The Association of Frailty With In-Hospital Bleeding Among Older Adults With Acute Myocardial Infarction: Insights From the ACTION Registry

OBJECTIVES

The aim of this study was to determine whether frailty is associated with increased bleeding risk in the setting of acute myocardial infarction (AMI).

BACKGROUND

Frailty is a common syndrome in older adults.

METHODS

Frailty was examined among AMI patients ≥65 years of age treated at 775 U.S. hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. Frailty was classified on the basis of impairments in 3 domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of 3 categories was then created: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding.

RESULTS

Among 129,330 AMI patients, 16.4% had any frailty. Frail patients were older, more often female, and were less likely to undergo cardiac catheterization. Major bleeding increased across categories of frailty (fit/well 6.5%; vulnerable/mild frailty 9.4%; moderate-to-severe frailty 9.9%; p < 0.001). Among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the non-frail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.23 to 1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24 to 1.58). Among patients managed conservatively, there was no association of frailty with bleeding (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86 to 1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81 to 1.14).

CONCLUSIONS

Frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) than nonfrail patients, making attention to clinical strategies to avoid bleeding imperative in this population.

Plant Protein Intake Is Not Associated with Cardiovascular Disease Risk Factors in Diabetic Patients with Chronic Kidney Disease (P08-055-19)

Objectives

A higher percentage of protein consumed from plants may have cardiovascular benefits and be associated with lower mortality in chronic kidney disease (CKD) patients. The purpose of this study was to examine the association of self-reported dietary protein intake with cardiovascular disease (CVD) risk factors in patients with type 2 diabetes (T2D) and CKD.

Methods

Baseline 3-day food records were obtained from 202 participants of an ongoing lifestyle intervention study, and analyzed using Nutrition Data System for Research (2014). Participants were categorized into tertiles based on total protein intake (<66.9 g, 66.9–92.4 g, > 92.4 g) and percent of total protein coming from plant sources (<27.9%, 27.9–37.8%, >37.8%). CVD risk factors included estimated glomerular filtration rate (eGFR), pulse wave velocity (PWV), fasting lipids (total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides [TG]), and hemoglobin A1c [HbA1c]). Analyses of covariance examined mean differences in CVD risk factors among the tertiles, controlling for age and total energy intake.

Results

The participants were 57% male, 89% non-Hispanic, 69% white, and 66 ± 9 years of age with a mean body mass index of 33.6 ± 5 kg/m2. Prior myocardial infarction was reported by 25(12.6%) of participants. Average daily protein intake was 83.3 ± 29.3 g (0.9 ± 0.3 g/kg body weight), with the average % of protein consumed from plant sources 34 ± 13%. There were no statistically significant differences between the total protein intake tertiles for the CVD risk factors (eGFR [P = .36], PWV [P = .86], total cholesterol [P = .09], LDL-cholesterol [P = .26], HDL-cholesterol [P = .88], TG [P = .88], HbA1c [P = .82]. Additionally, there were no statistically significant differences between the % of total protein intake from plant sources tertiles for the CVD risk factors (eGFR [P = .32], PWV [P = .92], total cholesterol [P = .29], LDL-cholesterol [P = .10], HDL-cholesterol [P = .57], TG [P = .13], HbA1c [P = .93].

Conclusions

Contrary to expectations, CVD risk factors did not differ among tertiles for total protein intake or % of total protein from plant sources. These findings suggest that, at baseline, dietary protein was not associated with CVD risk factors in patients with T2D and CKD.

Funding Sources

National Institutes of Health (NIDDK, NINR).

The Impact of Daytime Sleepiness on Dietary Intake in Overweight/Obese Individuals with Diabetes and Chronic Kidney Disease (P08-019-19)

Objectives

Sleep disturbances have been recognized as risk factors in the etiology of chronic disease and obesity. Although multifactorial, the link may be due to dietary intake, mediated by appetite hormones, hedonic feeding, altered intake times, and extended intake hours. The purpose of this study was to examine daytime sleepiness and dietary intake in overweight/obese individuals with diabetes and chronic kidney disease.

