Comparison of Incidence and Outcomes of Cardiogenic Shock Complicating Posterior (Inferior) Versus Anterior ST-Elevation Myocardial Infarction

Cardiogenic shock (CS) is a catastrophic consequence of ST-elevation myocardial infarction (STEMI). CS has been reported to be associated less often with inferior wall (IWMI) than anterior wall STEMI (AWMI). We queried the National Inpatient Sample databases from January 2010 to September 2015 to identify all patients aged ≥18 years admitted with AWMI or IWMI. Patients with a concomitant diagnosis of CS were then identified. Complex samples multivariable logistic regression models were used to compare the incidence, management, and in-hospital mortality of CS complicating IWMI versus AWMI. The incidence of CS was lower in IWMI (9.5%) versus AWMI (14.1%), adjusted OR (aOR) 0.84 (95% confidence interval [CI] 0.81 to 0.87). Revascularization rates with either percutaneous coronary intervention or coronary artery bypass grafting were similar in CS complicating IWMI versus AWMI (80.9% vs 80.3%; aOR 1.05; 95% CI 0.97 to 1.14). The reported use of percutaneous mechanical circulatory support devices was lower in patients with CS-IWMI versus CS-AWMI (44.7% vs 61.0%; aOR 0.55; 95% CI 0.52 to 0.59). In-hospital mortality was modestly lower in patients with CS complicating IWMI versus AWMI (30.3% vs 31.9%; aOR, 0.80; 95% CI 0.75 to 0.86). Use of percutaneous mechanical circulatory support was not associated with lower in-hospital mortality in either CS-AWMI (30.0% vs 34.7; aOR 1.04; 95% CI 0.94 to 1.14) or CS-IWMI (31.0% vs 29.8%; aOR 1.20; 95% CI 1.08 to 1.33). In conclusion, the incidence of CS in the contemporary era is lower in patients with IWMI compared with those with AWMI. CS complicating STEMI is associated with higher in-hospital mortality in AWMI versus IWMI, and outcomes were not different with or without percutaneous circulatory support.

The Prognostic Role of Late Gadolinium Enhancement in Aortic Stenosis: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review was to explore the prognostic value of late gadolinium enhancement (LGE) in patients with aortic stenosis (AS).

BACKGROUND

Myocardial fibrosis is a common feature of many cardiac diseases. Cardiac magnetic resonance (CMR) has the ability to noninvasively detect regional fibrosis by using the LGE technique. Several studies have explored whether LGE is associated with adverse outcome in patients with AS.

METHODS

Electronic databases were searched to identify studies investigating the ability of LGE to predict all-cause mortality in patients with AS. A random effects model meta-analysis was conducted. Heterogeneity was assessed with the I2 statistic.

RESULTS

Six studies comprising 1,151 patients met our inclusion criteria. LGE was present in 49.1% of patients with AS. In the pooled analysis, LGE was found to be a strong univariate predictor of all-cause mortality (pooled unadjusted odds ratio: 2.56; 95% confidence interval: 1.83 to 3.57; I2 = 0%). Four of the included studies reported adjusted hazard ratios for mortality. LGE was independently associated with mortality, even after adjusting for baseline characteristics (pooled adjusted hazard ratio: 2.50; 95% confidence interval: 1.64 to 3.83; I2 = 0%).

CONCLUSIONS

Fibrosis on LGE-CMR is a powerful predictor of all-cause mortality in patients with AS and may serve as a novel marker for risk stratification. Future studies should explore whether LGE-CMR can also be used to optimize timing of AS-related interventions.

Meta-Analysis of Transthoracic Echocardiography Versus Cardiac Magnetic Resonance for the Assessment of Aortic Regurgitation After Transcatheter Aortic Valve Implantation

Residual aortic regurgitation (AR) is a major complication after transcatheter aortic valve implantation (TAVI). Although the echocardiographic assessment of post-TAVI AR remains challenging, cardiac magnetic resonance (CMR) allows direct quantification of AR. The aim of this study was to review the level of agreement between 2-dimensional transthoracic echocardiography (2D TTE) and CMR on grading the severity of AR after TAVI, and determine the accuracy of TTE in detecting moderate or severe AR. Electronic databases were searched in order to identify studies comparing 2D TTE to CMR for post-TAVI AR assessment. Kappa coefficient was used to determine the level of agreement between the 2 imaging modalities. CMR was used as the reference standard in order to assess the diagnostic accuracy of 2D TTE. Seven studies were included in this systematic review. Six studies reported a low correlation between 2D TTE and CMR (kappa coefficient ranging from -0.02 to 0.41), whereas one study showed good agreement with a kappa coefficient of 0.72. Given the heterogeneity in the included studies the diagnostic accuracy of TTE was evaluated by estimating the hierarchical summary receiver operator characteristic curve. The area under the curve for detection of moderate or severe AR with TTE was 0.83 (95% confidence interval 0.79 to 0.86). In conclusion, despite the reported significant disconcordance between TTE and CMR grading of AR, TTE has sufficient ability to discriminate moderate or severe AR from mild or none AR after TAVI in the clinical setting. CMR should be considered when TTE results are equivocal.

