and improves the predictive value of EuroSCORE-II.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:37-45
Olsen FJ, Lindberg S, Fritz-Hansen T, Modin D, ... Møgelvang R, Biering-Sørensen T
Am J Cardiol: 31 Mar 2021; 144:37-45 | PMID: 33383008
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Abstract

Transcatheter Aortic Valve Implantation for Failed Surgical Aortic Bioprostheses Using a Self-Expanding Device (from the Prospective VIVA Post Market Study).

Kornowski R, Chevalier B, Verhoye JP, Holzhey D, ... Tchétché D, VIVA Investigators
Patients with symptomatic aortic stenosis are often treated with a surgical valve replacement. Surgical bioprosthetic valves degenerate over time and therefore may necessitate a redo surgery. This analysis reports the 2-year clinical outcomes of the Valve-in-Valve study, which evaluated transcatheter aortic valve implantation using the CoreValve and Evolut R devices in patients with degenerated surgical aortic bioprostheses at high risk for surgery. The prospective Valve-in-Valve study enrolled 202 eligible patients with failing surgical aortic bioprostheses due to stenosis, regurgitation, or a combination of both. The Evolut R bioprosthesis was used in 90.5% of valve-in-valve transcatheter aortic valve implantation cases. Two-year all-cause and cardiovascular mortality rates were 16.5% and 11.1%, respectively. Other clinical events included stroke (7.9%), disabling stroke (1.7%), and new pacemaker implantation (10.1%). The 2-year all-cause mortality rate was significantly higher in patients with discharge mean gradients ≥20 mmHg vs. those with lower mean gradients (21.0% vs 7.6%, p = 0.025). Discharge mean gradients ≥20 mm Hg were associated with smaller surgical bioprostheses (OR, 7.2 [95% CI 2.3 to 22.1]. In patients with failing surgical aortic bioprostheses, valve-in-valve treatment using a supra-annular self-expanding bioprosthesis provides significant functional improvements with acceptable rates of complications, especially if a postprocedural mean gradient of <20 mmHg can be achieved.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:118-124
Kornowski R, Chevalier B, Verhoye JP, Holzhey D, ... Tchétché D, VIVA Investigators
Am J Cardiol: 31 Mar 2021; 144:118-124 | PMID: 33383007
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Abstract

Transcatheter Aortic Valve Implantation in Patients With Severe Aortic Stenosis Hospitalized With Acute Heart Failure.

Kaewkes D, Ochiai T, Flint N, Patel V, ... Cheng W, Makkar R
Optimal timing and outcomes of transcatheter aortic valve implantation (TAVI) in patients presenting with acute heart failure (AHF) remain unclear. In this consecutive cohort of 1,547 patients with severe aortic stenosis undergoing TAVI, the AHF status at admission was collected, and patients were classified into AHF and elective TAVI groups. In the AHF group, early TAVI was defined as TAVI performed ≤60 hours after emergency room arrival. The primary outcome was all-cause mortality at 30-day and 2-year after TAVI. There were 139 (9%) patients who underwent TAVI while hospitalized with AHF. At baseline, this group had higher rates of chronic kidney disease, higher Society of Thoracic Surgeons score, and lower left ventricular ejection fraction. After adjusting for baseline differences, the AHF group had significantly higher all-cause mortality at 30-day and 2-year than the elective TAVI group (8% vs 2%; p = 0.002, and 33% vs 18%; p = 0.002, respectively). In the AHF group, 43 (31%) patients underwent early treatment with TAVI. No significant difference in all-cause mortality at 30-day was observed between early and non-early TAVI groups (5% vs 10%; p = 0.617). All-cause mortality at 2-year was lower in the early TAVI groups (16% vs 40%, log-rank p = 0.022); however, after multivariable adjustment, the difference was barely statistically significant (p = 0.053). In conclusion, TAVI in patients with AHF was associated with worse short and long-term outcomes. In AHF setting, early TAVI did not significantly reduce all-cause mortality at 30-day; however, it showed a strong trend for lower all-cause mortality at 2-year.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:100-110
Kaewkes D, Ochiai T, Flint N, Patel V, ... Cheng W, Makkar R
Am J Cardiol: 31 Mar 2021; 144:100-110 | PMID: 33383005
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Abstract

Incidence, Predictors, and Outcome of In-Hospital Bleeding in Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction.

Ratcovich H, Josiassen J, Helgestad OKL, Linde L, ... Møller JE, Holmvang L
Bleeding after acute myocardial infarction (AMI) is associated with an increased morbidity and mortality. The frequency and consequences of bleeding events in patients with AMICS are not well described. The objective was to investigate incidence and outcome of bleeding complications among unselected patients with AMI complicated by cardiogenic shock (AMICS) and referred for immediate revascularization. Bleeding events were assessed by review of medical records in consecutive AMICS patients admitted between 2010 and 2017. Bleedings during admission were classified according to Bleeding Academic Research Consortium classification. Patients who did not survive to admission in the intensive care unit were excluded. Of the 1,716 patients admitted with AMICS, 1,532 patients (89%) survived to ICU admission. At 30 days, mortality was 48%. Severe bleedings classified as BARC 3/5 were seen in 87 non-coronary bypass grafting patients (6.1%). Co-morbidity did not differ among patients; however, patients who had a BARC 3/5 bleeding had significantly higher lactate and lower systolic blood pressure at admission, indicating a more severe state of shock. The use of mechanical assist devices was significantly associated with severe bleeding events. Univariable analysis showed that patients with a BARC 3/5 bleeding had a significantly higher 30-day mortality hazard compared with patients without severe bleedings. The association did not sustain after multivariable adjustment (hazard ratio 0.90, 95% confidence interval 0.64; 1.26, p = 0.52). In conclusion, severe bleeding events according to BARC classification in an all-comer population of patients with AMICS were not associated with higher mortality when adjusting for immediate management, hemodynamic, and metabolic state. This indicates that mortality in these patients is primarily related to other factors.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:13-19
Ratcovich H, Josiassen J, Helgestad OKL, Linde L, ... Møller JE, Holmvang L
Am J Cardiol: 31 Mar 2021; 144:13-19 | PMID: 33383003
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Abstract

Comparison of Outcomes Among Patients With Cardiogenic Shock Admitted on Weekends Versus Weekdays.

Harhash AA, Kennedy KF, Fendler TJ, Khumri TM, ... Magalski A, Sperry BW
Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:20-25
Harhash AA, Kennedy KF, Fendler TJ, Khumri TM, ... Magalski A, Sperry BW
Am J Cardiol: 31 Mar 2021; 144:20-25 | PMID: 33417875
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Abstract

Dual Antiplatelet Therapy De-escalation Strategies.

Sinnaeve PR, Adriaenssens T
Dual antiplatelet therapy (DAPT), the combination of aspirin (ASA), and a P2Y12 inhibitor, protects against stent thrombosis and new atherothrombotic events after a stent implantation or an acute coronary syndrome, but exposes patients to an increased risk of bleeding. In most current practices, the P2Y12 inhibitor is stopped at 6 to 12 months and ASA is continued indefinitely. The advent of safer stents, with less risk of stent thrombosis, has challenged this standard of care, however. A number of alternative strategies involving earlier de-escalation of the antiplatelet therapy have therefore been proposed. In these approaches, standard DAPT is switched to a less potent antithrombotic combination at an earlier time-point than recommended by guidelines. Three different de-escalation variations have been tested to date. The first one maintains DAPT but switches from the potent P2Y12 inhibitors ticagrelor or prasugrel to either a lower dose or to clopidogrel, while maintaining ASA. The 2 other approaches involve changing DAPT to a single antiplatelet at some earlier time-point after the percutaneous coronary intervention procedure, by stopping either the P2Y12 inhibitor or ASA. These strategies have all demonstrated some benefit in clinical trials so far, but especially the contribution of ASA in secondary prevention is clearly evolving as its role in increasing bleeding complications while not providing increased ischemic benefit is becoming more and more clear. In contemporary practice, the type and duration of DAPT should now be based on an individualized decision, and the de-escalation strategies, if used wisely, can be added to the existing options.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Mar 2021; 144:S23-S31
Sinnaeve PR, Adriaenssens T
Am J Cardiol: 31 Mar 2021; 144:S23-S31 | PMID: 33706987
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Abstract

Incidence and Mortality trends of Atrial Fibrillation/Atrial Flutter in the United States 1990 to 2017.

