Journal: Am J Cardiol

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Abstract

Results and Predictive Factors After One Cryoablation for Persistent Atrial Fibrillation.

Hermida A, Diouf M, Kubala M, Fay F, ... Beyls C, Hermida JS
Cryoballoon pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) ablation is an increasingly used strategy. We aimed to determine the results and predictors of arrhythmia recurrence after a single procedure of cryoballoon PVI for patients with persistent and long-standing persistent AF. We included all consecutive patients who underwent cryoballoon PVI for the treatment of persistent symptomatic drug-refractory AF since 2012. All patients were prospectively followed to detect the recurrence of atrial tachyarrhythmia (ATa). Predictors of recurrence were assessed. Cryoballoon PVI was performed on 399 patients with persistent AF, among whom 52 (13%) had long-standing persistent AF. Patients with long-standing persistent AF had a significantly larger left atrium than those with persistent AF. A 28-mm cryoballoon was used for 322 patients (93%). In total, 359 patients (90%) completed the 12-month follow-up visit and the median follow-up was 24 months (interquartile range 43 to 13). The 2-year probability of freedom from ATa recurrence was 51% for persistent AF and 27% for long-standing persistent AF. Long-standing persistent AF and left atrial area/volume were independent predictors of ATa recurrence. Ten patients (2.5%) experienced phrenic nerve palsy, 1 tamponade (0.25%), 2 stroke (0.5%), 2 pericardial effusions (0.5%), and 5 vascular complications (1.25%). In conclusion, 2-year ATa-free survival rates were 51 and 27% for persistent and long-standing persistent AF patients, respectively. Complications were rare. Long-standing persistent AF and left-atrial area/volume were predictors of recurrence.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:65-71
Hermida A, Diouf M, Kubala M, Fay F, ... Beyls C, Hermida JS
Am J Cardiol: 14 Nov 2021; 159:65-71 | PMID: 34481590
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Abstract

Impact of Active and Historical Cancer on Short- and Long-Term Outcomes in Patients With Acute Myocardial Infarction.

Matsumoto T, Saito Y, Yamashita D, Sato T, ... Sano K, Kobayashi Y
Patients with cancer have an increased risk of cardiovascular events including myocardial infarction (MI) and vice versa, and are at high risks of ischemic and bleeding events after MI. However, short- and long-term clinical outcomes in patients with acute MI based on cancer status are not fully understood. This bi-center registry included 903 patients with acute MI undergoing primary percutaneous coronary intervention in a contemporary setting. Patients were divided into active cancer, a history of cancer, and no cancer according to the status of malignancy. Major adverse cardiovascular events (MACE), a composite of all-cause death, recurrent MI, and stroke, and major bleedings were evaluated. Of 903 patients, 49 (5.4%) and 65 (7.2%) had active cancer and a history of cancer, and 87 (9.6%) patients died during the hospitalization. In-hospital MACE was not significantly different among the 3 groups (16.3% vs 10.8% vs 10.9%, p = 0.48), whereas the rate of major bleeding events during the index hospitalization was significantly higher in patients with active cancer than their counterpart (20.4% vs 6.2% vs 5.8%, p = 0.002). After discharge, patients with active cancer had an increased risk of MACE and major bleedings compared with those with a history of cancer and no cancer during the mean follow-up period of 853 days. In conclusions, active cancer rather than a history of cancer and no cancer had significant impact on in-hospital bleeding events, and MACE and major bleedings after discharge in patients with acute MI undergoing primary percutaneous coronary intervention.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:59-64
Matsumoto T, Saito Y, Yamashita D, Sato T, ... Sano K, Kobayashi Y
Am J Cardiol: 14 Nov 2021; 159:59-64 | PMID: 34497007
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Abstract

Noninvasive Risk Score to Screen for Pulmonary Hypertension With Elevated Pulmonary Vascular Resistance in Diseases of Chronic Volume Overload.

Edmonston DL, Matsouaka R, Shah SH, Rajagopal S, Wolf M
Volume overload promotes pulmonary hypertension (PH) through pulmonary venous hypertension. However, PH with elevated pulmonary vascular resistance (hereafter PH-PVR) may develop in patients with diseases of volume overload, such as heart failure or chronic kidney disease (CKD). In such cases, volume management alone may be insufficient to slow PH progression. An accurate, noninvasive method to screen for PH-PVR in these diseases would facilitate early targeted therapy. We integrated invasive hemodynamic and echocardiography data collected from a single-center clinical cohort and identified patients with CKD or heart failure at the time of assessment. We applied penalized regression to derive a risk score of clinical parameters and echocardiography data associated with PH-PVR and categorized patients into low- (≤5 points), intermediate- (6-10 points), or high-risk (>10 points) groups. Using an internal validation strategy, we evaluated the ability of this risk score to predict PH-PVR and determined the association of this risk classification with 3-year all-cause mortality. Of 2422 patients, 42.4% had PH-PVR. In adjusted analyses, tricuspid regurgitant velocity, right ventricular function, BMI, heart rate, and hemoglobin most strongly associated with PH-PVR. The risk score significantly associated with PH-PVR (age-adjusted odds ratio 11.69 for the highest-risk group, 95% confidence interval [CI] 6.54-20.92). The high-risk group also associated with a significantly higher risk of 3-year all-cause mortality in adjusted analyses (hazard ratio 1.85, 95% CI 1.50-2.27). In conclusion, a noninvasive risk score derived from echocardiography and clinical parameters significantly associated with PH-PVR and all-cause mortality in a cohort of patients with CKD and heart failure.

Published by Elsevier Inc.

Am J Cardiol: 14 Nov 2021; 159:113-120
Edmonston DL, Matsouaka R, Shah SH, Rajagopal S, Wolf M
Am J Cardiol: 14 Nov 2021; 159:113-120 | PMID: 34497006
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Abstract

Effect of Polypharmacy on Long-Term Mortality After Percutaneous Coronary Intervention.

Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, ... Kimura T, CREDO-Kyoto PCI/CABG Registry Cohort-3 investigators
Polypharmacy was reported to be associated with increased mortality in various populations. However, there is a scarcity of data on status of polypharmacy and association with long-term mortality in patients who underwent percutaneous coronary intervention (PCI). Among 12,291 patients who underwent first PCI in the CREDO-Kyoto PCI/CABG registry Cohort-3, we evaluated the number of medications at discharge from index PCI hospitalization, and compared long-term mortality across the 3 groups divided by the tertiles of the number of medications. The median number of medications was 6 (interquartile range: 5 to 8), and 88.0% of the patients were on >=5 medications. Most of medications were those related to cardiovascular disease. Patients taking more medications were older and more often had co-morbidities and guideline-indicated medications. The cumulative 5-year incidence of all-cause death increased incrementally with increasing number of medications (Tertile 1 [<=5]: 13.1%, Tertile 2 [6 to 7]: 13.9%, and Tertile 3 [>=8]: 18.0%, log-rank p <0.001). After adjusting confounders, the mortality risks of Tertile 2 and Tertile 3 relative to Tertile 1 were no longer significant (Tertile 2: hazard ratio 0.93; 95% confidence interval 0.84 to 1.04; p = 0.23, and Tertile 3: hazard ratio 0.91; 95% confidence interval 0.81 to 1.03; p = 0.14, respectively). In conclusion, in a real-world population of patients who underwent PCI, approximately 90% of patients were on >=5 medications. Increasing medications was associated with higher crude incidence of all-cause death, whereas adjusted mortality risks were similar regardless of the number of medications. These data might suggest that achievement of optimal medical therapy would be preferred, even if it might increase the number of medications used.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:19-29
Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, ... Kimura T, CREDO-Kyoto PCI/CABG Registry Cohort-3 investigators
Am J Cardiol: 14 Nov 2021; 159:19-29 | PMID: 34497005
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Abstract

dST-Tiso Interval, a Novel Electrocardiographic Marker of Ventricular Arrhythmia Inducibility in Individuals With Ajmaline-Induced Brugada Type I Pattern.

Iacopino S, Chierchia GB, Sorrenti P, Pesce F, ... Brugada P, de Asmundis C
The aim of this study was to investigate the reliability of a novel electrocardiographic (ECG) marker in predicting ventricular arrhythmia (VA) inducibility in individuals with drug-induced Brugada syndrome (BrS) type I pattern. Consecutive patients with drug-induced type I BrS pattern underwent programmed ventricular stimulation (PVS) and, according to their response, were divided into 2 groups. Clinical characteristics and 12-lead ECG intervals before and after ajmaline infusion were compared between the 2 groups. A novel ECG marker named dST-Tiso interval consisting in the interval between the onset of the coved ST-segment elevation and its termination at the isoelectric line was also evaluated. Our cohort included 76 individuals (median age 44 years, 75% male). Twenty-five (32.9%) had VA inducibility requiring defibrillation. As compared with not inducible subjects, those with VA inducibility were more frequently male (92% vs 65%, p = 0.013), had longer PQ interval (basal: 172 vs 152 ms, p = 0.033; after ajmaline: 216 vs 200 ms, p = 0.040), higher J peak (0.6 vs 0.5 mV, p = 0.006) and longer dST-Tiso (360 vs 240 ms, p < 0.001). The dST-Tiso showed a C-statistics of 0.90 (95% confidence interval: 0.82 to 0.99) and an adjusted odds ratio for VA of 1.03 (1.01 to 1.04, p < 0.001). A dST-Tiso interval >300 ms yielded a sensitivity of 92.0%, a specificity of 90.2%, positive and negative predictive values of 82.1% and 95.8%. In conclusion, the dST-Tiso interval is a powerful predictor of VA inducibility in drug-induced BrS type I pattern. External validation is needed, but this marker might be useful in the clinical counseling process of these individuals before invasive PVS.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:94-99
Iacopino S, Chierchia GB, Sorrenti P, Pesce F, ... Brugada P, de Asmundis C
Am J Cardiol: 14 Nov 2021; 159:94-99 | PMID: 34503825
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Abstract

Clinical Diagnosis of Hypertrophic Cardiomyopathy Over Time in the United States (A Population-Based Claims Analysis).

Butzner M, Maron M, Sarocco P, Rowin E, ... Stanek E, Robertson L
Hypertrophic cardiomyopathy (HC) is a common genetic heart disease. However, the number of gene mutation carriers who develop HC and manifest clinical symptoms is not well established. Our objective was to estimate annual prevalence and incidence rates of clinically diagnosed HC in the United States. Data from the HealthCore Integrated Research Database (HIRD) were interrogated for years 2013-2019 to identify patients with ≥1 claim of HC International Classification of Diseases, Clinical Modification Ninth and Tenth Revision diagnosis codes. In 2013, among 16,243,109 patients, 8,526 were identified with HC, yielding an estimated prevalence of clinically diagnosed HC of 0.052% (0.035% for obstructive [oHC], 0.017% for nonobstructive [nHC]). This prevalence yielded an estimated 164,403 patients with clinical diagnosis of HC. For the same year, the incidence of new HC diagnoses was 0.030% (0.020% for oHC, 0.010% for nHC). Over the following 6 years, prevalence and incidence of HC increased by 0.005%/year (p <0.01) and 0.001%/year (p <0.01), respectively, with an estimated 262,591 patients with a clinical diagnosis of HC in 2019. Over this period, incidence of nHC increased (0.012% vs 0.026%, p <0.01), whereas incidence of oHC decreased (0.020% versus 0.015%, p <0.01). In conclusion, over 6 years, the number of patients with clinically diagnosed HC in the United States increased 1.5-fold to ∼262,591, primarily because of a rise in nHC diagnoses. These prevalence data support further investigation to better understand factors accounting for increasing clinical recognition of HC.

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

Am J Cardiol: 14 Nov 2021; 159:107-112
Butzner M, Maron M, Sarocco P, Rowin E, ... Stanek E, Robertson L
Am J Cardiol: 14 Nov 2021; 159:107-112 | PMID: 34503822
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Abstract

Comparison of Low and Full Dose Apixaban Versus Warfarin in Patients With Atrial Fibrillation and Renal Dysfunction (from a National Registry).

Gurevitz C, Giladi E, Barsheshet A, Klempfner R, ... Kornowski R, Elis A
The use of direct oral anticoagulants for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) is robust. However, the efficacy and safety of different dosage in patients with renal dysfunction is still a clinical challenge. We aimed to evaluate the clinical characteristics and outcomes of patients treated with apixaban in its different doses. A multicenter prospective cohort study, where consecutive eligible apixaban or warfarin treated patients with NVAF and renal impairment, were registered. Patients were followed-up for clinical events over a mean period of 1 year. Analyses were performed according to the dose of apixaban given, with consideration to the standard indications for dose reduction. Primary outcome was a composite of 1-year mortality, stroke or systemic embolism, major bleeding and myocardial infarction, while secondary outcomes included those components separated. Among the study population (n = 2,140), risk of composite outcome was significantly lower in the high dose apixaban group (10%, n = 491) than the low dose group (18%, n = 673) and the warfarin group (18%, n = 976) p <0.001. Results of 1-year mortality were similar. Apixaban dosing analysis revealed 65% of patients were appropriately dosed, while 31% were under-dosed and 4% were over-dosed. Furthermore, 53% of patients treated with low dose apixaban were under-dosed. Propensity score analysis revealed that patients who were appropriately treated with low-dose apixaban had a trend towards better composite outcome and mortality than 1:1 matched warfarin treated patients (18% vs 24%, p = 0.09 and 16% vs 23%, p = 0.06, respectively). Overall, appropriately dosed apixaban treated patients at any dose had significantly better outcomes than matched warfarin treated patients (composite outcome probability of 13.1% vs 18.6%, p = 0.007). In conclusion, apixaban at any dose is a reasonable alternative to warfarin in patients with renal impairment, possibly associated with improved outcomes.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:87-93
Gurevitz C, Giladi E, Barsheshet A, Klempfner R, ... Kornowski R, Elis A
Am J Cardiol: 14 Nov 2021; 159:87-93 | PMID: 34503821
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Abstract

Predictors of Recurrent Ischemic Events in Patients With ST-Segment Elevation Myocardial Infarction.

Galasso G, De Angelis E, Silverio A, Di Maio M, ... Parodi G, Vecchione C
Little is known about the predictors recurrent ischemic events in patients with ST-segment elevation myocardial infarction (STEMI). This study aimed at investigating the predictors of recurrent myocardial infarction (MI) at long-term follow-up in a real-world STEMI cohort. All consecutive STEMI patients who underwent emergent coronary angiography and primary percutaneous coronary intervention between February 2013 and June 2019 at our institution were included. The primary outcome was recurrent MI; secondary outcomes were all-cause death, target vessel revascularization (TVR), in-stent restenosis, definite stent thrombosis (ST) and non-TVR. The study population included 724 STEMI patients; at median follow-up of 803 (324 to 1,394) days, the primary outcome was reported in 70 patients (10.1%). All-cause death occurred in 6.8%, TVR in 4.2%, in-stent restenosis in 2.5%, and ST in 1.9% of cases. At multivariable analysis, diabetes (hazard ratio [HR] = 1.18), serum level of lipoprotein(a) [Lp(a), HR = 1.01], and angiographic evidence of restenotic lesion (HR = 2.98) resulted independent predictors of recurrent MI. Kaplan-Meier analysis confirmed that diabetes, restenotic lesion, and differential Lp(a) risk range values, identified patients with lower long-term survival free from recurrent MI. Lp(a) level ≥ 30 mg/dL had an incremental prognostic stratification capability in patients with diabetes (HR = 5.34), and in patients with both diabetes and restenotic lesion (HR = 17.07). In conclusion, in this contemporary cohort of STEMI patients, diabetes, Lp(a) serum levels and restenotic lesions were independently associated with recurrent MI at long term. The coexistence of Lp(a) level ≥ 30 mg/dL showed an incremental risk stratification capability, supporting its implementation for long-term prognostic assessment in this high-risk clinical setting.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:44-51
Galasso G, De Angelis E, Silverio A, Di Maio M, ... Parodi G, Vecchione C
Am J Cardiol: 14 Nov 2021; 159:44-51 | PMID: 34503819
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Abstract

Prognostic Value of Electrocardiographic QRS Diminution in Patients Hospitalized With COVID-19 or Influenza.

Lampert J, Miller M, Halperin JL, Oates C, ... Goldman ME, Reddy VY
During the clinical care of hospitalized patients with COVID-19, diminished QRS amplitude on the surface electrocardiogram (ECG) was observed to precede clinical decompensation, culminating in death. This prompted investigation into the prognostic utility and specificity of low QRS complex amplitude (LoQRS) in COVID-19. We retrospectively analyzed consecutive adults admitted to a telemetry service with SARS-CoV-2 (n = 140) or influenza (n = 281) infection with a final disposition-death or discharge. LoQRS was defined as a composite of QRS amplitude <5 mm or <10 mm in the limb or precordial leads, respectively, or a ≥50% decrease in QRS amplitude on follow-up ECG during hospitalization. LoQRS was more prevalent in patients with COVID-19 than influenza (24.3% vs 11.7%, p = 0.001), and in patients who died than survived with either COVID-19 (48.1% vs 10.2%, p <0.001) or influenza (38.9% vs 9.9%, p <0.001). LoQRS was independently associated with mortality in patients with COVID-19 when adjusted for baseline clinical variables (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.9 to 33.8, p <0.001), presenting and peak troponin, D-dimer, C-reactive protein, albumin, intubation, and vasopressor requirement (OR 13.8, 95% CI 1.3 to 145.5, p = 0.029). The median time to death in COVID-19 from the first ECG with LoQRS was 52 hours (interquartile range 18 to 130). Dynamic QRS amplitude diminution is a strong independent predictor of death over not only the course of COVID-19 infection, but also influenza infection. In conclusion, this finding may serve as a pragmatic prognostication tool reflecting evolving clinical changes during hospitalization, over a potentially actionable time interval for clinical reassessment.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:129-137
Lampert J, Miller M, Halperin JL, Oates C, ... Goldman ME, Reddy VY
Am J Cardiol: 14 Nov 2021; 159:129-137 | PMID: 34579830
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Abstract

Predictors, Treatments, and Outcomes of Do-Not-Resuscitate Status in Acute Myocardial Infarction Patients (from a Nationwide Inpatient Cohort Study).

Kobo O, Moledina SM, Slawnych M, Sinnarajah A, ... Mohamed MO, Mamas MA
Little is known about how frequently do-not-resuscitate (DNR) orders are placed in patients with acute myocardial infarction (AMI), the types of patients in which they are placed, treatment strategies or clinical outcomes of such patients. Using the United States (US) National Inpatient Sample (NIS) database from 2015 to 2018, we identified 2,767,549 admissions that were admitted to US hospitals and during the hospitalization received a principle diagnosis of AMI, of which 339,270 (12.3%) patients had a DNR order (instigated both preadmission and during in-hospital stay). Patients with a DNR status were older (median age 83 vs 65, p < 0.001), more likely to be female (53.4% vs 39.3%, p < 0.001) and White (81.0% vs 73.3%, p < 0.001). Predictors of DNR status included comorbidities such as heart failure (OR: 1.47, 95% CI: 1.45 to 1.48), dementia (OR: 2.53, 95% CI: 2.50 to 2.55), and cancer. Patients with a DNR order were less likely to undergo invasive management or be discharged home (13.5% vs 52.8%), with only 1/3 receiving palliative consultation. In hospital mortality (32.7% vs 4.6%, p < 0.001) and MACCE (37.1% vs 8.8%, p < 0.001) were higher in the DNR group. Factors independently associated with in-hospital mortality among patients with a DNR order included a STEMI presentation (OR: 2.90, 95% CI: 2.84 to 2.96) and being of Black (OR: 1.29, 95% CI: 1.26 to 1.33), Hispanic (OR: 1.36, 95% CI: 1.32 to 1.41) or Asian/Pacific Islander (OR: 1.56, 95% CI:1.49-race. In conclusion, AMI patients with a DNR status were older, multimorbid, less likely to receive invasive management, with only one third of patients with DNR status referred for palliative care.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:8-18
Kobo O, Moledina SM, Slawnych M, Sinnarajah A, ... Mohamed MO, Mamas MA
Am J Cardiol: 14 Nov 2021; 159:8-18 | PMID: 34656317
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Abstract

Risk of Major Bleeding in Patients With Atrial Fibrillation Taking Dronedarone in Combination With a Direct Acting Oral Anticoagulant (From a U.S. Claims Database).

