Posttraumatic Stress Disorder After Spontaneous Coronary Artery Dissection: A Report of the International Spontaneous Coronary Artery Dissection Registry

BACKGROUND

Myocardial infarction secondary to spontaneous coronary artery dissection (SCAD) can be traumatic and potentially trigger posttraumatic stress disorder (PTSD). In a large, multicenter, registry-based cohort, we documented prevalence of lifetime and past-month SCAD-induced PTSD, as well as related treatment seeking, and examined a range of health-relevant correlates of SCAD-induced PTSD.

METHODS AND RESULTS

Patients with SCAD were enrolled in the iSCAD (International SCAD) Registry. At baseline, site investigators completed medical report forms, and patients reported demographics, medical/SCAD history, psychosocial factors (including SCAD-induced PTSD symptoms), health behaviors, and health status via online questionnaires. Of 1156 registry patients, 859 patients (93.9% women; mean age, 52.3 years) completed questionnaires querying SCAD-induced PTSD. Nearly 35% (n=298) of patients met diagnostic criteria for probable SCAD-induced PTSD in their lifetime, and 6.4% (n=55) met criteria for probable past-month PTSD. Of 811 patients ever reporting any SCAD-induced PTSD symptoms, 34.8% indicated seeking treatment for this distress. However, 46.0% of the 298 patients with lifetime probable SCAD-induced PTSD diagnoses reported never receiving trauma-related treatment. Younger age at first SCAD, fewer years since SCAD, being single, unemployed status, more lifetime trauma, and history of anxiety were associated with greater past-month PTSD symptom severity in multivariable regression models. Greater past-month SCAD-induced PTSD symptoms were associated with greater past-week sleep disturbance and worse past-month disease-specific health status when adjusting for various risk factors.

CONCLUSIONS

Given the high prevalence of SCAD-induced PTSD symptoms, efforts to support screening for these symptoms and connecting patients experiencing distress with empirically supported treatments are critical next steps.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04496687.

Validation of a noninvasive cardiac output monitor in maternal cardiac disease: comparison of NICOM and transthoracic echocardiogram

BACKGROUND

The physiological changes to the cardiovascular system during pregnancy are considerable and are more pronounced in those with cardiac disease. In the general population, noninvasive hemodynamic monitoring is a valid alternative to pulmonary artery catheterization, which poses risk in the pregnant population. There is limited data on noninvasive cardiac output monitoring in pregnancy as an alternative to pulmonary artery catheterization.

OBJECTIVE

We sought to compare transthoracic echocardiography with a noninvasive cardiac output monitor (NICOM, Cheetah Medical) in pregnant patients with and without cardiac disease.

STUDY DESIGN

This was a prospective, open-label validation study that compared 2-dimensional transthoracic echocardiography with NICOM estimations of cardiac output in each trimester of pregnancy and the postpartum period. Participants with and without cardiac disease with a singleton gestation were included. NICOM estimations of cardiac output were derived from thoracic bioreactance and compared with 2-dimensional transthoracic echocardiography for both precision and accuracy. A mean percentage difference of ±30% between the 2 devices was considered acceptable agreement between the 2 measurement techniques.

RESULTS

A total of 58 subjects were enrolled; 36 did not have cardiac disease and 22 had cardiac disease. Heart rate measurements between the 2 devices were strongly correlated in both groups, whereas stroke volume and cardiac output measurements showed weak correlation. When comparing the techniques, the NICOM device overestimated cardiac output in the control group in all trimesters and the postpartum period (mean percentage differences were 50.3%, 52.7%, 48.1%, and 51.0% in the first, second, and third trimesters and the postpartum period, respectively). In the group with cardiac disease, the mean percentage differences were 31.9%, 29.7%, 19.6%, and 35.2% for the respective timepoints.

CONCLUSION

The NICOM device consistently overestimated cardiac output when compared with 2-dimensional transthoracic echocardiography at all timepoints in the control group and in the first trimester and postpartum period for the cardiovascular disease group. The physiological changes of pregnancy, specifically the mean chest circumference and total body water, may alter the accuracy of the cardiac output measurement by the NICOM device as they are currently estimated. Although NICOM has been validated for use in the critical care setting, there is insufficient data to support its use in pregnancy.

Spontaneous Coronary Artery Dissection (SCAD) in an Atypical Patient Without Risk Factors and Prior Asymptomatic COVID-19 Infection

Spontaneous coronary artery dissection (SCAD) is a condition primarily seen in young women and is characterized by non-atherosclerotic arterial damage. It can occur with or without conventional risk factors for coronary heart disease and is often associated with chronic inflammatory conditions. Here, we present a unique instance of a 67-year-old woman without known risk factors who developed sudden onset chest pain in the setting of an asymptomatic coronavirus 2019 (COVID-19) infection three weeks earlier. Subsequent evaluation revealed SCAD in the distal left anterior descending (LAD) artery.

An Overlooked Cause of Myocardial Infarction With Normal Coronaries Presenting as Stress Cardiomyopathy in Females

Spontaneous coronary artery dissection (SCAD) should be considered in the differential diagnosis of patients with provisional Takotsubo cardiomyopathy (TTS). However, because of overlapping clinical features, SCAD with subtle angiographic findings and wall motion abnormality like TTS can be easily missed. Therefore, our case highlights the importance of further investigation for SCAD.