DeLago AJ, Essa M, Ghajar A, Hammond-Haley M, ... Salciccioli JD, Philips B
Atrial fibrillation (AF) and flutter (AFL) are the most common clinically significant arrhythmias in older adults with an increasing disease burden due to an aging population. However, up-to-date trends in disease burden and regional variation remain unknown. In an observational study utilizing the Global Burden of Disease (GBD) database, age-standardized mortality and incidence rates for AF overall and for each state in the United States (US) from 1990-2017 were determined. All analyses were stratified by sex. The relative change in age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) over the observation period were determined. Trends were analyzed using Joinpoint regression analysis. The mean ASIR per 100,000 population for men was 92 (+/-8) and for women was 62 (+/-5) in the US in 2017. The mean ASDR per 100,000 population for men was 5.8 (+/-0.3) and for women was 4.4 (+/-0.4). There were progressive increases in ASIR and ASDR in all but one state. The states with the greatest percentage change in incidence were New Hampshire (+13.5%) and Idaho (+16.0%) for men and women, respectively. The greatest change regarding mortality was seen in Mississippi (+26.3%) for men and Oregon (+53.8%) for women. In conclusion these findings provide updated evidence of increasing AF/AFL incidence and mortality on a national and regional level in the Unites States, with women experiencing greater increases in incidence and mortality rates. This study demonstrates that the public health burden related to AF in the United States is progressively worsening but disproportionately across states and among women.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 24 Mar 2021; epub ahead of print
DeLago AJ, Essa M, Ghajar A, Hammond-Haley M, ... Salciccioli JD, Philips B
Am J Cardiol: 24 Mar 2021; epub ahead of print | PMID: 33640365
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Abstract

Six-Month Outcomes for COVID-19 Negative Patients with Acute Myocardial Infarction Before Versus During the COVID-19 Pandemic.

Aldujeli A, Hamadeh A, Tecson KM, Krivickas Z, ... Zaliaduonyte D, McCullough PA
The Coronavirus disease 2019 (COVID-19) pandemic has changed the way patients seek medical attention and how medical services are provided. We sought to compare characteristics, clinical course, and outcomes of patients presenting with acute myocardial infarction (AMI) during the pandemic compared with before it. This is a multicenter, retrospective cohort study of consecutive COVID-19 negative patients with AMI in Lithuania from March 11, 2020 to April 20, 2020 compared with patients admitted with the same diagnosis during the same period in 2019. All patients underwent angiography. Six-month follow-up was obtained for all patients. A total of 269 patients were included in this study, 107 (40.8%) of whom presented during the pandemic. Median pain-to-door times were significantly longer (858 [quartile 1=360, quartile 3 = 2,600] vs 385.5 [200, 745] minutes, p <0.0001) and post-revascularization ejection fractions were significantly lower (35 [30, 45] vs 45 [40, 50], p <0.0001) for patients presenting during vs. prior to the pandemic. While the in-hospital mortality rate did not differ, we observed a higher rate of six-month major adverse cardiovascular events for patients who presented during versus prior to the pandemic (30.8% vs 13.6%, p = 0.0006). In conclusion, 34% fewer patients with AMI presented to the hospital during the COVID-19 pandemic, and those who did waited longer to present and experienced more 6-month major adverse cardiovascular events compared with patients admitted before the pandemic.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 22 Mar 2021; epub ahead of print
Aldujeli A, Hamadeh A, Tecson KM, Krivickas Z, ... Zaliaduonyte D, McCullough PA
Am J Cardiol: 22 Mar 2021; epub ahead of print | PMID: 33631113
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Abstract

Assessment of Right-Sided Heart Failure in Patients with Dilated Cardiomyopathy using Magnetic Resonance Relaxometry of the Liver.

Bogaert J, Symons R, Rafouli-Stergiou P, Droogné W, Dresselaers T, Masci PG
In non-ischemic dilated cardiomyopathy (DC) patients at risk of developing right heart failure (RHF), early depiction of congestive heart failure (CHF) is pivotal to inform about the hemodynamic status and tailor medical therapy. We hypothesized increased liver relaxation times measured at routine cardiovascular magnetic resonance (CMR), reflecting passive hepatic congestion, may be a valuable imaging biomarker to depict CHF. The study cohort consisted of DC patients with LV dysfunction (i.e. ejection fraction <35%) with (n=48) and without (n=46) right ventricular dysfunction (RVD), defined as a right ventricular ejection fraction <35%, and >45%, respectively, and a control group (n=40). Native T1, T2, and extracellular volume (ECV) liver values were measured on routinely acquired cardiac maps. DC+RVD patients had higher C-reactive protein, troponin I and NT-pro BNP values, and worse LV functional parameters than DC-RVD patients (all p<0.001). T1, T2 and ECV Liver values were significantly higher in DC+RVD compared to DC-RVD patients and controls, i.e. T1: 675±88ms vs 538±39ms and 540±34ms; T2: 54±8ms vs 45±5ms and 46±4ms; ECV: 36±7% vs 29±4% and 30±3% (all p<0.001). Gamma-glutamyltranspeptidase (GGT) correlated moderately but significantly with native T1 (r2=0.34), T2 (r2=0.27), and ECV liver (r2=0.23)(all p<0.001). Using right atrial (RA) pressure, as surrogate measure of RHF (i.e. RA pressure >5 mm Hg), native T1 liver yielded at ROC analysis the highest AUC (0.906), significantly higher than ECV liver (0.813), GGT (0.806), T2 liver (0.797), total bilirubin (0.737) and alkaline phosphatase (0.561)(p=0.04). A T1 value of 617ms yielded a sensitivity of 79.5% and specificity of 91.0% to depict RHF. Excellent intra-/inter-observer agreement was found for assessment of native T1/T2/ECV liver values. In conclusion, in DC patients, assessment of liver relaxation times acquired on a CMR exam, may provide valuable information with regard to the presence of RHF.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 20 Mar 2021; epub ahead of print
Bogaert J, Symons R, Rafouli-Stergiou P, Droogné W, Dresselaers T, Masci PG
Am J Cardiol: 20 Mar 2021; epub ahead of print | PMID: 33762175
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Abstract

Exercise Performance in Adolescents with Fontan Physiology (From the Pediatric Heart Network Fontan Public Data Set).

Seckeler MD, Barber BJ, Colombo JN, Bernardi AM, ... Andrews JG, Klewer SE
In the pediatric population, exercise capacity differs between females and males and the gap widens through adolescence. However, specific age- and sex-based changes in adolescents with congenital heart disease and Fontan palliation have not been reported. The purpose of the current study is to identify age- and sex-specific changes in exercise performance at peak and ventilatory anaerobic threshold (AT) for adolescents with Fontan physiology. Retrospective review of the Pediatric Heart Network Fontan cross sectional study (Fontan 1) public use dataset. Comparisons were made for peak and AT exercise parameters for females and males at 2-year age intervals. In addition, normative values were generated by sex and age at 2-year intervals. χ2 test was used for comparison for categorical variables. Changes in exercise parameters between age groups by sex were compared by ANOVA with post-hoc analysis. Exercise testing was performed in 411 patients. AT was reached in 317 subjects (40% female), of whom, 166 (43% female) reached peak exercise. Peak oxygen consumption decreased 32% through adolescence in females and did not have the typical increase through adolescence for males. Oxygen consumption at AT also decreased with age in both sexes. In conclusion, age- and sex-based exercise performance for adolescents with Fontan physiology are predictably low, but there are additional significant decreases through adolescence for this population, especially in females. We have established normative exercise values for several parameters for this population which will better identify at risk patients and allow for earlier intervention.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Seckeler MD, Barber BJ, Colombo JN, Bernardi AM, ... Andrews JG, Klewer SE
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757789
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Abstract

Comparison of Metoprolol Versus Carvedilol After Acute Myocardial Infarction.