Gandhi SK, Reiffel JA, Boiron R, Wieloch M
Dronedarone may increase exposure and the risk of major bleeding when prescribed with a direct oral anticoagulant (DOAC). This retrospective cohort study examined the risk of the first occurrence of major bleeding (hospitalization or emergency room visit for gastrointestinal [GI] bleeding, intracranial hemorrhage [ICH], or bleeding at other sites) among new users of apixaban, dabigatran, and rivaroxaban in patients with AF ≥18 years (January 1, 2007 to September 30, 2017) from the United States Truven Health MarketScan claims, comparing concomitant users of dronedarone to DOAC alone users in patients with atrial fibrillation (AF). No increased risk of major bleeding was associated with use of dronedarone and apixaban (adjusted Hazard Ratio [aHR]: 0.69 [95% confidence interval [CI]: 0.40, 1.17], p = 0.16), a modestly increased risk of GI bleeding but not overall bleeding was associated with use of dronedarone and dabigatran (aHR bleeding: 1.18 [95% CI: 0.89, 1.56], p = 0.26; aHR GI bleeding: 1.40 [95% CI: 1.01, 1.93]; p = 0.04) and an increased risk of overall bleeding, driven by GI bleeding, was associated with use of dronedarone and rivaroxaban (aHR bleeding: 1.31 [95% CI: 1.01, 1.69]; p = 0.04; aHR GI bleeding: 1.39 [95% CI: 0.98, 1.95]; p = 0.06), compared to each DOAC respectively. There was no increased risk of ICH associated with combined use of dronedarone and any DOAC. Prospective analyses, preferably randomized controlled studies, are needed to further explore the risk of major bleeding with concomitant use of DOACs and CYP3A4/P-gp inhibitors such as dronedarone.

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

Am J Cardiol: 14 Nov 2021; 159:79-86
Gandhi SK, Reiffel JA, Boiron R, Wieloch M
Am J Cardiol: 14 Nov 2021; 159:79-86 | PMID: 34656316
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Abstract

Supraventricular Tachycardia Causing Left Ventricular Dysfunction.

Zaffalon D, Pagura L, Cannatà A, Barbati G, ... Merlo M, Sinagra G
There is limited evidence on characterization and natural history of supraventricular tachycardia (SVT)-induced left ventricular (LV) dysfunction. The aim of this work was to characterize clinical features and long-term evolution of SVT-induced LV dysfunction. Patients consecutively admitted with sustained SVT and heart rate >100 bpm as the only known cause of a new onset LV systolic dysfunction (i.e., LV ejection fraction [EF] <50%) were analyzed. Patients were then revaluated periodically. Recovered LVEF (i.e., ≥50%) and a composite of death, heart transplant or first episode of major ventricular arrhythmias were evaluated as study end-points. We enrolled 83 patients. After SVT therapy, 56 (67%) showed a recovered LVEF at the last follow-up of median 54 (interquartile range 36 to 87) months. Seventeen (30%) of those patients had a temporary new drop in LVEF during follow-up associated to high-rate SVT relapse. At presentation, patients with recovered LVEF were younger (52 vs 67 years respectively, p <0.001) and had higher LVEF (34% vs 27% respectively, p = 0.005) compared to non-recovered LVEF patients. Finally, 4% of recovered LVEF patients vs 26% of nonrecovered LVEF patients experienced death/heart transplant/major ventricular arrhythmias during follow-up (p = 0.004). In conclusion, after almost 5 years of follow-up, two-thirds of patients with high-rate SVT causing a newly diagnosed LV systolic dysfunction recovered and maintained normal LV function after SVT control, with a subsequent benign outcome. Long term individual surveillance is required in those patients, as arrhythmic recurrences and new drops in LVEF are common in the long term.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:72-78
Zaffalon D, Pagura L, Cannatà A, Barbati G, ... Merlo M, Sinagra G
Am J Cardiol: 14 Nov 2021; 159:72-78 | PMID: 34656315
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Temporal Trends in the Characteristics, Treatment, and Outcomes of Conservatively Managed Patients With Non-ST Elevation Acute Coronary Syndrome (from the ACSIS Registry 2000 to 2016).

Aviv Y, Shechter A, Richter I, Kornowski R, ... Pereg D, Eisen A
Despite advances in percutaneous coronary interventions (PCI), a subgroup of acute coronary syndrome (ACS) patients are still managed medically by a conservative approach. We sought to characterize a contemporary, large-scale, real-world cohort of ACS patients treated conservatively via pharmacological management, without PCI. Data was gathered from the ACS Israeli Survey (ACSIS) between 2000 and 2016, encompassing all consecutive patients admitted to cardiology wards with an ACS diagnosis. Included were 3,543 conservatively managed patients with non-ST elevation ACS (NSTE-ACS). Patients with ST elevation MI or those who underwent any coronary revascularization (PCI or bypass surgery) were excluded. Primary endpoints were 30-day major adverse cardiovascular events (MACE) and 1-year mortality. The study cohort was divided to 4 time-periods. Over 2 decades, medically managed NSTE-ACS patients remained of similar age (67 ± 13 years, p = 0.78), but had more atherosclerotic risk-factors and comorbidities. During time, patients were more often referred to diagnostic angiography and treated with statins, ACE-I/ARBs, and P2Y12 inhibitors (p < 0.001 for each). Over time, there were less in-hospital complications such as kidney injury and heart failure. The rate of 30-day MACE decreased (from 20.7% to 10.3%, earliest to latest period, p < 0.001). Compared with the earliest period, the latest period was associated with a reduction in 1-year mortality (14.7% to 11.6%; adjusted HR 0.65, 95% CI 0.47 to 0.90). In conclusion, Over 2 decades, in medically managed NSTE-ACS patients, short term prognosis has significantly improved while 1-year mortality demonstrated improvement only recently, likely due to incremental benefits of medical management.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:52-58
Aviv Y, Shechter A, Richter I, Kornowski R, ... Pereg D, Eisen A
Am J Cardiol: 14 Nov 2021; 159:52-58 | PMID: 34656314
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Secular Trends in Cardiovascular Health in US Adults (from NHANES 2007 to 2018).

Zhu Z, Bundy JD, Mills KT, Bazzano LA, ... Chen J, He J
Deceleration in the decline of cardiovascular disease mortality has been observed recently in the US. We aimed to examine the recent secular trends of cardiovascular health metrics in the US general population. A total of 32,832 adults aged ≥20 years from the National Health and Nutrition Examination Surveys 2007 to 2018 were included in this analysis. Cardiovascular health included 7 health metrics: smoking status, body mass index, physical activity, healthy diet score, total cholesterol, blood pressure, and fasting plasma glucose. Age-standardized mean of overall cardiovascular health score did not significantly change during 2007 to 2010, 2011 to 2014, and 2015 to 2018 in the US adult population (7.88, 8.03, and 7.91, respectively, P-trend = 0.85). The age-standardized proportions of ideal smoking status (P-trend = 0.003), ideal physical activity (P-trend = 0.03), and untreated total cholesterol <200 mg/dL (P-trend <0.001) were significantly increased but the proportions of body mass index <25.0 kg/m2 (P-trend <0.001), systolic/diastolic blood pressure <120/80 mmHg (P-trend = 0.02), and fasting plasma glucose <100 mg/dL (P-trend <0.001) were significantly decreased during the same period of time in the US adults. In conclusion, from 2007 to 2018, overall cardiovascular health did not change in the US general adult population. Of note, body mass index, blood pressure, and fasting plasma glucose significantly worsened during the same period.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:121-128
Zhu Z, Bundy JD, Mills KT, Bazzano LA, ... Chen J, He J
Am J Cardiol: 14 Nov 2021; 159:121-128 | PMID: 34656312
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Abstract

Standard Versus Higher Intensity Anticoagulation for Patients With Mechanical Aortic Valve Replacement and Additional Risk Factors for Thromboembolism.

Hanigan S, Kong X, Haymart B, Kline-Rogers E, ... Froehlich J, Barnes G
Current guidelines recommend targeting an international normalized ratio (INR) of 2.5 to 3.5 for patients with mechanical aortic valve replacement (AVR) and additional risk factors for thromboembolic events. Available literature supporting the higher intensity (INR) goal is lacking. We aimed to evaluate the association of standard and higher intensity anticoagulation on outcomes in this patient population. The Michigan Anticoagulation Quality Improvement Initiative database was used to identify patients with mechanical AVR and at least one additional risk factor. Patients were classified into 2 groups based on INR goal: standard-intensity (INR goal 2.5) or higher-intensity (INR goal 3.0). Cox-proportional hazard model was used to calculate adjusted hazard ratios. One hundred and forty-six patients were identified of whom 110 (75.3%) received standard-intensity anticoagulation and 36 (24.7%) received higher intensity anticoagulation. Standard-intensity patients were older and more likely to be on aspirin. Atrial fibrillation was the most common additional risk factor for inclusion. The primary outcome of thromboembolic events, bleeding, or all-cause death was 13.9 and 19.5/100-person-years in the standard-intensity and higher intensity groups, respectively (adjusted HR 2.58, 95% confidence interval 1.28 to 5.18). Higher-intensity anticoagulation was significantly associated with any bleeding (adjusted HR 2.52, 95% confidence interval 1.27 to 5.00) and there were few thromboembolic events across both groups (5 events total). These results challenge current guideline recommendations for anticoagulation management of mechanical AVR in patients with additional risk factors.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:100-106
Hanigan S, Kong X, Haymart B, Kline-Rogers E, ... Froehlich J, Barnes G
Am J Cardiol: 14 Nov 2021; 159:100-106 | PMID: 34656311
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Abstract

Length of Preprocedure Fasting Was Associated With Contrast Associated-Acute Kidney Injury in High-Risk Patients Undergoing Coronary Angiography.

Shah A, Bazemore T, Wolf H, Yang H, Liu Y, Stouffer GA
Hydration is recommended to prevent contrast associated-acute kidney injury (CA-AKI) but interactions between blood pressure, left ventricular end diastolic pressure (LVEDP) and hydration status on CA-AKI are incompletely understood. This analysis presents the results of a single-center prospective study of patients undergoing coronary angiography with a predicted risk of CA-AKI >14%. 146 patients were enrolled with a mean (±SD) age of 71 ± 11 years; 94 (64.4%) were men, 142 (97.3%) had hypertension, 96 (65.8%) had diabetes mellitus and the mean (SD) serum creatinine was 1.21 ± 0.36 mg/dl. CA-AKI occurred in 31 (21%) patients. There were no significant differences in demographics, comorbidities, renal function, LVEDP, systolic blood pressure, diastolic blood pressure, heart rate, mean arterial pressure or pulse pressure in patients who developed versus those who did not develop CA-AKI. There was no association between the amount of peri-procedure intravenous fluids and change in creatinine postprocedure. In multivariate analysis, hemoglobin, the time that the patient was fasting from solids (NPO time), and contrast volume were associated with the development of CA-AKI. There was a highly significant interaction (p = 0.0028) between the amount of intravenous fluids, NPO time and contrast volume and changes in postprocedure creatinine. In summary, hemoglobin, NPO time and contrast volume, but not hemodynamic variables, correlated with worsening renal function following coronary angiography in this population of high-risk patients. Results suggested that intravenous hydration is important in subgroups of patients depending on NPO time and contrast volume.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:1-7
Shah A, Bazemore T, Wolf H, Yang H, Liu Y, Stouffer GA
Am J Cardiol: 14 Nov 2021; 159:1-7 | PMID: 34656310
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Abstract

Frequency and Significance of Right Bundle Branch Block and Subclinical Coronary Atherosclerosis in Asymptomatic Individuals.

Lee H, Jeon YJ, Kang BJ, Lee TY, ... Choi SH, Park GM
Limited data exist regarding the association between right bundle branch block (RBBB) and subclinical coronary atherosclerosis. This study investigated the influence of RBBB on subclinical coronary atherosclerosis detected by coronary computed tomographic angiography (CCTA) in an asymptomatic population. We retrospectively analyzed 7,205 asymptomatic individuals (mean age 54.4 ± 7.9 years and 4,695 men [65.2%]) with no prior history of coronary artery disease who voluntarily underwent CCTA and 12-lead electrocardiographic evaluation as part of a general health examination. The degree and extent of subclinical coronary atherosclerosis were evaluated by CCTA, and ≥50% diameter stenosis was defined as significant. The association between RBBB and subclinical coronary atherosclerosis was determined by logistic regression and propensity score matching analyses. Of study participants, 116 (1.6%) had RBBB. After adjustment for cardiovascular risk factors, there were no statistically significant differences in the adjusted odds ratios of RBBB for any atherosclerotic plaque (0.87, 95% confidence interval [CI] 0.57 to 1.32), calcified plaque (0.78, 95% CI 0.51 to 1.19), noncalcified plaque (1.44, 95% CI 0.77 to 2.69), mixed plaque (1.12, 95% CI 0.52 to 2.39), and significant coronary artery stenosis (0.92, 95% CI 0.48 to 1.74). Similarly, in the 5: 1 propensity score-matched population (n = 696), there were no statistically significant differences in the odds ratios for any subclinical coronary atherosclerosis between participants with and without RBBB (p for all >0.05). In conclusion, through this large cross-sectional study of asymptomatic individuals who underwent CCTA and electrocardiography evaluation, individuals with RBBB were not associated with an increased risk of subclinical coronary atherosclerosis compared with those without RBBB.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2021; 158:30-36
Lee H, Jeon YJ, Kang BJ, Lee TY, ... Choi SH, Park GM
Am J Cardiol: 31 Oct 2021; 158:30-36 | PMID: 34462052
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Abstract

Plaque Character and Progression According to the Location of Coronary Atherosclerotic Plaque.

Bax AM, Yoon YE, Gianni U, Ma X, ... Shaw LJ, Chang HJ
Although acute coronary syndrome culprit lesions occur more frequently in the proximal coronary artery, whether the proximal clustering of high-risk plaque is reflected in earlier-stage atherosclerosis remains unclarified. We evaluated the longitudinal distribution of stable atherosclerotic lesions on coronary computed tomography angiography (CCTA) in 1,478 patients (mean age, 61 years; men, 58%) enrolled from a prospective multinational registry of consecutive patients undergoing serial CCTA. Of 3,202 coronary artery lesions identified, 2,140 left lesions were classified (based on the minimal lumen diameter location) into left main (LM, n = 128), proximal (n = 739), and other (n = 1,273), and 1,062 right lesions were classified into proximal (n = 355) and other (n = 707). Plaque volume (PV) was the highest in proximal lesions (median, 26.1 mm3), followed by LM (20.6 mm3) and other lesions (15.0 mm3, p <0.001), for left lesions, and was lager in proximal (25.8 mm3) than in other lesions (15.2 mm3, p <0.001) for right lesions. On both sides, proximally located lesions tended to have greater necrotic core and fibrofatty components than other lesions (left: LM, 10.6%; proximal, 5.8%; other, 3.4% of the total PV, p <0.001; right: proximal, 8.4%; other 3.1%, p <0.001), with less calcified plaque component (left: LM, 18.3%; proximal, 30.3%; other, 37.7%, p <0.001; right: proximal, 23.3%, other, 36.6%, p <0.001), and tended to progress rapidly (adjusted odds ratios: left: LM, reference; proximal, 0.95, p = 0.803; other, 0.64, p = 0.017; right: proximal, reference; other, 0.52, p <0.001). Proximally located plaques were larger, with more risky composition, and progressed more rapidly.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2021; 158:15-22
Bax AM, Yoon YE, Gianni U, Ma X, ... Shaw LJ, Chang HJ
Am J Cardiol: 31 Oct 2021; 158:15-22 | PMID: 34465463
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Abstract

Impact of Low Body Mass Index on Features of Coronary Culprit Plaques and Outcomes in Patients With Acute Coronary Syndrome.

Kobayashi N, Shibata Y, Kurihara O, Todoroki T, ... Asai K, Miyauchi Y
The mechanisms behind poorer cardiac outcomes in underweight patients with acute coronary syndrome (ACS) are not understood and features of coronary culprit lesions in underweight ACS patients have not been fully examined. A total of 1,683 patients with ACS were divided into 4 groups according to body mass index (BMI): <18.5 (n = 73), 18.5 to 24.9 (n = 995), 25 to 29.9 (n = 488), and ≥30 (n = 117). Angiography and optical coherence tomography (OCT) images were analyzed for 1,428 of these patients who had primary percutaneous coronary intervention (PCI) and 838 who had primary PCI with OCT guidance, respectively. Diabetes (p <0.001), hypertension (p <0.001), and dyslipidemia (p <0.001) were less prevalent in BMI <18.5. Statin prescription at discharge was less frequent in the BMI <18.5 group (p <0.001). Quantitative coronary angiography analyses revealed smaller reference vessel (p = 0.001) and minimum lumen diameters after PCI (p = 0.019) and OCT revealed longer lipidic plaque length (p = 0.029) in the BMI <18.5 group. Kaplan-Meier analyses revealed higher rates of cardiac mortality (p <0.001) and major bleeding (p = 0.034) during the 2-year follow-up in the BMI <18.5 group. After adjusting for traditional cardiovascular risk factors, BMI <18.5 independently predicted 2-year cardiac mortality (hazard ratio 1.917 [95% confidence interval [1.082 to 3.397], p = 0.026). In conclusion, being underweight contributed to poorer cardiac outcomes in established ACS population. Smaller minimum lumen diameter after PCI and further progressed atherosclerosis at the culprit lesions despite their lower prevalence of comorbid metabolic risk factors may be related partly to poorer cardiac outcomes.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2021; 158:6-14
Kobayashi N, Shibata Y, Kurihara O, Todoroki T, ... Asai K, Miyauchi Y
Am J Cardiol: 31 Oct 2021; 158:6-14 | PMID: 34465460
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Abstract

Meta-Analysis Comparing Valve Durability Among Different Transcatheter and Surgical Aortic Valve Bioprosthesis.

Ueyama H, Kuno T, Takagi H, Kobayashi A, ... Søndergaard L, Attizzani GF
Durability of transcatheter heart valve (THV) is critical as the indication of transcatheter aortic valve implantation (TAVI) expands to patients with longer life-expectancy. We aimed to compare the durability of different THV systems (balloon-expandable [BE] and self-expandable [SE]) and surgical aortic valve replacement (SAVR) prosthesis. PUBMED and EMBASE were searched through February 2021 for randomized trials investigating parameters of valve durability after TAVI and/or SAVR in severe aortic stenosis. A network meta-analysis using random-effect model was performed. Synthesis was performed with 5-year follow-up data for echocardiographic outcomes and the longest available follow-up data for clinical outcomes. Ten trials with a total of 9,388 patients (BE-THV: 2,562; SE-THV: 2,863; SAVR: 3,963) were included. Follow-up ranged from 1 to 6 years. SE-THV demonstrated significantly larger effective orifice area, lower mean aortic valve gradient (AVG), and less increase in mean AVG at 5-year compared with BE-THV and SAVR. Structural valve deterioration (SVD) was less frequent in SE-THV compared with BE-THV and SAVR (HR 0.14, 95% CI 0.07 to 0.27; HR 0.34, 95% CI 0.24 to 0.47, respectively). Total moderate-severe aortic regurgitation and reintervention was more frequent in BE-THV (HR 4.21, 95% CI 2.40 to 7.39; HR 2.22, 95% CI 1.16 to 4.26, respectively), and SE-THV (HR 7.51, 95% CI 3.89 to 14.5; HR 2.86, 95% CI 1.59 to 5.13, respectively) compared with SAVR. In conclusion, TAVI with SE-THV demonstrated favorable forward-flow hemodynamics and lowest risk of SVD compared with BE-THV and SAVR at mid-term. However, both THV systems suffer an increased risk of AR and re-intervention, and long-term data from newer generation valves is warranted.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2021; 158:104-111
Ueyama H, Kuno T, Takagi H, Kobayashi A, ... Søndergaard L, Attizzani GF
Am J Cardiol: 31 Oct 2021; 158:104-111 | PMID: 34465458
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Abstract

Frequency of Lipid-Rich Coronary Plaques in Stable Angina Pectoris versus Acute Coronary Syndrome (from the Lipid Rich Plaque Study).

