Left ventricular unloading with Impella versus IABP in patients on VA-ECMO for cardiogenic shock

Background

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in shock is limited by increased left ventricular afterload. Impella and intra-aortic balloon pump (IABP) can be used in conjunction with VA-ECMO to help unload the left ventricle. Data comparing the two strategies are limited.

Purpose

We performed a systematic review and meta-analysis of published data to compare outcomes of patients with shock supported by VA-ECMO in conjunction with Impella versus IABP.

Methods

We conducted a search of Medline, Embase, and Cochrane databases to identify studies comparing the use of Impella versus IABP in patients on VA-ECMO. The primary outcome of interest was all-cause mortality (in-hospital or 30-day). Secondary outcomes included transition to destination therapy with left ventricular assist device (LVAD) or transplant, stroke, need for continuous renal replacement therapy (CRRT), bleeding, and hemolysis. Risk ratios (RR) with 95% confidence interval and the heterogeneity statistic I2 were reported for each outcome.

Results

Six observational studies with a total of 629 patients were included in the analysis. Of these, 205 (33%) and 424 (67%) patients were supported by Impella and IABP respectively, in addition to VA-ECMO. All six studies reported the primary outcome. No difference was observed in all-cause mortality between VA-ECMO with Impella and VA-ECMO with IABP (RR 1.02 [0.74–1.40], I2=74%). Similar rates were observed for transition to LVAD or transplant (RR 0.75 [0.45–1.27], I2=0%), stroke (RR 1.50 [0.80–2.83], I2=0%), and need for CRRT (RR 1.04 [0.82–1.32], I2=0%). However, use of VA-ECMO with Impella was associated with a higher risk of bleeding (RR 1.91 [1.28–2.86], I2=68%) and hemolysis (RR 4.61 [1.24–17.17], I2=66%) as compared with use of VA-ECMO with IABP.

Conclusion

In patients with shock requiring VA-ECMO, concurrent use of Impella and IABP had similar risk of mortality, transition to LVAD/transplant, stroke, and need for CRRT. However, Impella use was associated with higher risk of bleeding and hemolysis. Randomized trials are needed to identify the optimal strategy for left ventricular unloading in patients with cardiogenic shock on VA-ECMO.

Funding Acknowledgement

Type of funding sources: None.

Benefits of Adding Glucagon-Like Peptide 1 Receptor Agonists to Sodium-Glucose Co-Transporter 2 Inhibitors in Diabetic Patients With Atherosclerotic Disease and Heart Failure

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) reduce the risk of cardiovascular events and heart failure hospitalization (HFH) in patients with heart failure with reduced ejection fraction (HFrEF), diabetes mellitus type 2 (DM2), and atherosclerotic cardiovascular disease (ASCVD). The role of glucagon-like peptide 1 agonists (GLP1a) in these patients is unclear. We designed this study to assess if the addition of GLP1a to SGLT2i therapy improves outcomes in patients with HFrEF, DM2, and ASCVD. This was a retrospective cohort study of patients with DM2, ASCVD, and HFrEF in the national Veterans Affairs database. Patients on SGLT2i were propensity matched to patients on both SGTL2i and GLP1a. The co-primary outcomes were HFH and the composite of all-cause death, myocardial infarction, and stroke. We assessed them through a Cox regression model including unbalanced baseline characteristics. From a cohort of 5,576 patients, 343 were propensity matched to each study arm. The addition of GLP1a was associated with a 67% reduction in the 1-year risk of a composite event compared with therapy with SGLT2i (confidence interval 0.138 to 0.714, p = 0.007). The risk of HFH was not significantly different between both arms (p = 0.199). Sensitivity analyses in the unmatched dataset confirmed these findings. In conclusion, the addition of GLP1a to SGLT2i may reduce the risk of adverse events in patients with HFrEF who have DM2 and ASCVD, but it does not affect the risk of HFH.

Prognostic significance of exercise-induced diastolic dysfunction: A systematic review

BACKGROUND

Recent guidelines recommend diastolic stress testing among patients with unexplained dyspnea. Previous studies have reported exercise related change in diastolic parameters as a prognostic marker for worse outcomes. However, the role of exercise-induced diastolic dysfunction (DD) in predicting adverse outcomes has not been fully established.

METHOD

We conducted a meta-analysis to explore the prognostic significance of exercise-induced DD. PUBMED/EMBASE/SCOPUS databases were searched for studies reporting adverse outcomes in patients undergoing exercise echocardiography based on diastolic response during exercise. Exercise-induced DD was defined as an increase in E/e' or E/A ratio with stress. Outcomes of interest were cardiovascular mortality or hospitalizations.

RESULTS

A total of 8 studies were identified, including 4,462 patients who underwent exercise stress echocardiography. The follow-up ranged from 13 months to 5 years. The major indication for stress testing was exertional dyspnea. All studies reported cardiac mortality and hospitalization in the composite outcome. Meta-analysis conducted using random-effects model showed that exercise-induced DD was associated with a higher likelihood of cardiovascular mortality or hospitalization (HR = 1.32, P < .05). Significant heterogeneity was noted among the studies.