Zaatari G, Fintel DJ, Subacius H, Germano JJ, ... Goldberger JJ, Outcomes of Beta-blocker Therapy After myocardial INfarction (OBTAIN) Investigators
Beta-blockers are typically prescribed following myocardial infarction (MI), but no specific beta-blocker is recommended. Of 7,057 patients enrolled in the OBTAIN multi-center registry of patients with acute MI, 4142 were discharged on metoprolol and 1487 on carvedilol. Beta-blocker dose was indexed to the target daily dose used in randomized clinical trials (metoprolol-200 mg; carvedilol-50 mg), reported as %. Beta-blocker dosage groups were >0% to12.5% (n = 1,428), >12.5% to 25% (n = 2113), >25% to 50% (n = 1,392), and >50% (n = 696). The Kaplan-Meier method was used to calculate 3-year survival. Correction for baseline differences was achieved by multivariable adjustment. Patients treated with carvedilol were older (64.4 vs 63.3 years) and had more comorbidities: hypertension, diabetes, prior MI, congestive heart failure, reduced left ventricular ejection fraction, and a longer length of stay. Mean doses for metoprolol and carvedilol did not significantly differ (37.2 ± 27.8% and 35.8 ± 31.0%, respectively). The 3-year survival estimates were 88.2% and 83.5% for metoprolol and carvedilol, respectively, with an unadjusted HR = 0.72 (p <0.0001), but after multivariable adjustment HR = 1.073 (p = 0.43). Patients in the >12.5% to 25% dose category had improved survival compared with other dose categories. Subgroup analysis of patients with left ventricular ejection fraction ≤40%, showed worse survival with metoprolol versus carvedilol (adjusted HR = 1.281; 95% CI: 1.024 to 1.602, p = 0.03). In patients with left ventricular ejection fraction >40%, there were no differences in survival with carvedilol versus metoprolol. In conclusion, overall survival after acute MI was similar for patients treated with metoprolol or carvedilol, but may be superior for carvedilol in patients with left ventricular ejection fraction ≤40%.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Zaatari G, Fintel DJ, Subacius H, Germano JJ, ... Goldberger JJ, Outcomes of Beta-blocker Therapy After myocardial INfarction (OBTAIN) Investigators
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33621525
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Abstract

Long-Term Outcomes and Valve Performance in Patients Undergoing Transcatheter Aortic Valve Implantation.

Stathogiannis K, Synetos A, Latsios G, Karanasos A, ... Tsioufis C, Toutouzas K
Transcatheter aortic valve implantation (TAVI) is an established method for treating patients with aortic valve stenosis. We sought to determine the long-term clinical outcomes and performance of a self-expanding bioprosthesis beyond 5 years. Consecutive patients scheduled for TAVI were included in the analysis. Primary end points were all-cause and cardiovascular mortality, structural valve deterioration (SVD) and bioprosthetic valve failure (BVF), based on the VARC-2 criteria and consensus statement by ESC/EAPCI. The study prospectively evaluated 273 patients (80.61 ± 7.00 years old, 47% females) who underwent TAVI with CoreValve/Evolut-R (Medtronic Inc.). The median follow-up duration was 5 years (interquartile range: 2.9 to 6; longest: 8 years). At 1, 5, and 8 years, estimated survival rates were 89.0%, 61.1%, and 56.0%, respectively, while cardiovascular mortality was 8% at the end of follow-up. Regarding valve performance, 5% of patients had early BVF and 1% had late BVF. Concerning SVD, 16 patients (6% of the total population) had moderate SVD (91% had an increase in mean gradient), with no severe SVD cases. Five patients with SVD died during follow-up. Actual analysis of the 8-year cumulative incidence of function of moderate SVD was 5.9% (2.5% to 16.2%). At multivariate analysis, the factor that emerged as an independent predictor for future SVD, was smaller bioprosthetic valve size (HR 0.58, 95% CI 0.41 to 0.82, p = 0.002). Long-term evaluation beyond 5 years after TAVI with a self-expanding bioprosthesis demonstrated low rates of cardiovascular mortality and structural valve deterioration. Valve size was an independent predictor for SVD.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Stathogiannis K, Synetos A, Latsios G, Karanasos A, ... Tsioufis C, Toutouzas K
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33621524
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Abstract

Sex-Based Differences in Prevalence and Outcomes of Common Acute Conditions Associated With Type 2 Myocardial Infarction.

Mohamed MO, Contractor T, Abramov D, Parwani P, ... Bagur R, Mamas MA
Little is known about the association between acute prevalent conditions in patients with type 2 Myocardial Infarction (T2MI) and clinical outcomes, particularly between genders. Using the Nationwide Inpatient Sample (2017), we examined outcomes of T2MI in patients stratified by prevalent associated conditions (renal failure, decompensated heart failure, infection, acute respiratory failure, cardiac arrhythmias, bleeding) and gender. Multivariable logistic regression was performed to assess the odds ratios (OR) of in-hospital all-cause mortality in each of the study groups. A total of 38,715 T2MI patients were included in the analysis, of which 47.9% (n = 18,540) were females. Renal failure was the most common prevalent condition in both genders (males: 60%; females: 52.6%). Acute respiratory failure was associated with the greatest odds of mortality (OR 5.46, 95% confidence interval (CI) 5.02 to 5.94) when compared with other conditions: renal failure (OR 2.20 95% CI 2.01 to 2.40), infections (OR 2.96 95% CI 2.72 to 3.21), major bleeding (OR 1.71 95% CI 1.52 to 1.93), arrhythmias (OR 1.30 95% CI 1.19 to 1.43) and decompensated heart failure (OR 0.71, 95% CI 0.65 to 0.77). However, there was no difference in mortality between genders for all acute conditions except renal failure (females OR: 1.02, 95% CI 1.02 to 1.02, p = 0.011). In conclusion, in-hospital mortality after T2MI differs according to the underlying acute condition, with acute respiratory failure being associated with the highest rate of mortality. No significant differences in mortality were observed between genders amongst all prevalent acute conditions, with the exception of renal failure which was marginally higher in females.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Mohamed MO, Contractor T, Abramov D, Parwani P, ... Bagur R, Mamas MA
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33621523
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Abstract

Cardiovascular Outcomes According to Polypharmacy and Drug Adherence in Patients with Atrial Fibrillation on Long-Term Anticoagulation (from the RE-LY Trial).

Millenaar D, Schumacher H, Brueckmann M, Eikelboom JW, ... Yusuf S, Böhm M
Prevalence of atrial fibrillation (AF) increases with age, along with comorbidities and, thus, polypharmacy. Non-adherence is associated with polypharmacy. This study aimed to identify patients at risk for cardiovascular events according to their pharmacological treatment intensity and adherence. Patients (n=18,113) with a mean age of 71.5±8.7 years, at high cardiovascular risk were followed between December 2005 until December 2007 for a median time of 2 years. The association between polypharmacy and adherence and their impact on cardiovascular and bleeding events were explored. Adherence was defined as a study drug intake of ≥80%. Patients with more co-medications had a higher body mass index, higher prevalence of hypertension, coronary heart disease, heart failure, and diabetes mellitus (all p<0.0001) compared to ≤4 or 5-8 co-medications, but no differences in history of stroke (p=0.68) or transient ischemic attack (p=0.065). Across all treatments, the adjusted hazard ratios (HRs) increased in patients with more co-medications (>=9 vs <=4) for all-cause death (HR 1.30; 1.06-1.59), major bleeding (HR 1.65; 1.33-2.05), and all bleeding events (HR 1.44; 1.31-1.59). Yearly event rates were higher in non-adherent than adherent patients for stroke and systemic embolism (SSE) (3.14 vs 1.00), all-cause death (7.76 vs. 2.66), major bleeding (6.21 vs. 2.65), and all bleeding (28.71 vs. 19.05; all p<0.0001). After an event the patients were more likely to become non-adherent (adherence after SSE 30.3%, after major bleeding 33.4%, after all bleeding 66.7%; all p<0.0001). The treatment effects were consistent to the overall group in the different polypharmacy groups. In conclusion, polypharmacy and non-adherence are risk indicators for increased adverse cardiovascular and bleeding events. Dabigatran is safe to use across the full spectrum of AF patients, independent of the number of co-medications and adherence. Patients with co-medications and comorbidities require special attention and encouragement to adhere to oral anticoagulation.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Millenaar D, Schumacher H, Brueckmann M, Eikelboom JW, ... Yusuf S, Böhm M
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757788
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Abstract

Peripheral Oxygen Extraction and Exercise Limitation in Asymptomatic Patients with Diabetes Mellitus.