Management of May Thurner Syndrome in Pregnant Patients

May Thurner Syndrome contributes to thromboembolic disease and can cause significant morbidity in pregnant patients secondary to exaggerated anatomic relationships and physiologic changes in the hematologic system favoring thrombogenesis. Because this condition is both underrecognized and underreported, management in pregnant and postpartum patients is based on expert opinion without any formal evidence-based guidance. Herein, we review five pregnancies in four patients with May Thurner Syndrome and general management strategies. Through collaborative and multidisciplinary care, patients with May Thurner Syndrome can be safely and successfully managed during pregnancy and the postpartum period with appropriate anticoagulation.

Cardiology perspective on seizure-related bradyarrhythmias and SUDEP: A survey study

OBJECTIVE

To determine cardiologist knowledge of and experience with seizure-related bradyarrhythmias and sudden unexpected death in epilepsy (SUDEP).

BACKGROUND

Autonomic changes related to acute seizures are common and can occur during the ictal or postictal period. Two concerning changes in these periods are significant bradycardia and asystole. Postictal asystole has been investigated as a potential mechanism for SUDEP.

METHODS

A 27-question survey delivered to cardiologists and cardiology fellows assessed demographics, personal experience, and training involving SUDEP and seizure-related bradycardia and asystole. Following IRB approval, a list of US cardiology fellowships was constructed using the AAMC public website. Surveys were distributed by email to all programs whose program director or coordinator's email was readily available on their website. They were asked to forward the survey to both cardiology fellows and practicing cardiologists.

RESULTS

Fifty one surveys were completed: 23 from fellows and 28 from practicing cardiologists. Forty nine were from academic centers. Twenty four respondents (47%) reported being consulted for ictal bradycardia or asystole. Nine and 13 recommended treatment for ictal bradycardia or ictal asystole, respectively. Nineteen respondents (37%) reported being consulted for postictal bradycardia or asystole. Eight recommended treatment for postictal bradycardia or asystole, respectively. Treatment recommendations included medical management and/or pacemaker. None reported a substantial knowledge of SUDEP. The most common response interrogating SUDEP awareness (63%) was "no knowledge of SUDEP". Formal SUDEP education was not reported by any participant with only one reporting formal didactics regarding seizure-related arrhythmias.

DISCUSSION

Our results suggest ictal bradyarrhythmias are less commonly known to cardiologists, with SUDEP awareness being far less. Formal education to cardiologists on these two topics could prove beneficial at the intersection of cardiology and care for patients with epilepsy.

Working Agenda for Black Mothers: A Position Paper From the Association of Black Cardiologists on Solutions to Improving Black Maternal Health

Following decades of decline, maternal mortality began to rise in the United States around 1990—a significant departure from the world’s other affluent countries. By 2018, the same could be seen with the maternal mortality rate in the United States at 17.4 maternal deaths per 100 000 live births. When factoring in race/ethnicity, this number was more than double among non-Hispanic Black women who experienced 37.1 maternal deaths per 100 000 live births. More than half of these deaths and near deaths were from preventable causes, with cardiovascular disease being the leading one. In an effort to amplify the magnitude of this epidemic in the United States that disproportionately plagues Black women, on June 13, 2020, the Association of Black Cardiologists hosted the Black Maternal Heart Health Roundtable—a collaborative task force to tackle the maternal health crisis in the Black community. The roundtable brought together diverse stakeholders and champions of maternal health equity to discuss how innovative ideas, solutions and opportunities could be implemented, while exploring additional ways attendees could address maternal health concerns within the health care system. The discussions were intended to lead the charge in reducing maternal morbidity and mortality through advocacy, education, research, and collaborative efforts. The goal of this roundtable was to identify current barriers at the community, patient, and clinician level and expand on the efforts required to coordinate an effective approach to reducing these statistics in the highest risk populations. Collectively, preventable maternal mortality can result from or reflect violations of a variety of human rights—the right to life, the right to freedom from discrimination, and the right to the highest attainable standard of health. This is the first comprehensive statement on this important topic. This position paper will generate further research in disparities of care and promote the interest of others to pursue strategies to mitigate maternal mortality.

Contraception for the Cardiac Patient: a Cardiologist’s Primer

Purpose of review

Cardiovascular disease (CVD) is the number one cause of maternal mortality in the USA. There are many cardiac conditions which pose significant risk to maternal health, and these women should be offered options to avoid unwanted pregnancies. Individualized contraceptive counseling focusing on woman’s desire for future pregnancy, comorbid conditions, and desire for hormone or non-hormonal (contraceptive) options is paramount to avoid adverse or unwanted side effects. The purpose of this review is to give general guidance on prescribing both hormonal and non-hormonal contraceptives for providers caring for women with heart disease.

Recent findings

Specific recommendation for the use of either non-hormonal or hormonal contraception requires knowledge of the types of contraceptive options available, cost, failure rates, and contraindications to use. Newer progestin-only options have become available and should be considered first-line therapy for women with cardiovascular disease.

Summary

The physiologic burden of pregnancy on the cardiovascular system can cause significant maternal morbidity and mortality for women with underlying CVD. These women should be offered safe and effective options for birth control, and both cardiology and obstetrical providers alike should possess fundamental knowledge of appropriate options.

Cardiovascular Contribution to Maternal Mortality

The United States is the only industrialized nation with an increasing maternal mortality. Many factors contribute to this worrisome US trend; among them, social and demographic factors, and congenital and acquired cardiac conditions. Cardiovascular disease is the leading cause of maternal mortality, and adverse outcomes related to cardiovascular disease disproportionately affect black and Hispanic mothers. This article addresses knowledge gaps related to the treatment of heart disease in pregnancy, initiatives to address these gaps, and guidelines and best practices surrounding the care of women affected by cardiovascular disease and their babies affected by cardiovascular disease.