Methods

Three-day food records were completed at baseline from 133 participants in an ongoing lifestyle intervention study, and analyzed using the Nutrition Data System for Research (2014). Daily dietary intakes were summarized for energy (kcal), carbohydrate (g), fat (g), alcohol (g), added sugars (g), and refined grains (ounce equivalents). Self-reported measures of daytime sleepiness were measured using the Epworth Sleepiness Scale (ESS). Participants rated their level of sleepiness (scale 0–3) in eight different situations, which were summed to provide a total score. The ESS scores were dichotomized with 0–10 indicating “normal daytime sleepiness” (NDS) and 11–24 indicating “excessive daytime sleepiness” (EDS). IBM SPSS Statistics (version 25.0) was utilized to complete the descriptive and inferential analyses. Independent sample t-tests examined differences between the two sleepiness groups. Results were considered significant at p ≤ 0.05.

Results

The participants were 53.4% male, 89.5% non-Hispanic, 65.4% white, and 65.0 ± 9.4SD years of age with a mean body mass index of 34.0 ± 5.1SD kg/m2. Although there were no differences between sleepiness groups for fat and alcohol intakes, the EDS group reported a higher mean intake of carbohydrate (EDS: 247 ± 148SD g, NDS: 183 ± 76SD g; P = 0.048) and refined grains (EDS: 7.0 ± 6.5SD ounce, NDS: 4.2 ± 3.0SD ounce; P = 0.048). Although not statistically significant, the EDS group exhibited a trend toward having a higher energy intake (EDS: 2130 ± 1083SD kcal, NDS: 1776 ± 618SD kcal; P = 0.133) and added sugar intake (EDS: 44 ± 53SD g, NDS: 28 ± 26SD g, P = 0.179).

Conclusions

Similar to other reports, sleep disturbances, as noted by EDS, were associated with a higher intake of carbohydrate and refined grains. The results of this study support the role of sleep, alongside diet and physical activity, as important modifiable risk factors for chronic disease and obesity.

Funding Sources

National Institutes of Health (NIDDK, NINR)

Inflammasome Signaling and Impaired Vascular Health in Psoriasis

Objective- Psoriasis is an inflammatory skin disease which heightens the risk of cardiovascular disease. This study directly investigated vascular endothelial health and systemically altered pathways in psoriasis and matched controls. Approach and Results- Twenty patients (mean age, 40 years; 50% male) with active psoriasis and 10 age-, sex-matched controls were recruited. To investigate systemically alerted pathways, a deep sequencing omics approach was applied, including unbiased blood transcriptomic and targeted proteomic analysis. Vascular endothelial health was assessed by transcriptomic profiling of endothelial cells obtained from the brachial veins of recruited participants. Blood transcriptomic profiling identified inflammasome signaling as the highest differentially expressed canonical pathway ( Z score 1.6; P=1×10^-7) including upregulation of CASP5 and interleukin ( IL) -1β. Proteomic panels revealed IL-6 as a top differentially expressed cytokine in psoriasis with pathway analysis highlighting IL-1β ( Z score 3.7; P=1.02×10^-23) as an upstream activator of the observed upregulated proteins. Direct profiling of harvested brachial vein endothelial cells demonstrated inflammatory transcript (eg, IL-1β, CXCL10, VCAM-1, IL-8, CXCL1, Lymphotoxin beta, ICAM-1, COX-2, and CCL3) upregulation between psoriasis versus controls. A linear relationship was seen between differentially expressed endothelial inflammatory transcripts and psoriasis disease severity. IL-6 levels correlated with inflammatory endothelial cell transcripts and whole blood inflammasome-associated transcripts, including CASP5 and IL-1β. Conclusions- An unbiased sequencing approach demonstrated the inflammasome as the most differentially altered pathway in psoriasis versus controls. Inflammasome signaling correlated with psoriasis disease severity, circulating IL-6, and proinflammatory endothelial transcripts. These findings help better explain the heightened risk of cardiovascular disease in psoriasis. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT03228017.