Kobayashi Y, Christle JW, Contrepois K, Nishi T, ... Palaniappan L, Haddad F
Patients with diabetes mellitus (DM) frequently present reduced exercise capacity. We aimed to explore the extent to which peripheral extraction relates to exercise capacity in asymptomatic patients with DM. We prospectively enrolled 98 asymptomatic patients with type-2 DM (mean age of 59±11 years and 56% male sex), and compared with 31 age, sex and body mass index (BMI)-matched normoglycemic controls. Cardiopulmonary exercise testing (CPX) with resting echocardiography was performed. Exercise response was assessed using peak oxygen uptake (peak VO2) and ventilatory efficiency was measured using the slope of the relationship between minute ventilation and carbon dioxide production (VE/VCO2). Peripheral extraction was calculated as the ratio of VO2to cardiac output. Cardiac function was evaluated using left ventricular longitudinal strain (LVLS), E/e\', and relative wall thickness (RWT). Among patients with DM, 26 patients (27%) presented reduced percent-predicted-peak VO2(<80%) and 18 (18%) presented abnormal VE/VCO2slope (>34). There was no significant difference in peak cardiac output; peripheral extraction was lower in patients with DM compared to controls. Higher peak E/e\' (beta=-0.24, p=0.004) was associated with lower peak VO2along with age, sex and BMI (R2=0.53). A network correlation map revealed the connectivity of peak VO2as a central feature and cluster analysis found LVLS, E/e\', RWT and peak VO2in different clusters. In conclusion, impaired peripheral extraction may contribute to reduced peak VO2in asymptomatic patients with DM. Furthermore, cluster analysis suggests that CPX and echocardiography may be complementary for defining subclinical heart failure in patients with DM.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Kobayashi Y, Christle JW, Contrepois K, Nishi T, ... Palaniappan L, Haddad F
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757787
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Abstract

Sex Differences in Coronary Arterial Calcification in Symptomatic Patients.

Kim BS, Chan N, Hsu G, Makaryus AN, ... Cohen S, Makaryus JN
Despite the increasing use of Coronary Artery Calcium (CAC) scoring for cardiovascular risk stratification in asymptomatic patients, the gender differences in CAC among symptomatic patients have not been well evaluated. We analyzed patients presenting to the emergency department (ED) with chest pain suggesting possible coronary artery disease (CAD) who received coronary computed tomography angiography (CCTA). Ordinal logistic regression was used to determine the odds ratio for the association of traditional cardiovascular risk factors and CAC. Patients with a CAC score ≥ 100 were followed for cardiovascular events or changes in medical management. Our cohort included 542 individuals (263 male, 279 female). Ordinal logistic regression model showed that among traditional cardiovascular risk factors, male sex had the highest odds ratio (OR) of 3.04 (p < 0.001, 95% CI [2.01, 4.59]) for the presence of CAC. Also, males had more diffuse distribution of coronary atherosclerosis (p=0.01). Subgroup analysis revealed that obesity was a bigger risk factor in male patients (OR 2.16), while smoking showed the greatest effect (OR 4.27) on CAC in women. Of patients who had CAC > 100 with an average follow-up of 346 days, there was an increase in both aspirin and statin use, yet significant sex differences were observed especially in patients with non-obstructive lesions on CCTA. Among male patients with non-obstructive lesions, 68.2% were on aspirin and 86.4% were on statin therapy after the CCTA compared to 27.3% and 45.5% respectively in their female counterparts. In conclusion, sex not only is the most powerful predictor for higher CAC among traditional cardiovascular risk factors in symptomatic patients but also influences the contribution of various traditional risk factors to elevated CAC. Furthermore, the discovery of CAD led to the initiation of medical therapy in male patients more frequently than in female patients, even after adjusting for the degree of luminal stenosis detected on coronary CT angiography.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Kim BS, Chan N, Hsu G, Makaryus AN, ... Cohen S, Makaryus JN
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757786
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Abstract

Impact of Chronic Obstructive Pulmonary Disease in Heart Failure with Preserved Ejection Fraction.

Jain S, Obeid MJ, Yenigalla S, Paravathaneni M, ... Akers S, Chirinos J
COPD often coexists with HFpEF, but its impact on cardiovascular structure and function in HFpEF is incompletely understood. We aimed to compare cardiovascular phenotypes in patients with Chronic Obstructive Pulmonary Disease (COPD), Heart Failure with Preserved Ejection Fraction (HFpEF), or both. We studied 159 subjects with COPD alone (n=48), HFpEF alone (n=79) and HFpEF + COPD (n=32). We used MRI and arterial tonometry to assess cardiac structure and function, thoracic aortic stiffness, and measures of body composition. Relative to participants with COPD only, those with HFpEF with or without COPD exhibited a greater prevalence of female sex and obesity, whereas those with HFpEF + COPD were more often African-American. Compared to the other groups, participants with HFpEF and COPD demonstrated a more concentric LV geometry (LV wall-cavity ratio 1.2, 95%CI: 1.1-1.3; p=0.003), a greater LV mass (67.4, 95%CI: 60.7-74.2; p=0.03, and LV extracellular volume (49.4, 95%CI: 40.9-57.9; p=0.002). Patients with comorbid HFpEF + COPD also exhibited greater thoracic aortic stiffness assessed by pulse-wave velocity (11.3, 95% CI: 8.7-14.0 m/s; p=0.004) and pulsatile load imposed by the ascending aorta as measured by aortic characteristic impedance (139 dsc; 95%CI=111-166; p=0.005). Participants with HFpEF, with or without COPD, exhibited greater abdominal and pericardial fat, without difference in thoracic skeletal muscle size. In conclusion, individuals with co-morbid HFpEF and COPD have a greater degree of systemic large artery stiffening, LV remodeling, and LV fibrosis than those with either condition alone.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Jain S, Obeid MJ, Yenigalla S, Paravathaneni M, ... Akers S, Chirinos J
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757785
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Abstract

Trends in Acute Myocarditis Related Pediatric Hospitalizations in the United States, 2007-2016.

Vasudeva R, Bhatt P, Lilje C, Desai P, ... Dapaah-Siakwan F, Yagnik P
There has been little exploration of acute myocarditis trends in children despite notable advancements in care over the past decade.  We explored trends in pediatric hospitalizations for acute myocarditis from 2007-2016 in the United States (US). This was a retrospective, serial cross-sectional study of the National Inpatient Sample database from 2007 to 2016, identifying patients ≤18 years hospitalized with acute myocarditis. Patient demographics and incidence trends were examined. Other relevant clinical and resource utilization outcomes were also explored. Out of 60,390,000 weighted pediatric hospitalizations, 6371 were related to myocarditis. The incidence of myocarditis increased from 0.7 to 0.9 per 100,000 children (p<0.0001) over the study period. The mortality decreased from 7.5% to 6.1% (p=0.02). A significant inflation-adjusted increase by $4,574 in the median hospitalization cost was noted (p=0.02) while length of stay (LOS) remained stable (median 6.1 days). Tachyarrhythmias were identified as the most common type of associated arrhythmia. The occurrence of congestive heart failure (CHF) remained steady at 27%. In conclusion, in-hospital mortality associated with pediatric acute myocarditis has decreased in the United States over years 2007-2016 with a concurrent rise in incidence. Despite steady length of stay, hospitalization costs have increased. Future studies investigating long-term outcomes relating to acute myocarditis are warranted.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Vasudeva R, Bhatt P, Lilje C, Desai P, ... Dapaah-Siakwan F, Yagnik P
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757784
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Abstract

Effect of Corticosteroid Therapy in Patients with Cardiac Sarcoidosis on Frequency of Venous Thromboembolism.