Therapeutic management of hyperlipoproteinemia (a)

Cardiovascular disease (CVD) has consistently been the leading cause of death worldwide. Several clinical and epidemiological studies have demonstrated that an elevated plasma concentration of lipoprotein (a) [Lp(a)] is a causative and independent major risk factor for the development of CVD, as well as calcific aortic valve stenosis. Thus, the therapeutic management of hyperlipoproteinemia (a) has received much attention, as significant reductions in Lp(a) levels may, potentially, favorably affect cardiovascular risk. Aspirin, niacin, estrogens, and statins, which act on different molecular pathways, may be prescribed to patients with mild or modest elevations of Lp(a) levels. Other therapeutic interventions, such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, Lp(a) apheresis, and the novel antisense oligonucleotides APO(a)-Rx and APO(a)-LRx, which are being evaluated in ongoing clinical trials, have provided some promising results and can potentially be used in severe cases of hyperlipoproteinemia (a). This review aims to present and discuss the current clinical and scientific data pertaining to the therapeutic options for the management of hyperlipoproteinemia (a).

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Coronary Artery Bypass Grafting: Trends in Utilization and Propensity-Matched Analysis of In-Hospital Outcomes

BACKGROUND

A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited.

METHODS AND RESULTS

We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 (P_trend<0.001). There were 3880 records in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% versus 2.4%; P=0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; P<0.001), stroke (1.4% versus 2.7%; P<0.001), bleeding complications (10.6% versus 24.6%; P<0.001), and acute kidney injury (16.2% versus 19.3%; P<0.001). Requirement for prior permanent pacemaker was higher in the TAVR cohort, whereas the incidence of vascular complications and acute kidney injury requiring dialysis was similar in the 2 groups. Average length of stay was shorter in patients undergoing TAVR.

CONCLUSIONS

TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients.

Contemporary Sex-Based Differences by Age in Presenting Characteristics, Use of an Early Invasive Strategy, and Inhospital Mortality in Patients With Non-ST-Segment-Elevation Myocardial Infarction in the United States

BACKGROUND

Prior studies have reported higher inhospital mortality in women versus men with non-ST-segment-elevation myocardial infarction. Whether this is because of worse baseline risk profile compared with men or sex-based disparities in treatment is not completely understood.

METHODS AND RESULTS

We queried the 2003 to 2014 National Inpatient Sample databases to identify all hospitalizations in patients aged ≥18 years with the principal diagnosis of non-ST-segment-elevation myocardial infarction. Complex samples multivariable logistic regression models were used to examine sex differences in use of an early invasive strategy and inhospital mortality. Of 4 765 739 patients with non-ST-segment-elevation myocardial infarction, 2 026 285 (42.5%) were women. Women were on average 6 years older than men and had a higher comorbidity burden. Women were less likely to be treated with an early invasive strategy (29.4% versus 39.2%; adjusted odds ratio, 0.92; 95% confidence interval, 0.91-0.94). Women had higher crude inhospital mortality than men (4.7% versus 3.9%; unadjusted odds ratio, 1.22; 95% confidence interval, 1.20-1.25). After adjustment for age (adjusted odds ratio, 0.96; 95% confidence interval, 0.94-0.98) and additionally for comorbidities, other demographics, and hospital characteristics, women had 10% lower odds of inhospital mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.89-0.92). Further adjustment for differences in the use of an early invasive strategy did not change the association between female sex and lower risk-adjusted inhospital mortality.

CONCLUSIONS

Although women were less likely to be treated with an early invasive strategy compared with men, the lower use of an early invasive strategy was not responsible for the higher crude inhospital mortality in women, which could be entirely explained by older age and higher comorbidity burden.

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

OBJECTIVE

To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients.

DESIGN

Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies.

DATA SOURCES

Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups.

RESULTS

Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)).

CONCLUSIONS

In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42012002780.

Anti-inflammatory therapy for cardiovascular disease

Chronic subclinical inflammation is a central process in the pathogenesis of cardiovascular disease (CVD) and it has been linked with both the initiation and progression of atherosclerosis. Several pro-inflammatory cytokines, such as the C-reactive protein (CRP), tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) have been described as independent risk factors for coronary heart disease and promoters of atherogenesis. Thus, extensive research is being conducted to assess the role of anti-inflammatory therapy in the primary and secondary prevention of CVD. Our review aims to provide the clinical and scientific data pertaining to the effects of different anti-inflammatory agents administered in patients with CVD.

Reduced global longitudinal strain is associated with increased risk of cardiovascular events or death after kidney transplant

BACKGROUND

Patients with chronic kidney disease are at increased risk of cardiovascular disease (CVD). Even after kidney transplant, the rate of CVD events and death remain elevated. Early detection of patients at risk would be helpful for guiding aggressive preventive therapy. The purpose of this study was to evaluate global longitudinal strain (GLS) as a predictor of CVD events and death after kidney transplant.

