Journal: Am J Cardiol

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Abstract

Comparison of Clinical Characteristics, Natural History and Predictors of Disease Progression in Patients With Degenerative Mitral Stenosis Versus Rheumatic Mitral Stenosis.

Kuyama N, Hamatani Y, Okada A, Irie Y, ... Tsujita K, Izumi C
Mitral annular calcification (MAC) is a common echocardiographic finding and an increasingly recognized cause of degenerative mitral stenosis (DMS). However, little is known about the clinical characteristics and disease progression in DMS, particularly in comparison with rheumatic mitral stenosis (RMS). We retrospectively reviewed 203 consecutive patients with mitral stenosis (113 with DMS and 90 with RMS) who underwent echocardiography at our institution between January 2014 and December 2017. We compared the clinical characteristics and disease progression between the 2 groups. In addition, we analyzed the predictors of disease progression (defined as annual progression rate of a mean gradient >0 mm Hg/year) among patients with DMS. Patients with DMS were significantly older and had higher prevalence of atherosclerotic comorbidities than those with RMS. During the median follow-up period of 2.2 years, the annual progression rates were comparable (0.8 ± 0.8 mm Hg/year in DMS vs 1.0 ± 1.2 mm Hg/year in RMS; p = 0.32) and were highly variable (0.0 to 3.5 mm Hg/year in DMS and 0.0 to 5.5 mm Hg/year in RMS) within both groups among disease progression. In DMS patients, atherosclerotic comorbidities and lower initial mean gradient were significantly associated with disease progression even after adjustment by age and sex. There was no significant difference in the disease progression according to the circumferential MAC severity determined by echocardiography among DMS. In conclusion, DMS disease progression was slow but highly variable, similar to that of RMS. In patients with DMS, the baseline MAC severity did not correlate with disease progression, suggesting the importance of follow-up echocardiography regardless of the MAC severity.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:118-124
Kuyama N, Hamatani Y, Okada A, Irie Y, ... Tsujita K, Izumi C
Am J Cardiol: 14 Mar 2021; 143:118-124 | PMID: 33352211
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Abstract

Sudden Unexpected Death Due to Myocarditis in Young People, Including Athletes.

Harris KM, Mackey-Bojack S, Bennett M, Nwaudo D, Duncanson E, Maron BJ
Sudden deaths in young active people and athletes are distinctly uncommon and frequently related to highly visible cardiovascular conditions including hypertrophic cardiomyopathy and congenital coronary anomalies. Myocarditis is also a cause of sudden death in the young, but frequently under-recognized clinically, and therefore deserving of the present analysis. Two large registries were interrogated for cases of myocarditis, and clinical, demographic, and pathologic findings were assessed. Of 97 cases of myocarditis identified, ages were 19.3 ± 6.2 years, 76% male, and 58 were physically active at or near the time of death. Almost one-half of the 97 cases (47%) had a viral prodrome or symptoms (i.e., syncope, malaise, chest pain or palpitations). Nine were evaluated by cardiologists, but in none was a diagnosis of myocarditis established before death. The inflammatory cellular infiltrate was predominantly lymphocytic (67%), was most frequently multifocal (59%) and involved the conduction system (including atrioventricular node), 38%. In conclusion, myocarditis is an important but under-recognized cause of sudden death in young people including competitive athletes. Clinical diagnosis is difficult because symptoms are nonspecific and often ignored, requiring high index of suspicion for diagnosis. Our data support the ACC/AHA consensus guidelines recommending removal of individuals with myocarditis from competitive sports during recovery. Selective examination of conduction systems showed a number of cases with involvement of myocarditis, suggesting a novel mechanism for sudden death.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:131-134
Harris KM, Mackey-Bojack S, Bennett M, Nwaudo D, Duncanson E, Maron BJ
Am J Cardiol: 14 Mar 2021; 143:131-134 | PMID: 33347841
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Abstract

Chronotropic Response to Exercise Testing and the Risk of Stroke.

Jae SY, Heffernan K, Kurl S, Kunutsor SK, ... Savonen K, Laukkanen JA
Although the chronotropic response to exercise testing, defined as an inadequate heart rate response to incremental exercise to volitional fatigue, is associated with adverse cardiovascular outcomes, it remains unclear whether this response is related to the future risk of cerebrovascular events. We tested the hypothesis that the chronotropic response to exercise is associated with an increased risk of stroke in a general population. This prospective study was based on a population sample of 2,036 men aged 42 to 60 years in the Kuopio Ischemic Heart Disease cohort study. Chronotropic response to exercise was defined as the percentage of chronotropic index ([maximum heart rate - resting heart rate] / [220 - age - resting heart rate] × 100). Incident strokes were obtained from the Finnish national hospital discharge registry. During a median 27-year follow-up, 343 incident stroke (289 ischemic and 66 hemorrhagic) events occurred. Twelve events were diagnosed as both ischemic and hemorrhagic stroke. Comparing the bottom versus top quintile of chronotropic reserve, there was an increased risk of stroke (hazard ratio [HR] 1.73, 95% confidence Interval [CI]: 1.09 to 2.75) and ischemic stroke (HR 1.72, 95% CI, 1.04 to 2.85), but not hemorrhagic stroke (HR 2.23, 95% CI, 0.77 to 6.46) in analyses that adjusted for potential risk factors. These results suggest that an impaired chronotropic response to exercise is independently associated with a higher risk of total and ischemic stroke events in middle-aged men. The role of chronotropic incompetence during exercise testing as a potential prognostic indicator for stroke risk needs further investigation.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:46-50
Jae SY, Heffernan K, Kurl S, Kunutsor SK, ... Savonen K, Laukkanen JA
Am J Cardiol: 14 Mar 2021; 143:46-50 | PMID: 33347840
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Abstract

Is Aortic Z-score an Appropriate Index of Beneficial Drug Effect in Clinical Trials in Aortic Aneurysm Disease?

Elkinany S, Weismann CG, Curtis A, Smith T, ... Ziganshin BA, Elefteriades JA
Aortic Z-score (Z-score) is utilized in clinical trials to monitor the effect of medications on aortic dilation rate in Marfan (MFS) patients. Z-scores are reported in relation to body surface area and therefore are a function of height and weight. However, an information void exists regarding natural, non-pharmacological changes in Z-scores as children age. We had concerns that Z-score decrease attributed to \"therapeutic\" effects of investigational drugs for Marfan disease connective tissue diseases might simply reflect normal changes (\"filling out\" of body contour) as children age. This investigation studies natural changes with age in Z-score in normal and untreated MFS children, teasing out normal effects that might erroneously be attributed to drug benefit. (1) We first compared body mass index (BMI) and Z-scores (Boston Children\'s Hospital calculator) in 361 children with \"normal\" single echo exams in four age ranges (0 to 1, 5 to 7, 10 to 12, 15 to 18 years). Regression analysis revealed that aging itself decreases ascending Z-score, but not root Z-score, and that increase in BMI with aging underlies the decreased Z-scores. (2) Next, we examined Z-score findings in both \"normal\" and Marfan children (all pharmacologically untreated) as determined on sequential echo exams over time. Of 27 children without aortic disease with sequential echos, 19 (70%) showed a natural decrease in root Z-score and 24 (89%) showed a natural decrease in ascending Z- score, over time. Of 25 untreated MFS children with sequential echos, 12 (40%) showed a natural decrease in root Z-score and 10 (33%) showed a natural decrease in ascending Z-score. Thus, Z-score is over time affected by natural factors even in the absence of any aneurysmal pathology or medical intervention. Specifically, Z-score decreases spontaneously as a natural phenomenon as children age and with fill out their BMI. Untreated Marfan patients often showed a spontaneous decrease in Z-score. In clinical drug trials in aneurysm disease, decreasing Z-score has been interpreted as a sign of beneficial drug effect. These data put such conclusions into doubt.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:145-153
Elkinany S, Weismann CG, Curtis A, Smith T, ... Ziganshin BA, Elefteriades JA
Am J Cardiol: 14 Mar 2021; 143:145-153 | PMID: 33352210
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Abstract

Impact of Arrhythmias on Hospitalizations in Patients With Cardiac Amyloidosis.

Thakkar S, Patel HP, Chowdhury M, Patel K, ... Rao M, Deshmukh A
Cardiac involvement in amyloidosis is associated with a poor prognosis. Data on the burden of arrhythmias in patients with cardiac amyloidosis (CA) during hospitalization are lacking. We identified the burden of arrhythmias using the National Inpatient Sample (NIS) database from January 2016 to December 2017. We compared patient characteristics, outcomes, and hospitalization costs between CA patients with and without documented arrhythmias. Out of 5,585 hospital admissions for CA, 2,020 (36.1%) had concurrent arrhythmias. Propensity-score matching for age, sex, income, and co-morbidities was performed with 1,405 CA patients with arrhythmias and 1,405 patients without. The primary outcome of all-cause mortality was significantly higher in CA patients with arrhythmia than without(13.9% vs 5.3%, p-value <0.001). Atrial fibrillation (AF) was the most common (72.2%) arrhythmia in CA patients with concurrent arrhythmia. The secondary outcomes of AF-related mortality (11.95% vs 9.16%, p-value = 0.02) and acute and acute on chronic as heart failure (HF) exacerbation (32.38% vs 24.91%, p-value <0.0001) were significantly higher in CA and concurrent arrhythmia compared with CA patients without. The total length of hospital stay (6[3 to 12] vs 5[3 to 10], p-value <0.001) and cost of hospitalization were ($ 15,086[7,813 to 30,373] vs $ 12,219[6,865 to 23,997], p-value = 0.001) were significantly greater among CA with arrhythmia compared with those without. These data suggest that the presence of arrhythmias in CA patients during hospital admission is associated with a poorer prognosis and may reflect patients with a higher risk of HF exacerbation and mortality.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:125-130
Thakkar S, Patel HP, Chowdhury M, Patel K, ... Rao M, Deshmukh A
Am J Cardiol: 14 Mar 2021; 143:125-130 | PMID: 33352208
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Abstract

Diagnostic and Prognostic Value of Several Color Doppler Jet Grading Methods in Patients With Mitral Regurgitation.

Kamoen V, Calle S, El Haddad M, De Backer T, De Buyzere M, Timmermans F
Color Doppler is a widely used ultrasound imaging method for assessing mitral regurgitation (MR) in clinical practice. Nevertheless, color Doppler-based grading of the MR jet has been rarely considered in clinical studies. We investigated the diagnostic and prognostic value of several color Doppler MR jet grading methods and compared them with quantitative grading of MR. The MR color Doppler jet was assessed in 476 MR patients using an \'integrated\' eyeballing approach by quantifying the color Doppler jet area, jet area/left atrium area and jet length and using quantitative methods. Clinical endpoints were scored as major adverse clinical events, including cardiovascular death, heart failure hospitalization and mitral valve intervention. When assessed by three echocardiographers, there was a moderate inter-observer agreement for eyeballing color Doppler grade of MR (intraclass correlation coefficient 0.69, p < 0.001). The intra-observer agreement was good for all color Doppler approaches. In primary MR, eyeballing color Doppler correlated well with (in)direct measures of MR severity, with a negative predictive value of 91% when using a grade 2 color Doppler as cut-off. In secondary MR, eyeballing color Doppler grade and jet length were predictors of clinical outcome in Cox proportional hazards analysis (p = 0.003), independent of pulmonary pressures, atrial and ventricular volumes. Overall, the integrated eyeballing approach performed better than color Doppler quantification of the MR jet area and length. In conclusion, this study shows that color Doppler grading of the distal MR jet performs well in predicting events in primary and secondary MR, compared to quantitative grading methods.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:111-117
Kamoen V, Calle S, El Haddad M, De Backer T, De Buyzere M, Timmermans F
Am J Cardiol: 14 Mar 2021; 143:111-117 | PMID: 33352207
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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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Abstract

Prognostic Value of Pre-operative Atrial Fibrillation in Patients With Secondary Mitral Regurgitation Undergoing MitraClip Implantation.