Kolluri N, Elwazir MY, Rosenbaum AN, Maklady FA, ... McBane RD, Bois JP
Sarcoidosis is a multisystem inflammatory condition with occasional cardiac involvement (CS), which may be associated with risk of venous thromboembolism (VTE). As data on VTE in CS are sparse and corticosteroid therapy has not been previously examined, we aim to determine the association between CS, corticosteroid treatment for CS, and VTE. Patients referred to our institution with concern for sarcoidosis and underwent a positron emission tomography (PET) scan were retrospectively assessed. Chi-squared and multivariate regression analyses were conducted to determine the association between a diagnosis of sarcoidosis, CS, corticosteroid use, and VTE events. Six hundred and forty nine patients were split into three categories: 235 with no sarcoidosis (NS), 91 with extra-cardiac sarcoidosis only (ECS), and 323 with CS (isolated CS and/or CS with extra cardiac sarcoid). Thirty nine CS, 7 ECS, and 9 NS patients developed PE while 44 CS, 3 ECS, and 18 NS patients developed DVT. On multivariate regression, neither CS nor ECS was an independent risk factor for VTE (p>0.05) but corticosteroid use was independently associated with VTE (HR 3.06, p=0.007 for PE, HR 6.21, p<0.0001 for DVT). On logistic regression analysis, corticosteroid dose was found to be independently associated with both PE (p=0.001) and DVT (p=0.007). Optimal threshold for defining VTE risk with corticosteroid therapy was a prednisone-equivalent dose of 17.5 mg. In conclusion, contrary to previous studies, this current study found that neither sarcoidosis nor CS is an independent risk factor for VTE. Rather, corticosteroid therapy was associated with an increased risk of VTE.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Kolluri N, Elwazir MY, Rosenbaum AN, Maklady FA, ... McBane RD, Bois JP
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757783
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Abstract

The Burden of Radiation Exposure During Transcatheter Closure of Atrial Septal Defect.

Harrison DJ, Shirley L, Michaud J, Rivera J, ... Bergersen L, Maschietto N
Radiation reduction in the pediatric cardiac catheterization laboratory is well-suited for targeted quality improvement (QI) interventions. Transcatheter atrial septal defect (ASD) closure was chosen for this QI project based on a homogenous procedural population and inter-operator variability in radiation usage, with the aim to reduce radiation exposure during ASD device closure by 50% over 1 year. The aim for this project was defined and a Key Driver Diagram (KDD) was created with three domains for change: modification of procedural practice, reporting and monitoring/feedback, and team engagement. All patients undergoing attempted transcatheter ASD closure were considered for inclusion. The primary outcome, % reduction in median radiation dose (DAP/Kg), was determined through comparison with a historical cohort. Additional radiation metrics, procedural characteristics, and adverse events (AE) were compared to the historical cohort. Radiation exposure (DAP/kg) was reduced by 55% with a median dose reduction from 26 (15, 61) in a historical cohort to 12 (6, 22) in the intervention population (p <0.001). Fluoroscopy time and cine acquisition utilization significantly decreased. Procedure time, procedural success (defined as successful delivery of the device) and AE did not increase in the QI cohort. Successful practice changes included standardized procedural strategies to limit fluoroscopy and cine acquisition, improved fluoroscopic practice, engagement of the multidisciplinary team, and feedback with data reporting by electronic and in-person reminders. In conclusion, application of QI methodologies such as KDD with engagement of a multidisciplinary team can effectively reduce radiation in the pediatric catheterization laboratory.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Harrison DJ, Shirley L, Michaud J, Rivera J, ... Bergersen L, Maschietto N
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757782
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Abstract

Pre-operative Continued Oral Anticoagulation Impact on Early Outcomes After Transcatheter Aortic Valve Implantation.

Tagliari AP, Perez-Camargo D, Ferrari E, Haager PK, ... Maisano F, Taramasso M
Considering that there is a lack of evidence and guideline-based recommendations on the best preoperative anticoagulation management (OAC) for transcatheter aortic valve implantation (TAVI), this cohort study aimed to evaluate bleeding, access site complications, and early safety in patients undergoing TAVI on continued OAC therapy vs. no-OAC therapy. Three-hundred forty-four patients submitted to a TAVI procedure (66.3% no-OAC vs. 33.7% OAC) were consecutively enrolled. Primary endpoint was defined as in-hospital VARC-2 life-threatening or disabling bleeding. Secondary endpoints were in-hospital VARC-2 major vascular complications, and VARC-2 early safety at 30 days. Propensity score matching analysis was performed to reduce potential distribution bias, resulting in 2 well-balanced groups (92 patients in each arm). In the overall cohort, mean age, median EuroScore II, and STS-score were 78.7±7.6, 2.9 (1.7-5.9), and 2.3 (1.6-3.6), respectively. Despite being older (78±8 vs. 80±6, p=0.004) and having higher STS score (2.1 vs. 2.6, p=0.001), patients on OAC had similar incidence of in-hospital VARC-2 life-threatening or disabling bleeding (1.3% vs. 0.9%, p=0.711), major vascular complications (4.8% vs. 5.2%, p=0.888), and VARC-2 early safety at 30 days (10.1% vs. 12.1%, p=0.575). No significant differences in the main outcomes were observed when propensity score matching was applied. In conclusion, the management of patients on OAC submitted to a TAVI procedure is challenging and requires balancing the risk of bleeding with the risk of thromboembolic events. The present study suggests that continued OAC was not associated with increased in-hospital VARC-2 life-threatening or disabling bleeding, major vascular complications, and VARC-2 early safety at 30 days.

Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Tagliari AP, Perez-Camargo D, Ferrari E, Haager PK, ... Maisano F, Taramasso M
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757781
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Abstract

Patient and Provider Perspectives on Remote Monitoring of Pacemakers and Implantable Cardioverter-Defibrillators.

Fraiche AM, Matlock DD, Gabriel W, Rapley FA, Kramer DB
The use of remote monitoring technology for cardiovascular electronic implantable devices has grown significantly in recent decades, yet several key questions about its integration into clinical care remain. We performed semi-structured interviews of patients, clinicians, and device clinic technicians involved in clinical remote monitoring of cardiovascular implantable devices at our institution. Twenty-eight interviews comprised of 15 patients and 13 clinicians were conducted from October 2019 through February 2020. Interview transcripts were analyzed using a mixed inductive and deductive approach. Perspectives among clinicians and patients varied regarding familiarity, educational experiences, and preferences regarding how remote monitoring data are handled. Three key domains emerged including knowledge and understanding, managing alerts, and cost transparency. Within these domains, key findings included identifying very limited understanding of how remote monitoring functions and how alerts in particular are handled. These knowledge deficits (patients and providers) appeared to arise in part from different equipment and platforms among manufacturers, the complexity of the technology, and lack of formalized education in remote monitoring. However, interviewees expressed generally high levels of trust in the technology and care systems supporting remote monitoring. Few respondents described concerns around cybersecurity, but patients in particular did raise concerns about cost transparency and frequent billing. In conclusion, conflicting perceptions around remote monitoring persist and indicate important knowledge gaps despite high trust in the care pathway. This qualitative analysis offers insight into patient and clinician understanding of and attitudes toward remote monitoring to guide future efforts to improve education and patient-centeredness of remote monitoring.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Mar 2021; epub ahead of print
Fraiche AM, Matlock DD, Gabriel W, Rapley FA, Kramer DB
Am J Cardiol: 19 Mar 2021; epub ahead of print | PMID: 33757780
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Abstract

Long-Term Prognostic Value of the Society of Thoracic Surgery Risk Score in Patients Undergoing Transcatheter Aortic Valve Implantation (From the OCEAN-TAVI Registry).