METHOD

Among patients with successful kidney transplant between 3/2009 and 12/2012 at our institution, 111 individuals had an echocardiogram within 6 months of the transplant. Medical records were evaluated for demographics and patient characteristics. Echocardiograms were analyzed for conventional measurements, and GLS was assessed using speckle-tracking analysis.

RESULTS

The median age of the study sample was 54 years. Overall, 60% were men; 35% were non-Hispanic black, and 50% Hispanic. After a mean follow-up of 3.8 ± 0.5 years, there were 21 cardiovascular events or deaths. Patients who experienced an event were older, more frequently had a history of coronary artery disease, and had higher LV filling/longitudinal diastolic annular velocity (E/e') than those who did not. GLS was significantly associated with event-free survival even after adjusting for age, sex, race-ethnicity, hypertension, diabetes, history of coronary artery disease or heart failure, and E/e'.

CONCLUSION

Reduced GLS peri-transplant is significantly associated with increased CVD events or death after kidney transplant. Larger studies are required to determine the incremental predictive value of GLS over clinical and other echocardiographic parameters for adverse CVD events following renal transplantation.

Three-dimensional echocardiography demonstrates a skewered left ventricular thrombus in a patient with a heart transplant

A left ventricular (LV) false tendon is a frequently visualized structure in echocardiography with unclear clinical significance. We present the case of a false tendon serving as a nidus for thrombus in a post-orthotopic heart transplantation patient. Three-dimensional transthoracic echocardiography (3DTTE) was utilized to visualize a LV mass and facilitate its identification as a thrombus as well as the surrounding structures. Using datasets from 3DTTE, the lack of ventricular wall attachment and circumferential formation of the thrombus around the false tendon was identified. Serial imaging demonstrated resolution of the thrombus with anticoagulation.

Starfish in the heart: Congenital anomaly of the papillary muscles

Most common congenital anatomical abnormalities of the subvalvular apparatus (papillary muscles and chordae tendineae) are parachute or parachute like mitral valve. This is more commonly reported among the pediatric population as they develop heart failure symptoms shortly after birth. Reports of adult cases are rare and incidental. Multimodality imaging has an important role in evaluating such anatomical abnormalities, and identification of possible related complications. We are describing a rare atypical variant of parachute like mitral valve.

Clinical outcomes in patients with atrial fibrillation receiving amiodarone on NOACs vs. warfarin

PURPOSE

Amiodarone is a potent inhibitor of the CYP450:3A4 and inhibitor of the P-glycoprotein, both of which metabolize new oral anticoagulants (NOACs). Patients who are on NOACs and are concomitantly treated with amiodarone may have a higher risk of major bleeding according to recent retrospective trials. Whether this increased risk outweighs the benefits of NOACs compared to warfarin is unknown. We aimed to compare clinical outcomes between NOACs and warfarin in patients with atrial fibrillation (AF) being treated with amiodarone.

METHODS

We performed a systematic review of MEDLINE, Cochrane, and Embase for randomized controlled trials that compared NOACs to warfarin for prophylaxis of ischemic stroke/thromboembolic events (TEs) in patients with AF and reported outcomes on TE, major bleeding, and intracranial bleeding (ICB). Risk ratio (RR) and 95% confidence intervals were measured using the Mantel-Haenszel method. Fixed effects model was used, and if heterogeneity (I2) was > 25%, effects were analyzed using a random model.

RESULTS

A total of four studies comparing NOACs to warfarin were included in the analysis. The total number of patients on amiodarone was 6197. Mean follow up was 23 ± 5 months. No statistically significant difference for TE prevention (RR, 0.73; 95% CI 0.50-1.07), major bleeding (RR, 1.02; 95% CI 0.68-1.53), or ICB outcomes (RR, 0.58; 95% CI 0.22-1.51) between patients on NOACs + amiodarone when compared to patients on warfarin + amiodarone.

CONCLUSION

Among patients with AF taking amiodarone, there is no increased risk of stroke, major bleeding, or ICB with NOACs compared to warfarin.

Case report and systematic review of pulmonary embolism mimicking ST-elevation myocardial infarction

Background

To study trends in the clinical presentation, electrocardiograms, and diagnostic imaging in patients with pulmonary embolism presenting as ST segment elevation.

Methods

We performed a systematic literature search for all reported cases of pulmonary embolism mimicking ST-elevation myocardial infarction. Pre-specified data such as clinical presentation, electrocardiogram changes, transthoracic echocardiographic findings, cardiac biomarkers, diagnostic imaging, therapy, and outcomes were collected.