Godino C, Sisinni A, Pivato CA, Adamo M, ... Margonato A, MiZüBr registry
Limited data are available regarding the independent prognostic role of preoperative atrial fibrillation (AF) after transcatheter mitral valve repair with MitraClip. We sought to evaluate the impact of preoperative AF in patients with heart failure (HF) and concomitant secondary mitral regurgitation (MR) after MitraClip treatment. The study included 605 patients with significant secondary MR from a multicenter international registry. Patients were stratified into 2 groups according to the presence or absence of preoperative AF. Primary end point was 5-year overall death, secondary end points were 5-year cardiac death and first re-hospitalization for HF. To account for baseline differences, patients were propensity score matched 1:1. The overall prevalence of preoperative AF was 44%. At 5-year Kaplan-Meier analysis, compared with patients without AF, those with AF had significantly more adverse events in term of overall death (67% vs 43%; HR 1.84, log-rank p <0.001) and cardiac death (56% vs 29%; HR 2.11, log-rank p <0.001) and re-hospitalization for HF (63% vs 52%; HR 1.33, log-rank p = 0.048). Multivariate analysis identified AF as independent predictor of worse outcome in term of primary end point (HR 1.729, 95% C.I. 1.060 to 2.821; p = 0.028). After propensity score matching, patients with AF had higher rates of death and cardiac mortality but similar rates of re-hospitalization for HF. In conclusion, in patients with HF undergoing MitraClip treatment for secondary MR, preoperative AF is common and an unfavourable predictor of 5-year death and cardiac death. However, AF did not affect the frequency of re-hospitalization for HF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:51-59
Godino C, Sisinni A, Pivato CA, Adamo M, ... Margonato A, MiZüBr registry
Am J Cardiol: 14 Mar 2021; 143:51-59 | PMID: 33359201
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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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Abstract

Long-Term Durability of Transcatheter Aortic Valve Implantation With Self-Expandable Valve System (from a Real-World Registry).

Carrabba N, Migliorini A, Fumagalli C, Taborchi G, ... Marchionni N, Valenti R
As transcatheter aortic valve Implantation (TAVI) moves to younger and lower risk patients with longer life expectancy, the long-term durability of TAVI is becoming an increasingly relevant issue. We sought to evaluate the long-term clinical outcome and prosthesis performance of the CoreValve self-expandable valve. Clinical registry of 182 patients consecutively treated with TAVI in a tertiary center from January 2009 to July 2017. Of these, 111 died during an average follow-up (FU) of 1,026 ± 812 days (median IQR: 745, 477 to 1,400 days; longest survival 11 years; 61% mortality at Kaplan-Meier analysis). At 1 month, functional profile improved in all survivors, with 93.9% of them achieving NYHA class I or II. At Cox analysis, the Society of Thoracic Surgeons score (HR: 1.55; p = 0.001), left ventricular ejection fraction <40% (HR: 1.65; p = 0.017) and incident acute kidney injury (HR: 1.96; p = 0.001) were independently associated with all-cause mortality. During FU, echocardiographically assessed mean transprosthetic aortic gradient remained substantially unchanged (from 9.0 ± 2.7 after TAVI to 9.0 ± 5.0 mm Hg at FU; p >0.05). Most patients had none and/or trivial (34%), or mild (58%), fewer had moderate (8%) and none had severe perivalvular leak, without significant change during FU. At 11 years, cumulative incidence of bioprosthetic valve failure and moderate structural valve deterioration (SVD) were 2.9% (95% CI 0.8% to 10%) and 9.3% (95% CI 3.3% to 26.7%), respectively. In conclusion, our registry confirmed that TAVI with the self-expandable CoreValve system was associated with favorable long-term clinical outcomes, with a reassuring low rate of significant bioprosthetic valve failure and moderate SVD.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:104-110
Carrabba N, Migliorini A, Fumagalli C, Taborchi G, ... Marchionni N, Valenti R
Am J Cardiol: 14 Mar 2021; 143:104-110 | PMID: 33359196
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Influence of Chronic Obstructive Pulmonary Disease on Atrial Mechanics by Speckle Tracking Echocardiography in Patients With Atrial Fibrillation.

Goedemans L, Leung M, van der Bijl P, Abou R, ... Delgado V, Bax JJ
The present study aimed to examine differences in left- and right atrial characteristics between atrial fibrillation (AF) patients with and without chronic obstructive pulmonary disease (COPD). For this, 420 patients (mean age 68 ± 10 years, 73% female) with first diagnosis of AF and baseline echocardiography were included. Of these, 143 COPD patients were compared with 277 patients without COPD matched by age, gender and body surface area. Additionally 38 healthy controls without cardiovascular risk factors, matched for age, were included. For all 3 groups, left atrial (LA) volumes and diameter, LA reservoir strain (LASr), left ventricular ejection fraction (LVEF), right atrial (RA) area and diameter, RA reservoir strain (RASr) and tricuspid annular plane systolic excursion were evaluated on transthoracic echocardiography. Baseline characteristics were similar in patients with and without COPD except for smoking and a history of heart failure (42% vs 11%, p < 0.001 and 48% vs 37%, p = 0.036 for COPD and non-COPD patients, respectively). Also, COPD patients less often used β-blockers (63% vs 75%, p = 0.017). There were no significant differences in LVEF, LA volume and RA area between COPD and non-COPD patients. Compared to the controls, AF patients had impaired LVEF, LASr and RASr. Only RASr was significantly worse in COPD patients as compared to non-COPD patients (15.3% [9.0 to 25.1] vs 19.6% [11.8 to 28.5], p = 0.013). Additionally, a trend towards worse RASr was observed with increasing COPD severity. In conclusion, AF patients with concomitant COPD have more impaired RA function compared to patients without COPD but with similar atrial size and LA function.

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

Am J Cardiol: 14 Mar 2021; 143:60-66
Goedemans L, Leung M, van der Bijl P, Abou R, ... Delgado V, Bax JJ
Am J Cardiol: 14 Mar 2021; 143:60-66 | PMID: 33359195
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Systolic Blood Pressure and Risk for Ventricular Arrhythmia in Patients With an Implantable Cardioverter Defibrillator.

Beinart R, Goldenberg I, Younis A, McNitt S, ... Kutyifa V, Nof E
Low systolic blood pressure (SBP) was previously suggested to be a marker for heart failure and mortality in patients with low left ventricular ejection fraction. We aimed to explore the association of SBP on risk of ventricular tachyarrhythmias (VTA) and atrial arrhythmias as well as appropriate and inappropriate Implantable Cardioverter Defibrillator (ICD) therapy. The study population comprised 1,481 of 1,500 (99%) patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial - Reduce Inappropriate Therapy trial. Multivariate Cox proportional hazards regression modeling was used to identify the association of baseline SBP (recorded prior to ICD implantation) with the risk of VTA > 170 beats/min during follow-up (primary end point) and atrial arrhythmia, appropriate and inappropriate ICD therapy, hospitalization and death (secondary end points). SBP was dichotomized at 120 mm Hg (approximate mean and median) and was also assessed as a continuous measure. Multivariate analysis showed that each 10 mm Hg decrement in SBP was associated with corresponding 11% increased risk for VTA (p = 0.008). Low SBP (≤120 mm Hg) was associated with a significant 58% (p = 0.002) increased risk for VTA ≥170 beats/min; 53% (p = 0.019) increased risk for VTA ≥200 beats/min; and 65% (p = 0.001) increased risk for appropriate ICD therapy, as compared with SBP >120 mm Hg. Low SBP was not associated with increased risk of atrial arrhythmias, and inappropriate ICD therapy. In conclusion, in MADIT-RIT, SBP (≤120 mm Hg) predicted higher rates of VTA. These findings suggest that SBP may be utilized for VTA risk stratification in candidates for primary ICD therapy.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:74-79
Beinart R, Goldenberg I, Younis A, McNitt S, ... Kutyifa V, Nof E
Am J Cardiol: 14 Mar 2021; 143:74-79 | PMID: 33359194
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Relation of Left Atrial Enlargement to Subsequent Thromboembolic Events in Nonvalvular Atrial Fibrillation Patients With Low to Borderline Embolic Risk.

Cho MS, Choi KJ, Kim M, Do U, Kim J, Nam GB
The current thromboembolic risk stratification of non-valvular atrial fibrillation (NVAF) does not include parameters from transthoracic echocardiography (TTE). We hypothesized that left atrial enlargement (LAE) on TTE could discriminate who require anticoagulation therapy among NVAF patients with low/borderline clinical embolic risk. This single-center cohort study included 6,602 patients with NVAF (median age, 56 years, 70.0% male) with a low to borderline clinical embolic risk (CHA2DS2-VASc score: 0 to 1 in males, 1 to 2 in females). LAE was classified as mild (≥41 mm in males; ≥39 mm in females) or moderate-severe (≥47 mm in males; ≥43 mm in females). The main study outcome was thromboembolic event (ischemic stroke and systemic embolism). Mild and moderate-severe LAE was diagnosed in 26.1% and 32.9% of the cohort, respectively. The patients with moderate-severe LAE showed a higher prevalence of baseline comorbidities and valvular heart disease and had a higher incidence of thromboembolic events than patients with mild or no LAE at 2 years of follow-up (2.5% vs 1.3% vs 1.1%, respectively, p < 0.001). After multivariable adjustment, patients with moderate-severe LAE were at a higher risk of thromboembolic event (hazard ratio, 2.54; 95% CI, 1.65 to 3.90; p < 0.001) compared to those with no LAE. This result persisted in a subgroup analysis of anticoagulant-naïve patients. The rate of thromboembolic events in patients with low clinical embolic risk and moderate-severe LAE was not different to those with high clinical embolic risk without LAE. In conclusion, Moderate-severe LAE on TTE was a significant predictor of thromboembolic events in NVAF patients at low/borderline clinical embolic risk.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:67-73
Cho MS, Choi KJ, Kim M, Do U, Kim J, Nam GB
Am J Cardiol: 14 Mar 2021; 143:67-73 | PMID: 33359192
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Incidence, Management, Immediate and Long-Term Outcome of Guidewire and Device Related Grade III Coronary Perforations (from G3CAP - Cardiogroup VI Registry).

Cerrato E, Pavani M, Barbero U, Colombo F, ... Varbella F, G3-CAP – Cardiogroup IV Investigators (Appendix)
Ellis grade III coronary artery perforations (G3-CAP) remain a life-threatening complication of percutaneous coronary intervention (PCI), with high morbidity and mortality and lack of consensus regarding optimal treatment strategies. We reviewed all PCIs performed in 10 European centers from 1993 to 2019 recording all G3-CAP along with management strategies, in-hospital and long-term outcome according to Device-related perforations (DP) and Guidewire-related perforations (WP). Among 106,592 PCI (including 7,773 chronic total occlusions), G3-CAP occurred in 311 patients (0.29%). DP occurred in 194 cases (62.4%), more commonly in proximal segments (73.2%) and frequently secondary to balloon dilatation (66.0%). WP arose in 117 patients (37.6%) with chronic total occlusions guidewires involved in 61.3% of cases. Overall sealing success rate was 90.7% and usually required multiple maneuvers (80.4%). The most commonly adopted strategies to obtain hemostasis were prolonged balloon inflation (73.2%) with covered stent implantation (64.4%) in the DP group, and prolonged balloon inflation (53.8%) with coil embolization (41%) in the WP group.  Procedural or in-hospital events arose in 38.2% of cases: mortality was higher after DP (7.2% vs 2.6%, p = 0.05) and acute stent thrombosis 3-fold higher (3.1% vs 0.9%, p = 0.19). At clinical follow-up, median 2 years, a major cardiovascular event occurred in one-third of cases (all-cause mortality 8.2% and 7.1% respectively, without differences between groups). In conclusion, although rare and despite improved rates of adequate perforation sealing G3-CAP cause significant adverse events. DP and WP result in different patterns of G3-CAP and management strategies should be based on this classification.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:37-45
Cerrato E, Pavani M, Barbero U, Colombo F, ... Varbella F, G3-CAP – Cardiogroup IV Investigators (Appendix)
Am J Cardiol: 14 Mar 2021; 143:37-45 | PMID: 33387472
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Abstract

Comparison of the Efficacy and Safety of Sacubitril/Valsartan versus Ramipril in Patients With ST-Segment Elevation Myocardial Infarction.

Rezq A, Saad M, El Nozahi M
The role of sacubitril and/or valsartan in patient with heart failure (HF) is established. Whether sacubitril and/or valsartan plays a role in improving outcomes in patients after ST-segment elevation myocardial infarction (STEMI) is unknown. The current study aims to comparing the efficacy and safety of sacubitril and/or valsartan versus ramipril in post-STEMI patients. Patients presenting with STEMI were randomized to receive either sacubitril and/or valsartan or ramipril after primary percutaneous coronary intervention. The main efficacy endpoint was major adverse cardiac events (MACE) at 30 days and 6 months, defined as a composite of cardiac death, myocardial infarction, and HF hospitalizations. Multiple secondary clinical safety and efficacy endpoints were examined. A total of 200 patients were randomized from January 2018 to March 2019, mean age 54.5±10.4, 87% men, 75% presented with anterior wall STEMI. Baseline clinical and echocardiographic characteristics were comparable between groups. The primary endpoint of MACE was similar with sacubitril/valsartan versus ramipril at 30 days (p = 0.18); however, at 6 months, sacubitril/valsartan was associated with significant reduction of MACE (p = 0.005), mainly driven by reduction in HF hospitalizations (18% vs 36%, OR 0.40, 95% 0.22 to 0.75; p = 0.004). At 6 months, LV ejection fraction was higher with sacubitril/valsartan (46.8±12.5% vs 42.09±13.8%; p = 0.012), with improved LV remodelling (LV end diastolic dimension 50.6±3.9 mm vs 53.2±2.7 mm, p = 0.047; and LV end systolic dimension 36.1±3.4 mm versus 39.9±6.3 mm, p = 0.001) compared with ramipril. No difference in other efficacy or safety clinical endpoints was observed. In conclusion, early initiation of sacubitril/valsartan may offer clinical benefit and improvement in myocardial remodelling in post-STEMI patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:7-13
Rezq A, Saad M, El Nozahi M
Am J Cardiol: 14 Mar 2021; 143:7-13 | PMID: 33417876
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Abstract

Association of Coronary Calcium, Carotid Wall Thickness, and Carotid Plaque Progression With Low-Density Lipoprotein and High-Density Lipoprotein Particle Concentration Measured by Ion Mobility (From Multiethnic Study of Atherosclerosis [MESA]).