Evolution of Diagnostic and Treatment Patterns of Cardiac Sarcoidosis

Cardiac sarcoidosis (CS) may impart substantial morbidity and mortality, and novel imaging modalities are now available to aid in early diagnosis of this clinically silent disease. A better understanding of the clinical experience with CS is important. Twenty-eight patients were diagnosed with the aid of multimodality imaging techniques and were treated by a multidisciplinary team. Demographics, symptomatology, imaging, and therapeutic interventions were compiled from our referral center. In patients with CS, nuclear and MR techniques were often the first studies performed. Echocardiographic findings differed widely. Immunosuppressive therapy and cardiac devices were frequently used. Importantly, isolated CS was not an infrequent finding.

Longevity in a Patient With Hypertrophic Cardiomyopathy, Anomalous Coronary Artery, and Gastrointestinal Bleeding

We report an unusual case of an elderly woman who presented to the hospital with melena of five-day duration. She has a past medical history of hypertrophic cardiomyopathy diagnosed three years before presentation. She was found to have arteriovenous malformations in the stomach and the duodenum, causing gastrointestinal bleeding. An association between hypertrophic cardiomyopathy and arteriovenous malformations in the gastrointestinal tract was felt likely. The patient was treated with beta-blocker therapy. Later, she was incidentally found to have an anomalous right coronary artery. We discussed potential medical and surgical options, and the patient chose to be treated medically. She was successfully treated with beta-blocker therapy with no further gastrointestinal bleeding. Her clinical course was uncomplicated without cardiac arrhythmia, heart failure, or sudden cardiac death.

Abstract 105: Rehospitalization After Admission With Myocardial Infarction and Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is one of the most common non-atherosclerotic causes of myocardial infarction (MI) in young patients, yet little is known about post-discharge outcomes. Given the high psychological stress of a SCAD diagnosis, we sought to understand the rehospitalization burden after SCAD so as to provide more prognostic data to SCAD patients.

Methods: Using data from the Nationwide Readmission Database 2010-16, we identified patients 18-55 years of age hospitalized with MI with and without SCAD. We compared readmission over 1 year after index hospitalization for all-cause, MI, chest pain without MI, and heart failure. Cox proportional regression was used to examine factors associated with readmission, and we explored interactions of patient factors*SCAD to identify factors associated with differential risk of readmission in patients with SCAD.

Results: Among 327,227 young patients admitted with an MI, 3704 (1.1%) had a diagnosis of SCAD. Patients with SCAD were more likely to be younger, women, have a higher burden of anxiety or depression, and longer length of stay compared with those without SCAD. While the risk of all-cause rehospitalization over 1 year was similar in those with versus without SCAD (KM-estimated rates: 22.3% vs. 24.1%; log-rank p=0.596, Figure), patients with SCAD were more likely to be rehospitalized for MI (4.9% vs. 4.2%, log-rank p=0.012) and chest pain without MI (3.6% vs. 2.8%, log-rank p=0.060) but less likely to be rehospitalized for heart failure (1.0 % vs. 1.8%, log-rank p=0.005). In the multivariable model, a diagnosis of SCAD was not associated with risk of rehospitalization (HR 1.00, 95% CI 0.92-1.08) nor was a diagnosis of SCAD associated with a differential effect of any of the patient factors on the risk of rehospitalization (all interaction p-values >0.05).

Conclusion: Although patients with SCAD had a similar risk of rehospitalization compared with young patients with MI but without SCAD, we identified different patterns of hospitalization, which may be explained by the different underlying conditions. Further studies are needed to investigate possible interventions to reduce the high burden of post-SCAD rehospitalizations.

Creating a maternal cardiac center of excellence: a call to action

In contrast to most industrialized countries, maternal mortality in the USA is rising. Cardiovascular disease, both acquired heart disease (e.g. coronary disease, arrhythmias, and heart failure), as well as congenital heart disease survivors, are all potentially important factors in explaining this worrisome trend. Increase in acquired cardiac disease is likely attributable to greater rates of obesity, diabetes, hypertension, and an increase in the incidence of advanced maternal age, while congenital heart disease in pregnancy is increasing due to advances in pediatric cardiovascular surgery. Despite the growing cardiovascular risk of pregnant women, most obstetricians and cardiologists have limited experience in caring for women with heart disease. Accordingly, management is largely guided by expert opinion likely to vary greatly across centers. To address these challenges, a multidisciplinary approach to care that includes both cardiologists and obstetricians could leverage the knowledge of both specialties and support streamlined communication between the patient and her providers. Our experience highlights the necessary components and essential infrastructure for building a center of excellence in treating pregnant women with heart disease.Condensation: A guide for creating a center of excellence for prenatal care for women with cardiovascular disease.The problem: Cardiac disease is the leading cause of maternal mortality, and pregnancies affected by cardiac disease continue to rise, both congenital and acquired.The solution: Maternal fetal medicine, obstetricians, and cardiologists can join together in tertiary facilities to create Maternal Cardiac Centers of Excellence to provide multidisciplinary, structured care for these high-risk patients.