Results

We identified a total of 34 case reports. There were 23 males. Mean age of the population was 56.5 ± 15.5 years. Patients presented with dyspnea (76.4%), chest pain (63.6%), and tachycardia (71.4%). All patients presented with ST-elevations, with the most common location being in the anterior-septal distribution, lead V3 (74%), V2 (71%), V1 (62%) and V4 (47%). ST-segment elevations in the inferior distribution were present in lead II (12%), III (18%), and aVF (21%). Presentation was least likely in the lateral distribution. Troponin was elevated in 78.9% of cases. Right ventricular strain was the most common echocardiographic finding. Over 80% of patients had findings consistent with elevated right ventricular pressure, with 50% reported RV dilatation and 20% RV hypokinesis. The most commonly used imaging modality was contrast-enhanced pulmonary angiography. There was a greater incidence of bilateral compared to unilateral pulmonary emboli (72.4% vs. 10%). About 65% patients received anticoagulation and 36.3% were treated with thrombolytics. Forty-six percent of patients required intensive care and 18.7% intubation. Overall mortality was 25.8%.

Conclusions

A review of the literature reveals that in patients presenting with pulmonary embolism, electrocardiogram findings of ST-segment elevations will occur predominantly in the anterior-septal distribution.

Pharmacogenetic association study on clopidogrel response in Puerto Rican Hispanics with cardiovascular disease: a novel characterization of a Caribbean population

Introduction

High on-treatment platelet reactivity (HTPR) to clopidogrel imparts an increased risk for ischemic events in adults with coronary artery disease. Platelet reactivity varies with ethnicity and is influenced by both clinical and genetic variables; however, no clopidogrel pharmacogenetic studies with Puerto Rican patients have been reported. Therefore, we sought to identify clinical and genetic determinants of on-treatment platelet reactivity in a cohort of Puerto Rican patients with cardiovascular disease.

Methods

We performed a retrospective study of 111 patients on 75 mg/day maintenance dose of clopidogrel. Patients were allocated into 2 groups: Group I, without HTPR; and Group II, with HTPR. Platelet function was measured ex vivo using the VerifyNow® P2Y12 assay and HTPR was defined as P2Y12 reaction units (PRU) ≥230. Genotyping testing was performed using Taqman^® Genotyping Assays.

Results

The mean PRU across the cohort was 203±61 PRU (range 8–324), and 42 (38%) patients had HTPR. Multiple logistic regression showed that 27% of the total variation in PRU was explained by a history of diabetes mellitus, hematocrit, CYP2C19*2, and PON1 p.Q192R. Body mass index (odds ratio [OR]=1.15; 95% CI: 1.03–1.27), diabetes mellitus (OR=3.46; 95% CI: 1.05–11.43), hematocrit (OR=0.75; 95% CI: 0.65–0.87), and CYP2C19*2 (OR=4.44; 95% CI: 1.21–16.20) were the only independent predictors of HTPR.

Conclusion

Moreover, we propose a predictive model to determine PRU values as measured by VerifyNow P2Y12 assay for the Puerto Rican Hispanic population. This model has the potential to identify Hispanic patients at higher risk for adverse events on clopidogrel.

Pharmacologic inhibition of the enzymatic effects of tissue transglutaminase reduces cardiac fibrosis and attenuates cardiomyocyte hypertrophy following pressure overload

Tissue transglutaminase (tTG) is a multifunctional protein with a wide range of enzymatic and non-enzymatic functions. We have recently demonstrated that tTG expression is upregulated in the pressure-overloaded myocardium and exerts fibrogenic actions promoting diastolic dysfunction, while preventing chamber dilation. Our current investigation dissects the in vivo and in vitro roles of the enzymatic effects of tTG on fibrotic remodeling in pressure-overloaded myocardium. Using a mouse model of transverse aortic constriction, we demonstrated perivascular and interstitial tTG activation in the remodeling pressure-overloaded heart. tTG inhibition through administration of the selective small molecule tTG inhibitor ERW1041E attenuated left ventricular diastolic dysfunction and reduced cardiomyocyte hypertrophy and interstitial fibrosis in the pressure-overloaded heart, without affecting chamber dimensions and ejection fraction. In vivo, tTG inhibition markedly reduced myocardial collagen mRNA and protein levels and attenuated transcription of fibrosis-associated genes. In contrast, addition of exogenous recombinant tTG to fibroblast-populated collagen pads had no significant effects on collagen transcription, and instead increased synthesis of matrix metalloproteinase (MMP)3 and tissue inhibitor of metalloproteinases (TIMP)1 through transamidase-independent actions. However, enzymatic effects of matrix-bound tTG increased the thickness of pericellular collagen in fibroblast-populated pads. tTG exerts distinct enzymatic and non-enzymatic functions in the remodeling pressure-overloaded heart. The enzymatic effects of tTG are fibrogenic and promote diastolic dysfunction, but do not directly modulate the pro-fibrotic transcriptional program of fibroblasts. Targeting transamidase-dependent actions of tTG may be a promising therapeutic strategy in patients with heart failure and fibrosis-associated diastolic dysfunction.