Ishizu K, Shirai S, Isotani A, Hayashi M, ... Hayashida K, OCEAN-TAVI Investigators
The Society of Thoracic Surgeons (STS) risk model, designed to predict operative mortality after cardiac surgery, is often used for the risk assessment of patients considered for transcatheter aortic valve implantation (TAVI). We investigated the long-term prognostic value of the STS score by utilizing the data of 2588 patients undergoing TAVI from the OCEAN (Optimized CathEter vAlvular iNtervention)-TAVI Japanese multicenter registry. The patients were divided into 3 groups according to their pre-procedural STS score as follows: low-risk (STS score <4%, n = 467 [18%]), intermediate-risk (4%≤ STS score <8%, n = 1200 [46.4%]), and high-risk (8%≤ STS score, n = 921 [35.6%]). Low-risk patients were younger and were more frequently male. The prevalence of most of the comorbidities were higher in high-risk patients, while active cancer was more frequent in low-risk patients (P <0.001).The cumulative 4-year all-cause mortality rates were higher in high-risk patients (49.0%) but comparable in low-risk (22.6%) and intermediate-risk patients (28.7%) (hazard ratio [HR] for intermediate-risk versus low-risk, 1.03; 95% confidence interval [CI], 0.77 to 1.37; P = 0.85; HR for high-risk versus low-risk, 2.27; 95% CI 1.72 to 2.99; P = <0.001). Similarly, the cumulative 4-year cardiovascular mortality rates were higher in high-risk patients (20.5%) but comparable in low-risk (9.9%) and intermediate-risk patients (10.3%) (HR for intermediate-risk versus low-risk, 1.10; 95% CI, 0.68 to 1.77; P = 0.69; HR for high-risk versus low-risk, 2.33; 95% CI 1.48 to 3.67; P = <0.001). After adjustment for several confounders, STS score ≥8% was independently associated with increased long-term mortality (HR, 1.35; 95% CI, 1.08 to 1.68). In conclusion, the risk stratification according to STS score demonstrated an increased risk of long-term mortality after TAVI in high-risk patients, albeit with comparable risks in intermediate- and low-risk patients.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Ishizu K, Shirai S, Isotani A, Hayashi M, ... Hayashida K, OCEAN-TAVI Investigators
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753041
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Abstract

Electrophysiological Study-Guided Permanent Pacemaker Implantation In Patients With Conduction Disturbances Following Transcatheter Aortic Valve Implantation.

Bourenane H, Galand V, Boulmier D, Leclercq C, ... Breton HL, Auffret V
Conduction disturbances remain common following transcatheter aortic valve implantation (TAVI). Aside from high-degree atrioventricular block (HAVB), their optimal management remains elusive. Invasive electrophysiological studies (EPS) may help stratify patients at low or high risk of HAVB allowing for an early discharge or permanent pacemaker (PPM) implantation among patients with conduction disturbances. We evaluated the safety and diagnostic performances of an EPS-guided PPM implantation strategy among TAVI recipients with conduction disturbances not representing absolute indications for PPM. All patients who underwent TAVI at a single expert center from June 2017 to July 2020 who underwent an EPS during the index hospitalization were included in the present study. False negative outcomes were defined as patients discharged without PPM implantation who required PPM for HAVB within 6 months of the initial EPS. False positive outcomes were defined as patients discharged with a PPM with a ventricular pacing percentage < 1% at follow-up. A total of 78 patients were included (median age: 82.4 years, 38% female), among whom 35 patients (45%) received a PPM following EPS. The sensitivity, specificity, positive and negative predictive values of the EPS-guided PPM implantation strategy were 100%, 89.6%, 81.5%, and 100%, respectively. Six patients suffered a mechanical HAVB during EPS and received a PPM. These 6 patients showed PPM dependency at follow-up. In conclusion, an EPS-guided PPM implantation strategy for managing post-TAVI conduction disturbances appears effective to identify patients who can be safely discharged without PPM implantation.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Bourenane H, Galand V, Boulmier D, Leclercq C, ... Breton HL, Auffret V
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753040
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Abstract

The Cardiovascular Physical Examination - Is It Still Relevant?

Lekic M, Lekic V, Riaz IB, Mackstaller L, Marcus FI
Advances in technology have reshaped the practice of medicine. These changes have greatly benefited our patients. However, in the setting of these advances, the importance of basic clinical tools is more pertinent than ever. Despite the growing reliance on technology, the physical exam remains valuable and cost effective, often enabling the well-trained clinician to arrive at the diagnosis, rapidly and accurately. The physical exam must not become a relic of a distant past. We aim to investigate current competency and proficiency, proposals for change in teaching curriculums, and the relationship with technology such as hand-held echocardiography. A skillful exam provides both emotional and intellectual satisfaction. It may be a lost art but it is well worth the effort to restore.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Lekic M, Lekic V, Riaz IB, Mackstaller L, Marcus FI
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753042
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Abstract

Pre-Diabetic Patient Outcomes 8-15 Years after Drug-Eluting Coronary Stenting.

Ellis SG, Cho L, Raymond R, Nair R, ... Lincoff AM, Kapadia S
Guidelines suggest differential management of diabetics and non-diabetics with coronary artery disease (CAD) referred for revascularization, but pre-diabetics, who now comprise up to 20-30% of CAD patients, have been excluded from the diabetic group. To address this, we studied long-term cardiac outcomes in 1323 consecutively drug-eluting stent (DES)-stented patients from pre-specified local zip codes, dividing patients into normal-glycemic patients, pre-diabetics and diabetics, based upon conventional definitions. Patient age was 63±11 years, 65.5% male, mean baseline SYNTAX score of 10.2±6.8 and residual SYNTAX score = 3.0±4.6. Only 2.9% of patients were lost to follow up at 10 years. Duration of follow up for alive patients was 124±33 mos. Major adverse cardiac events (MACE) by Kaplan Meier (KM) was similar for normal glycemics and pre-diabetics (42.9±2.5% vs 38.6±3.1% at 10 years, p=0.35), whereas that for diabetics was worse (56.7±2.6% at 10 years, p<0.001 vs pre-diabetics). KM cardiac death rates at 10 years were 14.2±1.8%, 16.0±2.4% and 31.2±2.3% for normal glycemics, pre-diabetics and diabetics, respectively (p=0.34 and p<0.001 [covariate adjusted p=0.018] for pre-diabetics versus normal glycemics and versus diabetics, respectively). We found that pre-diabetics have long-term post-DES outcomes far more similar to those of normal-glycemic patients than diabetics.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Ellis SG, Cho L, Raymond R, Nair R, ... Lincoff AM, Kapadia S
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753039
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Abstract

Role of the Ambulatory Assessed Apnea-Hypopnea Index for Predicting Recurring Atrial Fibrillation After Ablation Therapy.

Trenkwalder T, Grebmer C, Tydecks M, Blažek P, ... Deisenhofer I, Kolb C
Catheter ablation is an effective treatment for atrial fibrillation (AF). Obstructive sleep apnea (OSA) is a known risk factor for recurrent AF. The apnea-hypopnea index (AHI) is a measurement tool to screen patients for OSA. We sought to evaluate if the ambulatory assessed AHI is associated with AF recurrence following AF catheter ablation. 187 patients with paroxysmal (n=155) or early persistent (n=32) AF presenting for catheter ablation were included in the study. AHI was determined prior to ablation using an ambulatory screening device. All patients underwent pulmonary vein isolation (PVI). In patients with early persistent AF (17%) additional ablation of complex fractionated atrial electrograms (CFAE) was performed. Clinical follow-up was available after 3 and 12 months including 7-day Holter-ECG. All 187 patients (60.3±11.4 years, 64.2% male) completed the 3 months follow-up and 170 patients the 12 months follow-up. A pathological AHI≥15 was found in 45/187 (24.1%) patients. Additional CFAE did not differ between patients with an AHI≥15 and AHI<15 (p=0.663). After 3 months, 12/41 (29.3%) patients with AHI≥15 showed recurrent AF compared to 24/146 (16.4%) patients with AHI<15 (p=0.066). After 12 months, AHI≥15 was associated with a significant higher rate of AF recurrence of 47.4% (18/38) versus 26.5% (35/132) in patients with AHI<15 (p=0.014). In the logistic regression analysis AHI≥15 was an independent predictor of recurrent AF at 12 months (p=0.011). In conclusion, ambulatory assessed AHI≥15 is associated with increased risk for AF recurrence following catheter ablation. OSA screening should be performed in AF patients as it might influence catheter ablation success.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Trenkwalder T, Grebmer C, Tydecks M, Blažek P, ... Deisenhofer I, Kolb C
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753038
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Abstract

Malignant Ventricular Tachycardia, Ventricular Wall Ablation, and Orthotopic Heart Transplantation.