Residual Angina After Elective Percutaneous Coronary Intervention in Patients With Diabetes Mellitus

BACKGROUND

Previous studies suggest that among patients with stable coronary artery disease, patients with diabetes mellitus (DM) have less angina and more silent ischemia when compared with those without DM. However, the burden of angina in diabetic versus nondiabetic patients after elective percutaneous coronary intervention (PCI) has not been recently examined.

METHODS AND RESULTS

In a 10-site US PCI registry, we assessed angina before and at 1, 6, and 12 months after elective PCI with the Seattle Angina Questionnaire angina frequency score (range, 0-100, higher=better). We also examined the rates of antianginal medication prescriptions at discharge. A multivariable, repeated-measures Poisson model was used to examine the independent association of DM with angina over the year after treatment. Among 1080 elective PCI patients (mean age, 65 years; 74.7% men), 34.0% had DM. At baseline and at each follow-up, patients with DM had similar angina prevalence and severity as those without DM. Patients with DM were more commonly prescribed calcium channel blockers and long-acting nitrates at discharge (DM versus not: 27.9% versus 20.9% [P=0.01] and 32.8% versus 25.5% [P=0.01], respectively), whereas β-blockers and ranolazine were prescribed at similar rates. In the multivariable, repeated-measures model, the risk of angina was similar over the year after PCI in patients with versus without DM (relative risk, 1.04; range, 0.80-1.36).

CONCLUSIONS

Patients with stable coronary artery disease and DM exhibit a burden of angina that is at least as high as those without DM despite more antianginal prescriptions at discharge. These findings contradict the conventional teachings that patients with DM experience less angina because of silent ischemia.

The clot thickens: an incompletely ligated left atrial appendage

Our patient presented with known mechanical mitral valve endocarditis documented by 2D transesophageal echocardiogram (TOE) from a recent hospitalization at an outside facility. On admission to our center, there was no prior knowledge of an incompletely ligated left atrial appendage (LAA) according to patient- or family-reported history, review of outside records or the outside facility’s 2D TOE report. A 3D TOE performed at our center to assess her pathology, since a month had passed from her prior hospitalization, revealed a LAA ligation with evidence of communication to the left atrium and with clot present in the appendage. This case report highlights the common finding of incomplete closure of the LAA following surgical ligation, thus making it inadequate for stroke prevention in patients with atrial fibrillation, and that 3D TOE plays a valuable role in assessing the durability of LAA ligation.

Abstract 063: Diagnostic and Treatment Patterns of Cardiac Sarcoidosis: a Single Center Experience

Background: Clinically manifest cardiac involvement occurs in approximately 5% of patients with sarcoidosis. The principal manifestations of cardiac sarcoidosis (CS) are conduction abnormalities, ventricular arrhythmias, and heart failure. In 2014, the first international guideline for the diagnosis and management of CS was published. There are emerging data to support cardiac MRI and PET imaging in the diagnosis of CS. Additionally, despite a paucity of data, immunosuppression therapy (primarily with corticosteroids) has been advocated for the treatment of clinically manifest CS. Device therapy, primarily with implantable cardioverter-defibrillators, is often recommended for patients with clinically manifest disease. There are few contemporary descriptions of treatment and outcomes related to CS. In this case series, we describe diagnostic and treatment patterns of thirty patients with CS.

Methods: We performed a retrospective chart review of 30 patients with diagnosed CS. We used a spreadsheet with deidentified patient information to describe baseline patient characteristics including age, presenting symptoms, diagnostic modality, duration of follow up, medication regimen and follow up imaging, as well as the variables listed above concerning those who are deceased.

Results: Of thirty patients included in this case series, age at diagnosis ranged from 28-69, the diagnostic modalities included autopsy of explanted heart, cardiac MRI in combination with mediastinal lymph node biopsy, endomyocardial biopsy, cardiac MRI, and cardiac PET. For the majority of patients, dyspnea was the presenting symptom. Most patient presented with NYHA class I or II symptoms. Half of patients underwent ICD implantation. Eleven patients had documented arrhythmias, including ventricular tachycardia, complete heart block, and atrial fibrillation. Of our cohort, eight patients have concomitant pulmonary sarcoidosis. Follow up duration has ranged between 1 and 12 years. Five patients proceeded to cardiac transplantation. Two patients are deceased, including one patient who suffered recurrence of cardiac sarcoidosis following orthotropic heart transplantation.

Conclusions: In this case series of thirty patients with cardiac sarcoidosis, we describe that patients are commonly undergoing cardiac MR and PET imaging to support the diagnosis of CS. Tissue diagnosis remains a standard. Immunomodulators and cardiac device are frequently used, and further follow up data would be helpful in describing outcomes related to these therapies. This descriptions may prompt longer term observational studies that document diagnostic and therapeutic modalities, as well as cardiovascular outcomes, related to cardiac sarcoidosis.

THE IMPACT OF CARDIOVASCULAR DRUGS ON GLYCEMIC CONTROL: A REVIEW

OBJECTIVE

The prevalence of diabetes mellitus (DM) is steadily rising in the U.S., both in the general population and among those with cardiovascular disease (CVD). Understanding how to treat a patient with both conditions is becoming increasingly important. With multiple therapeutic options for CVD management, some medications will invariably impact glycemia in this group of patients. The concept of "DM-friendly" management of CVD is based on a treatment approach of selecting medications that do not impair glycemic control and provide equivalent cardioprotective effects. This article reviews the glycemic effects of various classes of medications commonly used to treat CVD.