Torguson R, Shlofmitz E, Mintz GS, Mario CD, ... Garcia-Garcia HM, Waksman R
The multicenter prospective Lipid Rich Plaque (LRP) registry showed that nonculprit (NC) lipid-rich plaques identified by near-infrared spectroscopy (maxLCBI4mm >400) with an intravascular ultrasound plaque burden (PB) >70% and/or minimum lumen area (MLA) <4 mm2 within the maxLCBI4mm segment were more frequently associated with major adverse cardiac events (MACE) within 2 years. The aim of this sub-study was to report the relationship between initial clinical presentation and subsequent NC-MACE. Patients enrolled in the LRP study were stratified post hoc as having a stable angina pectoris or silent ischemia presentation versus acute coronary syndrome, excluding patients presenting with acute ST-elevation myocardial infarction. Among the 1552 patients, 717 presented with stable angina pectoris or silent ischemia. Patients presenting with acute coronary syndrome were more likely to be younger and Black, current smokers, and have less chronic kidney disease. Of the scanned nonculprit vessels, there was no difference between the 2 clinical presentation groups regarding lipidic content, and the rate of lipid-rich plaques (maxLCBI4mm >400) was 31.9% in both groups. Finally, there was no difference in NC-MACE at 2 years\' follow-up, although within each group (stable versus acute coronary syndrome), the NC-MACE rate associated with maxLCBI4mm >400 was significantly higher than maxLCBI4mm ≤400 (stable 13.8% vs 6.5%; acute patients 11.6% vs 6.3%, respectively). In conclusion, in patient groups that present with stable angina pectoris or silent ischemia versus acute coronary syndrome, the NC lipidic content was similar, as was NC-MACE, through 2 years of follow-up.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 31 Oct 2021; 158:1-5
Torguson R, Shlofmitz E, Mintz GS, Mario CD, ... Garcia-Garcia HM, Waksman R
Am J Cardiol: 31 Oct 2021; 158:1-5 | PMID: 34465457
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Abstract

Prognosticators of All-Cause Mortality in Patients With Heart Failure With Preserved Ejection Fraction.

Lopuszynski JB, Downing AJ, Finley CM, Zahid M
Heart failure with preserved ejection fraction (HFpEF) represents ∼50% of all cases of congestive heart failure (CHF) with prevalence expected to increase with aging of the population. We performed an observational study of all patients admitted to 3 hospitals in the ExcelaHealth care system, Greensburg, PA, with a primary diagnosis of HFpEF heart failure exacerbation between January 2014 and January 2017. Demographic data, laboratory results, and echocardiograms performed closest to index hospitalization were collected. A total of 487 patients were admitted with a primary diagnosis of CHF exacerbation and HFpEF, with a mean age of 80.5 years (±10.9), 62% women and predominantly Caucasian (98.8%). Over a median follow-up of 21.7 months, 246 patients died with an all-cause mortality rate of 51.3%. Receiver operator curves were generated for multiple continuous variables to identify optimal cut-off values Kaplan-Meir survival curves were then generated. Clinical factors were tested by univariate Cox regression modeling, with significant factors entered into a step-wise multivariate model. Our modeling identified age>80 years, serum albumin level<3.2 g/dl, N-terminal pro-brain natriuretic peptide (NT-proBNP) >5,000 pg/mL and medial E/e\'≥20 as significant, independent predictors of all-cause mortality (p-value <0.0001). Surprisingly, lack of a diagnosis of hypertension was associated with significantly increased mortality risk. In a community-based sample of HFpEF patients, we identified multiple factors that were strong, independent predictors of all-cause mortality that can be easily applied in a clinical setting.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2021; 158:66-73
Lopuszynski JB, Downing AJ, Finley CM, Zahid M
Am J Cardiol: 31 Oct 2021; 158:66-73 | PMID: 34465456
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Abstract

Preservation of Cardiac Reserve and Cardiorespiratory Fitness in Patients With Acute De Novo Versus Acute on Chronic Heart Failure With Reduced Ejection Fraction.

Del Buono MG, Mihalick V, Damonte JI, Billingsley H, ... Abbate A, Canada JM
There is limited understanding on the potential differences in the pathophysiology between de novo heart failure with reduced ejection fraction (HFrEF) and acute on chronic HFrEF. The aim of this study was to assess differences in cardiorespiratory fitness (CRF) parameters between de novo heart failure and acute on chronic HFrEF using cardiopulmonary exercise testing (CPX). We retrospectively analyzed CPX data measured within 2 weeks of discharge following acute hospitalization for HFrEF. Data are reported as median and interquartile range or frequency and percentage (%). We included 102 patients: 32 (31%) women, 81 (79%) black, 57 (51 to 64) years of age, BMI of 34 (29 to 39) Kg/m2. Of these, 26 (25%) had de novo HFrEF and 76 (75%) had acute on chronic HFrEF. When compared with acute on chronic, patients with de novo HFrEF had a significantly higher peak oxygen consumption (VO2) (16.5 [12.2 to 19.4] vs 12.8 [10.1 to 15.3] ml·kg-1·min-1, p <0.001), %-predicted peak VO2 (58% [51 to 75] vs 49% [42 to 59]) p = 0.012), peak heart rate (134 [117 to 147] vs 117 [104 to 136] beats/min, p = 0.004), peak oxygen pulse (12.2 [10.5 to 15.5] vs 9.9 [8.0 to 13.1] ml/beat, p = 0.022) and circulatory power (2,823 [1,973 to 3,299] vs 1,902 [1,372 to 2,512] mm Hg·ml·kg-1·min-1, p = 0.002). No significant difference in resting left ventricular ejection fraction was found between groups. In conclusion, patients with de novo HFrEF have better CRF parameters than those with acute on chronic HFrEF. These differences are not explained by resting left ventricular systolic function but may be related to greater preservation in cardiac reserve during exercise in de novo HFrEF patients.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2021; 158:74-80
Del Buono MG, Mihalick V, Damonte JI, Billingsley H, ... Abbate A, Canada JM
Am J Cardiol: 31 Oct 2021; 158:74-80 | PMID: 34465455
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Abstract

High-Risk Percutaneous Coronary Intervention of Native Coronary Arteries Without Mechanical Circulatory Support in Acute Coronary Syndrome Without Cardiogenic Shock.

Khalid N, Zhang C, Shea C, Shlofmitz E, ... Satler LF, Waksman R
Widespread utilization of mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI) remains controversial, with a lack of randomized supporting evidence and associated risk of device-related complications. We investigated whether high-risk PCI of native coronary arteries without elective MCS in patients with acute coronary syndrome (ACS) is safe and feasible. We performed a single-center, retrospective analysis for ACS patients meeting American College of Cardiology high-risk criteria: unprotected left main disease, last remaining conduit, ejection fraction <35%, 3-vessel coronary artery disease, severe aortic stenosis, or severe mitral regurgitation. Patients with cardiogenic shock and those undergoing PCI of the bypass grafts were excluded. Major in-hospital and 30-day cardiovascular outcomes were assessed. From 2003 through 2018, 499 patients (847 lesions) with unstable angina pectoris (UAP), 1218 patients (1807 lesions) with non-ST-elevation myocardial infarction (NSTEMI), and 868 patients (1260 lesions) with ST-segment elevation myocardial infarction (STEMI) underwent high-risk PCI. Procedural success was achieved in 97.2% of UAP, 98.3% of NSTEMI, and 96.6% of STEMI patients. In-hospital and 30-day all-cause mortality were as follows: UAP, 2%; NSTEMI, 2.1%; and STEMI 4.7%. Bailout intra-aortic balloon pump was required in 1.6% of UAP, 3.1% of NSTEMI, and 10.3% of STEMI patients. Major complications for UAP, NSTEMI, and STEMI were, respectively: target lesion revascularization (2.3%, 1.4%, and 1.5%), stroke or transient ischemic attack (0.8%, 0.6%, and 1.3%), acute renal failure (8.2%, 7.2%, and 10.2%), major bleeding (1.6%, 3.1%, and 8.5%). In conclusion, our results show that high-risk PCI without elective MCS is safe and feasible in most ACS patients, challenging professional societies\' current recommendations. A randomized trial comparing unprotected versus protected high-risk PCI for non-shock ACS patients is warranted.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 31 Oct 2021; 158:37-44
Khalid N, Zhang C, Shea C, Shlofmitz E, ... Satler LF, Waksman R
Am J Cardiol: 31 Oct 2021; 158:37-44 | PMID: 34465454
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Abstract

Clinical and Echocardiographic Characteristics of Patients Hospitalized With Acute Versus Chronic Heart Failure With Preserved Ejection Fraction (From the ARIC Study).

Chunawala ZS, Fudim M, Arora S, Qamar A, ... Pandey A, Caughey MC
An expanding number of therapies are now indicated for comorbidity management in heart failure with preserved ejection fraction (HFpEF). Whether comorbidity burdens differ for patients with HFpEF who are hospitalized for acute decompensated heart failure (ADHF) versus those with chronic stable heart failure (CSHF) who are hospitalized for other causes is uncertain. Since 2005, the Atherosclerosis Risk in Communities (ARIC) study has conducted adjudicated community surveillance of hospitalized heart failure. Hospitalized ADHF and CSHF were sampled identically, using prespecified discharge codes and demographic strata, but were differentiated by signs or symptoms of acute or worsening heart failure upon physician review of the medical record. HFpEF was defined by an ejection fraction ≥50%. All events were weighted by the inverse of the sampling probability for statistical analyses. From 2005 to 2014, 13,706 weighted (2,936 unweighted) hospitalizations (mean age 77 years, 64% women, 29% Black) were sampled among patients with HFpEF and adjudicated ADHF (86%) or CSHF (14%). Comorbidity prevalence was high both for ADHF and CSHF hospitalizations, irrespective of gender. Women hospitalized with ADHF versus CSHF had greater prevalence of hypertension (89% vs 84%) diabetes mellitus (48% vs 39%) and renal disease (85% vs 74%). Echocardiographic features such as left ventricular hypertrophy and valvular abnormalities were more common with ADHF than CSHF, for both genders. However, the 28-day and 1-year mortality risk were comparable for ADHF and CSHF. In conclusion, hospitalized patients with HFpEF have a high comorbidity burden and risk of death, irrespective of the cause of hospitalization.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2021; 158:59-65
Chunawala ZS, Fudim M, Arora S, Qamar A, ... Pandey A, Caughey MC
Am J Cardiol: 31 Oct 2021; 158:59-65 | PMID: 34474908
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Abstract

Independent Association of Fatty Liver Index With Left Ventricular Diastolic Dysfunction in Subjects Without Medication.

Furuhashi M, Muranaka A, Yuda S, Tanaka M, ... Shimamoto K, Miura T
Nonalcoholic fatty liver disease has been reported to be potentially linked to cardiovascular disease. Fatty liver index (FLI) is a noninvasive and simple predictor of nonalcoholic fatty liver disease. However, little is known about the relationship between FLI and cardiac function, especially in a general population. We investigated the relationships of FLI with echocardiographic parameters in 185 subjects (men/women: 79/106) of the Tanno-Sobetsu Study, a population-based cohort, who were not being treated with any medication and who underwent echocardiography. FLI was negatively correlated with high-density lipoprotein cholesterol and peak myocardial velocity during early diastole (e\'; r = -0.342, p <0.001), an index of left ventricular (LV) diastolic function, and ratio of peak mitral velocities during early and late diastole (E/A) and was positively correlated with age, systolic and diastolic blood pressures, creatinine, uric acid, homeostasis model assessment of insulin resistance, high-sensitivity C-reactive protein, ratio of mitral to myocardial early diastolic peak velocity (E/e\'), left atrial volume index and LV mass index. No significant correlation was found between FLI and LV ejection fraction. Stepwise multivariable regression analysis showed that FLI was independently and negatively associated with e\' after adjustment of age, gender, high-density lipoprotein cholesterol, homeostasis model assessment of insulin resistance, and high-sensitivity C-reactive protein. Conversely, e\' was independently and negatively associated with FLI after adjustment of age, gender, systolic blood pressure, and LV ejection fraction. In conclusion, elevated FLI is independently associated with LV diastolic dysfunction in a general population without medication. FLI would be a novel marker of LV diastolic dysfunction as an early sign of myocardial injury.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2021; 158:139-146
Furuhashi M, Muranaka A, Yuda S, Tanaka M, ... Shimamoto K, Miura T
Am J Cardiol: 31 Oct 2021; 158:139-146 | PMID: 34474907
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Abstract

Impact of Sustained Weight Loss on Cardiometabolic Outcomes.

Bailey-Davis L, Wood GC, Benotti P, Cook A, ... Kumar N, Still CD
Obesity increases the risk of developing type 2 diabetes, hypertension, and hyperlipidemia. We sought to determine the impact of obesity maintenance, weight regain, weight loss maintenance, and magnitudes of weight loss on future risk and time to developing these cardiometabolic conditions. This was a retrospective cohort study of adults receiving primary care at Geisinger Health System between 2001 and 2017. Using electronic health records, patients with ≥3-weight measurements over a 2-year index period were identified and categorized. Obesity maintainers (OM) had obesity (body mass index ≥30 kg/m²) and maintained their weight within ±3% from baseline (reference group). Both weight loss rebounders (WLR) and weight loss maintainers (WLM) had obesity at baseline and lost >5% body weight in year 1; WLR regained ≥20% of weight loss by end of year 2 and WLM maintained ≥80% of weight loss. Incident type 2 diabetes, hypertension, and hyperlipidemia, and time-to-outcome were determined for each study group and by weight loss category for WLM. Of the 63,567 patients included, 67% were OM, 19% were WLR, and 14% were WLM. The mean duration of follow-up was 6.6 years (SD, 3.9). Time until the development of electronic health record-documented type 2 diabetes, hypertension, and hyperlipidemia was longest for WLM and shortest for OM (log-rank test p <0.0001). WLM had the lowest incident type 2 diabetes (adjusted hazard ratio [HR] 0.676 [95% confidence interval [CI] 0.617 to 0.740]; p <0.0001), hypertension (adjusted HR 0.723 [95% CI 0.655 to 0.799]; p <0.0001), and hyperlipidemia (adjusted HR 0.864 [95% CI 0.803 to 0.929]; p <0.0001). WLM with the greatest weight loss (>15%) had a longer time to develop any of the outcomes compared with those with the least amount of weight loss (<7%) (p <0.0001). In an integrated delivery network population, sustained weight loss was associated with a delayed onset of cardiometabolic diseases, particularly with a greater magnitude of weight loss.

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

Am J Cardiol: 23 Oct 2021; epub ahead of print
Bailey-Davis L, Wood GC, Benotti P, Cook A, ... Kumar N, Still CD
Am J Cardiol: 23 Oct 2021; epub ahead of print | PMID: 34702552
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Abstract

Functional Tricuspid Regurgitation and Right Atrial Remodeling in Heart Failure With Preserved Ejection Fraction.

Harada T, Obokata M, Omote K, Iwano H, ... Borlaug BA, Kurabayashi M
Tricuspid regurgitation (TR) is common in patients with heart failure with preserved ejection fraction (HFpEF), but it has not been well characterized. We hypothesized that right atrial (RA) remodeling would be associated with TR in HFpEF, forming a type of atrial functional TR (AFTR). Echocardiography was performed in 328 patients with HFpEF. TR severity was defined using a guidelines-based approach. Ventricular functional TR was defined as the presence of right ventricular (RV) systolic pressure >50 mm Hg or RV dilation, and the remaining patients were classified as having AFTR if they had RA dilation or tricuspid annular enlargement. RA dilation was common (78%) in the significant TR group (more than mild), exceeding the prevalence of RV dilation (32%), and RA dilation was correlated with tricuspid annular diameter and TR vena contracta width (r = 0.67 and r = 0.70, both p <0.0001). Despite the absence of RV dilation and pulmonary hypertension, 38% of patients with significant TR had AFTR. Patients with AFTR and those with ventricular functional TR displayed higher heart failure hospitalization rates than those with nonsignificant TR (adjusted hazard ratios, 2.45 and 4.31; 95% confidence interval 1.12 to 5.35 and 2.44 to 7.62, p = 0.02 and p <0.0001, respectively). In conclusion, TR in HFpEF is related to RA remodeling, and the presence of AFTR was associated with poor clinical outcomes. The current data highlight the importance of RA remodeling in the pathophysiology of TR in HFpEF.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 22 Oct 2021; epub ahead of print
Harada T, Obokata M, Omote K, Iwano H, ... Borlaug BA, Kurabayashi M
Am J Cardiol: 22 Oct 2021; epub ahead of print | PMID: 34702555
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Abstract

Extramitral Valvular Cardiac Involvement in Patients With Significant Secondary Mitral Regurgitation.

Singh GK, Namazi F, Hirasawa K, van der Bijl P, ... Delgado V, Bax JJ
Patients with secondary mitral regurgitation (SMR) often have extramitral valve cardiac involvement, which can influence the prognosis. SMR can be defined according to groups of extramitral valve cardiac involvement. The prognostic implications of such groups in patients with moderate and severe SMR (significant SMR) are unknown. A total of 325 patients with significant SMR were classified according to the extent of cardiac involvement on echocardiography: left ventricular involvement (group 1), left atrial involvement (group 2), tricuspid valve and pulmonary artery vasculature involvement (group 3), or right ventricular involvement (group 4). The primary end point was all-cause mortality. The prevalence of each cardiac involvement group was 17% in group 1, 12% in group 2, 23% in group 3%, and 48% in group 4. Group 3 and group 4 were independently associated with all-cause mortality (hazard ratio 1.794, 95% confidence interval 1.067 to 3.015, p = 0.027 and hazard ratio 1.857, 95% confidence interval 1.145 to 3.012, p = 0.012, respectively). In conclusion, progressive extramitral valve cardiac involvement (group 3 and group 4) was independently associated with all-cause mortality in patients with significant SMR.

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

Am J Cardiol: 22 Oct 2021; epub ahead of print
Singh GK, Namazi F, Hirasawa K, van der Bijl P, ... Delgado V, Bax JJ
Am J Cardiol: 22 Oct 2021; epub ahead of print | PMID: 34702554
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Abstract

Cardiac and Obstetric Outcomes Associated With Mitral Valve Prolapse.

Wilkie GL, Qureshi WT, O\'Day KW, Aurigemma GP, ... Leftwich HK, Harrington CM
Mitral valve prolapse (MVP) is the most common valvular heart disease in women of reproductive age. Whether MVP increases the likelihood of adverse outcomes in pregnancy is unknown. The study objective was to examine the cardiac and obstetric outcomes associated with MVP in pregnant women. This retrospective cohort study, using the Healthcare Cost and Utilization Project National Readmission Sample database between 2010 and 2017, identified all pregnant women with MVP using the International Classification of Disease, Ninth and Tenth Revisions codes. The maternal cardiac and obstetric outcomes in pregnant women diagnosed with MVP were compared with women without MVP using multivariable logistic and Cox proportional hazard regression models adjusted for baseline demographic characteristics. There were 23,000 pregnancy admissions with MVP with an overall incidence of 16.9 cases per 10,000 pregnancy admissions. Pregnant women with MVP were more likely to die during pregnancy (adjusted hazard ratio 5.13, 95% confidence interval [CI] 1.09 to 24.16), develop cardiac arrest (adjusted odds ratio [aOR] 4.44, 95% CI 1.04 to 18.89), arrhythmia (aOR 10.96, 95% CI 9.17 to 13.12), stroke (aOR 6.90, 95% CI 1.26 to 37.58), heart failure (aOR 5.81, 95% CI 3.84 to 8.79), or suffer a coronary artery dissection (aOR 25.22, 95% CI 3.42 to 186.07) compared with women without MVP. Pregnancies with MVP were also associated with increased risks of preterm delivery (aOR 1.21, 95% CI 1.02 to 1.44) and preeclampsia/hemolysis, elevated liver enzymes, and low platelets syndrome (aOR 1.22, 95% CI 1.05 to 1.41). In conclusion, MVP in pregnancy is associated with adverse maternal cardiac outcomes and higher obstetric risks.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 20 Oct 2021; epub ahead of print
Wilkie GL, Qureshi WT, O'Day KW, Aurigemma GP, ... Leftwich HK, Harrington CM
Am J Cardiol: 20 Oct 2021; epub ahead of print | PMID: 34689956
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Abstract

Spleen Size and Thrombocytopenia After Transcatheter Aortic Valve Implantation.