Reversal and Resumption of Antithrombotic Therapy in LVAD-Associated Intracranial Hemorrhage

BACKGROUND

Little data exist regarding reversal and resumption of antithrombotics after left ventricular assist device (LVAD)-associated intracranial hemorrhage.

METHODS

Prospectively collected data of LVAD patients with intracranial hemorrhage were reviewed. Coagulopathy reversal agents, antithrombotic regimens, and thrombotic (venous thromboembolism, ischemic stroke, myocardial infarction) and hemorrhagic (recurrent intracranial hemorrhage, gastrointestinal bleed, anemia requiring transfusion) complications were recorded.

RESULTS

Of 405 patients, intracranial hemorrhage occurred in 39 (10%): 23 intracerebral hemorrhages, 10 subarachnoid hemorrhages, and 6 subdural hematomas. Of 27 patients who received antithrombotic reversal, 8 (30%) had inadequate coagulopathy reversal, and 3 of these patients had hemorrhage expansion or died before repeat imaging. One (4%) patient had a thrombotic complication (deep vein thrombosis). Antithrombotic therapy was resumed in 17 (100%) survivors in a median time 8 days for antiplatelet agents and 14 days for warfarin. Recurrent intracranial hemorrhage occurred within a median of 7 days of antithrombotic resumption, while ischemic stroke occurred in a median of 428 days. Patients who resumed antiplatelets alone (n = 4) had a trend toward more thrombotic events (1.37 versus 0.14 events/patient-year [EPPY]; p = 0.08), including more fatal thrombotic events (0.34 EPPY versus 0.08 EPPY; p = 0.89) compared with those resuming warfarin ± antiplatelet (n = 14). Nonfatal hemorrhage event rates were 0.34 EPPY in the warfarin ± antiplatelet versus 0 EPPY in the antiplatelet-alone group (p = 0.16). No fatal hemorrhagic events occurred.

CONCLUSIONS

Reversal of anticoagulation appears safe after LVAD-associated intracranial hemorrhage, though inadequate reversal was common. Resumption of warfarin ± antiplatelet was associated with fewer fatal and nonfatal thrombotic events compared with antiplatelets alone, though more nonfatal hemorrhage events occurred.

Glucocorticoid-induced osteoporosis preventive care in rheumatology patients

Glucocorticoid-induced osteoporosis (GIOP) is common in patients prescribed with long-term glucocorticoids. Guidelines suggest patients receiving moderate-dose glucocorticoid therapy receive GIOP preventive care. Previous studies have shown preventive care rates are not optimal. We look at GIOP preventive care rates in rheumatology patients and predictors of various components of care.

PURPOSE

Glucocorticoid-induced osteoporosis (GIOP) is a common concern in patients prescribed with long-term glucocorticoids. Studies have shown GIOP preventive care is not provided optimally in the general population; however, little is published on GIOP preventive care among patients with rheumatic disease. The objective of this study is to determine the proportion of rheumatology patients who received GIOP preventive care.

METHODS

A population-based retrospective quality assurance study of adults seen at the University of Alberta Rheumatology Clinic was performed using the electronic outpatient medical record. Records of adult patients prescribed with prednisone from January 1st to December 31st, 2016 by a rheumatologist were initially included for review. Those who had been prescribed ≥ 7.5 mg/day for ≥ 3 months were assessed for concurrent GIOP preventive care.

RESULTS

A total of 745 discreet courses of prednisone were prescribed in 433 patients with 113 meeting the above inclusion criteria. Following the prednisone prescription, 79% were taking vitamin D, 86% were taking calcium, and 50% were prescribed with osteoporosis pharmacotherapy. Twenty-five percent of patients had DXA imaging ordered by the rheumatologist within the first 6 months; of these, 86% of patients completed the DXA.

CONCLUSIONS

Overall, our study shows that patients under the care of rheumatologists receive better GIOP preventative care than previously reported care in the general population. However, there is still room for improvement. In particular, men, younger patients, and rural patients seem to be at the most at risk of not receiving optimal GIOP prevention.