METHODS

Data sources were all PubMed- and Google Scholar-referenced articles in English-language peer-reviewed journals from 1980 through April 2016. Studies selected could include observational studies or prospective clinical trials. Prospective clinical trials included in this review focused on investigating the association of the medication of interest with glycemic outcomes. Meta-analyses and systematic reviews were also included.

RESULTS

The data on glycemic effects were lacking for many of the medication classes and individual medications examined. However, in our review, certain beta-blockers and renin angiotensin aldosterone system inhibitors, and select calcium channel blockers were consistently shown to have favorable glycometabolic profiles when compared with other commonly used cardiovascular therapies.

CONCLUSION

Several commonly prescribed medications for the treatment of CVD, such as certain beta-blockers and renin angiotensin aldosterone system inhibiting agents, are associated with favorable glycometabolic effects. As clinicians are more often faced with the challenge of treating patients with DM and concomitant CVD, consideration of how common cardiovascular medications may affect glycemia should be incorporated into the clinical decision making process.

ABBREVIATIONS

A1C = hemoglobin A1C ACE = angiotensin-converting enzyme ARB = angiotensin II receptor blocker CCB = calcium channel blocker CI = confidence interval CVD = cardiovascular disease DM = diabetes mellitus MI = myocardial infarction RR = relative risk.

Bleeding risk following percutaneous coronary intervention in patients with diabetes prescribed dual anti-platelet therapy

BACKGROUND

Patients with diabetes mellitus (DM) experience higher rates of in-stent restenosis and greater benefit from drug-eluting stents implant at the time of percutaneous coronary intervention (PCI), necessitating prolonged dual anti-platelet therapy (DAPT). While DAPT reduces risk of ischemic events post-PCI, it also increases risk of bleeding. Whether bleeding rates differ among patients with and without DM, receiving long-term DAPT is unknown.

METHODS

Among patients who underwent PCI and were maintained on DAPT for 1 year in a multicenter US registry, we assessed patient-reported bleeding over one year following PCI in patients with and without DM. Multivariable, hierarchical Poisson regression was used to evaluate the association of DM with bleeding during follow-up.

RESULTS

Among 2334 PCI patients from 10 US hospitals (mean age 64, 54% ACS), 32.6% had DM. In unadjusted analyses, patients with DM had fewer bleeding events over the year following PCI (DM vs no DM: BARC = 1: 78.0% vs 87.7%, P < .001; BARC ≥2: 4.3% vs 5.3%, P = .33). Following adjustment, patients with (vs without DM) had a lower risk of BARC ≥1 bleeding during follow-up (relative risk [RR] 0.89, 95% CI 0.83-0.96). This decreased bleeding risk persisted after removing bruising from the endpoint definition.

CONCLUSIONS

In a real-world PCI registry, patients with DM experienced lower risk of bleeding risk on DAPT. As patients with DM also derive greater ischemic benefit from drug-eluting stents, which requires prolonged DAPT, our findings suggest that the balance between benefit and risk of this therapeutic approach may be even more favorable in patients with DM than previously considered.

Predictors of Physician Under-Recognition of Angina in Outpatients With Stable Coronary Artery Disease

BACKGROUND

Under-recognition of angina by physicians may result in undertreatment with revascularization or medications that could improve patients' quality of life. We sought to describe characteristics associated with under-recognition of patients' angina.

METHODS AND RESULTS

Patients with coronary disease from 25 US cardiology outpatient practices completed the Seattle Angina Questionnaire before their clinic visit, quantifying their frequency of angina during the previous month. Immediately after the clinic visit, physicians independently quantified their patients' angina. Angina frequency was categorized as none, monthly, and daily/weekly. Among 1257 patients, 411 reported angina in the previous month, of whom 173 (42%) were under-recognized by their physician, defined as the physician reporting a lower frequency category of angina than the patient. In a hierarchical logistic model, heart failure (odds ratio, 3.06, 95% confidence interval, 1.89-4.95) and less-frequent angina (odds ratio for monthly angina [versus daily/weekly], 1.69; 95% confidence interval, 1.12-2.56) were associated with greater odds of under-recognition. No other patient or physician factors were associated with under-recognition. Significant variability across physicians (median odds ratio, 2.06) was observed.

CONCLUSIONS

Under-recognition of angina is common in routine clinical practice. Although patients with less-frequent angina and those with heart failure more often had their angina under-recognized, most variation was unrelated to patient and physician characteristics. The large variation across physicians suggests that some physicians are more accurate in assessing angina frequency than others. Standardized prospective use of a validated clinical tool, such as the Seattle Angina Questionnaire, should be tested as a means to improve recognition of angina and, potentially, improve appropriate treatment of angina.

Prevalence and Prognosis of Hyperkalemia in Patients with Acute Myocardial Infarction

BACKGROUND

Hyperkalemia is common and potentially dangerous in hospitalized patients; its contemporary prevalence and prognostic importance after acute myocardial infarction are not well described.

METHODS

In 38,689 consecutive patients with acute myocardial infarction from the Cerner Health Facts database, we evaluated the association between maximum in-hospital potassium levels and in-hospital mortality. Patients were stratified by dialysis status and grouped by maximum potassium as follows: <5 mEq/L, 5 to <5.5 mEq/L, 5.5 to <6.0 mEq/L, 6.0 to <6.5 mEq/L, and ≥6.5 mEq/L. Multivariable logistic regression was used to adjust for multiple patient and site characteristics. The relationship between the number of hyperkalemic values and the in-hospital mortality was evaluated.