Ceponiene I, Li D, El Khoudary SR, Nakanishi R, ... Tattersall MC, Budoff MJ
Current risk stratification strategies do not fully explain cardiovascular disease (CVD) risk. We aimed to evaluate the association of low-density lipoprotein (LDL-P) and high-density lipoprotein (HDL-P) particles with progression of coronary artery calcium and carotid wall injury. All participants in the Multi-Ethnic Study Atherosclerosis (MESA) with LDL-P and HDL-P measured by ion mobility, coronary artery calcium score (CAC), carotid intima-media thickness (IMT), and carotid plaque data available at Exam 1 and 5 were included in the study. CAC progression was annualized and treated as a categorical or continuous variable. Carotid IMT and plaque progression were treated as continuous variables. Fully adjusted regression models included established CVD risk factors, as well as traditional lipids. Mean (±SD) follow-up duration was 9.6 ± 0.6 years. All LDL-P subclasses as well as large HDL-P at baseline were positively and significantly associated with annualized CAC progression, however, after adjustment for established risk factors and traditional lipids, only the association with medium and very small LDL-P remained significant (β -0.02, p = 0.019 and β 0.01, p = 0.003, per 1 nmol/l increase, respectively). Carotid plaque score progression was positively associated with small and very small LDL-P (p <0.01 for all) and non-HDL-P (p = 0.013). Only the association with very small LDL-P remained significant in a fully adjusted model (p = 0.035). Mean IMT progression was not associated with any of the lipid particles. In conclusion, in the MESA cohort, LDL-P measured by ion mobility was significantly associated with CAC progression as well as carotid plaque progression beyond the effect of traditional lipids.

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Am J Cardiol: 28 Feb 2021; 142:52-58
Ceponiene I, Li D, El Khoudary SR, Nakanishi R, ... Tattersall MC, Budoff MJ
Am J Cardiol: 28 Feb 2021; 142:52-58 | PMID: 33278360
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Abstract

Usefulness of the Right Parasternal Echocardiographic View to Improve the Hemodynamic Assessment After Valve Replacement for Aortic Stenosis.

Benfari G, Nistri S, Cerrito LF, Maritan L, ... Rossi A, Ribichini FL
Right-parasternal-view (RPV) often provides the best hemodynamic assessment of the aortic-valve-stenosis by echocardiography. However, no detailed study on patients with aortic prosthesis is available. Thus, RPV usefulness is left as an anecdotical notion in this context. We aimed to define feasibility and clinical-impact of RPV before and soon-after percutaneous implantation (TAVI) or surgical (SAVR) aortic-valve-replacement (AVR) for AS. Patients with severe-AS electively referred for AVR between September-2019 and February-2020 were prospectively evaluated. Echocardiographic examinations inclusive of apical and RPV to measure aortic-peak-velocity , gradients and area (AVA) were performed the day before AVR and at hospital discharge and compared by matched-pair-analysis. Forty-seven patients (mean age 79 ± 8 years, 63% female, ejection-fraction 61 ± 6%) referred for SAVR (24 [51%]) or TAVI (23 [49%]) were enrolled. RPV was feasible in 45 patients (96%) before-AVR but in only 32 after-AVR (68%), particularly after SAVR (50%) than TAVI (87% p = 0.005). RPV remained the best acoustic window after TAVI in 75% of cases. Hemodynamic assessment of TAVI, but not SAVR, invariably benefit from RPV versus apical evaluation (aortic-peak-velocity: 2.57 ± 0.39 vs 2.23 ± 0.47 m/sec, p = 0.002; mean gradient: 15 ± 5 vs 12 ± 5 mm Hg, p = 0.01). Five (11%) patients presented severe patient-prosthesis-mismatch, 4 of which were detectable only by RPV. This pilot-experience demonstrates that RPV feasibility is slightly reduced after AVR. RPV can improve the hemodynamic assessment of the prosthetic valve versus apical view, including the detection of patient-prosthesis-mismatch. Furthermore, when RPV is the best acoustic windows in patients with severe AS, it generally remains so after-TAVI.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:103-108
Benfari G, Nistri S, Cerrito LF, Maritan L, ... Rossi A, Ribichini FL
Am J Cardiol: 28 Feb 2021; 142:103-108 | PMID: 33278359
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Abstract

Impact of Age on Gender Difference in Long-term Outcome of Patients With Acute Myocardial Infarction (from J-MINUET).

Kimura T, Akahori H, Asakura M, Nakao K, ... Ishihara M, J-MINUET Investigators
Although gender difference in long-term outcomes after acute myocardial infarction have been shown previously, impact of age on gender difference is still controversial. This study focused on the association between age and gender difference in long-term outcome. We analyzed data from 3,283 consecutive patients who were included in a prospective, nationwide, multicenter registry (Japan Registry of Acute Myocardial Infarction Diagnosed by Universal Definition) from 2012 to 2014. The primary end point was the major adverse cardiovascular event (MACE), which was defined as a composite of death, myocardial infarction, stroke, heart failure, and revascularization for unstable angina during 3 years. Patients were divided into 4 strata according to age: those with age <65 years (group 1: n = 1161), 65 to 74 years (group 2: n = 954), 75 to 84 years (group 3: n = 866) and 84< years (group 4: n = 302). Although the crude incidence of 3-year MACE was significantly higher in women than men (36.4% vs. 28.5%, p <0.001), there was not significant gender difference in each group (group 1, 19.6% vs 19.0%, p = 0.74; group 2, 33.1% vs 28.3%, p = 0.25; group 3, 38.9% vs 39.6%, p = 0.54; and group 4, 54.0% vs 56.8%, p = 0.24). In conclusion, although women had higher crude incidence of 3-year MACE than men, there was no gender difference in each group.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:5-13
Kimura T, Akahori H, Asakura M, Nakao K, ... Ishihara M, J-MINUET Investigators
Am J Cardiol: 28 Feb 2021; 142:5-13 | PMID: 33279486
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Abstract

Role of Ischemic Heart Disease in Major Adverse Renal and Cardiac Events Among Individuals With Heart Failure With Preserved Ejection Fraction (from the TOPCAT Trial).

Rahimi G, Tecson KM, Elsaid O, McCullough PA
Despite improvements in the prognosis of patients with heart failure with reduced ejection fraction (HFrEF), established therapy for heart failure patients with preserved ejection fraction (HFpEF) is lacking. Additionally, ischemic heart disease adversely impacts the clinical course of HFrEF patients; however, its role in HFpEF is not fully understood. We conducted a post hoc analysis of propensity score matched patients from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial to compare HFpEF patients with versus without myocardial ischemia in terms of major adverse renal and/or cardiac events (MARCE). Of 3,445 participants, the prevalence of ischemia was 59%. For this analysis, we included 1,747 ischemic patients and 1,207 propensity matched nonischemic patients. Ischemia was associated with a 20% increased risk (HR = 1.20, 95% confidence interval [CI] = 1.042 to 1.382, p value = 0.0112) of major adverse renal and/or cardiac events (MARCE) in adjusted analyses. Other important predictors of MARCE were diabetes (hazard ratio [HR] = 1.60, 95% CI = 1.38 to 1.87, p <0.0001), dyslipidemia (HR = 1.30, 95% CI = 1.10 to 1.52, p = 0.001) and smoking (HR = 1.33, 95% CI = 1.04 to 1.69, p = 0.0197). Revascularization was not significantly associated with MARCE in the subgroup of ischemic HFpEF patients. Future work is warranted to develop tailored interventions for patients with both HFpEF and ischemic heart disease to mitigate the risk of MARCE .

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:91-96
Rahimi G, Tecson KM, Elsaid O, McCullough PA
Am J Cardiol: 28 Feb 2021; 142:91-96 | PMID: 33279481
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Abstract

Periprocedural Stroke After Coronary Revascularization (from the CREDO-Kyoto PCI/CABG Registry Cohort-3).

Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, ... Kimura T, CREDO-Kyoto PCI/CABG Registry Cohort-3 investigators
There is a scarcity of data on incidence, risk factors, especially clinical severity, and long-term prognostic impact of periprocedural stroke after coronary revascularization in contemporary real-world practice. Among 14,867 consecutive patients undergoing first coronary revascularization between January 2011 and December 2013 (percutaneous coronary intervention [PCI]: N = 13258, and coronary artery bypass grafting [CABG]: N = 1609) in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG registry Cohort-3, we evaluated the details on periprocedural stroke. Periprocedural stroke was defined as stroke within 30 days after the index procedure. Incidence of periprocedural stroke was 0.96% after PCI and 2.13% after CABG (log-rank p <0.001). Proportions of major stroke defined by modified Rankin Scale ≥2 at hospital discharge were 68% after PCI, and 77% after CABG. Independent risk factors of periprocedural stroke were acute coronary syndrome (ACS), carotid artery disease, advanced age, heart failure, and end-stage renal disease after PCI, whereas they were ACS, carotid artery disease, atrial fibrillation, chronic obstructive pulmonary disease, malignancy, and frailty after CABG. There was excess long-term mortality risk of patients with periprocedural stroke relative to those without after both PCI and CABG (hazard ratio 1.71 [1.25 to 2.33], and hazard ratio 4.55 [2.79 to 7.43]). In conclusion, incidence of periprocedural stroke was not negligible not only after CABG, but also after PCI in contemporary real-world practice. Majority of patients with periprocedural stroke had at least mild disability at hospital discharge. ACS and carotid artery disease were independent strong risk factors of periprocedural stroke after both PCI and CABG. Periprocedural stroke was associated with significant long-term mortality risk after both PCI and CABG.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:35-43
Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, ... Kimura T, CREDO-Kyoto PCI/CABG Registry Cohort-3 investigators
Am J Cardiol: 28 Feb 2021; 142:35-43 | PMID: 33279479
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Abstract

Outcomes With Ultrafiltration Among Hospitalized Patients With Acute Heart Failure (from the National Inpatient Sample).

Yazdanyar A, Sanon J, Lo KB, Joshi AM, ... Donato A, Rangaswami J
Acute heart failure (HF) management is a complex and often involves a delicate balance of both cardiac and renal systems. Although pharmacologic diuresis is a mainstay of the pharmacologic management of decompensated HF, ultrafiltration (UF) represents a nonpharmacologic approach in the setting of diuretic resistance. We conducted a cross-sectional analysis of the 2009 through 2014 hospitalization data from the National Inpatient Sample. The study population consisted of hospitalizations with a discharge Diagnosis Related Groups of HF who were older than 18 years of age, did not have end-stage kidney disease, acute kidney injury and had not undergone hemodialysis or hemofiltration. There were 6,174 hospitalizations which included UF among the 7,799,915 hospitalizations for HF. Hospitalizations which included UF were among patients significantly younger in age (68.1 ± 1.0 vs 73.8 ± 0.1 years), male (61.9% vs 47.7%), and with higher prevalence of co-morbid conditions including chronic kidney disease (58% vs 31%), diabetes mellitus (53% vs 42%), and higher rates of co-morbidity (Charlson comorbidity score ≥2, 92% vs 80%). All-cause mortality was significantly higher among hospitalizations which included an UF (4.68% vs 2.24%). Hospitalizations with UF had a longer mean length of stay (6.2 vs 4.3 days, p <0.01) average total charges ($42,035 vs 24,867 USD, p <0.01) as compared with those without UF. Hospitalizations with UF were associated with a greater adjusted odds of all-cause mortality (odds ratio: 3.36, [95% confidence interval 1.76,6.40]), greater than DRG-level target length of stay (odds ratio, 2.46; [95 confidence interval 1.65,3.67]), and a 72% increase in the average hospital charges. In conclusion, hospitalizations which included UF identified a subgroup of HF patients with more co-morbid conditions who are at higher risk of mortality and increased resource burden in terms of length of stay and costs. These findings also highlight that the need for UF may identify patients who are most likely to benefit from a multidisciplinary cardiorenal approach to alter the trajectory of their disease.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:97-102
Yazdanyar A, Sanon J, Lo KB, Joshi AM, ... Donato A, Rangaswami J
Am J Cardiol: 28 Feb 2021; 142:97-102 | PMID: 33285095
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Abstract

Impact of Economic Status on Utilization and Outcomes of Transcatheter Aortic Valve Implantation and Mitraclip.