Sugiura A, Treiling L, Al-Kassou B, Shamekhi J, ... Nickenig G, Sedaghat A
The pathophysiology of thrombocytopenia after transcatheter aortic valve implantation (TAVI) thrombocytopenia is still poorly understood. We assessed the association of spleen size with acquired thrombocytopenia in patients undergoing TAVI. We included 732 patients who underwent TAVI with new generation transcatheter heart valves (THVs) at our center from February 2016 to July 2019. We measured splenic volume index in consecutive patients derived from multidetector row computed tomographic datasets. Patients were stratified according to post-TAVI thrombocytopenia, which was defined as a decline in platelet count (DPC) ≥50% at nadir, and evaluated regarding baseline characteristics and outcome parameters. After the procedure, platelet counts declined from 212.9 ± 67.4 × 109/L at baseline to 138.8 ± 49.8 × 109/L at nadir after a median of 2 days (interquartile range [IQR] 2 to 3). Of all patients, 10.1% showed a DPC ≥50%. Compared with patients with DPC <50%, patients with DPC ≥50% had significantly lower splenic volume index (95.5 ml/m2 [IQR 78.0 to 123.7] vs 85.8 ml/m2 [IQR 71.4 to 102.6], p = 0.008). A multivariable analysis revealed that the splenic volume index was negatively associated with a DPC ≥50% (OR 0.89, 95% CI 0.82 to 0.97, p = 0.005), independent of the type of THV (balloon-expandable THV: OR 2.06, 95% CI 1.13 to 3.76, p = 0.02), major bleeding (OR 13.40, 95% CI 3.58 to 50.40, p <0.001), blood transfusion (OR 3.63, 95% CI 1.54 to 8.56, p = 0.003), or postprocedural paravalvular leakage ≥moderate (OR 5.48, 95% CI 1.23 to 24.40, p = 0.03). Furthermore, DPC ≥50% was independently associated with 1-year mortality (HR 3.36, 95% CI 1.66 to 6.81, p <0.001). In conclusion, acquired thrombocytopenia remains prevalent in modern TAVI patients. Spleen size appears to be associated with the occurrence of thrombocytopenia after TAVI, which is independently correlated with 1-year mortality.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2021; 157:85-92
Sugiura A, Treiling L, Al-Kassou B, Shamekhi J, ... Nickenig G, Sedaghat A
Am J Cardiol: 14 Oct 2021; 157:85-92 | PMID: 34404506
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Abstract

Evolution of Management and Outcomes of Patients with Myocardial Injury During the COVID-19 Pandemic.

Case BC, Abramowitz J, Shea C, Rappaport H, ... Weintraub WS, Waksman R
Cardiac involvement in coronavirus disease 2019 (COVID-19) has been established. This is manifested by troponin elevation and associated with worse patient prognosis. We evaluated whether patient outcomes improved as experience accumulated during the pandemic. We analyzed COVID-19-positive patients with myocardial injury (defined as troponin elevation) who presented to the MedStar Health system (11 hospitals in Washington, DC, and Maryland) during the \"Early Phase\" of the pandemic (March 1 - June 30, 2020) and compared their characteristics and outcomes to the COVID-19-positive patients with the presence of troponin elevation in the \"Later Phase\" of the pandemic (October 1, 2020 - January 31, 2021). The cohort included 788 COVID-19-positive admitted patients for whom troponin was elevated, 167 during the \"Early Phase\" and 621 during the \"Later Phase.\" Maximum troponin-I in the \"Early Phase\" was 13.46±34.72 ng/mL versus 11.21±20.57 ng/mL in the \"Later Phase\" (p = 0.553). In-hospital mortality was significantly higher in the \"Later Phase\" (50.3% vs. 24.6%; p<0.001), as were incidence of intensive-care-unit admission (77.8% vs. 46.1%; p<0.001) and need for mechanical ventilation (61.7% versus 28%; p<0.001). In addition, more \"Early Phase\" patients underwent coronary angiography (6% vs. 2.3%; p=0.013). Finally, 3% of \"Early Phase\" and 0.8% of \"Later Phase\" patients underwent percutaneous coronary intervention (p=0.025). In conclusion, treatment outcomes have significantly improved since the beginning of the pandemic in COVID-19-positive patients with troponin elevation. This may be attributed to awareness, severity of the disease, improvements in therapies, and provider experience.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 14 Oct 2021; 157:42-47
Case BC, Abramowitz J, Shea C, Rappaport H, ... Weintraub WS, Waksman R
Am J Cardiol: 14 Oct 2021; 157:42-47 | PMID: 34384590
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Abstract

Changes in Global Left Ventricular Myocardial Work Indices and Stunning Detection 3 Months After ST-Segment Elevation Myocardial Infarction.

Lustosa RP, Fortuni F, van der Bijl P, Mahdiui ME, ... Delgado V, Bax JJ
Global left ventricular (LV) myocardial work (MW) indices (GLVMWI) are derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure measurements. Changes in global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) after ST-segment elevation myocardial infarction (STEMI) have not been explored. The aim of present study was to assess the evolution of GLVMWI in STEMI patients from baseline (index infarct) to 3 months\' follow-up. Three-hundred and fifty patients (265 men; mean age 61 ± 10 years) with STEMI treated with primary percutaneous coronary intervention (PCI) and guideline-based medical therapy were retrospectively evaluated. Clinical variables, conventional echocardiographic measures and GLVMWI were recorded at baseline within 48 hours post-primary PCI and 3 months\' follow-up. LV ejection fraction (from 54 ± 10% to 57 ± 10%, p < 0.001), GWI (from 1449 ± 451 mm Hg% to 1953 ± 492 mm Hg%, p < 0.001), GCW (from 1624 ± 519 mm Hg% to 2228 ± 563 mm Hg%, p < 0.001) and GWE (from 93% (interquartile range (IQR) 86%-95%) to 95% (IQR 91%-96%), p < 0.001) improved significantly at 3 months\' follow-up with no significant difference in GWW (from 101 mm Hg% (IQR 63-155 mm Hg%) to 96 mm Hg% (IQR 64-155 mm Hg%); p = 0.535). On multivariable linear regression analysis, lower values of troponin T at baseline, increase in systolic blood pressure and improvement in LV global longitudinal strain were independently associated with higher GWI and GCW at 3 months\' follow-up. In conclusion, the evolution of GWI, GCW and GWE in STEMI patients may reflect myocardial stunning, whereas the stability in GWW may reflect permanent myocardial damage and the development of non-viable scar tissue.

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

Am J Cardiol: 14 Oct 2021; 157:15-21
Lustosa RP, Fortuni F, van der Bijl P, Mahdiui ME, ... Delgado V, Bax JJ
Am J Cardiol: 14 Oct 2021; 157:15-21 | PMID: 34366114
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Abstract

Risk of Ischemic Stroke in Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Prior Stroke.

Ando T, Ashraf S, Briasoulis A, Takagi H, Grines CL, Malik AH
It has not been well studied whether transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) have lower risk of ischemic stroke (IS) in those with prior history of IS. From the Nationwide Readmission Database from October 2015 to November 2017, TAVI and SAVR above age 50 were identified with the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System codes. Transapical TAVI and SAVR with concomitant bypass, mitral, or tricuspid surgery were excluded. The primary outcome was in-hospital IS. A total of 92,435 TAVI (13,292 with prior stroke) and 68,651 SAVR (5,365 with prior stroke) were identified. In-hospital IS was significantly lower in TAVI compared with SAVR (3.7% vs 8.0%, adjusted odds ratio 0.65, 95% confidence interval 0.47 to 0.89, p <0.01) with prior stroke whereas it was similar between TAVI and SAVR (1.7% vs 2.1%, adjusted odds ratio 0.97, 95% confidence interval 0.78 to 1.19, p = 0.75) in those without prior stroke (P interaction < 0.001). In-hospital mortality, acute kidney injury, and bleeding were lower in TAVI compared with SAVR in patients with and without prior stroke (P interaction > 0.05 for all). This analysis of a national claims database showed that TAVI was associated with a lower risk of in-hospital IS compared with SAVR among patients with prior stroke.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2021; 157:79-84
Ando T, Ashraf S, Briasoulis A, Takagi H, Grines CL, Malik AH
Am J Cardiol: 14 Oct 2021; 157:79-84 | PMID: 34366113
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Incidence and Outcomes of Pericardial Effusion and Cardiac Tamponade Following Permanent Pacemaker Implantation After Transcatheter Aortic Valve Implantation.

Bansal A, Kalra A, Puri R, Saliba W, ... Kapadia SR, Reed GW
Permanent pacemaker (PPM) implantation is required in 5% to 10% of patients following transcatheter aortic valve implantation (TAVI). However, there are limited data on the impact of PPM implantation on the incidence of pericardial effusion, cardiac tamponade, and outcomes after TAVI. We identified all hospitalizations in patients ≥18 years of age who underwent TAVI in the years 2016 to 2017 in the Nationwide Readmission Database. The endpoints of the study were pericardial effusion, cardiac tamponade, and percutaneous or surgical drainage of the pericardial cavity in patients that required PPM implantation after TAVI. Multivariable logistic regression determined associations of PPM implantation, pericardial effusion, and tamponade with patient outcomes. A total of 54,317 unweighted hospitalizations for TAVI were identified, of which 5,639 (10.4%) required PPM. The risk of pericardial effusion was significantly greater in patients who required PPM (2.4% vs 1.6%, adjusted odds ratio (aOR) 1.39 (1.15 to 1.70), p <0.001)), and risk of cardiac tamponade nearly doubled (1.6% vs 0.8%, p <0.001; aOR: 1.90 (1.48 to 2.40), p <0.001). Female gender was independently associated with increased risk of pericardial effusion and cardiac tamponade whereas history of previous  CABG was associated with decreased risk of both. Pericardial complications following PPM implantation were associated with increased in-hospital mortality, length of stay (LOS), hospital costs, and risk of 30-day readmission following TAVI (p <0.01 for all comparisons). In conclusion, although common, PPM implantation post-TAVI carries increased risks of pericardial effusion and associated cardiac tamponade. Patients developing these pericardial complications are at particularly high-risk for in-hospital mortality, greater LOS, and 30-day readmission.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2021; 157:135-139
Bansal A, Kalra A, Puri R, Saliba W, ... Kapadia SR, Reed GW
Am J Cardiol: 14 Oct 2021; 157:135-139 | PMID: 34366112
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Abstract

Impact of the Geriatric Nutritional Risk Index in Patients Undergoing Transcatheter Aortic Valve Implantation.

Koseki K, Yoon SH, Kaewkes D, Koren O, ... Komuro I, Makkar R
Several studies have shown that nutritional indexes are associated with cardiovascular events; however, limited studies have investigated the prognostic value of the Geriatric Nutritional Risk Index (GNRI) in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to evaluate the clinical impact of GNRI in patients undergoing TAVI. This single-center retrospective study analyzed consecutive patients treated with TAVI, stratified into groups according to their median baseline GNRI. The primary endpoint was 2-year all-cause mortality. In total, 968 patients with a mean age of 82.1 years and a median Society of Thoracic Surgeons (STS) score of 4.8% who underwent TAVI were included. The median GNRI was 103. Compared with the high-GNRI group (GNRI≥103, n = 451), the low-GNRI group (GNRI<103, n = 517) had higher STS scores and renal insufficiency rates. The 2-year all-cause mortality was significantly higher in the low-GNRI group than in the high-GNRI group (24.9% vs. 9.3%, p<0.001), despite no significant differences in procedural and clinical outcomes between the groups. On multivariable analysis, lower GNRI was independently associated with higher 2-year all-cause mortality (adjusted hazard ratio: 1.07; 95% confidence interval: 1.05-1.10; p<0.001). The GNRI retained its predictive value in subgroup analyses stratified by age (>75 vs. ≤75 years) and STS score (≥4 vs. <4). In conclusion, The GNRI is an important surrogate marker for predicting prognosis and mortality in patients undergoing TAVI.

Published by Elsevier Inc.

Am J Cardiol: 14 Oct 2021; 157:71-78
Koseki K, Yoon SH, Kaewkes D, Koren O, ... Komuro I, Makkar R
Am J Cardiol: 14 Oct 2021; 157:71-78 | PMID: 34373077
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Abstract

Characteristics and Outcomes of Patients Admitted With Type 2 Myocardial Infarction.

Tripathi B, Tan BE, Sharma P, Gaddam M, ... Deshmukh A, Klein J
Type 2 myocardial infarction (Type 2 MI) is a common problem and carries a high diagnostic uncertainty. Large studies exploring outcomes in type 2 MI are lacking. Nationwide Readmission Database (2017) was queried using the International Classification of Diseases codes (ICD-10-CM) to identify type 2 MI patients. Characteristics, in-hospital outcomes, 30-day readmissions, and predictors of in-hospital mortality as well as 30-day readmissions were explored. We identified 21,738 patients with a diagnosis of type 2 MI. Most common primary diagnosis at presentation included infection/sepsis (27.5%), hypertensive heart disease (15.3%) and pulmonary diseases (8.5%). Overall, in-hospital mortality and 30-day readmission for patients with type 2 MI were 9.0% and 19.1% respectively. On multivariable analysis, significant predictors of increased in-hospital mortality included male gender, coexisting atrial fibrillation/flutter, peripheral vascular disease, coagulopathy, malignancy, and fluid/electrolyte abnormalities. Significant predictors of 30-day readmission were coexisting diabetes mellitus, atrial fibrillation/ flutter, carotid artery stenosis, anemia, COPD, CKD and prior history of myocardial infarction, A primary diagnosis of sepsis, pulmonary issues including respiratory failure, neurological conditions including stroke carried highest risk of mortality however readmission risk was not influenced by primary diagnosis at presentation. In conclusion, approximately 1 in 10 patients admitted for type 2 MI died during admission, and nearly 1 in 5 patients were readmitted at 30 days after discharge. In-hospital mortality varied based on associated primary diagnosis at presentation. Proposed predictive model for mortality and 30-day readmission in our study can help to target high risk patients for post-Type 2 MI care.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2021; 157:33-41
Tripathi B, Tan BE, Sharma P, Gaddam M, ... Deshmukh A, Klein J
Am J Cardiol: 14 Oct 2021; 157:33-41 | PMID: 34373076
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Abstract

Comparison of Outcomes of Asymptomatic Moderate Aortic Stenosis With Preserved Left Ventricular Ejection Fraction in Patients ≥80 Years Versus 70-79 Years Versus <70 Years.

Chew NW, Kong G, Ngiam JN, Phua K, ... Tan HC, Poh KK
Aortic stenosis (AS) is increasingly diagnosed in the aging population with more studies focused on the prognostic outcomes of severe asymptomatic AS. However, little is known about the outcomes of moderate asymptomatic AS in the elderly population. From 2001 to 2020, 738 consecutive patients with asymptomatic moderate AS with preserved left ventricular ejection fraction were studied. They were allocated according to the age group at the index echocardiography: very elderly (≥80 years), elderly (70 to 79 years) and control group (<70 years). The primary study outcomes were aortic valve replacement (AVR), congestive cardiac failure (CCF) and all-cause mortality. Overall, about one-third of the subjects were in the very elderly, elderly and control groups each. The median follow-up duration was 114.2 (interquartile range, 27.0 to 183.7) months. There was significantly higher all-cause mortality in the very elderly group (47.9%) followed by elderly (34.8%) and control group (21.9%). Similarly, there was significantly higher CCF rates in the very elderly group (5.8%) compared to elderly (5.1%) and control group (2.8%). There were significantly lower rates of AVR offered and completed in the very elderly group compared to control group. Multivariable logistic regression demonstrated that age ≥80 years remained an independent predictor of mortality after adjusting for important prognostic cofounders (Adjusted HR 2.424, 95% CI 1.728 to 3.400, p < 0.001). Cox regression showed no significant difference in mortality between patients ≥80 years with moderate AS compared to a younger age-group ≥70 years with severe AS. In conclusion, very elderly patients of ≥80 years of age with moderate AS have worse prognostic outcomes than their younger counterparts. They share similar unfavorable prognostic outcomes as those of a younger age-group ≥70 years with severe AS. Closer surveillance are warranted in this group of at-risk elderly patients.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2021; 157:93-100
Chew NW, Kong G, Ngiam JN, Phua K, ... Tan HC, Poh KK
Am J Cardiol: 14 Oct 2021; 157:93-100 | PMID: 34373075
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Abstract

Meta-Analysis of Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease.

Latif A, Ahsan MJ, Mirza MM, Aurit S, ... Bhatt DL, Velagapudi P
Data comparing outcomes of transradial (TR) versus transfemoral (TF) access for percutaneous coronary intervention (PCI) in chronic kidney disease (CKD) including patients with eGFR< 30 ml/min/1.73m2 and patients with end-stage renal disease on dialysis (ESRD) are lacking. This meta-analysis compares the outcomes of TR versus TF approach for PCI in patients with CKD. PubMed, Embase, Cochrane, ClinicalTrials.gov, and Google Scholar were searched for studies including adults with CKD undergoing PCI via a TR versus TF approach from January 1, 2000, until January 15, 2021. The primary outcome was in-hospital all-cause mortality and secondary outcomes included major bleeding, stroke, myocardial infarction (MI), blood transfusion, contrast volume, and fluoroscopy time. The analysis was performed using a random-effects-model using the Mantel-Haenszel method. Five observational studies met inclusion criteria, including 1,156 and 6,156 patients in the TR and TF arms, respectively. The mean age of included patients was 70.5 years, 66% were male and 90% had ESRD. In patients with CKD, TR access for PCI was associated with lower all-cause mortality (RR = 0.48; 95% CI: 0.32 to 0.73), major bleeding (RR = 0.51; 95% CI: 0.36 to 0.73), blood transfusion (RR = 0.53, 95% CI: 0.42 to 0.68) and contrast volume (SMD -0.34 [-0.60 to -0.08]) with no difference in stroke, MI, or fluoroscopy time compared with TF access. In conclusion, in patients with CKD undergoing PCI, the TR approach was associated with a lower risk of in-hospital mortality, post-procedural bleeding, and blood transfusion compared with TF access.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2021; 157:8-14
Latif A, Ahsan MJ, Mirza MM, Aurit S, ... Bhatt DL, Velagapudi P
Am J Cardiol: 14 Oct 2021; 157:8-14 | PMID: 34389155
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Abstract

Mitral Regurgitation Following Acute Myocardial Infarction Treated by Percutaneous Coronary Intervention-Prevalence, Risk factors, and Predictors of Outcome.

Sharma H, Radhakrishnan A, Nightingale P, Brown S, ... Adnan Nadir M, Steeds RP
Mitral regurgitation (MR) following acute myocardial infarction (AMI) worsens prognosis and reports of prevalence vary significantly. The objective was to determine prevalence, risk factors, and outcomes related to MR following AMI. We identified 1000 consecutive patients admitted with AMI in 2016/17 treated by percutaneous coronary intervention with pre-discharge transthoracic echocardiography. MR was observed in 294 of 1000 (29%), graded as mild (n = 224 [76%]), moderate (n = 61 [21%]) and severe (n = 9 [3%]). Compared with patients without MR, patients with MR were older (70 ± 12 vs 63 ± 13 years; p <0.001), with worse left ventricular ejection fraction (LVEF) (52 ± 15% vs 55 ± 11%; p <0.001) and creatinine clearance (69 ± 33 ml/min vs 90 ± 39 ml/min; p <0.001). They also had higher rates of hypertension (64% vs 55%; p = 0.012), heart failure (3.4% vs 1.1%; p = 0.014), previous MI (28% vs 20%; p = 0.005) and severe flow-limitation in the circumflex (50% vs 33%; p <0.001) or right coronary artery (51% vs 42%; p = 0.014). Prevalence and severity of MR were unaffected by AMI subtype. Revascularization later than 72 hours from symptom-onset was associated with increased likelihood of MR (33% vs 25%; p = 0.036) in patients with non-ST elevation myocardial infarction (NSTEMI). After a mean of 3.2 years, 56 of 288 (19%) patients with untreated MR died. Age and LVEF independently predicted mortality. The presence of even mild MR was associated with increased mortality (p = 0.029), despite accounting for confounders. In conclusion, MR is observed in over one-quarter of patients after AMI and associated with lower survival, even when mild. Prevalence and severity are independent of MI subtype, but MR was more common with delayed revascularization following NSTEMI.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2021; 157:22-32
Sharma H, Radhakrishnan A, Nightingale P, Brown S, ... Adnan Nadir M, Steeds RP
Am J Cardiol: 14 Oct 2021; 157:22-32 | PMID: 34417016
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Abstract

Effect of the Emergency Department Assessment of Chest Pain Score on the Triage Performance in Patients With Chest Pain.