Roberts WC, Kietzman AT, Rao PK
Described herein are 3 patients with refractory ventricular tachycardia and one or more unsuccessful ablation procedures finally leading to orthotropic heart transplantation (OHT). The latter procedure allowed examination of the ventricular ablation sites, an unusual opportunity reported previously in few patients (all case reports). The acute ablation lesions are unique, with necrosis of the myocardial fibers adjacent to the endocardium and encircled by layers of extravasated erythrocytes in the deeper myocardial wall. All 3 patients returned to normal activities following the OHT.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Roberts WC, Kietzman AT, Rao PK
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753037
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Abstract

Ten-year Mortality in Patients with ST-Elevation Myocardial Infarction.

Watanabe N, Takagi K, Tanaka A, Yoshioka N, ... Morishima I, Murohara T
Knowledge of the long-term prognosis (>10 years) and mortality predictors of ST-elevation myocardial infarction (STEMI) patients who have undergone primary percutaneous coronary intervention (p-PCI) is scarce. Therefore, this study evaluated the long-term prognosis and determined the predictors of long-term outcomes for STEMI patients after p-PCI. Between January 2006 and December 2010, we collected data and analyzed 459 consecutive patients with acute STEMI who underwent p-PCI and were discharged from the hospital (mean age, 66.8 years; male, 75.2%; peak creatine phosphokinase level, 2,292.5 IU/L). The primary endpoint was 10-year all-cause mortality. The cumulative 10-year incidence of all-cause death was 23.8%. The Cox multivariate regression analysis identified age ≧65 years (adjusted hazard ratio [aHR], p<0.001), body mass index (aHR, 0.93, p=0.033), presence of atrial fibrillation (aHR, 1.69, p=0.038), mineralocorticoid receptor antagonist use (aHR, 1.95, p=0.008), ejection fraction <40% (aHR, 2.14, p=0.005), and albumin <3.5 g/dL (aHR, 2.01, p=0.005) as independent predictors of all-cause mortality. In conclusion, a post-discharge 10-year survival rate of 76.2% was identified for STEMI patients who underwent p-PCI.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Watanabe N, Takagi K, Tanaka A, Yoshioka N, ... Morishima I, Murohara T
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753036
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Abstract

Usefulness of Antiplatelet Therapy After Transcatheter Aortic Valve Implantation.

Yerasi C, Forrestal BJ, Case BC, Ben-Dor I, ... Mintz GS, Waksman R
The rationale for dual antiplatelet therapy (DAPT) after transcatheter aortic valve implantation (TAVI) is to facilitate endothelialization of metallic struts of the transcatheter heart valve (THV) and to prevent thrombosis that could lead to thromboembolic events. Based on expert consensus, current societal guidelines recommend DAPT for 1 to 6 months after TAVI with weak evidence. Although the pivotal TAVI trials mandated this regimen, the evidence for the efficacy of DAPT to prevent THV thrombosis is limited to 3 small trials and a handful of observational studies. Multiple coronary trials have demonstrated that DAPT is associated with increased bleeding in comparison with single antiplatelet therapy, especially in elderly patients. TAVI patients are predominantly elderly and frequently have risk factors that predispose them to bleeding. Herein, we summarize the evidence for antiplatelet therapy after TAVI and explore the theoretical benefit of DAPT to prevent thromboembolic events versus the risk of increased bleeding.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Yerasi C, Forrestal BJ, Case BC, Ben-Dor I, ... Mintz GS, Waksman R
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753035
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Abstract

Effect of Availability of Transcatheter Aortic-Valve Implantation on Survival For All Patients with Severe Aortic Stenosis.

Chao A, Picard MH, Passeri JJ, Cui J, Nethery RC, Wasfy JH
Clinical outcomes for the overall severe aortic stenosis (AS) patient population are not well described because those medically managed are not included in procedural registries, and AS severity is not identifiable from administrative data. We aim to assess whether transcatheter aortic valve implantation (TAVI) availability has been associated with overall changes in survival for the whole AS patient population. This is important because patients with AS in real-world practice may differ from those included in randomized controlled trials, potentially attenuating the purported treatment efficacy estimated in trials. Classic severe AS patients (mean gradient ≥40 mmHg) were identified from an echocardiography database. Survival was defined as time since severe AS diagnosis until death. We first compared survival among all patients before and after TAVI availability in 2008. To further understand mechanism, we then assessed whether any survival changes were attributable to TAVI with extended Cox regression models comparing survival among TAVI, surgical aortic valve replacement (SAVR), and medically managed patients. 3663 classic severe AS patients were included in the study. Median survival years for all patients were greater during the TAVI-era than Pre-TAVI-era (>11.5 vs. 6.8, 5-year-HR=0.8, time-varying effect p<0.0001), and increased median survival was greatest for patients age 65-74 (>11.5 vs. 9.5, 5-year-HR=0.7, time-varying effect p=0.045). TAVI patients age 65-74 had the lowest risk of death compared to medically managed patients (HR=0.2, 95% CI=[0.1, 0.3], p<0.0001). In conclusion, in the TAVI-era, overall survival for patients with severe AS has doubled. This improvement is most marked for patients 65-74 years of age.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Mar 2021; epub ahead of print
Chao A, Picard MH, Passeri JJ, Cui J, Nethery RC, Wasfy JH
Am J Cardiol: 18 Mar 2021; epub ahead of print | PMID: 33753034
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Abstract

Outcome of Patients With Severe Aortic Stenosis and Normal Coronary Arteries Undergoing Transcatheter Aortic Valve Implantation.

Kuzo N, Stähli BE, Erhart L, Anwer S, ... Ruschitzka F, Tanner FC
Coronary artery disease and severe aortic stenosis (AS) often coexist. This study sought to investigate the impact of normal coronary arteries as negative risk marker in patients undergoing transcatheter aortic valve implantation (TAVI). Consecutive patients with severe AS undergoing TAVI were dichotomized according to the presence or absence of normal coronary arteries, defined as absence of coronary lesions with diameter stenosis ≥30% in vessels ≥1.5 mm in diameter on coronary angiogram in patients without prior coronary revascularization. The primary end point was 1-year mortality. Out of 987 patients with severe AS undergoing TAVI, 258 (26%) patients had normal coronary arteries. These patients were younger, more likely women, and had lower EuroSCORE II and STS risk scores. Although mortality at 30 days was similar in the normal coronary artery and the coronary atherosclerosis groups (3.1% vs 5.6%, p = 0.11), it was lower in those with normal coronary arteries at 1 year (8.9% vs 17%, p = 0.003). In multivariable analysis, the presence of normal coronary arteries on coronary angiogram independently predicted 1-year mortality (adjusted HR 0.57, 95% CI 0.37 to 0.90, p = 0.02). In conclusion, this study defined normal coronary arteries as negative risk marker in patients with severe AS undergoing TAVI.

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

Am J Cardiol: 14 Mar 2021; 143:89-96
Kuzo N, Stähli BE, Erhart L, Anwer S, ... Ruschitzka F, Tanner FC
Am J Cardiol: 14 Mar 2021; 143:89-96 | PMID: 33359230
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Abstract

Trends and Predictors of Transcatheter Aortic Valve Implantation Related In-Hospital Mortality (From the National Inpatient Sample Database).