Farwati M, Saad AM, Jain V, Ahuja KR, ... Krishnaswamy A, Kapadia S
Data on the impact of economic status on Transcatheter aortic valve implantation (TAVI) and MitraClip (MC) is lacking. Patients who underwent TAVI and/or MC during 2012 to 2017 were identified in the Nationwide Readmission Database and divided by zip code estimated income quartile into 4 groups (Q1 to Q4). The utilization of TAVI and/or MC was defined as the number of TAVIs and/or MCs over all admissions with an aortic and/or mitral valve disease (AVD and/or MVD) and represented per 1,000 admissions. A total of 168,853 patients underwent TAVI; 20.6% in Q1, 26.3% in Q2, 27.3% in Q3, and 25.8% in Q4, while 15,387 patients underwent MC; 22% in Q1, 26.2% in Q2, 26.3% in Q3, and 25.5% in Q4. The annual utilization of TAVIs and/or MCs increased over the study period and was generally lower with lower income. In 2012, TAVI was performed for 8.2, 8.8, 10.8, and 11.3 per 1,000 AVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2017, TAVI was performed for 54.1, 65.1, 68.6, and 71 per 1,000 AVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2014, MC was performed for 1.6, 2.1, 1.8, and 1.9 per 1,000 MVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2017, MC was performed for 5.6, 6.5, 8, and 8 per 1,000 MVD admissions in Q1, Q2, Q3, and Q4, respectively. In-hospital mortality, stroke, and 30-day readmissions were generally comparable across groups. Lower-income patients may be underrepresented among patients undergoing TAVI and MC despite comparable outcomes. Further studies are needed to examine the etiologies behind these disparities and identify targeted strategies for its mitigation.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:116-123
Farwati M, Saad AM, Jain V, Ahuja KR, ... Krishnaswamy A, Kapadia S
Am J Cardiol: 28 Feb 2021; 142:116-123 | PMID: 33285094
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Abstract

In-Hospital Outcomes in Patients With a History of Malignancy Undergoing Transcatheter Aortic Valve Implantation.

Grant JK, Vincent L, Ebner B, Maning J, ... Lopes G, Braghiroli J
A history of malignancy is incorporated in the Society of Thoracic Surgeons score to assess presurgical risk in patients undergoing surgical aortic valve replacement, however data on the prognostic importance in those undergoing transcatheter aortic valve implantation (TAVI) remains limited. We sought to investigate the utilization and in-hospital outcomes of TAVI in patients with a history of malignancy. The National Inpatient Sample Database was queried from 2012 to 2017 to identify patients who underwent TAVI using International Classification of Diseases (ICD) 9 and ICD-10 procedure codes. Between 2012 and 2017, there were 123,070 patients who underwent TAVI, of these 23,670 patients (19.2%) had a previous history of malignancy. The proportion of patients undergoing TAVI with a history of malignancy trended upward between 2012 and 2017. Patients with a history of malignancy were similar in age to those without (81.1 ± 7.9 vs 80.1 ± 6.7 years old, p <0.001), with a higher prevalence of tobacco use and major depressive disorder (p <0.001 for both). Patients with a history of malignancy had higher rates of post-TAVI pacemaker implantation (p <0.001), otherwise periprocedural complication rates were similar to those without. Using a multivariate logistic regression model to adjust for confounding factors, a history of malignancy was predictive of decreased odds of death in patients underwent TAVI (OR: 0.67, 95% CI, 0.60 to 0.76, p <0.001) and higher odds of pacemaker implantation (OR: 1.14, 95% CI, 1.09 to 1.19, p <0.001). In conclusion, with time the proportion of TAVI patients with a history of malignancy trended upward. Despite a greater prevalence of previous tobacco use and major depressive disorder, patients with a history of malignancy had TAVI safely with a low in-hospital all-cause mortality, yet greater cost of hospitalization and more frequent implantation of pacemaker devices.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:109-115
Grant JK, Vincent L, Ebner B, Maning J, ... Lopes G, Braghiroli J
Am J Cardiol: 28 Feb 2021; 142:109-115 | PMID: 33285093
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Abstract

Benefits and Risks of Prolonged Duration Dual Antiplatelet Therapy (Clopidogrel and Aspirin) After Percutaneous Coronary Intervention in High-Risk Patients With Diabetes Mellitus.

Wang HY, Cai ZX, Yin D, Yang YJ, Song WH, Dou KF
The efficacy and safety of prolonged (>1-year) dual antiplatelet therapy (DAPT) duration in high-risk patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) remain unknown. All patients undergoing PCI at Fuwai hospital between January 2013 and December 2013 were prospectively enrolled into the Fuwai PCI registry. A total of 3,696 high-risk diabetics patients with at least one additional atherothrombotic risk factor were screened for inclusion. The primary efficacy outcome was the composite of all-cause mortality, myocardial infarction, or stroke. The median follow-up duration was 887 days. 69.8% of DM patients were on DAPT at 1 year without discontinuation. Based on multivariate Cox regression model and inverse probability of treatment weighting (IPTW) analysis, long-term (>1-year) DAPT reduced the risk of primary efficacy outcome (1.7% vs 4.1%; adjusted hazard ratio [adjHR]: 0.382, 95% confidence interval [CI]: 0.252 to 0.577; IPTW-HR: 0.362 [0.241 to 0.542]), as well as cardiovascular death and definite/probable stent thrombosis, compared with short-course (≤1-year) DAPT. Risk of the safety end point of clinically relevant bleeding (adjHR: 0.920 [0.467 to 1.816]; IPTW-HR: 0.969 [0.486 to 1.932]) was comparable between longer DAPT and shorter DAPT. A lower number of net clinical benefit adverse outcomes was observed with >1-year DAPT versus ≤1-year DAPT (adjHR: 0.471 [0.331 to 0.671]; IPTW-HR: 0.462 [0.327 to 0.652]), which appeared increasingly favorable in those with multiple atherothrombotic risk characteristics. In high-risk patients with DM receiving PCI who were event free at 1 year, DAPT prolongation resulted in significant reduction in the risk of ischemic events not offset by increase of clinically meaningful bleeding events, thereby achieving a net clinical benefit. Extending DAPT beyond the period mandated by guidelines seems reasonable in high-risk DM patients not deemed at high bleeding risk.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:14-24
Wang HY, Cai ZX, Yin D, Yang YJ, Song WH, Dou KF
Am J Cardiol: 28 Feb 2021; 142:14-24 | PMID: 33285091
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Abstract

Comparison of Long-Term Mortality in Patients With Single Coronary Narrowing and Diabetes Mellitus to That of Patients With Multivessel Coronary Narrowing Without Diabetes Mellitus.

Omair M, Koshy AN, Dinh DT, Brennan AL, ... Yudi MB, Clark DJ
It is well recognized that patients with diabetes mellitus (DM) and multivessel coronary artery disease (MVD) undergoing percutaneous coronary intervention (PCI) have poorer long-term outcomes compared with those undergoing coronary artery bypass grafting. However, the relative impact of DM status and extent of coronary artery disease on long term mortality in patients undergoing PCI is unknown. We sought to compare patients with DM undergoing PCI for single and multivessel disease to their non-DM counterparts. Overall, 34,690 consecutive patients undergoing PCI from the Melbourne Interventional Group registry (2005 to 2017) were included (mean age 64.5 ± 12 years, 76.6% male). Our cohort was stratified by the presence of DM and extent of CAD (DM-SVD [single-vessel disease] [n = 2,669], DM-MVD [n = 6,118], no-DM-SVD [n = 10,993], no-DM-MVD [n = 14,910]). DM-SVD and no-DM-MVD cohorts demonstrated comparable baseline cardiovascular risk profiles, although the no-DM-MVD cohort had higher rates of prior myocardial infarction, while the DM-SVD cohort had a higher proportion of patients with renal impairment. Over a median follow-up of 4.8 (IQR 2.0 to 8.2) years, 6,031 (17.5%) patients died. Using the no-DM-SVD group as the reference category, adjusted risk of mortality was highest in the MVD-DM cohort (HR 1.90; 95% CI 1.71 to 2.09). Similar adjusted risk of long-term mortality was observed in the DM-SVD (HR 1.32, 95%CI 1.15 to 1.51) and no-DM-MVD (HR 1.30, 95%CI 1.20 to 1.40) groups. In conclusion, we found that the long-term mortality of patients with DM and SVD undergoing PCI was the risk equivalent of non-DM patients with MVD.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:1-4
Omair M, Koshy AN, Dinh DT, Brennan AL, ... Yudi MB, Clark DJ
Am J Cardiol: 28 Feb 2021; 142:1-4 | PMID: 33285090
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Abstract

Treatment of Patients With Recurrent Coronary In-stent Restenosis With Failed Intravascular Brachytherapy.

Yerasi C, Chen Y, Case BC, Forrestal BJ, ... Satler LF, Waksman R
Intravascular brachytherapy (VBT) is an effective and safe treatment option for recurrent drug-eluting stent (DES) in-stent restenosis (ISR). However, the optimal therapy for patients with failed VBT is not well-defined. In this study, we sought to evaluate the optimal treatment strategy for patients after a failed VBT. Patients with recurrent ISR after an initial unsuccessful VBT were identified from our percutaneous coronary intervention database. Patients were divided into 2 cohorts (standard treatment with DES or balloon angioplasty versus repeat VBT). Baseline characteristics and clinical outcomes during follow-up were extracted. A total of 279 patients underwent PCI after an initial unsuccessful VBT at our institution. Of those, 215 (77%) patients underwent standard treatment with balloon angioplasty with or without DES, and 64 (33%) underwent balloon angioplasty followed by repeat VBT. The mean age of the cohort was 64±11 years. Overall, 71% were men, 47% had diabetes, and 22% had heart failure. The majority (64%) presented with unstable angina. The groups had similar baseline characteristics. The rate of major adverse cardiovascular events (defined as all-cause mortality, myocardial infarction, or target vessel revascularization) was significantly lower in the repeat VBT group at 1 year (31% vs 14%, p = 0.03), 2 years (51% vs 31%, p = 0.03), and 3 years (57% vs 41%, p = 0.08). Target lesion revascularization and target vessel revascularization were consistently lower in the repeat VBT group at all follow-up intervals than in the standard treatment group. Treatment of recalcitrant ISR following an initial failed VBT is associated with a high MACE rate at 3-year follow-up. Repeat VBT is safe and effective and should be considered as the preferred strategy.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:44-51
Yerasi C, Chen Y, Case BC, Forrestal BJ, ... Satler LF, Waksman R
Am J Cardiol: 28 Feb 2021; 142:44-51 | PMID: 33285089
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Abstract

Meta-analysis of the Usefulness of Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure With Preserved Ejection Fraction.

Aldaas OM, Lupercio F, Darden D, Mylavarapu PS, ... Feld GK, Hsu JC
Catheter ablation improves clinical outcomes in atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, the role of catheter ablation in HF with a preserved ejection fraction (HFpEF) is less clear. We performed a literature search and systematic review of studies that compared AF recurrence at one year after catheter ablation of AF in patients with HFpEF versus those with HFrEF. Risk ratio (RR; where a RR <1.0 favors the HFpEF group) and mean difference (MD; where MD <0 favors the HFpEF group) 95% confidence intervals (CI) were measured for dichotomous and continuous variables, respectively. Six studies with a total of 1,505 patients were included, of which 764 (51%) had HFpEF and 741 (49%) had HFrEF. Patients with HFpEF experienced similar recurrence of AF 1 year after ablation on or off antiarrhythmic drugs compared with those with HFrEF (RR 1.01; 95% CI 0.76, 1.35). Fluoroscopy time was significantly shorter in the HFpEF group (MD -5.42; 95% CI -8.51, -2.34), but there was no significant difference in procedure time (MD 1.74; 95% CI -11.89, 15.37) or periprocedural adverse events between groups (RR 0.84; 95% CI 0.54,1.32). There was no significant difference in hospitalizations between groups (MD 1.18; 95% CI 0.90, 1.55), but HFpEF patients experienced significantly less mortality (MD 0.41; 95% CI 0.18, 0.94). In conclusion, based on the results of this meta-analysis, catheter ablation of AF in patients with HFpEF appears as safe and efficacious in maintaining sinus rhythm as in those with HFrEF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:66-73
Aldaas OM, Lupercio F, Darden D, Mylavarapu PS, ... Feld GK, Hsu JC
Am J Cardiol: 28 Feb 2021; 142:66-73 | PMID: 33290688
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Abstract

Meta-Analysis Evaluating the Efficacy and Safety of Low-Intensity Warfarin for Patients >65 Years of Age With Non-Valvular Atrial Fibrillation.