Abstract 256: The Direct Characterization of Endothelial Inflammation in Patients with Psoriasis

Objective: Psoriasis, an inflammatory autoimmune disease, increases the risk of cardiovascular disease (CVD). Active psoriatic disease is linked to systemic vascular inflammation, yet how this contributes to CVD is unknown. Using in vivo and ex-vivo measures of the vascular endothelium our study investigates the vascular health of psoriasis patients to better understand the mechanism(s) that predispose psoriatics to CVD.

Methods: Ten patients with active psoriasis (average age 46 years, 50% male (5 of 10), 6% [3.5% – 90%] body surface area involvement) were compared to age- and sex- matched controls. In vivo vascular endothelial function was assessed by brachial artery reactivity testing (BART, %) with high resolution ultrasonography. Venous endothelial cells were collected from the brachial vein using guidewires inserted through an angiocatheter and isolated with magnetic beads directed against CD146. Following collection, endothelial RNA was isolated, converted to cDNA and inflammatory gene profiling performed by RT-qPCR with Taqman probes and primers.

Results: Transcriptomic profiling of venous endothelial cells revealed upregulation of genes associated with inflammatory cytokines and chemokines ( lymphotoxin beta [2.5 - fold], CCL3 [3.5 - fold], and IL-1 β [2.8 - fold], P < 0.05 for all) and genes related to intracellular adhesion and inflammation ( ICAM1 [2.3 – fold] and COX-2 [1.4 – fold], P < 0.05 for both) in psoriatics vs. controls. Unexpectedly, endothelial nitric oxide synthase (eNOS) and phosphorylated eNOS (higher levels indicate healthy endothelial NO production) were upregulated (2 - 3 fold) in psoriatics vs. controls (p = 0.24, p = 0.14 respectively). BART was also higher in psoriatics when compared to controls (7.1 ± 1% vs. 3.9 ± 2.7%, P = 0.03).

Conclusion: This cross-sectional study is the first to directly examine the vascular endothelium of psoriatic patients. Compared to controls, active psoriatic disease was associated with upregulation of cytokines, chemokines and genes regulating intracellular adhesion as well as increased expression of eNOS, and increased BART. These findings suggest potential mechanisms to explain the increased prevalence of atherosclerosis and CVD risk seen in those with psoriasis.

Impact of Pharmacy Student-Driven Postdischarge Telephone Calls on Heart Failure Hospital Readmission Rates: A Pilot Program

Background: Heart failure (HF) hospitalization rates have remained high in the past 10 years. Numerous studies have shown significant improvement in HF readmission rates when pharmacists or pharmacy residents conduct postdischarge telephone calls. Objective: The purpose of this retrospective review of a pilot program was to evaluate the impact of pharmacy student-driven postdischarge phone calls on 30- and 90-day hospital readmission rates in patients recently discharged with HF. Methods: A retrospective manual chart review was conducted for all patients who received a telephone call from the pharmacy students. The primary endpoint compared historical readmissions, 30 and 90 days prior to hospital discharge, with 30 and 90 days post discharge readmissions. For the secondary endpoints, historical and postdischarge 30-day and 90-day readmission rates were compared for patients with a primary diagnosis of HF and for patients with a secondary diagnosis of HF. Descriptive statistics were calculated in the form of means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Results: Statistically significant decrease was observed for both the 30-day (P = .006) and 90-day (P = .007) readmission periods. Prior to the pharmacy students' phone calls, the overall group of 131 patients had historical readmission rates of 24.43% within 30 days and 38.17% within 90 days after hospital discharge. After the postdischarge phone calls, the readmission rates decreased to 11.45%, for 30 days, and 22.90%, for 90 days. Conclusion: Postdischarge phone calls, specifically made by pharmacy students, demonstrated a positive impact on reducing HF-associated hospital readmissions, adding to the growing body of evidence of different methods of pharmacy interventions and highlighting the clinical impact pharmacy students may have in transition of care services.