Zaboli A, Ausserhofer D, Sibilio S, Toccolini E, ... Pfeifer N, Turcato G
The sensitivity of triage systems in identifying acute cardiovascular events in patients presented to the emergency department with chest pain is not optimal. Recently, a clinical score, the Emergency Department Assessment of Chest Pain Score (EDACS), has been proposed for a rapid assessment without additional instruments. To evaluate whether the integration of EDACS into triage evaluation of patients with chest pain can improve the triage\'s predictive validity for an acute cardiovascular event, a single-center prospective observational study was conducted. This study involved all patients who needed a triage admission for chest pain between January 1, 2020, and December 31, 2020. All enrolled patients first underwent a standard triage assessment and then the EDACS was calculated. The primary outcome of the study was the presence of an acute cardiovascular event. The discriminatory ability of EDACS in triage compared with standard triage assessment was evaluated by comparing the areas under the receiver operating characteristic curve, decision curve analysis, and net reclassification improvement. The study involved 1,596 patients, of that 7.3% presented the study outcome. The discriminatory ability of triage presented an area under the receiver operating characteristic curve of 0.688 that increased to 0.818 after the application of EDACS in the triage assessment. EDACS improved the baseline assessment of priority assigned in triage, with a net reclassification improvement of 33.6% (p <0.001), and the decision curve analyses demonstrated that EDACS in triage resulted in a clear net clinical benefit. In conclusion, the results of the study suggest that EDACS has a good discriminatory capacity for acute cardiovascular events and that its implementation in routine triage may improve triage performance in patients with chest pain.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 08 Oct 2021; epub ahead of print
Zaboli A, Ausserhofer D, Sibilio S, Toccolini E, ... Pfeifer N, Turcato G
Am J Cardiol: 08 Oct 2021; epub ahead of print | PMID: 34635312
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Abstract

Cardiac and Pregnancy Outcomes of Pregnant Patients With Congenital Heart Disease According to Risk Classification System.

Steiner JM, Lokken E, Bayley E, Pechan J, ... Buber J, Albright C
Pregnancy risk assessment for patients with adult congenital heart disease (ACHD) must include physiologic and anatomic impacts. We aimed to determine whether maternal cardiac and pregnancy outcomes vary by disease severity defined according to the following 3 different classifications: ACHD anatomic severity, ACHD physiologic class, and modified World Health Organization (mWHO) class. Cardiac outcomes included a composite of arrhythmia, heart failure, stroke, and thromboembolism. Pregnancy outcomes included a composite of intrauterine growth restriction, preterm birth, preeclampsia, or postpartum hemorrhage. We employed generalized estimating equations to account for multiple pregnancies. Of the 245 pregnancies, 17.1% were preterm and 45.7% were cesarean deliveries. Cardiac hospitalizations occurred in 22.0% and arrhythmias in 12.7%. Cardiac outcomes tended to be more prevalent in people with more severe heart disease. Pregnancy outcomes were U-shaped or less prevalent in people with more severe disease. There was a 2.9-fold increased risk for the composite cardiac outcome for complex anatomy (adjusted incidence rate ratio 2.90, 95% confidence interval 1.08 to 7.81, p = 0.04), a 9.4-fold increased risk for physiologic class C or D (9.37, 1.28 to 68.79, p = 0.03), and a fourfold increased risk for mWHO class III or IV (3.99, 1.53 to 10.40, p = 0.005). There was a lower risk for the composite pregnancy outcome for mWHO class II or II to III (0.54, 0.36 to 0.79, p = 0.002) but no association with anatomy or physiology. In conclusion, physiologic class may be most accurately associated with adverse outcomes and therefore efforts to optimize hemodynamics before pregnancy may help to mitigate the risk.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 07 Oct 2021; epub ahead of print
Steiner JM, Lokken E, Bayley E, Pechan J, ... Buber J, Albright C
Am J Cardiol: 07 Oct 2021; epub ahead of print | PMID: 34635313
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Abstract

Prognostic Implications of Bicuspid and Tricuspid Aortic Valve Phenotype on Progression of Moderate Aortic Stenosis and Ascending Aorta Dilatation.

Chew NWS, Phua K, Ho YJ, Zhang A, ... Kong WKF, Poh KK
Studies on the impact of aortic valve anatomy (bicuspid aortic valve [BAV] or tricuspid aortic valve [TAV]) on the progression of moderate aortic stenosis (AS) and ascending aorta (AA) dilatation and its prognostic implications are limited. From 1991 to 2016, 288 asymptomatic patients with moderate AS detected during index echocardiography with at least 1 year of echocardiographic follow-up were retrospectively studied. Baseline clinical and echocardiographic characteristics were compared between patients with BAV (n = 80) and patients with TAV (n = 208). Co-primary outcomes were 1-year hemodynamic and anatomic progression of AS and AA dilatation. Secondary end points were the incidence of AA rapid progressors, all-cause mortality, aortic valve replacement, and congestive heart failure. Determinants of AS progression, AA diameters, AA dilatation, and prognostic outcomes were evaluated. Similar 1-year progression of the aortic valve peak velocity, Vmax (9 ± 18 vs 9 ± 23 cm/s), mean gradient (1.5 ± 2.3 vs 1.3 ± 3.2 mm Hg), and aortic valve area (AVA) (-0.04 ± 0.09 vs -0.05 ± 0.10 cm2) were noted for BAV and TAV groups, respectively. One-year progressions of AA were similar at Valsalva (0.11 ± 0.88 vs 0.14 ± 1.10 mm) and tubular levels (0.12 ± 0.68 vs 0.30 ± 1.51 mm) in BAV and TAV groups, respectively. A trend toward increased rapid AA progression in patients with BAV (31.3%) was observed compared with patients with TAV (14.8%, p = 0.099). BAV was associated with progression of Vmax (β = 0.17, p = 0.036), the dimensionless index (β = -0.17, p = 0.008), and AVA (β = -0.14, p = 0.048), but not mean gradient after adjusting for age, baseline severity indexes, gender, hypertension, diabetes, and body surface area. Although BAV was a determinant of larger baseline AA diameter, there was no significant association between BAV and AA rapid progressors. Adjusted Kaplan-Meier curves demonstrated no differences in congestive heart failure, aortic valve replacement, or mortality between valve morphology. In conclusion, there was a similar 1-year disease progression in terms of AVA, Vmax, mean gradient, and AA diameters between patients with BAV and patients with TAV. BAV was associated with a significant increase in Vmax, dimensionless index, and AVA after adjusting for important confounders. Close and prolonged follow-up is warranted in both groups of patients.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 05 Oct 2021; epub ahead of print
Chew NWS, Phua K, Ho YJ, Zhang A, ... Kong WKF, Poh KK
Am J Cardiol: 05 Oct 2021; epub ahead of print | PMID: 34627597
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Abstract

Cardiac Amyloidosis Screening at Trigger Finger Release Surgery.

Sperry BW, Khedraki R, Gabrovsek A, Donnelly JP, ... Seitz W, Hanna M
Cardiac amyloidosis is often preceded by orthopedic manifestations such as carpal tunnel syndrome, and 10% of patients who underwent idiopathic carpal tunnel release surgery will have biopsy-confirmed amyloid deposits in the tenosynovial sheath. Trigger finger is also commonly reported in patients with amyloidosis and involves the same tendon sheath as carpal tunnel syndrome, but the prevalence of amyloid deposition is unclear. This prospective cross-sectional study enrolled 100 patients aged ≥50 years at the time of surgery for idiopathic trigger finger. Patients underwent release surgery, and a sample of the tenosynovium of the affected finger was excised, stained with Congo red, and subtyped with mass spectrometry if amyloid was demonstrated. Further cardiac evaluation was performed in patients with amyloid deposition. Of the 100 patients (mean age 65.5 ± 8.1 years) enrolled, only 2 demonstrated amyloid deposits on Congo red staining. One patient with previous proteinuric kidney disease had fibrinogen A α-chain amyloidosis, and the other patient had untyped amyloidosis. Neither patient had cardiac involvement. A total of 13 of the 100 patients underwent concomitant carpal tunnel release surgery, and 2 of these patients had amyloid deposits in the carpal tunnel with \"false-negative\" samples from the trigger finger tenosynovium. In conclusion, biopsy during trigger finger release surgery demonstrated a 2% yield for amyloidosis, which is significantly lower than the previously published yield of 10% during carpal tunnel release surgery. This observation has important implications for the development of diagnostic algorithms to screen patients for amyloidosis during orthopedic operations.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 03 Oct 2021; epub ahead of print
Sperry BW, Khedraki R, Gabrovsek A, Donnelly JP, ... Seitz W, Hanna M
Am J Cardiol: 03 Oct 2021; epub ahead of print | PMID: 34620488
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Abstract

Relation of Left Ventricular Assist Device Infections With Cardiac Transplant Outcomes.

Parikh A, Halista M, Raymond S, Feinman J, ... Lala A, Pinney S
Left ventricular assist device (LVAD)-specific infections (LSIs) are common in patients on LVAD support awaiting heart transplant (HT), yet their impact on post-HT outcomes is not completely understood. We hypothesized that LSIs would result in vasoplegia and negatively affect post-HT 30-day and 1-year outcomes. LSI was defined as driveline, pump, or pocket infection. The short-term outcome was a composite of acute renal failure, allograft rejection, and mortality at 30 days after HT. The long-term outcome was a composite of allograft rejection and death within 1 year after HT. We performed a retrospective analysis of 111 HT recipients bridged with durable LVAD support at our institution from May 2012 to August 2019. Of these, 63 patients had LSIs, with 94% of the infections being driveline infections. Vasoplegia was more prevalent in the LSI group but not significantly (7 vs 2 persons, p = 0.3). There was no difference in the composite end point of acute renal failure, rejection, or death at 30 days (30% vs 25%, p = 0.55) or 1-year end point of rejection and death (38% vs 40%, p = 0.87) in patients with LSI versus those without LSI. In conclusion, LSIs were common in patients on LVAD who underwent HT in our single-center contemporary cohort. However, LSI was not associated with adverse outcomes at 30 days or at 1 year after HT.

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

Am J Cardiol: 02 Oct 2021; epub ahead of print
Parikh A, Halista M, Raymond S, Feinman J, ... Lala A, Pinney S
Am J Cardiol: 02 Oct 2021; epub ahead of print | PMID: 34615608
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Abstract

Misconceptions and Facts About Cardiac Amyloidosis.

Nguyen FD, Rodriguez Rivera M, Krittanawong C, Witteles R, Lenihan DJ
Cardiac amyloidosis is an important clinical entity associated with significant morbidity and mortality. Although the signs and symptoms can be apparent early in the disease course, diagnoses are often made late because of inadequate recognition. A diagnosis of cardiac amyloidosis requires careful scrutiny of a patient\'s symptoms, an electrocardiogram, and imaging studies, including echocardiography and magnetic resonance imaging. Further evaluation is required through the measurement of serum and urine light chains and the use of bone scintigraphy imaging to differentiate transthyretin amyloidosis from light-chain cardiac amyloidosis. The available treatments have expanded tremendously in recent years and have improved outcomes in the population with this disorder. Thus, it has become increasingly important to diagnose cardiac amyloidosis and provide timely therapies. This article will clarify the various misconceptions about cardiac amyloidosis and provide a framework for primary care providers to better identify this disease in their practice.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 01 Oct 2021; epub ahead of print
Nguyen FD, Rodriguez Rivera M, Krittanawong C, Witteles R, Lenihan DJ
Am J Cardiol: 01 Oct 2021; epub ahead of print | PMID: 34610875
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Abstract

Long-Term Outcomes After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents or Coronary Artery Bypass Grafting for Multivessel Coronary Disease.

Kim TO, Ahn JM, Kang DY, Park H, ... Park DW, Asan-Multivessel Registry Investigators
More evidence is required with respect to the comparative effectiveness of percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DESs) versus coronary artery bypass grafting (CABG) in contemporary clinical practice. This prospective observational registry-based study compared the outcomes of 6,647 patients with multivessel disease who underwent PCI with second-generation DES (n = 3,858) or CABG (n = 2,789) between January 2006 and June 2018 and for whom follow-up data were available for at least 2 to 13 years (median 4.8). The primary outcome was a composite of death, spontaneous myocardial infarction, or stroke. Baseline differences were adjusted using propensity scores and inverse probability weighting. In the overall cohort, there were no significant between-group differences in the adjusted risks for the primary composite outcome (hazard ratio [HR] for PCI vs CABG 1.03, 95% confidence interval [CI] 0.86 to 1.25, p = 0.73) and all-cause mortality (HR 0.95, 95% CI 0.76 to 1.20, p = 0.68). This relative treatment effect on the primary outcome was similar in patients with diabetes (HR 1.15, 95% CI 0.91 to 1.46, p = 0.25) and without diabetes (HR 0.95, 95% CI 0.73 to 1.22, p = 0.67) (p for interaction = 0.24). The adjusted risk of the primary outcome was significantly greater after PCI than after CABG in patients with left main involvement (HR 1.39, 95% CI 1.01 to 1.90, p = 0.044), but not in those without left main involvement (HR 0.94, 95% CI 0.76 to 1.16, p = 0.56) (p = 0.03 for interaction). In this prospective real-world long-term registry, we observed that the risk for the primary composite of death, spontaneous myocardial infarction, or stroke was similar between PCI with contemporary DES and CABG.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 01 Oct 2021; epub ahead of print
Kim TO, Ahn JM, Kang DY, Park H, ... Park DW, Asan-Multivessel Registry Investigators
Am J Cardiol: 01 Oct 2021; epub ahead of print | PMID: 34610874
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Abstract

A Multicenter External Validation of a Score Model to Predict Risk of Events in Patients With Brugada Syndrome.

Chow JJ, Leong KMW, Yazdani M, Huzaien HW, ... Kanagaratnam P, Varnava AM
A multivariate risk score model was proposed by Sieira et al in 2017 for sudden death in Brugada syndrome; their validation in 150 patients was highly encouraging, with a C-index of 0.81; however, this score is yet to be validated by an independent group. A total of 192 records of patients with Brugada syndrome were collected from 2 centers in the United Kingdom and retrospectively scored according to a score model by Sieira et al. Data were compiled summatively over follow-up to mimic regular risk re-evaluation as per current guidelines. Sudden cardiac arrest survivor data were considered perievent to ascertain the utility of the score before cardiac arrest. Scores were compared with actual outcomes. Sensitivity in our cohort was 22.7%, specificity was 57.6%, and C-index was 0.58. In conclusion, up to 75% of cardiac arrest survivors in this cohort would not have been offered a defibrillator if evaluated before their event. This casts doubt on the utility of the score model for primary prevention of sudden death. Inherent issues with modern risk scoring strategies decrease the likelihood of success even in robustly designed tools such as the Sieira score model.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 01 Oct 2021; epub ahead of print
Chow JJ, Leong KMW, Yazdani M, Huzaien HW, ... Kanagaratnam P, Varnava AM
Am J Cardiol: 01 Oct 2021; epub ahead of print | PMID: 34610873
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Abstract

Scope of Practice of US Interventional Cardiologists from an Analysis of Medicare Billing Data.

Murugiah K, Chen L, Castro-Dominguez Y, Khera R, Krumholz HM
The contemporary scope of practice of interventional cardiologists (ICs) in the United States and recent trends are unknown. Using Medicare claims from 2013 to 2017, we categorized ICs into 4 practice categories (only percutaneous coronary intervention [PCI], PCI with noninvasive imaging, PCI with specialized interventions [peripheral/structural], and all 3 services) and evaluated associations with region, hospital bed size and teaching status, gender, and graduation year. Of 6,083 ICs in 2017, 10.9% performed only PCI, 68.3% PCI with noninvasive imaging, 5.7% PCI with specialized interventions, and 15.1% all 3 services. A higher proportion of Northeast ICs (vs South ICs) were performing only PCI (24.8% vs 7.3%) and PCI with specialized interventions (12% vs 3.4%), but lower PCI and noninvasive imaging (53.8% vs 71.7%) and all 3 services (9.3% and 17.6%). Regarding ICs at larger hospitals (bed size >575 vs <218), a higher proportion was performing only PCI (23.8% vs 5.2%) or PCI with specialized interventions (13.5% vs 1.7%) and lower proportion was performing PCI with noninvasive imaging (48.8% vs 78%), similar to teaching hospitals. Female ICs (vs male ICs) more frequently performed only PCI (18.9% vs 10.6%) and less frequently all 3 services (8.3% vs 15.4%). A lower proportion of recent graduates (2001 to 2016) performed only PCI (9.8% vs 13.8%) and PCI with noninvasive imaging (66.3% vs 72.6%) but a higher proportion performed all 3 services (18% vs 8.4%) than earlier graduates (1959 to 1984). From 2013 to 2017, only PCI and PCI with noninvasive imaging decreased, whereas PCI and specialized interventions and all 3 services increased (all p <0.001). In conclusion, there is marked heterogeneity in practice responsibilities among ICs, which has implications for training and competency assessments.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 01 Oct 2021; epub ahead of print
Murugiah K, Chen L, Castro-Dominguez Y, Khera R, Krumholz HM
Am J Cardiol: 01 Oct 2021; epub ahead of print | PMID: 34610872
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Abstract

Trends, Predictors and In-Hospital Outcomes of the Next Day Discharge Approach After Transcatheter Mitral Valve Repair.

Grant JK, Vincent L, Ebner B, Singh H, ... Braghiroli J, De Marchena E
Early discharge strategies are associated with lower cost and resource utilization during hospitalization, as such we sought to evaluate trends, predictors and outcomes of the next day discharge (NDD) approach after transcatheter mitral valve repair (TMVR) procedures with the MitraClip device. The National Inpatient Sample (NIS) was queried between 2013 and 2018 for patients undergoing TMVR using the International Classification of Diseases (ICD) 9 procedure code \'3597\' and ICD-10 procedure code \'02UG3JZ\'. Patients undergoing TMVR were stratified into two groups, determined by hospital length of stay (LOS) [≤1 day, NDD versus >1-day, non-NDD]. Overall, 22,035 patients underwent TMVR with 35.7% (n  = 7,870) belonging to the NDD group (mean age 78.1 ± 9.7 years, women 45%). From 2013 to 2018, the proportion of patients being discharged using the NDD approach trended upward from 18.3% to 46.0%. Amongst demographic and social factors, female sex, black race, and low median household income were predictive of non-NDD (p <0.05 for all). Amongst clinical factors, anemia, iron deficiency anemia, major depressive disorder, thrombocytopenia, obesity and end stage renal disease were some predictors of non-NDD (p <0.05 for all). In the non-NDD group there was a downward trend of pooled post-procedure complications, post procedure cardiogenic shock, vascular complications, acute kidney injury, mechanical circulatory support use, acute respiratory distress and postoperative ischemic stroke and (p for trend <0.001 for all). Despite the overall downward trend, complications began increasing in 2017-18. In conclusion, these trends may reflect improving operator experience, advancement in vascular access device closures and techniques, and prioritization of decreasing length of stay. Ideally, the feasibility and safety of this approach should be confirmed in larger-sized multicenter, randomized trials.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:93-100
Grant JK, Vincent L, Ebner B, Singh H, ... Braghiroli J, De Marchena E
Am J Cardiol: 30 Sep 2021; 156:93-100 | PMID: 34332741
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Abstract

Risk Markers for Limited Coronary Artery Calcium in Persons With Significant Aortic Valve Calcium (From the Multi-ethnic Study of Atherosclerosis).

Razavi AC, Cardoso R, Dzaye O, Budoff M, ... Blaha MJ, Whelton SP
The early stages of aortic valve calcification (AVC) and coronary artery calcification (CAC) include shared ASCVD risk factors, yet there is considerable heterogeneity between the burden of AVC, and CAC. We sought to identify the markers associated with limited CAC among persons with significant AVC. There were 325 participants from the Multi-Ethnic Study of Atherosclerosis without clinical ASCVD and with AVC ≥100 Agatston units (AU) at Visit 1. Multivariable-adjusted prevalence ratios for limited CAC (0 to 99 AU) were calculated using modified Poisson regression. Participants had a mean age of 72.1 years, median AVC score of 209, and 34% were women. A total of 133 (41%) participants had CAC <100, of whom 46/133 had CAC = 0. Younger age (PR = 1.40, 95% CI: 1.22 to 1.62, per 10-years), female gender (PR = 1.68, 95% CI: 1.28 to 2.20), and low 10-year ASCVD risk (PR = 2.30, 95% CI: 1.85 to 2.85) were most strongly associated with limited CAC. Neither a normal lipoprotein(a) nor normal measures of inflammation were significantly associated with limited CAC. Lower serum phosphate (PR = 1.15, 95% CI: 1.01 to 1.31; per 0.5 mg/dl lower) and calcium-phosphate product (PR = 1.16, 95% CI: 1.02 to 1.34; per SD lower) were associated with an approximately 15% higher prevalence of limited CAC. In conclusion, more than 40% of persons with significant AVC had CAC. Beyond traditional risk factors, lower serum phosphate, and lower calcium-phosphate product were associated with a higher prevalence of limited CAC.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:58-64
Razavi AC, Cardoso R, Dzaye O, Budoff M, ... Blaha MJ, Whelton SP
Am J Cardiol: 30 Sep 2021; 156:58-64 | PMID: 34325879
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Abstract

Trends in the Outcomes of High-risk Percutaneous Ventricular Assist Device-assisted Percutaneous Coronary Intervention, 2008-2018.