Kang F, Ma Y, Cai A, Cheng X, ... Mai Z, Mai W
Nonvalvular atrial fibrillation (NVAF) is the most common arrhythmia. It is of a high disability and death rate, and seriously affects quality of life. Although New oral anticoagulants (NOACs) are recommended for anticoagulation therapy of atrial fibrillation, they are not widely used for the high cost and limited availability. Warfarin is effective and economical. The risk of thromboembolism and anticoagulant hemorrhage is higher in patients >65 years with NVAF. So, it is of great clinical significance to explore the optimal anticoagulation intensity of warfarin in patients >65 years of China, and other ethnicities. Some studies suggested that low-intensity international normalized ratio (INR) has similar antithrombotic efficacy comparing to standard-intensity INR, whereas bleeding risk was significantly reduced. But others showed conflicting results. We pooled the efficacy and safety data of low- and standard-intensity warfarin therapy for patients over 65 years with NVAF by meta-analysis, as to evaluate optimal INR intensity of warfarin therapy in patients over 65 years. We identified 18 studies providing data of 2105 patients receiving anticoagulation therapy with warfarin. On meta-analysis (odds ratio [OR] [95% confidence interval {CI}]), low-intensity INR conferred similar efficacy to standard intensity INR on all thrombosis (1.28 [0.90 to 1.81]), stroke (1.09 [0.67 to 1.77]), other thromboembolism ([peripheral and pulmonary embolism] 2.26 [0.89 to 5.79]), and all cause death (1.38 [0.94 to 2.02]). Low-intensity INR conferred better safety profile than standard intensity INR in major bleeding (intracranial and gastrointestinal hemorrhage) (0.32 [0.19 to 0.52]), minor bleeding (gum, nasal cavity and conjunctival hemorrhage, skin ecchymosis, hematuria, hemoptysis) (0.30 [0.20 to 0.45]), and all bleeding (0.30 [0.22 to 0.40]). In conclusion, low-intensity INR (1.5 to 2.0) of warfarin therapy is as effective as standard intensity INR (2.0 to 3.0) therapy in reducing thromboembolic risk in patients>65 years with NVAF, and has a safer profile of bleeding.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:74-82
Kang F, Ma Y, Cai A, Cheng X, ... Mai Z, Mai W
Am J Cardiol: 28 Feb 2021; 142:74-82 | PMID: 33307015
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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 (1-24), medium (25-39) or high (40+). Outcomes were in-hospital mortality and 1-year post-discharge 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 (1.23-1.84)] and medium-volume [OR=1.33, 95% CI (1.06-1.67)] compared to 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 to 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 one-year mortality and cardiovascular rehospitalizations were not significantly higher at low- or medium-volume MV surgery facilities, as compared to 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. Published by Elsevier Inc.

Am J Cardiol: 28 Feb 2021; epub ahead of print
Barker CM, Reynolds MR, Reardon MJ, Van Houten JL, ... Mollenkopf SA, Feldman TE
Am J Cardiol: 28 Feb 2021; epub ahead of print | PMID: 33662328
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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) narrowing was determined from histologic examination of each 5-mm segment. The degree of narrowing in each 5 mm segment was divided into 4 categories: 0 - 25%, 26 - 50%, 51 - 75%, and 76 - 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 - 50%) of the left main coronary artery (66 patients) was generally accompanied by 51 - 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. Published by Elsevier Inc.

Am J Cardiol: 25 Feb 2021; epub ahead of print
Arnett EN, Roberts WC
Am J Cardiol: 25 Feb 2021; epub ahead of print | PMID: 33647269
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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. 140 patients (median age 74±9.9 years, 67.9% male) with CHF who underwent successful TMVR were included. Primary endpoint 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 [0.60-0.81]; p=0.001) and 8.3 g/m-1/m2 for RVSWi (sensitivity 67.4%, specificity 57.0%, AUC 0.67 [0.56-0.78]; 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. Published by Elsevier Inc.

Am J Cardiol: 25 Feb 2021; epub ahead of print
Osteresch R, Diehl K, Dierks P, Schmucker J, ... Hambrecht R, Wienbergen H
Am J Cardiol: 25 Feb 2021; epub ahead of print | PMID: 33647268
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Abstract

COVID-19 and Gender Disparities in Pediatric Cardiologists with Dependent Care Responsibilities.

Ferns SJ, Gautam S, Hudak ML
The COVID-19 pandemic disproportionately affects females in the home and workplace. This study aimed to acquire information regarding the gender-specific effects of the COVID-19 lockdown on aspects of professional and personal lives of a subset of pediatric cardiologists. We sent an online multiple-choice survey to a listserv of Pediatric Cardiologists. Data collected included demographics, dependent care details, work hours, leave from work, salary cut, childcare hours before and after the COVID-19 peak lockdown/stay at home mandate and partner involvement. 242 pediatric cardiologists with dependent care responsibilities responded (response rate of 20.2%). A significantly higher proportion of females reported a salary cut (29.1% of females vs 17.6% of males, p=0.04) and scaled back or discontinued work (14% vs 5.3%; p=0.03). Prior to the COVID-19 lockdown phase, females provided more hours of dependent care. Females also reported a significantly greater increase in childcare hours overall per week (45 h post/30 h pre vs. 30 h post/20 h pre for men; p<0.001).  Male cardiologists were much more likely to have partners who reduced work hours (67% vs. 28%; p<0.001) and reported that their partners took a salary cut compared to partners of female cardiologists (51% vs. 22%; p<0.001). In conclusion, gender disparity in caregiver responsibilities existed among highly skilled pediatric cardiologists even before the COVID-19 pandemic. The pandemic has disproportionately affected female pediatric cardiologists with respect to dependent care responsibilities, time at work, and financial compensation.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 24 Feb 2021; epub ahead of print
Ferns SJ, Gautam S, Hudak ML
Am J Cardiol: 24 Feb 2021; epub ahead of print | PMID: 33640368
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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 TR. Clinical and echocardiographic characteristics of 1569 patients (age 71 (62-78) 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 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 to men (72 [62-79] years vs. 70 [61-77] 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 to 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 to 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. Published by Elsevier Inc.

Am J Cardiol: 24 Feb 2021; epub ahead of print
Dietz MF, Prihadi EA, van der Bijl P, Fortuni F, ... Bax JJ, Delgado V
Am J Cardiol: 24 Feb 2021; epub ahead of print | PMID: 33640367
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Abstract

Meta-Analysis of Sex 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
Sex 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 sex 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 42.5 min) and door-to-balloon time (mean 4.9 min). In-hospital, females had increased rates of mortality (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.84-1.99, p<0.00001), repeat myocardial infarction (MI) (OR 1.25, 95% CI 1.00-1.56, p=0.05), stroke (OR 1.67, 95% CI 1.27-2.20, p<0.001), and major bleeding (OR 1.82, 95% CI 1.56-2.12, p<0.00001) compared to 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. Sex 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 sex gap.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 24 Feb 2021; epub ahead of print
Shah T, Haimi I, Yang Y, Gaston S, ... Lansky A, Tirziu D
Am J Cardiol: 24 Feb 2021; epub ahead of print | PMID: 33640366
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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 Feb 2021; epub ahead of print
DeLago AJ, Essa M, Ghajar A, Hammond-Haley M, ... Salciccioli JD, Philips B
Am J Cardiol: 24 Feb 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 to 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 to 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 = 2600] vs. 385.5 [200, 745] mins, 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 (MACE) for patients who presented during vs. 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 MACE compared to patients admitted before the pandemic.

Copyright © 2021 Elsevier Ltd. All rights reserved.

Am J Cardiol: 21 Feb 2021; epub ahead of print
Aldujeli A, Hamadeh A, Tecson KM, Krivickas Z, ... Zaliaduonyte D, McCullough PA
Am J Cardiol: 21 Feb 2021; epub ahead of print | PMID: 33631113
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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%-12.5% (n=1428), >12.5%-25% (n=2113), >25%-50% (n=1392), and >50% (n=696). The Kaplan-Meier method was used to calculate three-year survival. Correction for baseline differences was achieved by multivariable adjustment. Patients treated with carvedilol were older (64.4 versus 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 >12.5-25% dose category had improved survival compared to 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: 1.024-1.602, 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. Published by Elsevier Inc.

Am J Cardiol: 19 Feb 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 Feb 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 - 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% (2.5-16.2%). At multivariate analysis, the factor that emerged as an independent predictor for future SVD, was smaller bioprosthetic valve size (HR 0.58, 95%CI 0.41-0.82, 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. Published by Elsevier Inc.

Am J Cardiol: 19 Feb 2021; epub ahead of print
Stathogiannis K, Synetos A, Latsios G, Karanasos A, ... Tsioufis C, Toutouzas K
Am J Cardiol: 19 Feb 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 sexes. Using the Nationwide Inpatient Sample (2015-2017), 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 sex. 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 sexes (males: 60%; females: 52.6%). Acute respiratory failure was associated with the greatest odds of mortality (OR 5.46, 95% confidence interval (CI) 5.02-5.94) when compared to other conditions: renal failure (OR 2.20 95% CI 2.01-2.40), infections (OR 2.96 95% CI 2.72-3.21), major bleeding (OR 1.71 95% CI 1.52-1.93), arrhythmias (OR 1.30 95% CI 1.19-1.43) and decompensated heart failure (OR 0.71, 95% CI 0.65-0.77). However, there was no difference in mortality between sexes for all acute conditions except renal failure (females OR: 1.02, 95% CI 1.02-1.02, 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 sexes amongst all prevalent acute conditions, with the exception of renal failure which was marginally higher in females.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 19 Feb 2021; epub ahead of print
Mohamed MO, Contractor T, Abramov D, Parwani P, ... Bagur R, Mamas MA
Am J Cardiol: 19 Feb 2021; epub ahead of print | PMID: 33621523
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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 1998-2017 (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 one 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. Published by Elsevier Inc.

Am J Cardiol: 19 Feb 2021; epub ahead of print
Vähätalo J, Holmström L, Pakanen L, Kaikkonen K, ... Huikuri H, Junttila J
Am J Cardiol: 19 Feb 2021; epub ahead of print | PMID: 33621522
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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 (LVEF) 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 [NYHA] class III or IV) or asymptomatic LVEF 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 to whites and others. The unadjusted cardiotoxicity risk was significantly higher in black compared with white women (OR, 2.10; 95% CI, 1.42-3.10). In a multivariable analysis, this disparity persisted after controlling for relevant cardiovascular risk factors (adjusted OR, 1.88; 95% CI, 1.25-2.84). 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. KEY WORDS: cardiotoxicity, race, trastuzumab, human epidermal growth factor receptor 2 (HER2).

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Al-Sadawi M, Hussain Y, Copeland-Halperin RS, Tobin JN, ... Johnson MN, Yu AF
Am J Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33617819
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Abstract

Impact of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Hypertensive Patients with COVID-19 (COVIDECA Study).

Mustafic H, Fayssoil A, Josseran L, Ouadahi M, ... Annane D, Mansencal N
Effect of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) among hypertensive patients with coronavirus disease 2019 (COVID-19) is debated. The aim of the COVIDECA study was to assess the outcome of ACEI and ARB among hypertensive patients presenting with COVID-19.We reviewed from the Assistance Publique-Hôpitaux de Parishealthcare record database all patients presenting with confirmed COVID-19 by RT-PCR. We compared hypertensive patients with ACEI or ARB and hypertensive patients without ACEI and ARB. Among 13,521 patients presenting with confirmed COVID-19 by RT-PCR, 2981 hypertensive patients (mean age: 78.4 ± 13.6 years, 1464 men) were included. Outcome of hypertensive patients was similar whatever the use or non-use of ACEI or ARB: admission in ICU (13.4% in patients with ACEI or ARB versus 14.8% in patients without ACEI/ARB, p = 0.35), need of mechanical ventilation (5.5% in patients with ACEI or ARB versus 6.3% in patients without ACEI/ARB, p = 0.45), in-hospital mortality (27.5% in patients with ACEI or ARB versus 26.7% in patients without ACEI/ARB, p = 0.70). In conclusion, the use of ACEI and ARB remains safe and can be maintained in hypertensive patients presenting with COVID-19.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Mustafic H, Fayssoil A, Josseran L, Ouadahi M, ... Annane D, Mansencal N
Am J Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33617818
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Abstract

Impact and Determinants of High-Sensitivity Cardiac Troponin-T Concentration in Patients With COVID-19 Admitted to Critical Care.