CONCLUSIONS

Exercise-induced DD is associated with worse cardiovascular outcomes. Changes in echocardiographic parameters such as e' with exercise might be useful for risk stratification and identification of high-risk patients.

170. Predictors of Recurrent Infective Endocarditis in Intravenous Drug Users

Background

Caring for hospitalized patients with infective endocarditis (IE) can be challenging due to the nature of the disease and its complications, underlying medical and psychiatric problems, socioeconomic status and environmental factors.Some of these patients develop recurrent IE after the first episode treated. On-going intravenous (IV) drug use after hospital discharge is the highest predictive factor for recurrent IE. Besides IV drug use, there are limited data of other contributing factors to recurrent IE. Those factors may be modifiable during the first hospitalization to reduce the incidence of recurrent IE.

Methods

A retrospective cohort study was conducted at a large tertiary acute care medical center in Tampa, Florida. All consecutive patients with IE with history of IV drug use from January, 2011 to December, 2017 were included. Basic demographic information, co-morbidities (diabetes, hypertension, chronic lung and kidney diseases, HIV, Hepatitis B and C status, coronary artery diseases), valves involved, length of stay, complications at their first IE episode such as septic shock and stroke were included. Groups were identified based on the first episode, first recurrence and second or more recurrences of IE.

Results

A total of 106 patients were identified based on the inclusion criteria. The association between the type of valve infection (right side and left side) and IE recurrence was found to be statistically significant. (P = 0.003). Right side valves are prone to have recurrent IE episodes. People with recurrent IE were more likely to have septic shock (P = 0.02) and requiring intensive care unit (ICU) admissions (P < 0.001) during their first episode There was no statistically significant difference between other demographic information and recurrent endocarditis as well as other parameters such as organisms or type of substance used. (Table 1)

Conclusion

Right-sided IE and presence of septic shock during their first episode of IE may be the predictors for recurrent IE. Interventions including closer follow-up, more aggressive septic shock recognition and management, socioeconomic assessment in addition to substance abuse treatments after discharge should be considered to prevent recurrent IE.

Disclosures

All authors: No reported disclosures.

Abstract 181: Application of the 2018 Cholesterol Guideline for Secondary Prevention in Very High-risk Patients with Atherosclerotic Cardiovascular Disease in the United States

Background: As opposed to the prior cholesterol guideline which did not include low-density lipoprotein cholesterol (LDL-C) goal for secondary prevention, the 2018 American Heart Association (AHA)/American College of Cardiology (ACC) guideline recommends to lower LDL-C levels below 70 mg/dL in patients with atherosclerotic cardiovascular disease (ASCVD) who are at very high-risk. In this cross-sectional study, we investigated an epidemiological impact of the 2018 guideline with the new LDL-C goal for secondary prevention in the U.S.

Methods: From the National Health and Nutrition Examination Survey (NHANES) 2005-2014, we identified very high-risk patients with clinical ASCVD who had completed a fasting blood test including LDL-C. ASCVD included self-reported coronary heart disease, angina, myocardial infarction, and any stroke. As per the guideline, very high-risk was defined as presence of multiple (≥ 2) high-risk conditions, such as old age (≥ 65 years), diabetes, hypertension, chronic kidney disease, current smoking, and history of heart failure. We estimated patients who were taking prescribed cholesterol medications and whose LDL-C level was ≥ 70 mg/dL despite the lipid-lowering therapy. Sampling weights were used in all statistical analyses to account for complex sampling design and nonresponse of the NHANES. Data are presented as weighted prevalence (%) and 95 % confidence interval (CI) or mean ± standard deviation.

Results: Among 1093 nationally representative patients with clinical ASCVD, we finally included 978 patients who were at very-high risk (86.3 % [95 % CI, 83.1-88.9]). Their mean LDL-C level was 100.3 ± 2.8 mg/dL, and 77.5 % (95 % CI, 74.0-80.6) had LDL-C levels ≥ 70 mg/dL. Among patients who answered the survey question regarding lipid-lowering therapy (n =574), 91.3 % (95 % CI, 88.3-93.6) were taking prescribed cholesterol medications. Mean LDL-C level of those who were taking the cholesterol medications was 98.2 ± 14.0 mg/dL, and 68.9 % (95 % CI, 64.0-73.5) of them had LDL-C levels ≥ 70 mg/dL despite the lipid-lowering therapy. When this result was extrapolated to the entire U.S. population using the sampling weights, 6.1 million ASCVD patients at very high-risk who were on lipid-lowering therapy had LDL-C levels above the goal. Although we used data from 2005 to 2014 to include more patients, results were not so much different when the analyses were restricted to the most recent survey cycle (2013-2014).