Effect of cilostazol on platelet reactivity among patients with peripheral artery disease on clopidogrel therapy

BACKGROUND

Antiplatelet therapy with clopidogrel is recommended to reduce cardiovascular events in patients with peripheral artery disease (PAD); however, clopidogrel efficacy has not been adequately studied in this patient population. Therefore, we aimed to determine the effects of cilostazol therapy on platelet reactivity among PAD patients on clopidogrel.

METHODS

We performed a cross-sectional pilot study of 46 Puerto Rican patients diagnosed with PAD. The cohort was divided based on use of clopidogrel and cilostazol (n=24) or clopidogrel alone (n=22). Platelet function was measured ex vivo using the VerifyNow P2Y12 assay. Genomic DNA was extracted from peripheral blood samples using the QIAamp DNA Blood Midi Kit, which was subjected to candidate variant genotyping (CYP2C19, ABCB1, PON1 and P2RY12) using TaqMan quantitative polymerase chain reaction assays. All analyses were performed using SAS version 9.4 (SAS Institute).

RESULTS

Among all enrolled patients, 18 (39%) had high on-treatment platelet reactivity (HTPR). The mean platelet reactivity was 207±53 (range, 78-325) with higher P2Y12 reaction units in the non-cilostazol group, 224±45 vs. 191±55 on the cilostazol group (p=0.03). No significant differences were observed in the clinical or genetic variables between the two groups. A multiple regression analysis determined that history of diabetes mellitus (p=0.03), use of cilostazol (p=0.03) and hematocrit (p=0.02) were independent predictors of platelet reactivity.

CONCLUSIONS

In Puerto Rican PAD patients on clopidogrel therapy, history of diabetes mellitus, use of cilostazol and hematocrit are independent predictors of platelet reactivity. Adjunctive cilostazol therapy may enhance clopidogrel efficacy among PAD patients with HTPR.

Relationship of Hospital Teaching Status with In-Hospital Outcomes for ST-Segment Elevation Myocardial Infarction

BACKGROUND

Prior analyses have largely shown a survival advantage with admission to a teaching hospital for acute myocardial infarction. However, most prior studies report data on patients hospitalized over a decade ago. It is important to re-examine the association of hospital teaching status with outcomes of acute myocardial infarction in the current era.

METHODS

We queried the 2010 to 2014 National Inpatient Sample databases to identify all patients aged ≥18 years hospitalized with the principal diagnosis of ST-segment elevation myocardial infarction (STEMI). Multivariable logistic regression models were constructed to compare rates of reperfusion and in-hospital outcomes between patients admitted to teaching vs nonteaching hospitals.

RESULTS

Of 546,252 patients with STEMI, 273,990 (50.1%) were admitted to teaching hospitals. Compared with patients admitted to nonteaching hospitals, those at teaching hospitals were more likely to receive reperfusion therapy during the hospitalization (86.7% vs 81.5%; adjusted odds ratio [OR] 1.41; 95% confidence interval [CI], 1.39-1.44; P < .001) and had lower risk-adjusted in-hospital mortality (4.9% vs 6.9%; adjusted OR 0.84; 95% CI, 0.82-0.86; P < .001). After further adjustment for differences in use of in-hospital reperfusion therapy, the association of teaching hospital status with lower risk-adjusted in-hospital mortality was significantly attenuated but remained statistically significant (adjusted OR 0.97; 95% CI, 0.94-0.99; P = .02).

CONCLUSIONS

Patients admitted to teaching hospitals are more likely to receive reperfusion and have lower risk-adjusted in-hospital mortality after STEMI compared with those admitted to nonteaching hospitals. Our results suggest that hospital performance for STEMI continues to be better at teaching hospitals in the contemporary era.

Regional Variation in Utilization, In-hospital Mortality, and Health-Care Resource Use of Transcatheter Aortic Valve Implantation in the United States

We queried the National Inpatient Sample database from 2012 to 2014 to identify all patients aged ≥18 years undergoing transcatheter aortic valve implantation (TAVI) in the United States. Regional differences in TAVI utilization, in-hospital mortality, and health-care resource use were analyzed. Of 41,025 TAVI procedures in the United States between 2012 and 2014, 10,390 were performed in the Northeast, 9,090 in the Midwest, 14,095 in the South, and 7,450 in the West. Overall, the number of TAVI implants per million adults increased from 24.8 in 2012 to 63.2 in 2014. The utilization of TAVI increased during the study period in all 4 geographic regions, with the number of implants per million adults being highest in the Northeast, followed by the Midwest, South, and West, respectively. Overall in-hospital mortality was 4.2%. Compared with the Northeast, risk-adjusted in-hospital mortality was higher in the Midwest (adjusted odds ratio [aOR] 1.26 [1.07 to 1.48]) and the South (aOR 1.61 [1.40 to 1.85]) and similar in the West (aOR 1.00 [0.84 to 1.18]). Average length of stay was shorter in all other regions compared with the Northeast. Among patients surviving to discharge, disposition to a skilled nursing facility or home health care was most common in the Northeast, whereas home discharge was most common in the West. Average hospital costs were highest in the West. In conclusion, we observed significant regional differences in TAVI utilization, in-hospital mortality, and health-care resource use in the United States. The findings of our study may have important policy implications and should provide an impetus to understand the source of this regional variation.