Demir OM, Ryan M, Cirillo C, Desai N, ... Marber M, Perera D
Cardiac Troponin (hs-TnT) elevation has been reported in unselected patients hospitalised with COVID-19 however the mechanism and relationship with mortality remain unclear. Consecutive patients admitted to a high-volume intensive care unit (ICU) in London with severe COVID-19 pneumonitis were included if hs-TnT concentration at admission was known. Kaplan-Meier survival analysis performed, with cohorts classified a priori by multiples of the upper limit of normal (ULN). 277 patients were admitted during a 7-week period in 2020; 176 were included (90% received invasive ventilation). hs-TnT at admission was 16.5 (9.0-49.3) ng/L, 56% had concentrations >ULN. 56 patients (31.8%) died during the index admission. Admission hs-TnT level was lower in survivors (12.0 (8.0-27.8) vs 28.5 (14.0-81.0) ng/L, p=0.001). Univariate predictors of mortality were age, APACHE-II Score and admission hs-TnT (HR 1.73, p=0.007). By multivariate regression, only age (HR 1.33, CI: 1.16.-1.51, p<0.01) and admission hs-TnT (HR 1.94, CI: 1.22-3.10, p=0.006) remained predictive. Survival was significantly lower when admission hs-TnT was >ULN (log-rank p-value<0.001). Peak hs-TnT was higher in those who died but was not predictive of death after adjustment for other factors. In conclusion, In critically ill patients with COVID-19 pneumonitis, the hs-TnT level at admission is a powerful independent predictor of the likelihood of surviving to discharge from ICU. In most cases, hs-TnT elevation does not represent major myocardial injury but acts as a sensitive integrated biomarker of global stress. Whether stratification based on admission Troponin level could be used to guide prognostication and management warrants further evaluation.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Demir OM, Ryan M, Cirillo C, Desai N, ... Marber M, Perera D
Am J Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33617816
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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 six-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 individuals with acute ischemic stroke (age 65±16; 47% women), the six-month incidence of monitor utilization was 36.5% (95% CI 31.7, 41.3), and six-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]; six-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 individuals with cryptogenic stroke, the six-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. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Khurshid S, Li X, Ashburner JM, Lipsanopoulos ATT, ... Trinquart L, Lubitz SA
Am J Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33617814
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Abstract

Spontaneous Coronary Artery Dissection and Menopause.

Díez-Villanueva P, García-Guimaraes MM, Macaya F, Masotti M, ... Salamanca J, Alfonso F
Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome (ACS) in women. The role of sexual hormones has been related to the pathophysiology of SCAD. However, clinical features, angiographic findings, management and outcomes of SCAD women in relation to menopause status remain unknown. The Spanish multicenter prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. All coronary angiograms were analyzed in a centralized Corelab. In this substudy, 245 women were classified according to their menopause state (pre-menopausal and post-menopausal). In-hospital outcomes were analyzed: 148 patients (60.4%) were post-menopausal. These patients were older (57 [52-66] vs. 49 [44-54] years, p<0.01) and had more often hypertension (49% vs. 27%, p<0.01) and dyslipidemia (46% vs. 25%, p<0.01). Post-menopausal women showed more often previous history of ACS, including previous SCAD (9% vs. 3%, p=0.046), and presented less frequently as ST-segment elevation myocardial infarction on admission, compared to pre-menopausal women (34% vs. 49%, p=0.014). On the other hand, premenopausal women showed more often proximal and multi-segment involvement (24% vs. 7%, and 32% vs. 18%, respectively, both p<0.01). Postmenopausal women were more often managed conservatively (85% vs. 71%, p<0.01) and presented less frequently left ventricular dysfunction (both, p<0.01). There were no differences between groups in terms of in-hospital stay or mortality, new acute myocardial infarction, unplanned coronary angiography or heart failure. In conclusion, postmenopausal women with SCAD show different clinical and angiographic characteristics compared with pre-menopausal SCAD patients. Initial treatment strategy was different between groups, though in-hospital outcomes did not significantly differ (NCT03607981).

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Díez-Villanueva P, García-Guimaraes MM, Macaya F, Masotti M, ... Salamanca J, Alfonso F
Am J Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33617813
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Abstract

Frequency of Atrial Arrhythmia in Hospitalized Patients with COVID-19.

Yarmohammadi H, Morrow JP, Dizon J, Biviano A, ... Wan EY, Garan H
There is growing evidence that COVID-19 can cause cardiovascular complications. However, there are limited data on the characteristics and importance of atrial arrhythmia (AA) in patients hospitalized with COVID-19. Data from 1029 patients diagnosed with of COVID-19 and admitted to Columbia University Medical Center between March 1st and April 15th 2020 were analyzed. The diagnosis of AA was confirmed by 12 lead electrocardiographic recordings, 24hour telemetry recordings and implantable device interrogations. Patients\' history, biomarkers and hospital course were reviewed. Outcomes of death, intubation and discharge were assessed. Of 1029 patients, 82 (8%) were diagnosed with AA. Out of the 82 patients with AA. Of the AA patients, new-onset AA was seen in 46 (56%) patients, recurrent paroxysmal and chronic persistent were diagnosed in 16 (20%) and 20 (24%) individuals, respectively. Sixty-five percent of the patients diagnosed with AA (n=53) died. Patients diagnosed with AA had significantly higher mortality compared to those without AA (65% vs. 21%; p < 0.001). Predictors of mortality were older age (Odds Ratio (OR) =1.12, [95% Confidence Interval (CI), 1.04 to 1.22]); male gender (OR=6.4 [95% CI, 1.3 to 32]); azithromycin use (OR=13.4 [95% CI, 2.14 to 84]); and higher D-dimer levels (OR=2.8 [95% CI, 1.1 to7.3]). In conclusion, patients diagnosed with AA had 3.1 times significant increase in mortality rate versus patients without diagnosis of AA in COVID-19 patients. Older age, male gender, azithromycin use and higher baseline D-dimer levels were predictors of mortality.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Yarmohammadi H, Morrow JP, Dizon J, Biviano A, ... Wan EY, Garan H
Am J Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33617812
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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 multi-organ dysfunction, and 1-year composite endpoint of death or HF hospitalization. B-type natriuretic peptide (BNP), high sensitivity cardiac troponin I (hscTnI), urine and serum neutrophil gelatinase-associated lipocalin (NGAL), 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 to admission. Earlier BNP decreases but not time to diuretics were associated with earlier and greater decreases in hscTnI and urine NGAL, and lower incidence of the composite endpoint. After adjustment for confounders, only no BNP decrease at discharge was significantly associated with mortality but not the composite endpoint (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. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Horiuchi Y, Wettersten N, van Veldhuisen DJ, Mueller C, ... Maisel A, Murray PT
Am J Cardiol: 18 Feb 2021; epub ahead of print | 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 [452-765] vs. 1055 [812-1340] pmol/L; P < 0.001), TAT (21.4 [16.2-37.0] vs. 38.7 [26.4-58.7] μg/mL; P < 0.001) and on day 1 in SFMC (18.2 [9.4-57.9] vs. 113.4 [70.9-157.3] μg/mL; P < 0.001) and day 2 in FDP (6.0 [4.7-10.0] vs. 12.6 [8.2-17.4] 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. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Katayama T, Yokoyama N, Watanabe Y, Takahashi S, ... Kawasugi K, Kozuma K
Am J Cardiol: 18 Feb 2021; epub ahead of print | 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 among dyspneic patients suspected of acute heart failure (AHF) 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. AHF prevalence, diagnostic accuracies, and medical resource use conditional on disease status and test results were derived from ICON-RELOADED. Several assumptions based on prior 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. Published by Elsevier Inc.

Am J Cardiol: 18 Feb 2021; epub ahead of print
Siebert U, Milev S, Zou D, Litkiewicz M, ... Masson S, Januzzi JL
Am J Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33617809
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Abstract

Meta-Analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients With ST Elevation Myocardial Infarction.

Jhand A, Atti V, Gwon Y, Dhawan R, ... Bhatt DL, Velagapudi P
Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:23-30
Jhand A, Atti V, Gwon Y, Dhawan R, ... Bhatt DL, Velagapudi P
Am J Cardiol: 14 Feb 2021; 141:23-30 | PMID: 33220324
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Abstract

Long Term Outcomes of Patients Treated With Transcatheter Aortic Valve Implantation.

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:72-78
Schamroth Pravda N, Codner P, Vaknin Assa H, Witberg G, ... Sagie A, Kornowski R
Am J Cardiol: 14 Feb 2021; 141:72-78 | PMID: 33217350
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Abstract

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

Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J
Various predictors of atrial fibrillation (AF) recurrence have been shown based on the baseline characteristics before catheter ablation (CA). This study aimed to develop a novel scoring system for predicting very late recurrences of AF (VLRAFs) after an initial CA, taking the postprocedural clinical data into account and reassessing VLRAFs in 12-month patients\' condition using previously known preprocedural predictors of AF recurrences. We retrospectively studied 327 patients who underwent an initial CA with freedom from AF for over 12 months. We elucidated the predictors of VLRAFs and created a new score to predict VLRAFs in the discovery AF cohort (n = 181). Thereafter, we investigated whether the new scoring system could accurately predict VLRAFs in the validation AF cohort (n = 146). In the discovery AF cohort, VLRAFs were observed in 53 patients (29%) during the follow-up period (mean follow-up duration: 55 months). The univariate and multivariate Cox proportional-hazards model demonstrated that non-pulmonary vein foci, early recurrences of AF (ERAFs), atrial premature contraction (APC) burden ≥ 142/24 hours, and minimum prematurity index of the APCs ≤ 48% were associated with VLRAFs after CA. We created a new scoring system to predict VLRAFs, the n-PReDCt score (non-pulmonary vein: 1 point, early recurrences of AFs (Recurrences of AF in early phase after CA): 1 point, APC burden ≥ 142/24 hours: 1 point, and minimum prematurity index (= Coupling interval) of the APCs of ≤ 48%: 1 point). The n-PReDCt score was significantly associated with VLRAFs by a Kaplan-Meier analysis in the discovery AF and validation AF cohorts (p < 0.0001 and p < 0.0001, respectively).

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:49-55
Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J
Am J Cardiol: 14 Feb 2021; 141:49-55 | PMID: 33217347
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Abstract

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

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

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 14 Feb 2021; 141:7-15
Katritsis DG, Pantos I, Zografos T, Spahillari A, ... Kastrati A, Cutlip D
Am J Cardiol: 14 Feb 2021; 141:7-15 | PMID: 33220322
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Abstract

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

Pastori D, Biccirè FG, Lip GYH, Menichelli D, ... Gaudio C, Tanzilli G
Patients with atrial fibrillation (AF) have an increased risk of coronary artery disease (CAD) compared to patients without. Angiographic characteristics, clinical presentation and severity of CAD according to the presence of AF have been poorly described. We performed a retrospective study of 303 consecutive patients (mean age 69.6 ± 10.8 years; 23.1% women) with and without AF undergoing percutaneous coronary intervention. Data on (1) type of CAD presentation, (2) coronary involvement, and (3) number of diseased coronary vessels (≥70%/luminal narrowing) were collected. CHA2DS2-VASc and 2 major adverse cardiac event (MACE) scores were calculated. Presentation of CAD was ST-segment elevation myocardial infarction (STEMI) in 37.6% of patients, non-STEMI- unstable angina in 55.1%, and other in 7.3%. Non-STEMI-unstable angina was more common in AF (69.6% vs 46.6%, p <0.001), while STEMI was more in the non-AF (22.3% vs 46.6%, p <0.001) group. Left anterior descending artery (LAD) was the most common diseased vessel (70.6%) followed by right coronary artery (RCA, 56.4%) and obtuse marginal artery (36.6%). Patients with AF had a significantly lower RCA involvement (47.3% vs 61.8%, p = 0.016), with a trend for LAD (64.3% vs 74.3%, p = 0.069). At multivariable logistic regression analysis, AF remained inversely associated with RCA involvement (odds ratio [OR] 0.541, 95% confidence interval [CI] 0.335 to 0.874, p = 0.012) and with ≥3 vessel CAD (OR 0.470, 95% CI 0.272 to 0.810, p = 0.007). The 2MACE score was associated with diseased LAD (OR 1.301, 95% CI 1.103 to 1.535, p = 0.002) and with ≥3 vessel CAD (OR 1.330, 95% CI 1.330 to 1.140, p <0.001). In conclusion, patients with AF show lower RCA involvement and generally less severe CAD compared to non-AF ones. The 2MACE score was higher in LAD obstruction and identified patients with severe CAD.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:1-6
Pastori D, Biccirè FG, Lip GYH, Menichelli D, ... Gaudio C, Tanzilli G
Am J Cardiol: 14 Feb 2021; 141:1-6 | PMID: 33220321
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Abstract

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

Ito S, Taniguchi T, Shirai S, Ando K, ... Yashima F, Hayashida K
Baseline thrombocytopenia was reported as a risk factor for bleeding or mortality in several medical areas, particularly in the cardiovascular field. This study aimed to assess the prognostic value of baseline thrombocytopenia in patients who had transcatheter aortic valve implantation. This study included 2,588 patients from the Optimized Catheter valvular intervention Japanese multicenter registry. Thrombocytopenia was defined as platelet count of <150 × 109/L and was classified into moderate/severe (<100 × 109/L) and mild (≧100-<150 × 109/L). At 3 years after index procedure, the moderate/severe thrombocytopenia group had a significantly higher cumulative composite late bleeding than the no thrombocytopenia group (log-rank test, p < 0.0001). Moreover, the moderate/severe thrombocytopenia group had a significantly higher cumulative all-cause, cardiovascular, and noncardiovascular mortality rates than the no thrombocytopenia group (log-rank test, p < 0.0001, p = 0.0014, p < 0.0001, respectively). After adjusting for confounders, the excess risk of moderate/severe and mild thrombocytopenia relative to no thrombocytopenia for the composite bleeding remained significant (hazard ratio 2.66: [95% confidence interval: 1.35 to 4.88], p = 0.006 and hazard ratio 2.10: [95% confidence interval: 1.36 to 3.21], p = 0.001, respectively). In conclusion, baseline thrombocytopenia was associated with an increased risk of late bleeding and poor prognosis. Baseline platelet level could be a prognostic marker for risk stratification.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:86-92
Ito S, Taniguchi T, Shirai S, Ando K, ... Yashima F, Hayashida K
Am J Cardiol: 14 Feb 2021; 141:86-92 | PMID: 33220320
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Abstract

Continuous Thermodilution Method to Assess Coronary Flow Reserve.