RESULTS

Of 38,689 patients with acute myocardial infarction, 886 were on dialysis. The rate of hyperkalemia (maximum potassium ≥5.0 mEq/L) was 22.6% in patients on dialysis and 66.8% in patients not on dialysis. Moderate to severe hyperkalemia (maximum potassium ≥5.5 mEq/L) occurred in 9.8% of patients. There was a steep increase in mortality with higher maximum potassium levels. In-hospital mortality exceeded 15% once maximum potassium was ≥5.5 mEq/L regardless of dialysis status. The relationship between higher maximum potassium and increased mortality risk persisted after multivariable adjustment. In addition, patients with a greater number of hyperkalemic values (vs a single value) experienced higher in-hospital mortality.

CONCLUSIONS

Hyperkalemia is common in patients who are hospitalized with acute myocardial infarction. Higher maximum potassium levels and number of hyperkalemic events are associated with a steep mortality increase, with higher risks for adverse outcomes observed even at mild levels of hyperkalemia. Whether more intensive management of hyperkalemia may improve outcomes in patients with acute myocardial infarction merits further study.

Association of smoking status with health-related outcomes after percutaneous coronary intervention

BACKGROUND

Patients who smoke at the time of percutaneous coronary intervention (PCI) would ideally have a strong incentive to quit, but most do not. We sought to compare the health status outcomes of those who did and did not quit smoking after PCI with those who were not smoking before PCI.

METHODS AND RESULTS

A cohort of 2765 PCI patients from 10 US centers were categorized into never, past (smoked in the past but had quit before PCI), quitters (smoked at time of PCI but then quit), and persistent smokers. Health status was measured with the disease-specific Seattle Angina Questionnaire and the EuroQol 5 dimensions, adjusted for baseline characteristics. In unadjusted analyses, persistent smokers had worse disease-specific and overall health status when compared with other groups. In fully adjusted analyses, persistent smokers showed significantly worse health-related quality of life when compared with never smokers. Importantly, of those who smoked at the time of PCI, quitters had significantly better adjusted Seattle Angina Questionnaire angina frequency scores (mean difference, 2.73; 95% confidence interval, 0.13-5.33) and trends toward higher disease specific (Seattle Angina Questionnaire quality of life mean difference, 1.97; 95% confidence interval, -1.24 to 5.18), and overall (EuroQol 5 dimension visual analog scale scores mean difference, 2.45; 95% confidence interval, -0.58 to 5.49) quality of life when compared with persistent smokers at 12 months.

CONCLUSIONS

Smokers at the time of PCI have worse health status at 1 year than those who never smoked, whereas smokers who quit after PCI have less angina at 1 year than those who continue smoking.

Impact of multivessel revascularization on health status outcomes in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease

BACKGROUND

Up to 65% of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (MVCAD). Long-term health status of STEMI patients after multivessel revascularization is unknown.

OBJECTIVES

This study investigated the relationship between multivessel revascularization and health status outcomes (symptoms and quality of life [QoL]) in STEMI patients with MVCAD.

METHODS

Using a U.S. myocardial infarction registry and the Seattle Angina Questionnaire (SAQ), we determined the health status of patients with STEMI and MVCAD at the time of STEMI and 1 year later. We assessed the association of multivessel revascularization during index hospitalization with 1-year health status using multivariable linear regression analysis, and also examined demographic, clinical, and angiographic factors associated with multivessel revascularization.

RESULTS

Among 664 STEMI patients with MVCAD, 251 (38%) underwent multivessel revascularization. Most revascularizations were staged during the index hospitalization (64.1%), and 8.0% were staged after discharge, with 27.9% performed during primary percutaneous coronary intervention. Multivessel revascularization was associated with age and more diseased vessels. At 1 year, multivessel revascularization was independently associated with improved symptoms (4.5 points higher SAQ angina frequency score; 95% confidence interval [CI]: 1.0 to 7.9) and QoL (6.6 points higher SAQ QoL score; 95% CI: 2.7 to 10.6). One-year mortality was not different between those who did and did not undergo multivessel revascularization (3.6% vs. 3.4%; log-rank test p = 0.88).

CONCLUSIONS

Multivessel revascularization improved angina and QoL in STEMI patients with MVCAD. Patient-centered outcomes should be considered in future trials of multivessel revascularization.

Angina Frequency After Acute Myocardial Infarction In Patients Without Obstructive Coronary Artery Disease

BACKGROUND

Myocardial infarction (MI) patients without obstructive coronary artery disease (CAD) are at increased risk for recurrent ischemic events, but angina frequency post-MI has not been described.

METHODS AND RESULTS

Among MI patients who underwent angiography, we assessed angina at baseline, 1, 6, and 12 months using the Seattle Angina Questionnaire (SAQ). A hierarchical repeated measures modified Poisson model assessed the association between the absence of obstructive CAD (defined as epicardial stenoses >70% or left main >50%) and angina. Among 5539 MI patients from 31 US hospitals (mean age 60, 68% male), 6.9% had no angiographic obstructive CAD. More patients without obstructive CAD (vs. obstructive CAD) were female (57% vs 30%), non-white (51% vs 24%) and had NSTEMI (87% vs 51%). In unadjusted analyses, patients without obstructive CAD had less angina prior to MI but more angina and worse health status post-discharge. After adjustment for socio-demographic and clinical factors, the risk of post-MI angina was similar in patients without vs. with obstructive CAD (IRR=0.89, 95% CI 0.77-1.02). Among patients without obstructive CAD, depression and self-reported avoidance of care due to cost were independently associated with angina (IRR=1.28 per 5 points on PHQ, 95% CI 1.17-1.41; IRR=1.34, 95% 1.02-1.1.74).