Circumferential strain acquired by CMR early after acute myocardial infarction adds incremental predictive value to late gadolinium enhancement imaging to predict late myocardial remodeling and subsequent risk of sudden cardiac death

PURPOSE

Late adverse myocardial remodeling after acute myocardial infarction (AMI) is strongly associated with sudden cardiac death (SCD). Cardiac magnetic resonance (CMR) performed early after AMI can predict late remodeling and SCD risk with moderate accuracy. This study assessed the ability of CMR-measured circumferential strain (CS) to add incremental predictive information to late gadolinium enhancement (LGE).

METHODS

Patients with an AMI and LVEF < 50% were screened for inclusion. A total of 27 patients, totaling 432 myocardial segments, prospectively underwent CMR 7 ± 5 days after percutaneous coronary intervention (PCI). LGE, microvascular obstruction (MVO), and myocardial CS were measured for each segment. The primary endpoint was late segmental adverse remodeling defined as segmental wall motion score (WMS) > 1 measured by echocardiography 3 months after PCI.

RESULTS

A total of 141 segments experienced the primary endpoint at 3 months. The mean LGE volume was higher in these segments, but LGE was also present in many segments with normal WMS (40 ± 28 versus 20 ± 26%, p < 0.01). Segments that met the primary endpoint also showed greater impairment of CS. Segments with both LGE > 17% and impaired CS >- 7.2% on CMR were more likely to experience late adverse remodeling (73%) as compared to segments with neither (9%, p < 0.001) or one abnormal parameter (36%, p < 0.001). CS >- 7.2% also added incremental accuracy to LGE > 17% for predicting late adverse remodeling (AUC 0.81 from 0.70, p < 0.001).

CONCLUSIONS

When performed early after AMI, LGE is a moderate predictor of late remodeling and CS is a powerful predictor of late myocardial remodeling. When combined, they can predict late remodeling, a surrogate of SCD, with high accuracy.

Association of Obesity With In-Hospital Mortality of Cardiogenic Shock Complicating Acute Myocardial Infarction

Several previous studies have shown obesity to be counterintuitively associated with more favorable mortality in patients with acute myocardial infarction (AMI); however, the association of obesity with in-hospital mortality of cardiogenic shock complicating AMI has not been previously examined. We queried the 2004 to 2013 National Inpatient Sample databases to identify all patients ≥18 years hospitalized with the principal diagnosis of AMI. Multivariable regression models adjusting for demographics, hospital characteristics, and co-morbidities were used to examine differences in incidence and in-hospital mortality of cardiogenic shock complicating AMI between obese and nonobese patients. Of 6,097,817 patients with AMI, 290,894 (4.8%) had cardiogenic shock. There was no difference in risk-adjusted incidence of cardiogenic shock between obese and nonobese patients (adjusted odds ratio 1.00, 95% CI 0.98 to 1.01; p = 0.46). Of the patients with cardiogenic shock complicating AMI, 8.9% had a documented diagnosis of obesity. Obese patients were on average 6 years younger and had higher prevalence of most cardiovascular co-morbidities. Obese patients were more likely to receive revascularization (73.0% vs 63.4%, p <0.001) and had lower risk-adjusted in-hospital mortality compared with nonobese patients (28.2% vs 36.5%; adjusted odds ratio 0.89, 95% CI 0.86 to 0.92; p <0.001). Similar findings were seen in subgroups of patients with cardiogenic shock complicating ST elevation or non-ST elevation MI. In conclusion, this large retrospective analysis of a nationwide cohort of patients with cardiogenic shock complicating AMI demonstrated that obese patients were younger, more likely to receive revascularization, and had modestly lower risk-adjusted in-hospital mortality compared with nonobese patients.

Diagnostic Strategies for Early Recognition of Cancer Therapeutics-Related Cardiac Dysfunction

Cardiovascular toxicity in the form of cardiac dysfunction continues to be an obstacle for patients with cancer. Survival and quality of life of cancer survivors are frequently affected by increased incidence of cardiovascular disease. The involvement of the cardiovascular system by primary or secondary malignancies, as well as its dysfunction secondary to the administration of antineoplastics, has led to the development of a new discipline called Cardio-Oncology, an exciting cardiology subspecialty with more questions than answers and as a result an enormous opportunity for research in the field. Multidisciplinary efforts have been focused on the prevention, diagnosis, and treatment of cancer therapeutics-related cardiovascular dysfunction (CTRCD). This review article will focus on the early diagnosis of left ventricular dysfunction associated with chemotherapy. Currently, the identification of cardiac toxicity associated with cancer treatment is the cornerstone for critical decisions regarding anticancer therapy and cardioprotective strategies. Its early detection, especially in subclinical phases, allows immediate intervention to prevent further impairment of the myocardium and other cardiovascular structures. The most significant published studies were selected for this revision, providing an updated document for the health professionals involved in the care of patients with cancer. We examined the current evidence and recommendations for biochemical and noninvasive diagnostic techniques, including their specific role for identification of CTRCD. Traditional and advanced imaging modalities, used alone or in combination with cardiovascular biomarkers, are essential for the recognition of cardiotoxicity during cancer therapy. Evolving basic and clinical research are focused on the development of more sensitive and specific diagnostic tools and for the recognition of cardiac toxicity.