Lemor A, Basir MB, Truesdell AG, Tamis-Holland JE, ... Pinto DS, O\'Neill W
Percutaneous ventricular assist devices (pVAD) are frequently utilized in high-risk percutaneous coronary intervention (HR-PCI) to provide hemodynamic support in patients with complex cardiovascular disease and/or multiple comorbidities who are poor candidates for surgical revascularization. Using the National Inpatient Sample we identified pVAD-assisted PCI (excluding intra-aortic balloon pump) in patients without cardiogenic shock from January 2008 to December 2018. We evaluated the trends in patient and procedural characteristics, and complication rates across the 11-year study period. A total of 26,661 pVAD-PCI was performed. From 2008 to 2018 there has was a 27-fold increase in the number of pVAD-PCIs performed annually. There has also been an increase in the proportion of procedures performed in small to medium sized hospitals. The use of atherectomy, image-guided PCI, FFR/iFR, drug-eluting stents, and multi-vessel intervention has significantly increased. Patients undergoing pVAD-PCI had a higher burden of comorbidities, without a significant difference in mortality over time. There were decreased rates of acute stroke and blood transfusions over time, while vascular complications and acute kidney injury (AKI) requiring dialysis remained mostly unchanged. In conclusion, the use of pVAD for HR-PCI has increased significantly, along with adjunctive PCI techniques such as atherectomy, intravascular imaging, and physiologic lesion assessment. With increasing use of this device, there appeared to be lower rates of peri-procedural stroke, and blood transfusions. Despite a higher burden of comorbidities, adjusted mortality remained stable over time.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:65-71
Lemor A, Basir MB, Truesdell AG, Tamis-Holland JE, ... Pinto DS, O'Neill W
Am J Cardiol: 30 Sep 2021; 156:65-71 | PMID: 34344515
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Abstract

Incidence and Predictors of Stent Thrombosis in Patients Treated with Stents for Coronary Bifurcation Narrowing (From the BIFURCAT Registry).

Franchin L, Kang J, De Filippo O, Gwon HC, ... Koo BK, D\'Ascenzo F
Percutaneous coronary interventions performed at coronary bifurcations yield high rates of stent thrombosis (ST). The aim of the present study was to investigate the predictors of ST in contemporary coronary bifurcation percutaneous coronary interventions. We retrospectively investigated the BIFURCAT (comBined Insights From the Unified RAIN and COBIS bifurcAtion regisTries) registry on coronary bifurcations to assess the incidence and predictors of definite ST, which were the study primary endpoints. Predictors of ST among patients on dual antiplatelet therapy (DAPT) were also examined. A total of 5330 patients were included. After a mean 2-years follow-up, 64 (1.2%) patients experienced ST. 42 (65.6%) ST patients were on DAPT. At multivariable analysis, age (HR 1.02, CI 1.01 to 1.05, p = 0,027), smoking status (HR 2.57, CI 1.49 to 4.44, p = 0.001), chronic kidney disease (HR 2.26, CI 1.24 to 4.12, p = 0.007) and a 2-stent strategy (HR 2.38, CI 1.37 to 4.14, p = 0.002) were independent predictors of ST, whereas intracoronary imaging (HR 0.42, CI 0.23 to 0.78, p = 0.006) and final kissing balloon (FKB) (HR 0.48, CI 0.29 to 0.82, p = 0.007) were protective against ST. Among patients on DAPT, smoking status and a 2-stent strategy significantly increased the risk of ST, while intracoronary imaging and FKB reduced the risk. In conclusion, age, smoking status, chronic kidney disease and a 2-stent strategy were significant predictors of ST, whereas intracoronary imaging use and FKB had a protective effect. Only smoking status and a 2-stent strategy significantly predicted ST in DAPT subgroup, while intracoronary imaging and FKB had a protective role.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 30 Sep 2021; 156:24-31
Franchin L, Kang J, De Filippo O, Gwon HC, ... Koo BK, D'Ascenzo F
Am J Cardiol: 30 Sep 2021; 156:24-31 | PMID: 34294409
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Abstract

Long-term (≥15 years) Follow-up of Percutaneous Coronary Intervention of Unprotected Left Main (From the GRAVITY Registry).

D\'Ascenzo F, Elia E, Marengo G, Wańha W, ... Sheiban I, Ferrari GM
Long term survival and its determinants after Percutaneous Coronary Intervention (PCI) on Unprotected Left Main Coronary Artery (ULMCA) remain to be appraised. In 9 European Centers 470 consecutive patients performing PCI on ULMCA between 2002 and 2005 were retrospectively enrolled. Survival from all cause and cardiovascular (CV) death were the primary end points, while their predictors at multivariate analysis the secondary ones. Among the overall cohort 81.5% of patients were male and mean age was 66 ± 12 years. After 15 years (IQR 13 to 16), 223 patients (47%) died, 81 (17.2%) due to CV etiology. At multivariable analysis, older age (HR 1.06, 95%CI 1.02 to 1.11), LVEF < 35% (HR 2.97, 95%CI 1.24 to 7.15) and number of vessels treated during the index PCI (HR 1.75, 95%CI 1.12 to 2.72) were related to all-cause mortality, while only LVEF <35% (HR 4.71, 95%CI 1.90 to 11.66) to CV death. Repeated PCI on ULMCA occurred in 91 (28%) patients during the course of follow up and did not significantly impact on freedom from all-cause or CV mortality. In conclusion, in a large, unselected population treated with PCI on ULMCA, 47% died after 15 years, 17% due to CV causes. Age, number of vessels treated during index PCI and depressed LVEF increased risk of all cause death, while re-PCI on ULMCA did not impact survival.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:72-78
D'Ascenzo F, Elia E, Marengo G, Wańha W, ... Sheiban I, Ferrari GM
Am J Cardiol: 30 Sep 2021; 156:72-78 | PMID: 34325877
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Abstract

Cost-effectiveness of Radial Access Percutaneous Coronary Intervention in Acute Coronary Syndrome.

Lee P, Liew D, Brennan A, Stub D, ... Reid CM, Zomer E
Clinical trials have shown that radial access percutaneous coronary intervention (PCI) is associated with improved patient outcomes compared to femoral artery access. However, few studies have evaluated the cost-effectiveness of radial access PCI. This analysis sought to evaluate the cost-effectiveness of transradial versus transfemoral access PCI for patients with acute coronary syndrome (ACS) using data from the Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox (MATRIX) trial. A decision analytic Markov model was constructed from an Australian health care perspective with a 2 year time horizon. The model simulated recurrent cardiovascular disease and death post PCI among a hypothetical cohort of 1000 individuals with ACS. Population and efficacy data were based on the MATRIX trial. Cost and utility data were drawn from published sources. Over a 2-year time horizon, radial access was predicted to save 12 (discounted) quality adjusted life years (QALYs) compared with femoral access PCI. Cost savings (discounted) amounted to AUD $51,305. Hence from a health economic point of view, radial access PCI was dominant over femoral access PCI. Sensitivity analyses supported the robustness of these findings. Radial access PCI is likely to be associated with both better outcomes and lower costs compared to femoral access PCI over 2 years post procedure. In conclusion, these findings support radial access being the preferred approach in PCI for ACS.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:44-51
Lee P, Liew D, Brennan A, Stub D, ... Reid CM, Zomer E
Am J Cardiol: 30 Sep 2021; 156:44-51 | PMID: 34325876
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Abstract

The Definition of \"Acute Kidney Injury\" Following Percutaneous Coronary Intervention and Cardiovascular Outcomes.

Skalsky K, Levi A, Bental T, Vaknin-Assa H, ... Kornowski R, Perl L
Acute kidney injury (AKI) is a complication of percutaneous coronary intervention (PCI), known to increase rates of adverse medical events. We aimed to identify the optimal definition of AKI in predicting adverse cardiovascular outcomes and mortality post PCI. From a large registry of patients undergoing PCI between 2006-2018 (n = 25,690) at our medical center, consecutive patients were assessed for the presence of AKI according to four different definitions: a relative elevation of ≥25% or ≥50%; or an absolute elevation of ≥0.3 mg/dL or ≥0.5 mg/dL in serum creatinine at 48 hours post PCI. We assessed the calculated rates of AKI according to the different definitions. The discriminant capacity for 30-day and 1-year mortality and MACE (MACE: all-cause death, myocardial infarction, target-vessel revascularization and coronary artery bypass graft surgery) of each definition was calculated using ROC curves and AUCs. Data of 15,153 patients was available for the final analysis. Rates of AKI were 12.1%, 3.2%, 8.1% and 3.9% according to the four definitions, respectively. The discriminant capacity of adverse outcomes was highest among those defined as AKI according to the third definition - an absolute elevation of ≥0.3 mg/dL in serum creatinine with an AUC of 0.82 (95% CI 0.80-0.84) for 30-day mortality (P value = 0.036) and an AUC of 0.78 (CI 0.76-0.79) for 30-day MACE. In conclusion, an absolute elevation of ≥ 0.3 mg/dL in serum creatinine 48 hours post PCI predicts overall mortality and MACE most accurately.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:39-43
Skalsky K, Levi A, Bental T, Vaknin-Assa H, ... Kornowski R, Perl L
Am J Cardiol: 30 Sep 2021; 156:39-43 | PMID: 34325874
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Abstract

Analysis of Differences in Assessment of Left Ventricular Function on Echocardiography and Nuclear Perfusion Imaging.

Jacobson AF, Narula J, Tijssen J
Two widely used methods for left ventricular (LV) ejection fraction (EF) determination, echocardiography (echo) and gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), often have wide limits of agreement. Factors influencing discrepancies between core laboratory echo and MPI LVEF determinations were examined in a large series of heart failure (HF) subjects and normal controls. 879 HF and 101 control subjects had core lab analyses of echo and MPI (mean time between procedures 7-8 days). LVEF differences were analyzed using one-way analysis of variance and Bland-Altman plots. Relationships between LVEF differences and patient characteristics and outcome endpoints (mortality and arrhythmias) were explored with logistic regression, Cox proportional hazards models, and Kaplan-Meier survival analyses. There was a systematic difference between the 2 modalities; echo LVEF was higher with more severe LV dysfunction, MPI LVEF higher when systolic function was normal. LVEF results were within ±5% in only 37% of HF and 23% of control subjects. Considering discordance around the LVEF threshold 35%, there was disagreement between the 2 methods in 305 HF subjects (35%). Male gender (odds ratio (OR) = 0.200), atrial fibrillation (OR = 2.314), higher body mass index (OR = 1.051) and lower LV end-diastolic volume (OR = 0.985) were the strongest predictors of methodologic discordance. Cardiac event rates were highest if both LVEF values were ≤35% and lowest when both LVEF values were >35%. In conclusion, substantial disagreements between LVEF results by echo and MPI are common. HF patients with LVEF ≤35% by both techniques have the highest 2-year event risk.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:85-92
Jacobson AF, Narula J, Tijssen J
Am J Cardiol: 30 Sep 2021; 156:85-92 | PMID: 34344513
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Abstract

Prevalence and Long-term Outcomes of Patients with Coronary Artery Ectasia Presenting with Acute Myocardial Infarction.

Wang X, Montero-Cabezas JM, Mandurino-Mirizzi A, Hirasawa K, ... Bax JJ, Delgado V
Coronary artery ectasia (CAE) is described in 5% of patients undergoing coronary angiography. Previous studies have shown controversial results regarding the prognostic impact of CAE. The prevalence and prognostic value of CAE in patients with acute myocardial infarction (AMI) remain unknown. In 4788 patients presenting with AMI referred for coronary angiography the presence of CAE (defined as dilation of a coronary segment with a diameter ≥1.5 times of the adjacent normal segment) was confirmed in 174 (3.6%) patients (age 62 ± 12 years; 81% male), and was present in the culprit vessel in 79.9%. Multivessel CAE was frequent (67%). CAE patients were more frequently male, had high thrombus burden and were treated more often with thrombectomy and less often was stent implantation. Markis I was the most frequent angiographic phenotype (43%). During a median follow-up of 4 years (1-7), 1243 patients (26%) experienced a major adverse cardiovascular event (MACE): 282 (6%) died from a cardiac cause, 358 (8%) had a myocardial infarction, 945 (20%) underwent coronary revascularization and 58 (1%) presented with a stroke. Patients with CAE showed higher rates of MACE as compared to those without CAE (36.8% versus 25.6%; p <0.001). On multivariable analysis, CAE was associated with MACE (HR 1.597; 95% CI 1.238-2.060; p <0.001) after adjusting for risk factors, type of AMI and number of narrowed coronary arteries. In conclusion, the prevalence of CAE in patients presenting with AMI is relatively low but was independently associated with an increased risk of MACE at follow-up.

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

Am J Cardiol: 30 Sep 2021; 156:9-15
Wang X, Montero-Cabezas JM, Mandurino-Mirizzi A, Hirasawa K, ... Bax JJ, Delgado V
Am J Cardiol: 30 Sep 2021; 156:9-15 | PMID: 34344511
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Abstract

Increased Rate of New-onset Left Bundle Branch Block in Patients With Bicuspid Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation (From a National Registry).

Shiyovich A, Kornowski R, Plakht Y, Aviv Y, ... Perlman GY, Hamdan A
There is a growing interest in transcutaneous aortic valve implantation (TAVI) therapy among patients with bicuspid severe aortic stenosis (BAV). Conduction disturbances remain a frequent complication of TAVI, and new-onset permanent LBBB (NOP-LBBB) post-TAVI may be a marker of worse outcomes. We aimed to evaluate the rate of NOP-LBBB following TAVI among patients with BAV as compared to tricuspid severe aortic stenosis (TAV). Patients enrolled in the multicenter (5 centers) Bicuspid AS TAVI Registry were reviewed and compared with patients with TAV. Patients with previous aortic valve replacement, other valve morphologies and those with preprocedural LBBB or pacemaker were excluded. NOP-LBBB was defined as LBBB first detected and persisting 30-days following TAVI. A total of 387 patients (66 with BAV, 321 with TAV), age 80.3 ± 7.3, 47% females were analyzed. The device success rates were 95% in both groups without any conversions to surgery. The rate of NOP-LBBB was significantly higher among patients with BAV versus TAV (29.2% vs 16.9%, p = 0.02). However, the rate of post procedural pacemaker implantation was similar (14.8% vs 12.5%; respectively, p = 0.62). In BAV and TAV groups, 1-year mortality (6.1% vs 7.2%; respectively, p = 0.75) and stroke rates (6.1% vs 3.5%; respectively, p = 0.30) were not significantly different. Multivariate analysis identified BAV as an independent predictor of NOP-LBBB (AdjOR = 2.7, 95%CI 1.3 to 5.4). Furthermore, BAV subtypes with raphe (type 1) were identified as independent predictors of NOP-LBBB (AdjOR = 3.2, 95%CI: 1.5 to 6.7). In conclusion, patients with BAV undergoing TAVI have greater risk for developing NOP-LBBB compared with patients with TAV and the presence of raphe was associated with increased risk of NOP-LBBB. The prognostic significance for this finding warrants further evaluation in future studies.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:101-107
Shiyovich A, Kornowski R, Plakht Y, Aviv Y, ... Perlman GY, Hamdan A
Am J Cardiol: 30 Sep 2021; 156:101-107 | PMID: 34344509
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Abstract

A Novel Two-Dimensional Echocardiography Method to Objectively Quantify Aortic Valve Calcium and Predict Aortic Stenosis Severity.

Slostad B, Twing A, Lee K, Hubbard C, ... Frazin L, Kansal M
Aortic valve calcium (AVC) is a strong predictor of aortic stenosis (AS) severity and is typically calculated by multidetector computed tomography (MDCT). We propose a novel method using pixel density quantification software to objectively quantify AVC by two-dimensional (2D) transthoracic echocardiography (TTE) and distinguish severe from non-severe AS. A total of 90 patients (mean age 76 ± 10 years, 75% male, mean AV gradient 32 ± 11 mmHg, peak AV velocity 3.6 ± 0.6 m/s, AV area (AVA) 1.0 ± 0.3 cm2, dimensionless index (DI) 0.27 ± 0.08) with suspected severe aortic stenosis undergoing 2D echocardiography were retrospectively evaluated. Parasternal short axis aortic valve views were used to calculate a gain-independent ratio between the average pixel density of the entire aortic valve in short axis at end diastole and the average pixel density of the aortic annulus in short axis (2D-AVC ratio). The 2D-AVC ratio was compared to echocardiographic hemodynamic parameters associated with AS, MDCT AVC quantification, and expert reader interpretation of AS severity based on echocardiographic AVC interpretation. The 2D-AVC ratio exhibited strong correlations with mean AV gradient (r = 0.72, p < 0.001), peak AV velocity (r = 0.74, p < 0.001), AVC quantified by MDCT (r = 0.71, p <0.001) and excellent accuracy in distinguishing severe from non-severe AS (area under the curve = 0.93). Conversely, expert reader interpretation of AS severity based on echocardiographic AVC was not significantly related to AV mean gradient (t = 0.23, p = 0.64), AVA (t = 2.94, p = 0.11), peak velocity (t = 0.59, p = 0.46), or DI (t = 0.02, p = 0.89). In conclusion, these data suggest that the 2D-AVC ratio may be a complementary method for AS severity adjudication that is readily quantifiable at time of TTE.

Published by Elsevier Inc.

Am J Cardiol: 30 Sep 2021; 156:108-113
Slostad B, Twing A, Lee K, Hubbard C, ... Frazin L, Kansal M
Am J Cardiol: 30 Sep 2021; 156:108-113 | PMID: 34344508
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Abstract

Comparison of Outcomes of Patients With Versus Without Chronic Liver Disease Undergoing Percutaneous Coronary Intervention.

Istanbuly S, Matetic A, Mohamed MO, Panaich S, ... Alkhouli M, Mamas MA
There are limited data on the outcomes of chronic liver disease (CLD) patients admitted for percutaneous coronary intervention (PCI). All PCI hospitalizations from the Nationwide Inpatient Sample (2004 to 2015) were analyzed and stratified by the presence, cause and severity of CLD, as well as the indication for PCI. Multivariable logistic regression analysis was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in patients with CLD compared with those without CLD. Among 7,296,679 PCI admissions, 54,368 (0.7%) had a CLD diagnosis. Among patients with CLD, 36,853 (67.8%) had severe CLD. Patients with CLD had higher likelihood of adverse outcomes including major adverse cardiovascular and cerebrovascular events (MACCE) (aOR 1.25, 95%CI 1.20 to 1.30), mortality (aOR 1.43, 95%CI 1.35 to 1.51), major bleeding (aOR 2.22, 95%CI 2.12 to 2.32). When accounting for severity, only severe CLD subgroup was more likely to have MACCE and all-cause mortality compared to no-CLD patients (p <0.001). Among CLD etiologic subgroups, those with \'alcohol-related liver disease\' and \'other CLD\' were consistently more likely to develop MACCE, all-cause mortality and major bleeding in comparison to no-CLD patients, while \'chronic viral hepatitis\' subgroup had only increased odds of major bleeding (p <0.001). In conclusion, CLD patients admitted for PCI are more likely to have worse in-hospital outcomes, particularly in the severe CLD subgroup and \'alcohol-related liver disease\' and \'other CLD\' etiologic subgroups.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:32-38
Istanbuly S, Matetic A, Mohamed MO, Panaich S, ... Alkhouli M, Mamas MA
Am J Cardiol: 30 Sep 2021; 156:32-38 | PMID: 34348842
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Abstract

Benefit of Extended Dual Antiplatelet Therapy Duration in Acute Coronary Syndrome Patients Treated with Drug Eluting Stents for Coronary Bifurcation Lesions (from the BIFURCAT Registry).