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:31-37
Gutiérrez-Barrios A, Izaga-Torralba E, Rivero Crespo F, Gheorghe L, ... Vázquez-García R, Alfonso F
Am J Cardiol: 14 Feb 2021; 141:31-37 | PMID: 33220317
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Abstract

Optimal Medical Therapy Following Transcatheter Aortic Valve Implantation.

Kaewkes D, Ochiai T, Flint N, Patel V, ... Cheng W, Makkar R
Limited data exist on optimal medical therapy post-transcatheter aortic valve implantation (TAVI) for late cardiovascular events prevention. We aimed to evaluate the benefits of beta-blocker (BB), renin-angiotensin system inhibitor (RASi), and their combination on outcomes following successful TAVI. In a consecutive cohort of 1,684 patients with severe aortic stenosis undergoing TAVI, the status of BB and RASi treatment at discharge was collected, and patients were classified into 4 groups: no-treatment, BB alone, RASi alone, and combination groups. The primary outcome was a composite of all-cause mortality and rehospitalization for heart failure (HHF) at 2-year. There were 415 (25%), 462 (27%), 349 (21%), and 458 (27%) patients in no-treatment, BB alone, RASi alone, and combination groups, respectively. The primary outcome was lower in RASi alone (21%; adjusted hazard ratio [HR]adj: 0.58; 95% confidence interval [CI]: 0.42 to 0.81) and combination (22%; HRadj: 0.53; 95% CI: 0.39 to 0.72) groups than in no-treatment group (34%) but no significant difference between RASi alone and combination groups (HRadj: 1.14; 95% CI: 0.80 to 1.62). The primary outcome results were maintained in a sensitivity analysis of patients with reduced left ventricular systolic function. Furthermore, RASi treatment was an independent predictor of 2-year all-cause mortality (HRadj: 0.68; 95% CI: 0.51 to 0.90), while that was not observed in BB therapy (HRadj: 0.94; 95% CI: 0.71 to 1.25). In conclusion, post-TAVI treatment with RASi, but not with BB, was associated with lower all-cause mortality and HHF at 2-year. The combination of RASi and BB did not add an incremental reduction in the primary outcome over RASi alone.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:62-71
Kaewkes D, Ochiai T, Flint N, Patel V, ... Cheng W, Makkar R
Am J Cardiol: 14 Feb 2021; 141:62-71 | PMID: 33221263
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Abstract

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

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:93-97
Ramberg E, Greve AM, Berg RMG, Sajadieh A, ... Wachtell K, Nielsen OW
Am J Cardiol: 14 Feb 2021; 141:93-97 | PMID: 33221262
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Abstract

Trends in Outcomes of Transcatheter and Surgical Aortic Valve Replacement in the United States (2012-2017).

Saad AM, Kassis N, Isogai T, Gad MM, ... Svensson LG, Kapadia S
As the use of transcatheter aortic valve implantation (TAVI) expands to varying patient populations, impacting the landscape of surgical aortic valve replacement (SAVR), this study sought to assess volume and performance trends of aortic valve replacement (AVR) in the United States during 2012-2017. The Nationwide Readmissions Database was queried for patients who underwent endovascular/transapical TAVI, isolated SAVR, or complex aortic valve surgery between 2012 and 2017. Temporal trends in annual case volume, admission costs, in-hospital outcomes, and 30-day readmission were evaluated. Of 624,303 patients (median age 72 years) who received AVR, 387,011 (62%) were men. Among these patients, 170,521 (27%) underwent TAVI and 453,782 (73%) underwent SAVR with 299,398 isolated and 154,384 complex aortic valve surgery. TAVI patients were significantly older and higher risk compared with SAVR patients. From 2012 to 2017, the annual number of TAVI increased from 8,295 to 55,168 whereas SAVR volume remained remarkably stable. Patients who underwent AVR demonstrated significant improvements in mortality, stroke, duration of hospitalization, and 30-day readmission. In conclusion, this large contemporary analysis reports the considerable growth of AVR in the United States. It remains unequivocal that the treatment of aortic stenosis is improving overall with reduced mortality following AVR, highlighting the effectiveness of various process improvements such as newer valves, enhanced patient selection, and the interdisciplinary Heart Team approach.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:79-85
Saad AM, Kassis N, Isogai T, Gad MM, ... Svensson LG, Kapadia S
Am J Cardiol: 14 Feb 2021; 141:79-85 | PMID: 33275895
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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: 08 Feb 2021; epub ahead of print
Lopez PD, Cativo-Calderon EH, Otero D, Rashid M, Atlas S, Rosendorff C
Am J Cardiol: 08 Feb 2021; epub ahead of print | PMID: 33577810
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Abstract

Meta-Analysis of Usefulness of Cerebral Embolic Protection During Transcatheter Aortic Valve Implantation.

Ahmad DY, Howard JP
One of the most feared complications of transcatheter aortic valve implantation (TAVI) is stroke, with increased mortality and disability observed in patients suffering a stroke after TAVI. There has been no significant decline in stroke rates seen over the last 5 years; attention has therefore been given to strategies for cerebral embolic protection. With the emergence of new randomized trial data, we sought to perform an updated systematic review and meta-analysis to examine the effect of cerebral embolic protection during TAVI both on clinical outcomes and on neuroimaging parameters. We performed a random-effects meta-analysis of randomized clinical trials of cerebral embolic protection during TAVI. The primary endpoint was the risk of stroke. The risk of stroke was not significantly different with the use of cerebral embolic protection: relative risk (RR) 0.88, 95% confidence interval (CI) 0.57 to 1.36, P=0.566. Nor was there a significant reduction in the risk of disabling stroke, non-disabling stroke or death. There was no significant difference in total lesion volume on MRI with cerebral embolic protection: mean difference -74.94, 95% CI -174.31 to 24.4, P=0.139. There was also not a significant difference in the number of new ischemic lesions on MRI: mean difference -2.15, 95% -5.25 to 0.96, P=0.176, although there was significant heterogeneity for the neuroimaging outcomes. In conclusion, cerebral embolic protection during TAVI is safe but there is no evidence of a statistically significant benefit on clinical outcomes or neuroimaging parameters.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 04 Feb 2021; epub ahead of print
Ahmad DY, Howard JP
Am J Cardiol: 04 Feb 2021; epub ahead of print | PMID: 33556360
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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 were 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 endpoint of the study was all-cause mortality at 30-days and during follow-up. A total of 652 patients were included and followed during a median time of 9.1 (2.5-22.1) months. Among this population, 117 (17.9%) had a recently diagnosed cardiomyopathy and had LVAD implantation after a median time of 15.0 (9.0-24.0) 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 prior to LVAD compared to the remotely diagnosed group. Post-operative in-hospital survival was similar among groups, but recently diagnosed patients had a better long-term survival after hospital discharge. SCA prior to LVAD and any cardiac surgery combined with LVAD implantation were identified as two independent predictors of post-operative 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 post-operative mortality and have a better long-term survival compared to remotely diagnosed patients.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 03 Feb 2021; epub ahead of print
Chen E, Nesseler N, Martins RP, Goéminne C, ... Flécher E, Galand V
Am J Cardiol: 03 Feb 2021; epub ahead of print | PMID: 33549526
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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 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 (PFO), 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 two giants of cardiovascular research, Jesse E. Edwards and Kurt A. Amplatz.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 02 Feb 2021; epub ahead of print
Saner H, Saner B, Meier B
Am J Cardiol: 02 Feb 2021; epub ahead of print | PMID: 33548188
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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. Published by Elsevier Inc.

Am J Cardiol: 02 Feb 2021; epub ahead of print
Milandt N, Birkelund T, Engholm M
Am J Cardiol: 02 Feb 2021; epub ahead of print | PMID: 33548186
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Abstract

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

Xia M, Yang X, Qian C

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jan 2021; 140:33-38
Xia M, Yang X, Qian C
Am J Cardiol: 31 Jan 2021; 140:33-38 | PMID: 33137319
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Abstract

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

Farag M, Gue YX, Brilakis ES, Egred M

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jan 2021; 140:47-54
Farag M, Gue YX, Brilakis ES, Egred M
Am J Cardiol: 31 Jan 2021; 140:47-54 | PMID: 33144169
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Abstract

Discharge Location and Outcomes After Transcatheter Aortic Valve Implantation.

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

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jan 2021; 140:95-102
Sweda R, Dobner S, Heg D, Lanz J, ... Windecker S, Stortecky S
Am J Cardiol: 31 Jan 2021; 140:95-102 | PMID: 33144166
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Abstract

Outcomes of Percutaneous Coronary Intervention in Patients With Rheumatoid Arthritis.

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

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

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 31 Jan 2021; 140:39-46
Dawson LP, Dinh D, O'Brien J, Duffy SJ, ... Ajani AE,
Am J Cardiol: 31 Jan 2021; 140:39-46 | PMID: 33144158
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Abstract

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

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

The association between serum adiponectin levels and cardiovascular events, particularly how adiponectin predicts the development of cardiovascular events and mortality in acute coronary syndrome (ACS) patients remains unresolved. Hence, we aimed to determine whether higher adiponectin levels predict cardiovascular events and mortality in these patients. Regression analyses were performed to clarify adiponectin\'s ability to predict cardiovascular events and mortality among 1,641 ACS patients. Subgroup analyses were performed according to gender, age, and body mass index (BMI). The primary end point was a composite of the first all-cause death, nonfatal myocardial infarction, or nonfatal stroke event. The secondary end point was all-cause death. Hazard ratios for the primary and secondary end points per 5-µg/ml increase in adiponectin levels were 1.31 (95% confidence interval [CI], 1.13 to 1.47; p = 0.0007) and 1.32 (95% CI, 1.13 to 1.51; p = 0.001), respectively. Higher adiponectin levels were associated with increased cardiovascular events in men, patients aged ≥65 years, and those with BMI <25 kg/m. In conclusion, higher adiponectin levels were associated with increased cardiovascular events and all-cause mortality in ACS patients. Its predictive ability might be limited in women, patients aged <65 years, and patients with BMI ≥25 kg/m.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jan 2021; 140:7-12
Nomura H, Arashi H, Yamaguchi J, Ogawa H, Hagiwara N
Am J Cardiol: 31 Jan 2021; 140:7-12 | PMID: 33144157
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Abstract

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

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

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jan 2021; 140:103-109
Hamandi M, Amiens P, Grayburn PA, Al-Azizi K, ... Harbaoui B, Lantelme P
Am J Cardiol: 31 Jan 2021; 140:103-109 | PMID: 33144156
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Abstract