CONCLUSIONS

Following MI, patients without obstructive CAD experience an angina burden at least as high as those with obstructive CAD, affecting 1 in 4 patients at 12 months. As these patients are not candidates for revascularization, other anti-anginal strategies are needed to improve their health status and quality of life.

Abstract 177: Residual Angina Following Elective PCI in Patients with Diabetes

Background: While patients with diabetes (DM) have more diffuse coronary artery disease (CAD), the data on whether they experience more (or less) angina than patients without DM are conflicting. Although older studies suggested that patients with DM have less angina (due to silent ischemia), this has been contradicted by more recent work among patients after myocardial infarction. However, the prevalence of angina after PCI in patients with DM and stable CAD has not been examined.

Methods: In a 10-site US PCI registry, we assessed angina in patients before elective PCI and at 1, 6, and 12 months after PCI with the Seattle Angina Questionnaire (SAQ) angina frequency (AF) score (range 0-100, higher=better). We also examined the rates of antianginal medication prescription at discharge. A multivariable, repeated measures Poisson model including demographic and clinical variables such as multivessel coronary disease was used to examine the association of diabetes with angina.

Results: Among 1080 elective PCI patients (mean age 65, 74.7% male), 34.0% had DM. At baseline, 1, 6, and 12 months, patients with DM had similar angina prevalence as those without DM (Figure). In addition, when assessed as a continuous variable, SAQ AF scores were also similar at baseline and each follow-up for patients with DM vs. without DM (Figure). Patients with DM were more commonly prescribed calcium channel blockers and nitrates at discharge (DM vs. not: 27.9% vs 20.9% [p=0.01] and 32.8% vs. 25.5%, [p=0.01], respectively), while beta-blockers and ranolazine were prescribed at similar rates. In the multivariable, repeated measures model, the risk of angina remained similar at 1 and 12 months, and was slightly higher at 6 months in patients with vs. without diabetes (1 month: RR 1.10, 95% CI 0.84-1.44; 6 month: RR 1.24, 1.06-1.44; 12 months RR 1.04, 0.80-1.36).

Conclusions: Patients with stable coronary artery disease and diabetes exhibit a burden of angina that is at least as high as those without diabetes, despite more aggressive antianginal prescription at discharge. These findings contradict the prevailing “conventional wisdom” which dictates that patients with diabetes experience less angina due to silent ischemia.

Abstract 332: Association of Body Mass Index with Health Status Outcomes in Patients Undergoing Percutaneous Coronary Intervention

Background: An obesity paradox, with better long-term survival in obese patients undergoing percutaneous coronary intervention (PCI), has been well described. The association between obesity and health status outcomes after PCI is unknown.

Methods: We prospectively enrolled 3,281 PCI patients in a 10-center observational cohort study and categorized their body mass index (BMI) into normal (18.5 to <25), overweight (25 to <30), obese (30 to <35) and morbidly obese (≥ 35).Generalized linear models were used to describe the association between BMI and health status measures at 6 & 12 months, after adjusting for baseline characteristics and health status scores. Health status outcomes included; Seattle Angina Questionnaire [SAQ] Angina Frequency (AF), and Quality of Life (QL) scores, as well as the EQ-5D visual analogue scale (EQ-5D VAS). Interaction with time was not significant, so an estimate of the average benefit over time was generated.

Results: The distribution of patients’ BMI revealed that 17% were normal, 35% overweight, 28% obese and 20% morbidly obese. Compared with normal weight patients, morbidly obese individuals were younger (mean 60.8 yr vs. 67.9 yr) and had a higher prevalence of diabetes, hypertension and heart failure. They underwent radial artery access (12.0% vs. 7.0%) and drug eluting stent implantation (80.4% vs. 76.0%) more frequently. Unadjusted changes in scores were lower (worse) among morbidly obese as compared with normal weight patients for SAQ AF (mean difference [MD] -1.52; 95% Confidence Interval [CI] -3.05, -0.02), SAQ QL (MD -2.51; CI -4.48, -0.54), and EQ-5D VAS (MD -5.74;CI -7.52, -3.96). After adjustment, these differences were no longer significantly different for SAQ AF and SAQ QL (figure), although EQ-5D VAS scores remained lower among obese and morbidly obese patients.

Conclusion: The overall health status was mildly worse among obese and morbidly obese individuals after PCI, but the benefits of PCI on patients’ disease-specific health status were similar across weight categories. This suggests that PCI is equally effective in improving angina and disease-specific quality of life, independent of patients’ weight.

Abstract 234: Prevalence and Prognosis of Hyperkalemia in Dialysis and Non-Dialysis Patients with Acute Myocardial Infarction

Background: Hyperkalemia is a potentially dangerous complication during hospitalization for acute myocardial infarction (AMI), but its prevalence and prognostic importance in contemporary practice have not been described.

Methods: We studied consecutive patients with AMI from 67 hospitals in the Cerner Health Facts database to assess the association between maximum in-hospital potassium levels (max K) and in-hospital mortality. Patients were stratified by dialysis status, and grouped into categories of max K (<5 mEq/L, 5-<5.5 mEq/L, 5.5-<6.0 mEq/L, 6.0-<6.5 mEq/L, and ≥ 6.5 mEq/L). Multivariable hierarchical logistic regression was used to adjust for multiple patient and site characteristics.