Filippo O, Kang J, Bruno F, Han JK, ... Koo BK, D\'Ascenzo F
Optimal dual antiplatelet therapy (DAPT) duration for patients undergoing percutaneous coronary intervention (PCI) for coronary bifurcations is an unmet issue. The BIFURCAT registry was obtained by merging two registries on coronary bifurcations. Three groups were compared in a two-by-two fashion: short-term DAPT (≤ 6 months), intermediate-term DAPT (6-12 months) and extended DAPT (>12 months). Major adverse cardiac events (MACE) (a composite of all-cause death, myocardial infarction (MI), target-lesion revascularization and stent thrombosis) were the primary endpoint. Single components of MACE were the secondary endpoints. Events were appraised according to the clinical presentation: chronic coronary syndrome (CCS) versus acute coronary syndrome (ACS). 5537 patients (3231 ACS, 2306 CCS) were included. After a median follow-up of 2.1 years (IQR 0.9-2.2), extended DAPT was associated with a lower incidence of MACE compared with intermediate-term DAPT (2.8% versus 3.4%, adjusted HR 0.23 [0.1-0.54], p <0.001), driven by a reduction of all-cause death in the ACS cohort. In the CCS cohort, an extended DAPT strategy was not associated with a reduced risk of MACE. In conclusion, among real-world patients receiving PCI for coronary bifurcation, an extended DAPT strategy was associated with a reduction of MACE in ACS but not in CCS patients.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:16-23
Filippo O, Kang J, Bruno F, Han JK, ... Koo BK, D'Ascenzo F
Am J Cardiol: 30 Sep 2021; 156:16-23 | PMID: 34353628
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Abstract

Pericarditis Recurrence After Initial Uncomplicated Clinical Course.

Del Buono MG, Vecchié A, Damonte JI, Chiabrando JG, ... Gal TS, Abbate A
Acute pericarditis is an inflammatory disease associated with a non-negligible risk of acute complications and future recurrence. However, the exact incidence of pericarditis recurrence in patients with a first uncomplicated clinical course is unknown. We sought to evaluate the incidence and clinical predictors of recurrence after a first episode of acute uncomplicated pericarditis in a large urban hospital in the United States. We conducted a retrospective review, through electronic health records, to complete a database that includes patients admitted with a first episode of acute pericarditis and selected only those with an uncomplicated course (without in-hospital death, large pericardial effusion [>20 mm] or tamponade, constriction, or incessant pericarditis) at the VCU Medical Center (Richmond, Virginia) from 2009 to 2018. A total of 240 patients met acute pericarditis criteria: of the 240 patients, 164 patients (68%) had an uncomplicated course (median age [interquartile range] in years: 50 [32 to 62], 43% females). The median follow-up time was 186 (19 to 467) days. Pericarditis was idiopathic in 84 patients (51%). Fifteen patients (9%) had at least 1 episode of recurrent pericarditis. Compared with those without recurrence, patients with recurrent pericarditis were younger (37 [25 to 59] vs 51 [34 to 62] years, p = 0.034), had a higher prevalence of subacute/delayed presentation (2 [13%] vs 1 [1%], p = 0.023), and less frequently received colchicine (6 [40%] vs 100 [67%], p = 0.036). At multivariate logistic regression analysis, subacute presentation and younger age remained predictors of recurrence at follow-up. In conclusion, 9% of patients with acute pericarditis experienced a recurrence over a 6-month median follow-up despite an initial uncomplicated course. Younger age and subacute presentation were associated with a significantly increased risk of recurrence.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 27 Sep 2021; epub ahead of print
Del Buono MG, Vecchié A, Damonte JI, Chiabrando JG, ... Gal TS, Abbate A
Am J Cardiol: 27 Sep 2021; epub ahead of print | PMID: 34598768
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Abstract

Breaking Point Toward Decreasing Prevalence of Myocardial Infarction Owing to Relative Stronger Decrease in Incidence Than Increase in Survival Rate (A Danish Cohort Study [1994-2016]).

Korsgaard S, Christiansen CF, Pedersen L, Sørensen HT, Schmidt M
The aim of this study was to examine whether myocardial infarction (MI) incidence rate continues to decrease and to determine whether the relative magnitude of a potentially decreasing incidence rate has surpassed increasing survival, demasking a breaking point in trends of MI prevalence proportion. This was a nationwide population-based cohort study using medical registries covering all hospitals in Denmark (1994 to 2016). We identified 193,870 persons with a first-time hospitalization for MI. Age-standardized incidence rates (per 100,000 persons) decreased from 154 (95% confidence interval [CI] 149 to 159) in 1994 to 90 (95% CI 86 to 93) in 2016 for females, and from 335 (95% CI 326 to 344) in 1994 to 205 (95% CI 199 to 211) in 2016 for males. Age-standardized prevalence proportion increased overall from 1994 to 2004 with a subsequent plateau. From 2006 to 2016, age-standardized prevalence proportion decreased by 0.09% (95% CI 0.07% to 0.11%) for females (from 1.07% to 0.98%) and by 0.20% (95% CI 0.17% to 0.23%) for males (from 2.85% to 2.65%). The age-standardized prevalence proportion decreased solely among persons aged 55 to 84 years. It remained stable among persons aged <55 years and increased among persons aged ≥85 years until 2012 with subsequent stable trends. We conclude that the continuous decreasing age-standardized incidence rate of MI over decades has, although with increasing survival, led to an overall breaking point toward a decreasing age-standardized prevalence proportion of MI since 2006.

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

Am J Cardiol: 26 Sep 2021; epub ahead of print
Korsgaard S, Christiansen CF, Pedersen L, Sørensen HT, Schmidt M
Am J Cardiol: 26 Sep 2021; epub ahead of print | PMID: 34593217
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Abstract

Outcomes After Transfemoral Transcatheter Aortic Valve Implantation With a SAPIEN 3 Valve in Patients With Cirrhosis of the Liver (a Tertiary Care Center Experience).

Lak HM, Chawla S, Gajulapalli RD, Verma BR, ... Fares M, Kapadia SR
Little is known about the utility of transcatheter aortic valve implantation (TAVI) in patients with cirrhosis of the liver, and their outcomes have not been studied extensively in literature. We performed a retrospective analysis of patients with severe symptomatic aortic stenosis (AS) who underwent transfemoral TAVI with a SAPIEN 3 valve at our institution between April 2015 and December 2018. We identified 32 consecutive patients with evidence of cirrhosis of the liver on imaging (including ultrasound and/or computed tomography) and patients with severe symptomatic AS who underwent transfemoral TAVI with a SAPIEN 3 valve. Among 1,028 patients, 32 had cirrhosis of the liver and 996 constituted the control group without cirrhosis. Mean age in the cirrhosis group was 74.5 years compared with 81.2 years in the control group. Baseline variables were comparable between the groups. Compared with the noncirrhotic group, patients with cirrhosis had a similar 1-year mortality (12% vs 12%, p = 1), a lower 30-day new pacemaker after TAVI rate (6% vs 9%, p = 0.85), a higher 30-day and 1-year readmission rate for heart failure (11% vs 1% and 12% vs 5%, p = 0.12, respectively), and a similar 1-year major adverse cardiac and cerebrovascular event rate (15% vs 14%, p = 0.98). In conclusion, patients with severe AS with concomitant liver cirrhosis who underwent TAVI demonstrated comparable outcomes to their noncirrhotic counterparts.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 24 Sep 2021; epub ahead of print
Lak HM, Chawla S, Gajulapalli RD, Verma BR, ... Fares M, Kapadia SR
Am J Cardiol: 24 Sep 2021; epub ahead of print | PMID: 34583810
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Abstract

Accuracy of Ankle-Brachial Index, Toe-Brachial Index, and Risk Classification Score in Discriminating Peripheral Artery Disease in Patients With Chronic Kidney Disease.

Chen J, He H, Starcke CC, Guo Y, ... Hamm LL, He J
The accuracy of ankle-brachial index (ABI) and toe-brachial index (TBI) in discriminating lower extremity peripheral artery disease (PAD) has not been evaluated in patients with chronic kidney disease (CKD). We measured ABI, TBI, and Doppler ultrasound in 100 predialysis patients with CKD without revascularization or amputation. Leg-specific ABI was calculated using higher systolic blood pressure (SBP) in posterior tibial or dorsalis pedis artery divided by higher brachial SBP; alternative ABI was calculated using lower SBP in posterior tibial or dorsalis pedis artery. PAD was defined as ≥50% stenosis detected by Doppler ultrasound. PAD risk classification score was calculated using cardiovascular disease risk factors. The area under the curve (AUC, 95% confidence interval [CI]) for discriminating ultrasound-diagnosed PAD was 0.78 (0.69 to 0.87) by ABI, 0.80 (0.71 to 0.89) by alternative ABI, and 0.74 (0.63 to 0.86) by TBI. Sensitivity and specificity were 25% and 97% for ABI ≤0.9, 41% and 95% for alternative ABI ≤0.9, and 45% and 93% for TBI ≤0.7, respectively. AUC (95% CI) of PAD risk classification score was 0.86 (0.78 to 0.94) with sensitivity and specificity of 95% and 60% for risk score ≥0.10, 76% and 76% for risk score ≥0.25, and 43% and 95% for risk score ≥0.55. Combining risk score with ABI, alternative ABI, and TBI increased AUC (95% CI) to 0.89 (0.82 to 0.96), 0.89 (0.80 to 0.98), and 0.87 (0.78 to 0.96), respectively. In conclusion, current ABI and TBI diagnostic criteria have high specificity but low sensitivity for classifying PAD in patients with CKD. PAD classification risk score based on cardiovascular disease risk factors improves the accuracy of PAD classification.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 24 Sep 2021; epub ahead of print
Chen J, He H, Starcke CC, Guo Y, ... Hamm LL, He J
Am J Cardiol: 24 Sep 2021; epub ahead of print | PMID: 34583809
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Abstract

Prevention and Treatment of Atrial Fibrillation via Risk Factor Modification.

O\'Keefe EL, Sturgess JE, O\'Keefe JH, Gupta S, Lavie CJ
Atrial fibrillation (AF) is the most common clinically significant arrhythmia, and it increases stroke risk. A preventive approach to AF is needed because virtually all treatments such as cardioversion, antiarrhythmic drugs, ablation, and anticoagulation are associated with high cost and carry significant risk. A systematic review was performed to identify effective lifestyle-based strategies for reducing primary and secondary AF. A PubMed search was performed using articles up to March 1, 2021. Search terms included atrial fibrillation, atrial flutter, exercise, diet, metabolic syndrome, type 2 diabetes mellitus, obesity, hypertension, stress, tobacco smoking, alcohol, Mediterranean diet, sodium, and omega-3 fatty acids. Additional articles were identified from the bibliographies of retrieved articles. The control of hypertension, ideally with a renin-angiotensin-aldosterone system inhibitor, is effective for preventing primary AF and recurrence. Obstructive sleep apnea is a common cause of AF, and treating it effectively reduces AF episodes. Alcohol increases the risk of AF in a dose-dependent manner, and abstinence reduces risk of recurrence. Sedentary behavior and chronic high-intensity endurance exercise are both risk factors for AF; however, moderate physical activity is associated with lower risk of AF. Recently, sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 agonists have been associated with reduced risk of AF. Among overweight/obese patients, weight loss of ≥10% is associated with reduced AF risk. Lifestyle changes and risk factor modification are highly effective for preventing AF.

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

Am J Cardiol: 24 Sep 2021; epub ahead of print
O'Keefe EL, Sturgess JE, O'Keefe JH, Gupta S, Lavie CJ
Am J Cardiol: 24 Sep 2021; epub ahead of print | PMID: 34583808
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Abstract

Risk of Myocardial Infarction and Death After Noncardiac Surgery Performed Within the First Year After Coronary Drug-Eluting Stent Implantation for Acute Coronary Syndrome or Stable Angina Pectoris.

Thim T, Egholm G, Kristensen SD, Olesen KKW, ... Bøtker HE, Maeng M
This study aimed to examine the 30-day risk of myocardial infarction (MI) and death in patients who underwent noncardiac surgery within 1 year after coronary drug-eluting stent implantation for acute coronary syndrome (ACS) or stable angina pectoris (SAP) and to compare it with the risk in surgical patients without known coronary artery disease. Patients with drug-eluting stent implantation for ACS (n = 2,291) or SAP (n = 1,804) who underwent noncardiac surgery were compared with a cohort from the general population without known coronary artery disease matched on the surgical procedure, hospital contact type, gender, and age. In patients with ACS, the 30-day MI risk was markedly increased when surgery was performed within 1 month after stenting (10% vs 0.8%; adjusted odds ratio [ORadj] 20.1, 95% confidence interval [CI] 8.85 to 45.6), whereas mortality was comparable (10% vs 8%, ORadj 1.17, 95% CI 0.76 to 1.79). When surgery was performed between 1 and 12 months after stenting, the 30-day absolute risk for MI was low but higher than in the comparison cohort (0.6% vs 0.2%, ORadj 2.18, 95% CI 0.89 to 5.38), whereas the mortality risks were similar (2.0% vs 1.8%, ORadj 1.03, 95% CI 0.69 to 1.55). In patients with SAP, the 30-day MI risk was low but higher than in the comparison cohort (0.4% vs 0.2%, ORadj 1.90, 95% CI 0.70 to 5.14), whereas the mortality risks were similar (2.2% vs 2.1%, ORadj 0.91, 95% CI 0.61 to 1.37). In conclusion, patients with ACS and SAP who underwent surgery between 1 and 12 months after stent implantation had a risk for MI and death that was similar to the risk observed in surgical patients without coronary artery disease.

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

Am J Cardiol: 24 Sep 2021; epub ahead of print
Thim T, Egholm G, Kristensen SD, Olesen KKW, ... Bøtker HE, Maeng M
Am J Cardiol: 24 Sep 2021; epub ahead of print | PMID: 34583812
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Abstract

Comparison of Circadian Variation for In-Hospital Versus Out-of-Hospital Sudden Cardiac Arrest Survivors.

Tang Y, Tertulien T, Bhonsale A, Kancharla K, ... Jain SK, Saba S
Several studies have reported circadian periodicity of sudden cardiac arrest (SCA). It remains unclear to what extent this circadian rhythm is influenced by variation in patients\' activities. One way to elucidate this is to compare patients with out-of-hospital cardiac arrests (OHCAs) with those with in-hospital cardiac arrests (IHCAs). We therefore examined the presence of a circadian pattern of SCA in a large cohort of OHCA and IHCA survivors. A total of 1,433 consecutive survivors of SCA in the Pittsburgh area from 2002 to 2012 were included. Patient demographics, including clinical histories and details of SCA, were collected. The distribution of SCA throughout the day was tested for differences using the chi-square test. Of the 1,224 patients analyzed, 706 had IHCA and 518 OHCA. We observed a nadir of SCA in the nighttime hours between 12 a.m. and 6 a.m. in both IHCA and OHCA groups (p <0.001), although this pattern was more blunted in the IHCA group. Patients who had an SCA in the nighttime window had more co-morbidities (p = 0.01). The circadian pattern was noted to be absent in patients with higher co-morbidity burden in IHCA only. In conclusion, the typical pattern of nighttime nadir in SCA is observed in patients with both OHCA and IHCA but is blunted in the hospital and especially in sicker patients. This suggests a common mechanistic pathway of SCA transcending differences in physical activities of patients and a difference in how co-morbidities interact with the timing of SCA in the inpatient setting.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 24 Sep 2021; epub ahead of print
Tang Y, Tertulien T, Bhonsale A, Kancharla K, ... Jain SK, Saba S
Am J Cardiol: 24 Sep 2021; epub ahead of print | PMID: 34583813
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Abstract

Alcohol Consumption and Systemic Hypertension (from the Third National Health and Nutrition Examination Survey).

Aladin AI, Chevli PA, Ahmad MI, Rasool SH, Herrington DM
Epidemiological studies have established the association between excessive alcohol consumption and systemic hypertension (SH). However, there are conflicting reports of the association of low to moderate alcohol consumption with SH. The objective of the study was to examine the associations of alcohol consumption and blood pressure categories using the 2017 American College of Cardiology/American Heart Association high blood pressure guidelines. This analysis included 17,059 participants from the Third National Health and Nutrition Examination Survey. Alcohol consumption was ascertained by way of a questionnaire. Blood pressure (mm Hg) was measured during the in-home interview and the participant\'s visit to the mobile examination center. We used multivariable logistic regression models to examine cross-sectional associations of alcohol consumption and blood pressure categories based on new American College of Cardiology/American Heart Association High Blood Pressure guidelines. Models were adjusted for age, gender, income, and cardiovascular risk factors. Compared with never drinkers, moderate drinkers (7 to 13 drinks/week) had increased odds of prevalent stage 1 and stage 2 SH (odds ratio [95% confidence interval] 1.51 [1.22 to 1.87] and 1.55 [1.20 to 2.00]). Similarly, there were significantly higher odds of prevalent stage 1 and stage 2 SH among heavy drinkers (≥14 drinks/week) (odds ratio [95% confidence interval] 1.65 [1.33 to 2.05] and 2.46 [1.93 to 3.14]). We did not find any association between alcohol consumption and elevated blood pressure category. Response bias must be considered because alcohol consumption was self-reported. Our study indicates the need for further research to understand the potential mechanisms by which alcohol consumption increases the risk of SH. In conclusion, this analysis from a population-based survey showed an association between moderate and heavy alcohol consumption and a higher prevalence of SH.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 17 Sep 2021; epub ahead of print
Aladin AI, Chevli PA, Ahmad MI, Rasool SH, Herrington DM
Am J Cardiol: 17 Sep 2021; epub ahead of print | PMID: 34548145
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Abstract

Comparison of Echocardiographic Variables in Patients With Severe Aortic Stenosis and Preserved Ejection Fraction Grouped by Flow and Gradient.

Berbarie RF, Joshi SS, Garvin R, Yu X, Sharifeh TA, Ahmad M
The pathophysiology of severe aortic stenosis (AS) is complex with vascular, valvular, and myocardial components. To better define this process, we compared echocardiographic and clinical variables in patients with severe AS and preserved EF according to flow and gradient. We retrospectively studied the clinical and echocardiographic data of 287 patients (mean age 76 ± 11 years, 57% men) from 2012 to 2017 with severe AS (indexed aortic valve area <0.6 cm2/m2) and preserved ejection fraction (>50%). Patients were divided into 4 groups based on flow (stroke volume index < or ≥35 ml/m2) and mean aortic pressure gradient (< or ≥40 mm Hg): normal flow, high gradient (NFHG), normal flow, low gradient (NFLG), low flow, high gradient (LFHG) and low flow, low gradient (LFLG). Among patients with severe AS, 23% had NFHG, 44% had NFLG, 10% had LFHG, and 23% had LFLG. Only diabetes was marginally significantly different among the clinical variables. Aortic valve area index was largest in NFLG and smallest in LFHG (p < 0.001 for pairwise comparisons). Valvuloarterial impedance was highest in LFHG (p < 0.01 for pairwise comparisons). Systemic arterial compliance was lower and systemic vascular resistance was higher in low flow compared with normal flow groups. In conclusion, LFHG had the smallest valve area index along with markers of increased vascular resistance combined with high gradients, which suggests a unique pathophysiology in this group of severe AS patients with preserved EF.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 17 Sep 2021; epub ahead of print
Berbarie RF, Joshi SS, Garvin R, Yu X, Sharifeh TA, Ahmad M
Am J Cardiol: 17 Sep 2021; epub ahead of print | PMID: 34548144
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Abstract

Impact of Frailty and Mitral Valve Surgery on Outcomes of Severe Mitral Stenosis Due to Mitral Annular Calcification.

Saijo Y, Chan N, Vega Brizneda M, Lak HM, ... Griffin BP, Xu B
We sought to evaluate the outcomes of patients with severe mitral stenosis (MS) resulting from mitral annular calcification and assessed the prognostic impact of co-morbidities and frailty in guiding management. Among 6,915 patients with calcific MS who underwent echocardiography between January 2011 and March 2020, a total of 283 patients with severe calcific MS were retrospectively enrolled. We calculated the Charlson co-morbidity index (CCI). Frailty was scored from 0 to 3 points, with 1 point each assigned for reduced hemoglobin, reduced albumin, and inactivity. The primary end point was all-cause death. The mean age was 72 ± 11 years. The mean mitral valve (MV) area was 1.1 ± 0.4 cm2, and the mean transmitral gradient was 12 ± 4 mm Hg. Although 33% of the patients underwent MV intervention, 67% were conservatively managed. During a median follow-up of 360 days, 35% died. Patients who underwent MV intervention had an improved prognosis compared with those who were treated conservatively, even after propensity score matching. On multivariate Cox regression analysis, higher CCI (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.04 to 1.38, p = 0.011) and frailty score (HR 1.58, 95% CI 1.12 to 2.23, p = 0.01) were predictors of all-cause mortality, and MV intervention (HR 0.45, 95% CI 0.25 to 0.83, p = 0.011) and angiotensin converting enzyme inhibitor/angiotensin receptor blocker use (HR 0.39, 95% CI 0.20 to 0.79, p = 0.009) were associated with an improved prognosis. In conclusion, patients with severe calcific MS were often frail with multiple co-morbidities and were often managed conservatively. Higher CCI and worse frailty were associated with worse prognosis, regardless of the treatment strategy. MV intervention for select patients was associated with improved prognosis.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 15 Sep 2021; epub ahead of print
Saijo Y, Chan N, Vega Brizneda M, Lak HM, ... Griffin BP, Xu B
Am J Cardiol: 15 Sep 2021; epub ahead of print | PMID: 34538607
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Abstract

Impact of Mitral Annular Calcium and Mitral Stenosis on Outcomes After Transcatheter Aortic Valve Implantation.