Transcatheter Valve-in-Valve Implantation: Failing Tricuspid Bioprosthesis in a Patient with Ebstein’s Anomaly

Transcatheter valve-in-valve (VIV) implantation has been recently proposed as an alternative to surgical reoperative aortic valve replacement in patients with a failing aortic bioprosthesis. Experience with transcatheter VIV implantation at other valve positions is very limited. Herein is reported the case of an 18-year-old man with Ebstein's anomaly and severe tricuspid valve (TV) regurgitation status after bioprosthetic valve replacement, who developed new dyspnea on exertion three years after the initial valve replacement. Transesophageal echocardiography showed a severely dilated right atrium and new TV stenosis with an immobile leaflet. The patient underwent successful VIV implantation of a 29-mm SAPIEN XT bioprosthetic valve, with resolution of symptoms and no residual TV regurgitation or stenosis at the two-year follow up. Video 1: Degenerative bioprosthetic tricuspid valve. TEE showing the degenerative bioprosthetic tricuspid valve, and color Doppler during systole showing severe tricuspid regurgitation. Video 2: Degenerative bioprosthetic tricuspid valve. Three-dimensional TEE showing stenosis with an immobile leaflet creating a coaptation defect, viewed from the right atrium. Video 3: Transcatheter VIV replacement with a 29-mm Edwards SAPIEN XT deployed within the tricuspid valve prosthesis. Final result after valve implantation, demonstrating a patent valve orifice, and appropriate apposition of transcatheter valve within a pre-existing surgical Carpentier-Edwards bioprosthetic valve, viewed from the right ventricle. Video 4: Transcatheter VIV replacement with a 29-mm Edwards SAPIEN XT deployed within the tricuspid valve prosthesis. Final result after valve implantation, demonstrating a patent valve orifice, and appropriate apposition of transcatheter valve within a pre-existing surgical Carpentier-Edwards bioprosthetic valve, viewed from the right atrium.

Outcomes of ≤6-month versus 12-month dual antiplatelet therapy after drug-eluting stent implantation: A meta-analysis and meta-regression

BACKGROUND

The benefit of ≤6-month compared with 12-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement remains controversial. We performed a meta-analysis and meta-regression of ≤6-month versus 12-month DAPT in patients undergoing PCI with DES placement.

METHODS

We conducted electronic database searches of randomized controlled trials (RCTs) comparing DAPT durations after DES placement. For studies with longer follow-up, outcomes at 12 months were identified. Odds ratios and 95% confidence intervals were computed with the Mantel-Haenszel method. Fixed-effect models were used; if heterogeneity (I) > 40 was identified, effects were obtained with random models.

RESULTS

Nine RCTs were included with total n = 19,224 patients. No significant differences were observed between ≤6-month compared with 12-month DAPT in all-cause mortality (OR 0.87; 95% confidence interval (CI): 0.69-1.11), cardiovascular (CV) mortality (OR 0.89; 95% CI: 0.66-1.21), non-CV mortality (OR 0.85; 95% 0.58-1.24), myocardial infarction (OR 1.10; 95% CI: 0.89-1.37), stroke (OR 0.97; 95% CI: 0.67-1.42), stent thrombosis (ST) (OR 1.37; 95% CI: 0.89-2.10), and target vessel revascularization (OR 0.95; 95% CI: 0.77-1.18). No significant difference in major bleeding (OR 0.72; 95% CI: 0.49-1.05) was observed, though the all-bleeding event rate was significantly lower in the ≤6-month DAPT group (OR 0.76; 95% CI: 0.59-0.96). In the meta-regression analysis, a significant association between bleeding events and non-CV mortality with 12-month DAPT was found, as well as between ST and mortality in addition to MI with ≤6-month DAPT.

CONCLUSION

DAPT for ≤6 months is associated with similar mortality and ischemic outcomes but less bleeding events compared with 12-month DAPT after PCI with DES.