Results: Of 38,689 patients, 886 (2.3%) were on dialysis. Hyperkalemia (max K ≥ 5.0 mEq/L) occurred in 23.6% of the overall cohort; 22.6% of non-dialysis patients; and 66.8% of dialysis patients. Moderate-severe hyperkalemia (max K ≥ 5.5 mEq/L) occurred in 9.8% of patients. There was an increase in mortality with higher max K levels; this relationship was linear in non-dialysis patients, while a plateau was observed in dialysis patients (Figure). Regardless of dialysis status, in-hospital mortality exceeded 15% once max K ≥5.5 mEq/L. The relationship between max K and mortality persisted after multivariable adjustment (adjusted odds ratios [OR] for max K of 5-<5.5, 5.5-<6.0, 6.0-<6.5, ≥ 6.5 vs. <5 were 2.03 (95% CI 1.79-2.31), 2.79 (2.35-3.31), 4.62 (3.74-5.71), 4.97 (3.96-6.25) respectively for dialysis patients; and 1.62 (1.41-1.87), 2.02 (1.68-2.43), 3.18 (2.51-4.03), 3.37 (2.60-4.36) respectively for non-dialysis patients).

Conclusions: Hyperkalemia occurs in >20% of non-dialysis and >65% of dialysis patients with AMI. There is a graded mortality increase with higher max K levels, particularly in non-dialysis patients, with marked increases in mortality at even mild levels of hyperkalemia. Additional research into the determinants, pathophysiology, and clinical scenarios in which hyperkalemia contributes to mortality is warranted.

Performance of the Medtronic Sentrino continuous glucose management (CGM) system in the cardiac intensive care unit

BACKGROUND

Maintaining glucose in the target range, while avoiding hypoglycemia, is challenging in critically ill patients. We investigated the performance and safety of Medtronic Sentrino, a newly developed continuous glucose management (CGM) system for critically ill adults.

METHODS

This was a prospective, single-center, single-arm, open-label study in adult patients with cardiac ICU admission. Sentrino subcutaneous glucose sensors were inserted into patients' thigh with planned study participation of 72 h. Sensor glucose results were displayed, and the system's alerts and alarms fully enabled. Reference blood glucose was collected from central venous catheter and analyzed with a blood gas analyzer. Treatment decisions were made independently of sensor glucose values, according to the existing standard of care.

RESULTS

A total of 21 patients were enrolled; all successfully completed the study. Sensor glucose values were displayed 96% of the time, and 870 paired blood glucose-sensor glucose points were analyzed. Overall mean absolute relative difference (MARD) was 12.8% (95% CI 11.9% to 13.6%). No clinically significant differences in accuracy were seen within subgroups of hemodynamic status (MARD 12.3% and 13.1% for compromised vs stable hemodynamics). Consensus grid analysis showed >99% of sensor glucose values within A/B zones. No device or study-related adverse events were reported. 100% of clinicians found Sentrino easy to use after two patients.

CONCLUSIONS

In our single-center experience, Sentrino CGM system demonstrated good accuracy and reliability, with no device-related adverse events in critically ill cardiac patients, and was easy to use and integrate in the cardiac ICU.

TRIAL REGISTRATION NUMBER

NCT01763567.

Telomeres and seed banks

We have found that a progressive loss of telomeric sequences occurs from high molecular weight DNA with an increasing appearance at low molecular weight as the periods of storage in the dry state were extended in time to provide seed germination loss from 98 to 0%. Telomere distribution would appear to follow the general pattern of DNA random fragmentation that occurs in the embryos of seeds stored in the dry state, but there are also indications of an overall telomere loss from DNA as a consequence of storage. There is a need for a convenient "equality marker" for the seeds that can be monitored over time. Reviewing the implications of our results very carefully we believe that there is considerable potential in the use of telomere sequences to mark embryo ageing of seeds held in Seed Banks.

Molecular basis of osteoarthritis: biomechanical aspects

The unique biomechanical properties of healthy cartilage ensure that articular cartilage is able to transmit force between the joints while maintaining almost friction-free limb movement. In osteoarthritis, the biomechanical properties are compromised, but we still do not understood whether this precedes the onset of the disease or is a result of it. This review focuses on the physical changes to cartilage with age, disease, and mechanical loading, with specific reference to the increased collagen cross-linking that occurs with age (nonenzymatic glycation), and the response of chondrocytes to physiological and pathological loads. In addition, the biomechanical properties and matrix biosynthesis of cartilage from various joint surfaces of the knee and ankle are compared to elucidate reasons why the ankle is less affected by progressive osteoarthritis than the knee.

Mechanical deformation of polymer matrix controlled release devices modulates drug release

When magnetic fields were applied to polymer matrices of ethylene-vinyl acetate copolymer embedded with drug and a small magnet, drug release was increased up to 30-fold above baseline levels. It has been hypothesized that the effect of magnetic stimulation on the release of drugs from these matrices is the transduction of the applied magnetic field into a mechanical deformation of the matrix through motion of the magnet within the matrix. This current study provides support for this hypothesis by demonstrating that repeated pulsatile mechanical deformation of matrices can enhance the release of macromolecules from ethylene-vinyl acetate copolymer matrices. Furthermore, similar modulated release kinetics were obtained with mechanically compressed and magnetically stimulated matrices. We also established that modulation was dependent on the ratio of compression area to matrix volume and that modulation was maximized when this ratio was optimized.