Ullah W, Zahid S, Hamzeh I, Birnbaum Y, Virani SS, Alam M
Existing surgical aortic valve replacement risk models accurately predict the post- surgical aortic valve replacement morbidity and mortality, but factors associated with post transcatheter aortic valve Implantation (TAVI) mortality are not well known. The National Inpatient Sample was queried to identify all cases of TAVI. The association of baseline comorbidities with in-hospital mortality was determined using a binary logistic regression model to obtain adjusted odds ratios (aOR). A total of 161,049 patients underwent TAVI between 2010 and 2017. Of these, 157,151 (97.6%) survived while 3,898 (2.4%) died during hospitalization. The baseline characteristics of TAVI-survivors and non-survivors showed a significant amount of variation, including age (80 vs 82 years, p ≤ 0.0001) and female sex (46% vs 52%, p ≤ 0.0001), respectively. The non-survivors had significantly higher adjusted odds of renal failure requiring hemodialysis (aOR 2.59, 95% CI 2.24 to 2.99, p ≤ 0.0001), history of mediastinal radiation (aOR 2.71, 95% CI 1.02 to 7.20, p = 0.05), liver disease (aOR 3.04, 95% CI 2.63 to 3.51, p ≤ 0.0001), pneumonia (aOR 2.47, 95% CI 2.15 to 2.83, p ≤ 0.0001), cardiogenic shock (aOR 9.83, 95% CI 8.93 to 10.82, p ≤ 0.0001), ventricular tachycardia (aOR 2.12, 95% CI 1.88 to 2.40, p ≤ 0.0001), acute ST-elevation myocardial infarction (aOR 7.38, 95% CI 5.53 to 9.84, p ≤ 0.0001), stroke (aOR 2.25, 95% CI 1.99 to 2.54, p ≤ 0.0001), and acute infective endocarditis (aOR 5.74, 95% CI 3.65 to 9.02, p ≤ 0.0001) compared to TAVI-survivors. The yearly trend of mortality showed an increase in the absolute number of TAVI procedures and mortality but the yearly rate showed a decline in mortality after an initial peak during 2012.Patients with renal failure on dialysis, ST-elevation myocardial infarction, cardiogenic shock, infective endocarditis, liver disease and pneumonia have a higher rate of in-hospital mortality post TAVI.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:97-103
Ullah W, Zahid S, Hamzeh I, Birnbaum Y, Virani SS, Alam M
Am J Cardiol: 14 Mar 2021; 143:97-103 | PMID: 33359229
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Abstract

Comparison of Outcomes with or without Beta-Blocker Therapy After Acute Myocardial Infarction in Patients Without Heart Failure or Left Ventricular Systolic Dysfunction (from the Acute Coronary Syndromes Israeli Survey [ACSIS]).

El Nasasra A, Beigel R, Klempfner R, Alnsasra H, ... Blatt A, Zahger D
The contemporary benefit of routine beta-blocker therapy following myocardial infraction in the absence of heart failure or left ventricular systolic dysfunction is unclear. We investigated the impact of beta-blockers on post myocardial infarction outcome in patients without heart failure or left ventricular systolic dysfunction among patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys. MACE rates at 30 days and overall mortality at one year were compared among patients discharged on beta-blockers versus not, after multivariate analysis to adjust for baseline differences. Between the years 2000 to 2016, data from 15.211consecutive ACS patients were collected. Of 7,392 patients who met the inclusion criteria, 6007 (79.9%) were discharged on beta-blocker therapy. Prescription of beta-blockers at discharge increased modestly from 32% to 38% over the 16-year period. The 30-day MACE rates were similar in patients on vs. not on beta-blockers at discharge (9.0% and 9.5%, respectively). One year survival did not differ significantly between those on vs. not on beta-blockers (HR 0.8, 95% CI 0.58 to 1.11, p = 0.18).In conclusion, beta-blocker therapy did not affect 30 days MACE or 1-year survival after myocardial infarction in patients without heart failure or reduced ejection fraction.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:1-6
El Nasasra A, Beigel R, Klempfner R, Alnsasra H, ... Blatt A, Zahger D
Am J Cardiol: 14 Mar 2021; 143:1-6 | PMID: 33359228
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Impact:
Abstract

Effect of Sex on Outcomes of Coronary Rotational Atherectomy Percutaneous Coronary Intervention (From the European Multicenter Euro4C Registry).

Bouisset F, Ribichini F, Bataille V, Reczuch K, ... Carrié D, Euro4C Registry Investigators
Data regarding the potential influence of gender on outcomes of rotational atherectomy (RA) percutaneous coronary intervention (PCI) are scarce and conflicting. Using the Euro4C registry, an international prospective multicentric registry of RA PCI, we evaluated the influence of gender on clinical outcomes of RA PCI. Between October 2016 and July 2018, 966 patients were included. In them, 267 (27.6%) were females. Female patients were older than males (77.7 years old ± 9.8 vs 73.3 ± 9.5 years old respectively, p < 0.001) had a poorer renal function (43,1% of females had a GFR < 60 ml/min:1.73m² vs 30.4% of males, p < 0.001) and were more frequently admitted for an acute coronary syndrome (32.2% vs 22.3% p = 0.002). During RA procedure, women were less likely to be treated by radial approach (65.0% vs 74.4%, p = 0.004). In-hospital major adverse cardiac event rate-defined as cardiovascular death, myocardial infarction, stroke/transient ischemic attack, target lesion revascularization, and coronary artery bypass grafting surgery-was higher in the female group (7.1% vs 3.7%, p = 0.043). However, coronary perforation, dissection, slow/low flow and tamponade did not significantly differ in gender, neither did cardiovascular medications at discharge. At 1 year follow-up, rate of major adverse cardiac event was 18.4% in the female group vs 11.2% in the male group (adjusted Hazard Ratio 1.82 [1.24 to 2.67], p = 0.002). No significant bleeding differences were observed in gender, neither in hospital, nor during follow-up. In conclusion women had worse clinical outcomes following RA PCI during hospitalization and at 1 year follow-up than did men.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 14 Mar 2021; 143:29-36
Bouisset F, Ribichini F, Bataille V, Reczuch K, ... Carrié D, Euro4C Registry Investigators
Am J Cardiol: 14 Mar 2021; 143:29-36 | PMID: 33359202
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Abstract

Usefulness of Coronary Computed Tomographic Angiography to Evaluate Coronary Artery Disease in Radiotherapy-Treated Breast Cancer Survivors.

Tagami T, Almahariq MF, Balanescu DV, Quinn TJ, ... Franklin BA, Bilolikar A
Breast cancer is the most commonly diagnosed cancer in women and radiotherapy is a widely used treatment approach. However, there is an increased risk of coronary artery disease and cardiac death in women treated with radiotherapy. The present study was undertaken to clarify the relation between radiotherapy and coronary disease in women with previous breast irradiation using coronary computed tomographic angiography (CCTA). We conducted a retrospective analysis of women with a history of right or left-sided breast cancer (RBC; LBC) treated with radiotherapy who subsequently underwent CCTA. RBC patients who had reduced radiation doses to the myocardium served as controls. Patients (n = 6,593) with a history of nonmetastatic breast cancer treated with radiotherapy were screened for completion of CCTA; 49 LBC and 45 RBC women were identified. Age and risk factor matched patients with LBC had higher rates of coronary disease compared with RBC patients; left anterior descending (LAD) coronary artery (76% vs 31% [p < 0.001]), left circumflex (33% vs. 6.7% [p = 0.004]), and right coronary artery (37% vs 13% [p = 0.018]). Mean LAD radiation dose and mean heart dose strongly correlated with coronary disease, with a 21% higher incidence of disease in the LAD per Gy for mean LAD dose and a 95% higher incidence of disease in the LAD per Gy for mean heart dose. In conclusion, LBC patients treated with radiotherapy have a significantly higher incidence of coronary disease when compared with a matched group of patients treated for RBC. Radiation doses correlated with the incidence of coronary disease.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:14-20
Tagami T, Almahariq MF, Balanescu DV, Quinn TJ, ... Franklin BA, Bilolikar A
Am J Cardiol: 14 Mar 2021; 143:14-20 | PMID: 33359199
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