Prognostic Value of Late Gadolinium Enhancement in Nonischemic Cardiomyopathy

The purpose of this study was to determine the prognostic value of late gadolinium enhancement seen on cardiac magnetic resonance (CMR) imaging in patients with nonischemic cardiomyopathy (NICMP). Patients with NICMP are at increased risk for cardiovascular events and death. The presence of late gadolinium enhancement (LGE) in CMR may be associated with a poor prognosis, but its significance is still under investigation. We retrospectively studied 105 consecutive patients with NICMP and left ventricular ejection fraction (LVEF) ≤40% referred for CMR. The cohort was analyzed for the presence of LGE and left and right ventricular functional parameters. Patients were followed for the composite end point of hospitalization for congestive heart failure, appropriate implantable cardioverter-defibrillator therapy, or all-cause mortality. LGE was observed in 68% (n = 71) of the cohort. Both groups were similar in age, LVEF and LV end-diastolic volume. The LGE+ patients were more often men and had larger right ventricular volumes. At a mean follow-up of 806 ± 582 days, there were 26 patients (23 in the LGE+ group) who reached the primary end point. Event-free survival was significantly worse for the LGE+ patients. After adjusting for traditional risk factors (age, gender, and LVEF), patients with LGE had an increased risk of experiencing the primary end point (hazard ratio 4.47, 95% CIs 1.27 to 15.74, p = 0.02). The presence of LGE in patients with NICMP strongly predicts the occurrence of adverse events. In conclusion, this may be important in risk stratification and management.

The prevalence of metabolic syndrome among law enforcement officers who responded to the 9/11 World Trade Center attacks

BACKGROUND

Law enforcement officers (LEOs) experience high rates of cardiovascular events compared with the general US population. Metabolic syndrome (MetS) confers an increased risk of cardiovascular disease and all-cause mortality. Data regarding MetS among LEOs are limited.

METHODS

We sought to determine the prevalence of MetS and its associated risk factors as well as gender differences among LEOs who participated in the World Trade Center (WTC) Law Enforcement Cardiovascular Screening (LECS) Program from 2008 to 2010. We evaluated a total of 2,497 participants, 40 years and older, who responded to the 9/11 WTC attacks.

RESULTS

The prevalence of MetS was 27%, with abdominal obesity and hypertension being the most frequently occurring risk factors. MetS and its risk factors were significantly higher among male compared to female LEOs, except for reduced HDL-cholesterol levels.

CONCLUSIONS

MetS is a rising epidemic in the United States, and importantly, approximately one in four LEOs who worked at the WTC site after 9/11 are affected. Am. J. Ind. Med. 59:752-760, 2016. © 2016 Wiley Periodicals, Inc.

Multimodality Imaging in Cardiac Sarcoidosis: Is There a Winner?

Sarcoidosis is a multisystem granulomatous disease of unknown cause that can affect the heart. Cardiac sarcoidosis may be present in as many as 25% of patients with systemic sarcoidosis, and it is frequently underdiagnosed. The early and accurate diagnosis of myocardial involvement is challenging. Advanced imaging techniques play important roles in the diagnosis and management of patients with cardiac sarcoidosis.

Drug-induced torsades de pointes in an underserved urban population. Methadone: is there therapeutic equipoise?

BACKGROUND

Although it has been well established that methadone use can result in prolonged QTc/torsades de pointes (TdP) and has been labeled as one of the main drugs that cause TdP, it is still prescribed indiscriminately, and several cases of methadone-associated TdP have been seen in our community.

METHODS

Our objective was to determine the associated factors for prolonged QTc and the development of torsades de pointes (TdP) in our underserved patient population. We found 12,550 ECGs with prolonged QTc between 2002 and 2013. Medical records were reviewed in order to identify precipitating factors for prolonged QTc and to detect incidence of TdP.

RESULTS

We identified 2735 patients with prolonged QTc who met the inclusion criteria. Of these, 89 (3%) experienced TdP. There was a greater prevalence of HIV infection in the TdP group (11.2 vs. 3.7%, p < 0.001). Furosemide, hydrochlorothiazide, selective serotonin reuptake inhibitors (SSRIs), amiodarone, ciprofloxacin, methadone, haloperidol, and azithromycin were the drugs most often associated with prolonged QTc (31, 8.2, 7.6, 7.1, 3.9, 3.4 and 3.3%, respectively). However, the agents most commonly associated with TdP were furosemide (39.3%), methadone (27%), SSRIs (19.1%), amiodarone (18%), and dofetilide (9%). The medications with statistical significance in the multivariate analysis for TdP development in descending order were as follows: ranolazine (odds ratios [OR] = 53.61, 95% confidence interval [CI] 5.4-524, p < 0.001), dofetilide (OR = 25, CI 6.47-103.16, p < 0.001), voriconazole (OR = 21.40, CI 3.24-124.25, p < 0.001), verapamil (OR = 10.98, CI 2.62-44.96, p < 0.001), sotalol (OR = 12.72, 1.95-82.81, p = 0.008), methadone (OR = 9.89, CI 4.05-24.15, p < 0.001), and SSRI (OR = 2.26, CI 1.10-5.96, p < 0.001). This multivariate analysis revealed that amiodarone and HIV infection were not implicated in TdP.

CONCLUSION

Methadone was by far the leading medication implicated in the development of TdP and an independent predictor in both univariate and multivariate analyses despite the fact that it was not the most common QT-prolonging medication in our population.