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

Qureshi WT, Kakouros N, Fahed J, Rade JJ

Whether very young patients (≤35-year-old) differ in the prevalence, presentation and prognosis of ACS is not well known. Of 43,446 patients who were referred to a tertiary care cardiac catheterization laboratory between January 1, 2006 and June 30, 2017, 26,545 patients were ACS (defined as ST Elevation MI, Non-ST Elevation MI or unstable angina pectoris). Detailed chart review was performed and characteristics at baseline were compared for ages ≤35 years, ages 36 to 54 years and ages ≥55 years. A total of 291 (1.1%) were ≤35-year-old, 7,649 (28.8) were 36 to 54-year-old and 18,605 (70.1%) were ≥55-year-old. ACS patients aged ≤35-year-old, were more likely to be men, Caucasian white, smoker, obese, and have family history of coronary artery disease and less likely to have comorbidities such as hypertension, diabetes mellitus, and hyperlipidemia compared with older patients. They were also more likely to present with elevated troponin levels than other groups. They also tended to present with late ST elevation myocardial infarction and were more likely to receive bare metal stents than older patients. The prevalence of 2- and 3-vessel disease was lower compared with older patients. They also had higher prevalence of cardiogenic shock. Compared with 36 to 54-year-old patients, ≤35-year-old were at significant higher risk of 30-day mortality in a multivariable adjusted regression model (Odds ratio 5.65, 95% confidence interval 2.49 to 12.82, p <0.001). Very young patients comprised ∼1% of all ACS cases but had much more prevalence of modifiable risk factors and significantly worse mortality. Modifying these risk factors may mitigate the risk in these patients and should be studied in the future.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jan 2021; 140:1-6
Qureshi WT, Kakouros N, Fahed J, Rade JJ
Am J Cardiol: 31 Jan 2021; 140:1-6 | PMID: 33166493
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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 post-procedural LVEDP in patients undergoing TAVI. Consecutive patients with severe symptomatic aortic stenosis undergoing TAVI were divided into 2 groups according to post-procedural LVEDP above and below or equal 12 mmHg. 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 16.5-48.0]). The mean age (±SD) was 82.3±6.2 years and mean Society of Thoracic Surgery (STS) score was 4.0%±3.0%. Patients with LVEDP>12 mmHg (n=591, 70%) and LVEDP≤12 mmHg (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, post-procedural LVEDP>12 mmHg 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 post-procedural LVEDP in patients undergoing TAVI is an independent predictor of mortality following TAVI. Further research regarding the use of LVEDP as a tool for post-procedural medical management is warranted.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 31 Jan 2021; epub ahead of print
Szekely Y, Borohovitz A, Hochstadt A, Topilsky Y, ... Finkelstein A, Arbel Y
Am J Cardiol: 31 Jan 2021; epub ahead of print | 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 (ACE2) 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] 1.10-1.58), CVD events (HR 1.34, 95% CI 1.13-1.60), and all-cause death (HR 1.26, 95% CI 1.01-1.57). 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. Published by Elsevier Inc.

Am J Cardiol: 31 Jan 2021; epub ahead of print
Hussain A, Tang O, Sun C, Jia X, ... Hoogeveen RC, Ballantyne CM
Am J Cardiol: 31 Jan 2021; epub ahead of print | 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: 31 Jan 2021; epub ahead of print
Tzani A, Doulamis IP, Tzoumas A, Avgerinos DV, ... Klein A, Kampaktsis PN
Am J Cardiol: 31 Jan 2021; epub ahead of print | 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: 31 Jan 2021; epub ahead of print
Canada JM, Reynolds MA, Myers R, West J, ... Arena R, Hundley WG
Am J Cardiol: 31 Jan 2021; epub ahead of print | 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 undergoing coronary angiography between 2008-2017 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 non-obstructive 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 to those with a negative troponin (HR 2.37; 95% CI, 1.67-3.34). Statin (HR 0.32; 95% CI, 0.22-0.49) and ACE inhibitor (HR 0.49; 95% CI, 0.32-0.75) 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 to 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. Published by Elsevier Inc.

Am J Cardiol: 31 Jan 2021; epub ahead of print
Kovach CP, Hebbe A, O'Donnell CI, Plomondon ME, ... Waldo SW, Valle JA
Am J Cardiol: 31 Jan 2021; epub ahead of print | PMID: 33539858
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Abstract

Relation of Cardiovascular Risk Factors to Mortality and Cardiovascular Events in Hospitalized Patients With Coronavirus Disease 2019 (from the Yale COVID-19 Cardiovascular Registry).

Pareek M, Singh A, Vadlamani L, Eder M, ... Ahmad T, Desai NR
Individuals with established cardiovascular disease or a high burden of cardiovascular risk factors may be particularly vulnerable to develop complications from coronavirus disease 2019 (COVID-19). We conducted a prospective cohort study at a tertiary care center to identify risk factors for in-hospital mortality and major adverse cardiovascular events (MACE; a composite of myocardial infarction, stroke, new acute decompensated heart failure, venous thromboembolism, ventricular or atrial arrhythmia, pericardial effusion, or aborted cardiac arrest) among consecutively hospitalized adults with COVID-19, using multivariable binary logistic regression analysis. The study population comprised 586 COVID-19 positive patients. Median age was 67 (IQR: 55 to 80) years, 47.4% were female, and 36.7% had cardiovascular disease. Considering risk factors, 60.2% had hypertension, 39.8% diabetes, and 38.6% hyperlipidemia. Eighty-two individuals (14.0%) died in-hospital, and 135 (23.0%) experienced MACE. In a model adjusted for demographic characteristics, clinical presentation, and laboratory findings, age (odds ratio [OR], 1.28 per 5 years; 95% confidence interval [CI], 1.13 to 1.45), previous ventricular arrhythmia (OR, 18.97; 95% CI, 3.68 to 97.88), use of P2Y12-inhibitors (OR, 7.91; 95% CI, 1.64 to 38.17), higher C-reactive protein (OR, 1.81: 95% CI, 1.18 to 2.78), lower albumin (OR, 0.64: 95% CI, 0.47 to 0.86), and higher troponin T (OR, 1.84; 95% CI, 1.39 to 2.46) were associated with mortality (p <0.05). After adjustment for demographics, presentation, and laboratory findings, predictors of MACE were higher respiratory rates, altered mental status, and laboratory abnormalities, including higher troponin T (p <0.05). In conclusion, poor prognostic markers among hospitalized patients with COVID-19 included older age, pre-existing cardiovascular disease, respiratory failure, altered mental status, and higher troponin T concentrations.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jan 2021; epub ahead of print
Pareek M, Singh A, Vadlamani L, Eder M, ... Ahmad T, Desai NR
Am J Cardiol: 31 Jan 2021; epub ahead of print | PMID: 33539857
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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: 31 Jan 2021; epub ahead of print
Imazio M, Andreis A, Agosti A, Piroli F, ... Giustetto C, De Ferrari GM
Am J Cardiol: 31 Jan 2021; epub ahead of print | PMID: 33539856
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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 Jan 2021; epub ahead of print
Kaur M, Ahuja KR, Khubber S, Zhou L, ... Puri R, Kapadia S
Am J Cardiol: 30 Jan 2021; epub ahead of print | PMID: 33535058
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Abstract

Comparison of Direct Oral Anticoagulants versus Warfarin in Patients with Atrial Fibrillation and Bioprosthetic Heart Valves.

Duan L, Doctor JN, Adams JL, Romley JA, ... An J, Lee MS
There are limited data regarding direct oral anticoagulants (DOACs) for stroke prevention in patients with bioprosthetic heart valves (BHVs) and atrial fibrillation (AF). The objectives of this study were to evaluate the ambulatory utilization of DOACs and to compare the effectiveness and safety of DOACs versus warfarin in patients with AF and BHVs. We conducted a retrospective cohort study at a large integrated health care delivery system in California. Patients with BHVs and AF treated with warfarin, dabigatran, rivaroxaban or apixaban between September 12, 2011 and June 18, 2020 were identified. Inverse probability of treatment-weighted comparative effectiveness and safety of DOACs compared with warfarin were determined. Use of DOACs gradually increased since 2011, with a significant upward in trend after a stay-at-home order related to COVID-19. Among 2672 adults with BHVs and AF who met the inclusion criteria, 439 were exposed to a DOAC and 2233 were exposed to warfarin. For the primary effectiveness outcome of ischemic stroke, systemic embolism and transient ischemic attack, no significant association was observed between use of DOACs compared with warfarin (HR 1.19, 95% CI 0.96-1.48, p=0.11). Use of DOACs was associated with lower risk of the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed (HR 0.69, 95% CI 0.56 to 0.85, p <0.001). Results were consistent across multiple subgroups in the sensitivity analyses. These findings support the use of DOACs for AF in patients with BHVs.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 29 Jan 2021; epub ahead of print
Duan L, Doctor JN, Adams JL, Romley JA, ... An J, Lee MS
Am J Cardiol: 29 Jan 2021; epub ahead of print | PMID: 33529622
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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: 29 Jan 2021; epub ahead of print
Stein PD, Matta F, Hughes MJ
Am J Cardiol: 29 Jan 2021; epub ahead of print | 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 TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. This was a post-hoc, exploratory analysis of the Americas cohort of TOPCAT. BMI≥30 kg/m2 was used to define the obese group and WC≥102cm in men and ≥88cm in women were defined as high WC (HWC). In separate analyses, BMI and WC were treated as continuous variables. The effect of spironolactone vs. placebo on outcomes was calculated by BMI and WC using Cox proportional hazard models. Obese patients were younger and had more comorbidities. In multivariate analysis, spironolactone use was associated with a significant reduction in the primary endpoint, compared to placebo in obese [hazard ratio (HR=0.618, 95% CI 0.460-0.831, p=0.001), but not in non-obese subjects (HR=0.946, 95% CI 0.623-1.437, 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 endpoint, cardiovascular death and HF hospitalizations, compared to placebo. Further prospective randomized studies in obese subjects are required.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 29 Jan 2021; epub ahead of print
Elkholey K, Papadimitriou L, Butler J, Thadani U, Stavrakis S
Am J Cardiol: 29 Jan 2021; epub ahead of print | 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 (AS) results in compensatory concentric hypertrophy which mitigates the increased systolic load. Surgical aortic valve replacement (SAVR) 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 SAVR patients who were generally younger with few comorbidities. Accordingly, we analyzed indices of LV structure and ventricular mechanics pre- and 1-year post TAVI in 397 patients (mean age 81±9, 46% women) with severe symptomatic AS, complete echocardiographic data was available in 156 patients and these patients compromised our study population. Our principal findings are: (1) LV remodeling occurs post TAVI; (2) afterload decreases significantly; (3) LV chamber and myocardial function, assessed by LVEF and midwall fractional shortening, and stroke volume, respectively, remain unchanged or decrease. In conclusion, TAVI effects LV remodeling despite significant comorbidities. 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: 29 Jan 2021; epub ahead of print
Harrington CM, Sorour N, Gottbrecht M, Nagy A, ... Chung ES, Aurigemma GP
Am J Cardiol: 29 Jan 2021; epub ahead of print | 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: 29 Jan 2021; epub ahead of print
Sharma S, Labib SB, Shah SP
Am J Cardiol: 29 Jan 2021; epub ahead of print | 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: 29 Jan 2021; epub ahead of print
Dave M, Kumar A, Majmundar M, Adalja D, ... Gullapalli N, Doshi R
Am J Cardiol: 29 Jan 2021; epub ahead of print | 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 - 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 - 0.83, p=0.02), procedural mortality (OR 0.41; 95% CI 0.18 - 0.96, p=0.04), 30-day mortality (OR 0.58; 95% CI 0.45 - 0.74, p<0.0001), and the rate of stroke (OR 0.65; 95% CI 0.52 - 0.81,p=0.0001) were significantly lower in the ViV- TAVI arm when compared to Redo-SAVR arm. The mean transvalvular pressure gradient was significantly higher post-implantation in the ViV-TAVI group when compared to the Redo-SAVR arm (Mean difference 3.92; 95% CI 1.97 - 5.88, p<0.0001). In conclusion, compared to 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 to Redo-SAVR.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 29 Jan 2021; epub ahead of print
Al-Abcha A, Saleh Y, Boumegouas M, Prasad R, ... Rayamajhi S, Abela GS
Am J Cardiol: 29 Jan 2021; epub ahead of print | PMID: 33529615
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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 (DRT). At a median follow-up of 2 (1-3) 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 undergoing LAAC had very high thrombotic and bleeding risks. While the rates of DRT or ischemic stroke post-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: 24 Jan 2021; epub ahead of print
Faroux L, Cruz-González I, Arzamendi D, Freixa X, ... O'Hara G, Rodés-Cabau J
Am J Cardiol: 24 Jan 2021; epub ahead of print | PMID: 33508268
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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: 22 Jan 2021; epub ahead of print
Reiffel JA, Verma A, Kowey PR, Halperin JL, ... Ziegler PD, REVEAL AF Investigators
Am J Cardiol: 22 Jan 2021; epub ahead of print | PMID: 33497655
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Abstract

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

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Jan 2021; 139:28-33
Napierkowski S, Banerjee U, Anderson HV, Charitakis K, ... Smalling RW, Dhoble A
Am J Cardiol: 14 Jan 2021; 139:28-33 | PMID: 33035466
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