Mesnier J, Urena M, Chong-Nguyen C, Fischer Q, ... Iung B, Himbert D
Mitral annular calcium (MAC) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI) and may be associated with mitral stenosis (MAC-MS). Their impact on post-TAVI outcomes remains controversial. We sought to assess the impact of MAC and MAC-MS on clinical outcomes following TAVI. We included 1,177 patients who consecutively underwent TAVI in our institution between January 2008 and May 2018. MAC diagnosis reposed on echocardiogram and computed tomography. The combination of MAC and a mean transmitral gradient ≥ 5 mmHg defined MAC-MS. The study included 1,177 patients, of whom 504 (42.8%) had MAC and 85 (7.2%) had MAC-MS. Patients with and without MAC had similar outcomes except for a higher rate of pacemaker implantation in MAC patients (adjusted HR: 1.32, 95% CI: 1.03-1.69, p = 0.03). The subgroup of patients with severe MAC had similar outcomes. However, MAC-MS was an independent predictor of all-cause mortality at 30 days (adjusted HR: 2.30, 95% CI: 1.08-4.86, p = 0.03) and 1 year (adjusted HR: 1.73, 95% CI: 1.04-2.89, p = 0.04). In conclusion, MAC is present in nearly half of the patients treated with TAVI but MAC-MS is far less frequent. In itself, even severe, MAC does not influence outcomes while MAC-MS is an independent predictor of all-cause 1-year mortality. Measurement of mean transmitral gradient identifies patients with MAC at high risk after TAVI.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Sep 2021; 155:103-112
Mesnier J, Urena M, Chong-Nguyen C, Fischer Q, ... Iung B, Himbert D
Am J Cardiol: 14 Sep 2021; 155:103-112 | PMID: 34284866
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Abstract

Usefulness of Adding Pre-procedural Glycemia to the Mehran Score to Enhance Its Ability to Predict Contrast-induced Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention Development and Validation of a Predictive Model.

Nusca A, Mangiacapra F, Sticchi A, Polizzi G, ... Ussia GP, Grigioni F
The Mehran score is the most widely accepted tool for predicting contrast-induced acute kidney injury (CI-AKI), a major complication of percutaneous coronary intervention (PCI). Similarly, abnormal fasting pre-procedural glycemia (FPG) represents a modifiable risk factor for CI-AKI, but it is not included in current risk models for CI-AKI prediction. We sought to analyze whether adding FPG to the Mehran score improves its ability to predict CI-AKI following PCI. We analyzed 671 consecutive patients undergoing PCI (age 69 [63,75] years, 23% females), regardless of their diabetic status, to derive a revised Mehran score obtained by including FPG in the original Mehran score (Derivation Cohort). The new risk model (GlyMehr) was externally validated in 673 consecutive patients (Validation Cohort) (age 69 [62,76] years, 21% females). In the Derivation Cohort, both FPG and the original Mehran score predicted CI-AKI (AUC 0.703 and 0.673, respectively). The GlyMehr score showed a better predictive ability when compared with the Mehran score both in the Derivation Cohort (AUC 0.749, 95%CI 0.662 to 0.836; p = 0.0016) and the Validation Cohort (AUC 0.848, 95%CI, 0.792 to 0.903; p = 0.0008). In the overall population (n = 1344), the GlyMehr score confirmed its independent and incremental predictive ability regardless of diabetic status (p ≤0.0034) or unstable/stable coronary syndromes (p ≤0.0272). In conclusion, adding FPG to the Mehran score significantly enhances our ability to predict CI-AKI. The GlyMehr score may contribute to improve the clinical management of patients undergoing PCI by identifying those at high risk of CI-AKI and potentially detecting modifiable risk factors.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Sep 2021; 155:16-22
Nusca A, Mangiacapra F, Sticchi A, Polizzi G, ... Ussia GP, Grigioni F
Am J Cardiol: 14 Sep 2021; 155:16-22 | PMID: 34284868
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Abstract

Relation of the Number of Cardiovascular Conditions and Short-term Symptom Improvement After Percutaneous Coronary Intervention for Stable Angina Pectoris.

Flynn CR, Orkaby AR, Valsdottir LR, Kramer DB, ... Yeh RW, Strom JB
With aging of the population, cardiovascular conditions (CC) are increasingly common in individuals undergoing PCI for stable angina pectoris (AP). It is unknown if the overall burden of CCs associates with diminished symptom improvement after PCI for stable AP. We prospectively administered validated surveys assessing AP, dyspnea, and depression to patients undergoing PCI for stable AP at our institution, 2016-2018. The association of CC burden and symptoms at 30-days post-PCI was assessed via linear mixed effects models. Included individuals (N = 121; mean age 68 ± 10 years; response rate = 42%) were similar to non-included individuals. At baseline, greater CC burden was associated with worse dyspnea, depression, and physical limitations due to AP, but not AP frequency or quality of life. PCI was associated with small improvements in AP and dyspnea (p ≤ 0.001 for both), but not depression (p = 0.15). After multivariable adjustment, including for baseline symptoms, CC burden was associated with a greater improvement in AP physical limitations (p = 0.01) and depression (p = 0.002), albeit small, but not other symptom domains (all p ≥ 0.05). In patients undergoing PCI for stable AP, increasing CC burden was associated with worse dyspnea, depression, and AP physical limitations at baseline. An increasing number of CCs was associated with greater improvements, though small, in AP physical limitations and depression. In conclusion, the overall number of cardiovascular conditions should not be used to exclude patients from PCI for stable AP on the basis of an expectation of less symptom improvement.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Sep 2021; 155:1-8
Flynn CR, Orkaby AR, Valsdottir LR, Kramer DB, ... Yeh RW, Strom JB
Am J Cardiol: 14 Sep 2021; 155:1-8 | PMID: 34281673
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Abstract

Impact of High Body Mass Index on Vascular and Bleeding Complications After Transcatheter Aortic Valve Implantation.

Berti S, Bartorelli AL, Koni E, Giordano A, ... Navarese EP, From the RISPEVA registry
Increased body mass index (BMI) is an established cardiovascular risk factor. The impact of high BMI on vascular and bleeding complications in patients undergoing transcatheter aortic valve implantation (TAVI) is not clarified. RISPEVA, a multicenter prospective database of patients undergoing TAVI stratified by BMI was used for this analysis. Patients were classified as normal or high BMI (obese and overweight) according to the World Health Organization criteria. A comparison of 30-day vascular and bleeding outcomes between groups was performed using propensity scores methods. A total of 3776 matched subjects for their baseline characteristics were included. Compared with normal BMI, high BMI patients had significantly 30-day greater risk of the composite of vascular or bleeding complications (11.1% vs 8.8%, OR: 1.28, 95% CI [1.02 to 1.61]; p = 0.03). Complications rates were higher in both obese (11.3%) and overweight (10.5%), as compared with normal weight patients (8.8%). By a landmark event analysis, the effect of high versus normal BMI on these complications appeared more pronounced within 7 days after the TAVI procedure. A significant linear association between increased BMI and vascular complications was observed at this time frame (p = 0.03). In conclusion, compared with normal BMI, both obese and overweight patients undergoing TAVI, experience increased rates of 30-day vascular and bleeding complications. These findings indicate that high BMI is an independent risk predictor of vascular and bleeding complications after TAVI.

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

Am J Cardiol: 14 Sep 2021; 155:86-95
Berti S, Bartorelli AL, Koni E, Giordano A, ... Navarese EP, From the RISPEVA registry
Am J Cardiol: 14 Sep 2021; 155:86-95 | PMID: 34284861
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Abstract

Sex-Based Disparities in Outcomes With Abdominal Aortic Aneurysms.

Sciria CT, Osorio B, Wang J, Lu DY, ... Wong SC, Kim LK
Although abdominal aortic aneurysms (AAA) are more common in men, women with AAA have increased morbidity and mortality. Additionally, there are discrepancies among professional society guidelines for AAA screening in women. In this retrospective study from the Nationwide Inpatient Sample (NIS) database from 2003 to 2014, we compared rates of AAA repair (rupture and elective) and AAA-related mortality in men vs. women to identify predictors of death among men and women with AAA. We divided the population into 1) AAA rupture 2) elective AAA repair. The main outcomes included temporal trends in AAA rupture, rupture-related death, AAA repair, in-hospital death, and predictors of AAA-related death. There were 570,253 discharge records for AAA admissions between 2003 and 2014, including 22.8% women and 77.2% men. Women had a higher proportion of rupture (18.4% vs 12.6%, p <0.01). A smaller proportion of women underwent endovascular aortic repair (EVAR) compared with men in the ruptured AAA (13.9% vs. 20.3%, p <0.01) and elective repair (55.7% vs. 67.4%, p <0.01) cohorts. Within the ruptured cohort, a higher proportion of women did not receive repair (46.4% vs. 26.1%, p <0.01). On multivariable analysis, female gender was a significant predictor of death with rupture (OR 1.39, 95% CI 1.16 to 1.66) and elective repair (OR 1.74, 95% CI 1.36 to 2.22), with both elective EVAR (OR 2.52, 95% CI 2.06 to 3.09) and elective open aortic repair (OAR; OR 1.50, 95% CI 1.33 to 1.68). Propensity score matching confirmed a higher risk of death in women in both the rupture (OR 1.19, 95% CI 1.09 to 1.30) and elective repair (OR 1.50, 95% CI 1.35 to 1.67) cohorts. In conclusion, AAA poses significant morbidity and mortality, especially in women. Women were more likely to die before repair with AAA rupture and female gender was an independent predictor of mortality in both the rupture and elective repair groups.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Sep 2021; 155:135-148
Sciria CT, Osorio B, Wang J, Lu DY, ... Wong SC, Kim LK
Am J Cardiol: 14 Sep 2021; 155:135-148 | PMID: 34294407
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Abstract

Percutaneous Coronary Intervention in Patients With a History of Gastrointestinal Bleeding (From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium).

Meloche C, Seth M, Madder RD, Kurlander JE, ... Gurm HS, Sukul D
Potent antithrombotic agents are routinely prescribed after percutaneous coronary intervention (PCI) to reduce ischemic complications. However, in patients who are at an increased bleeding risk, this may pose significant risks. We sought to evaluate the association between a history of gastrointestinal bleeding (GIB) and outcomes after PCI. We linked clinical registry data from PCIs performed at 48 Michigan hospitals between 1/2013 and 3/2018 to Medicare claims. We used 1:5 propensity score matching to adjust for patient characteristics. In-hospital outcomes included bleeding, transfusion, stroke or death. Post-discharge outcomes included 90-day all-cause readmission and long-term mortality. Of 30,206 patients, 1.1% had a history of GIB. Patients with a history of GIB were more likely to be older, female, and have more cardiovascular comorbidities. After matching, those with a history of GIB (n = 312) had increased post-procedural transfusions (15.7% vs 8.4%; p < 0.001), bleeding (11.9% vs 5.2%; p < 0.001), and major bleeding (2.8% vs 0.6%; p = 0.004). Ninety-day readmission rates were similar among those with and without a history of GIB (34.3% vs 31.3%; p = 0.318). There was no significant difference in post-discharge survival (1 year: 78% vs 80%; p = 0.217; 5 years: 54% vs 51%; p = 0.189). In conclusion, after adjusting for baseline characteristics, patients with a history of GIB had increased risk of post-PCI in-hospital bleeding complications. However, a history of GIB was not significantly associated with 90-day readmission or long-term survival.

Published by Elsevier Inc.

Am J Cardiol: 14 Sep 2021; 155:9-15
Meloche C, Seth M, Madder RD, Kurlander JE, ... Gurm HS, Sukul D
Am J Cardiol: 14 Sep 2021; 155:9-15 | PMID: 34325106
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Abstract

Serial Baseline, 12-, 24-, and 60-Month Optical Coherence Tomography Evaluation of ST Segment Elevation Myocardial Infarction Patients Treated with Absorb Bioresorbable Vascular Scaffold.

Koltowski L, Tomaniak M, Ochijewicz D, Zieliński K, ... Opolski G, Kochman J
Data on long-term neointimal healing and neoatherosclerosis progression after primary percutaneous coronary intervention (PCI) with implantation of everolimus-eluting bioresorbable vascular scaffold (BVS) (ABSORB BVS 1.0, Abbott Vascular) are limited. The mechanisms underlying very late scaffold failure remain to be further elucidated. This study sought to assess healing pattern and presence of neoatherosclerosis. This was a single-center, prospective, longitudinal study with serial optical coherence tomography (OCT) assessment at baseline, 12, 24 and 60 months after PCI performed in 12 patients presenting with ST-segment elevation myocardial infarction (STEMI). The median follow-up was 59 months. The diameter stenosis increased from 7.11 ± 4.99% at 1-year to 21.00 ± 11.31% at 5 years, (p = 0.03), whereas minimum lumen diameter remained stable throughout the follow-up period, as assessed by angiography. Minimum and mean lumen area declined over the 5-year follow-up by 1.00 ± 1.57 mm2 and 1.75 ± 0.87 mm2, respectively; a significant decrease in minimum and mean lumen area in the first two years, was followed by stable luminal dimensions between 2 and 5 years of follow-up. The lumen eccentricity (0.85 ± 0.03) and asymmetry (0.43 ± 0.10) indexes showed no change over 60-month follow-up. The incidence of atherosclerosis was high both in the in-scaffold (IS) and out-scaffold (OS) regions consisting of calcifications (IS = 100%, OS = 92%, p = 0.99), macrophages (IS = 92% and OS = 67%, p = 0.31), neovascularization (IS = 75%, OS = 50%, p = 0.40). In conclusion, serial OCT imaging up to 5 years after implantation of BVS in STEMI indicated complete scaffold resorption, stable lumen area following period of neointima growth in the first two years after PCI and high incidence of neoatherosclerosis.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Sep 2021; 155:23-31
Koltowski L, Tomaniak M, Ochijewicz D, Zieliński K, ... Opolski G, Kochman J
Am J Cardiol: 14 Sep 2021; 155:23-31 | PMID: 34315572
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Abstract

In-Hospital Mortality for Inpatient Percutaneous Coronary Interventions in the United States.

Chang KY, Chiu N, Aggarwal R
Cardiovascular mortality is substantially higher in rural communities compared with urban communities. Understanding if disparities in inpatient percutaneous coronary intervention (PCI) persist in the United States will help inform initiatives to improve cardiovascular health. Of the more than 7 million hospitalizations in the National Inpatient Sample (2016), we identified 80,793 unweighted hospitalizations for PCI using ICD-10 procedure codes. Using survey weights, these hospitalizations projected 371,040 US admissions for inpatient PCI. For the primary analysis, we determined the association between hospital urban-rural designation and in-hospital mortality after inpatient PCI. In the secondary analysis, we evaluated the association between teaching status and this outcome. Multivariable logistic regression models, adjusted for multiple risk factors and patient characteristics, were used. Of the 371,430 hospitalizations for inpatient PCI, there were 108.9 (±2.2) admissions per 100,000 US population from urban hospitals and 152.9 (±6.3) from rural hospitals. Of the urban hospitals, there were 77.7 (±1.9) admissions per 100,000 US population at teaching hospitals (71.7%) and 30.7 (±1.0) at urban nonteaching hospitals (28.3%). In-hospital mortality did not differ between urban and rural hospitals (1.8% urban vs 1.9% rural, adjusted odds ratio for rural compared with urban: 1.15 [95% confidence interval 0.98, 1.34], p = 0.08). In urban hospitals, however, in-hospital mortality was higher in nonteaching hospitals than in teaching hospitals (2.0% nonteaching vs 1.7% teaching, adjusted odds ratio for teaching compared with nonteaching: 1.17 [95% confidence interval 1.01, 1.36], p = 0.04). In conclusion, in-hospital mortality rates after inpatient PCI were similar between urban and rural hospitals in the United States. However, among urban hospitals, nonteaching hospitals had higher rates of in-hospital mortality after PCI. In conclusion, solutions to address disparities for inpatient PCI outcomes between teaching and nonteaching hospitals are needed.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 05 Sep 2021; epub ahead of print
Chang KY, Chiu N, Aggarwal R
Am J Cardiol: 05 Sep 2021; epub ahead of print | PMID: 34503823
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Abstract

Comparison of Diagnostic Performance of Fractional Flow Reserve Derived from Coronary Computed Tomographic Angiography Versus Single-Photon Emission Computed Tomographic Myocardial Perfusion Imaging.

Okonogi T, Kawasaki T, Koga H, Orita Y, ... Yamabe H, Koga N
Fraction flow reserve (FFR) derived from computed tomography (FFRCT) has been proposed to be an effective gatekeeper for invasive angiographic referral. The purpose of the present study is to examine the real-world diagnostic performance of FFRCT and myocardial perfusion imaging as well as to assess the utility of FFRCT as a gatekeeper for invasive coronary angiography in patients suspected of having obstructive coronary artery disease. Total of 146 consecutive patients underwent both single-photon emission computed tomography (SPECT) and invasive FFR were evaluated. An FFRCT value 1 to 2 cm distal to a stenosis ≤0.80 was defined as positive for ischemia and a summed stress score ≥2 or transient ischemic dilatation ≥1.2 were positive for ischemia with the invasive FFR value of <0.80 serving as the gold standard. The patient-based sensitivity of FFRCT was significantly higher than SPECT (91 vs 52%, p <0.001) and exhibited similar positive predictive value (82 vs 82%, p = 0.91). These trends were observed even in patients with multivessel and left main trunk disease and those with severe coronary calcification. In conclusion, our data suggest that FFRCT has higher diagnostic performance characteristics than SPECT and details the superior FFRCT analysis in detecting patients with hemodynamically significant coronary artery disease. Our results support the clinical utility of FFRCT analysis as a gatekeeper for invasive coronary angiography in clinical practice.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 05 Sep 2021; epub ahead of print
Okonogi T, Kawasaki T, Koga H, Orita Y, ... Yamabe H, Koga N
Am J Cardiol: 05 Sep 2021; epub ahead of print | PMID: 34503820
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Abstract

Comparison of Outcomes in Patients With COVID-19 and Thrombosis Versus Those Without Thrombosis.

Case BC, Abramowitz J, Shea C, Rappaport H, ... Weintraub WS, Waksman R
The occurrence of venous thromboembolisms in patients with COVID-19 has been established. We sought to evaluate the clinical impact of thrombosis in patients with COVID-19 over the span of the pandemic to date. We analyzed patients with COVID-19 with a diagnosis of thrombosis who presented to the MedStar Health system (11 hospitals in Washington, District of Columbia, and Maryland) during the pandemic (March 1, 2020, to March 31, 2021). We compared the clinical course and outcomes based on the presence or absence of thrombosis and then, specifically, the presence of cardiac thrombosis. The cohort included 11,537 patients who were admitted for COVID-19. Of these patients, 1,248 had noncardiac thrombotic events and 1,009 had cardiac thrombosis (myocardial infarction) during their hospital admission. Of the noncardiac thrombotic events, 562 (45.0%) were pulmonary embolisms, 480 (38.5%) were deep venous thromboembolisms, and 347 (27.8%) were strokes. In the thrombosis arm, the mean age of the cohort was 64.5 ± 15.3 years, 53.3% were men, and the majority were African-American (64.9%). Patients with thrombosis tended to be older with more co-morbidities. The in-hospital mortality rate was significantly higher (16.0%) in patients with COVID-19 with concomitant non-cardiac thrombosis than in those without thrombosis (7.9%, p <0.001) but lower than in patients with COVID-19 with cardiac thrombosis (24.7%, p <0.001). In conclusion, patients with COVID-19 with thrombosis, especially cardiac thrombosis, are at higher risk for in-hospital mortality. However, this prognosis is not as grim as for patients with COVID-19 and cardiac thrombosis. Efforts should be focused on early recognition, evaluation, and intensifying antithrombotic management for these patients.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 27 Aug 2021; epub ahead of print
Case BC, Abramowitz J, Shea C, Rappaport H, ... Weintraub WS, Waksman R
Am J Cardiol: 27 Aug 2021; epub ahead of print | PMID: 34607645
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This program is still in alpha version.