Conclusion: In the U.S., more than eight out of ten patients with clinical ASCVD were at very high-risk. Although majority of those very high-risk patients with ASCVD were receiving lipid-lowering therapy, about two thirds of them still had LDL-C levels above the goal recommended by the new cholesterol guideline. Therefore, more attention should be made for secondary prevention after ASCVD in very high-risk patients.

In-Hospital and Long-Term Outcomes of Beta-Blocker Treatment in Cocaine Users: A Systematic Review and Meta-analysis

Background

Although β-blocker treatment is generally contraindicated in patients presenting with acute cocaine intoxication due to concern for unopposed α-receptor stimulation, some studies have reported that β-blocker treatment did not increase adverse events in these patients. As this treatment is still controversial, we performed a meta-analysis of observational studies on this topic.

Methods

By searching three electronic databases (MEDLINE, EMBASE, and the Cochrane Library) from their inception to June 11, 2018, we identified eight observational studies with 2,048 patients who presented to hospital with cocaine-associated chest pain or after recent cocaine use. Outcomes of interest were myocardial necrosis or infarction (MI) and death during hospital stay or follow-up. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated by using a random-effects meta-analysis based on the DerSimonian-Laird method.

Results

Among patients presenting with cocaine-associated chest pain or recent cocaine use, there was no significant difference in in-hospital all-cause mortality (RR, 0.59; 95% CI, 0.24 - 1.47) and MI (RR, 1.24; 95% CI, 0.74 - 2.06) between patients who did and did not receive β-blocker treatment during their hospital stay. During long-term follow-up (mean 2.6 years), there was no significant difference in all-cause mortality (RR, 0.79; 95% CI, 0.44 - 1.41) and MI (RR, 0.96; 95% CI, 0.40 - 2.33) between the two groups.

Conclusions

These results suggest that β-blocker treatment in patients presenting with cocaine intoxication may not be as harmful as originally believed. Further clinical studies are needed to investigate this topic.

Abstract P172: A Correlative Study of Cuff Hypertension and Anthropometric Variables in Obese and Non Obese Subjects

Introduction: According to the National Health And Nutrition Examination Survey (NHANES), 65 million Americans have hypertension and one-quarter of adults have blood pressure in the “pre hypertension” range. In such scenario accurate BP measurement is very important. This study focused on prevalence of hypertension among Obese individuals.

Methods: 400 patients ( 200 patients each with < and > BMI 25 ) were studied in rural tertiary hospital in India. Inclusion criteria - patients aged 20-50 yrs. Obese ( defined by BMI > 25) . Exclusion criteria, Subjects on anti- hypertensive medication , Secondary causes of clinically identifiable hypertension Diabetic subjects who are known hypertensives or with complications of DM , Pregnant women, Known cases of Ischemic heart disease. Enrolled patient were evaluated for Height , weight. Two cuff sizes 12 cm/15 cm used to measure BP. Statistical analysis was done with SPSS package and MS Excel, Student’s t-test and linear correlation coefficient used. p values < 0.05 were considered t significant. SBP - systolic Blood pressure and DBP - Diastolic Blood pressure.

Results: SBP and DBP increased significantly with increase of BMI in both men and women ( p < 0.005 ). There is statistically significant standard and large cuff differences in SBP with P value 0.003 and 0.01 and DBP with p values were 0.004 and 0.00 for male and female respectively. There was also a statistically significant ( p value < 0.05) standard-large cuff difference in both SBP and DBP in W/H ratio categories ( <1 and >1 ) in males

Discussion: Cuff characteristics, i.e. the cuff-bladder width and length, can bias measurement of blood pressure in obese. Our study explained the potential for overdiagnosis of BP with using a wrong size cuff for people with BMI > 25 and W/H > 1. The prevalence of Systolic Hypertension based on JNC guidelines in the obese population with a regular cuff was 28% and with large appropriate size cuff it was 12%, a difference of 16% and similarly a difference of 12.5 % with diastolic BP. The prevalence of obesity in the US is 37% and this concept of Cuff Hypertension highlighted in our study is very important is such a setting as it can lead to lot of mis-diagnosed hypertension with unnecessary treatment burden and side effects.

Novel method versus the Friedewald method for estimating low-density lipoprotein cholesterol in determination of the eligibility for statin treatment for primary prevention in the United States

Although the Friedewald method has been used as the clinical standard to estimate low-density lipoprotein cholesterol (LDL-C) levels, a novel method with better accuracy was suggested and is now being adopted in real practice. We investigated the effect of this novel method on determining the eligibility for statin treatment for primary prevention in the United States.In this cross-sectional study, we determined the discordance in the statin-eligible population for primary prevention according to the 2 different LDL-C estimating methods based on the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Using data from the National Health and Nutrition Examination Survey 2005-2014, we included 5302 nationally representative US adults aged between 40 and 75 years without history of atherosclerotic cardiovascular disease (ASCVD). Sampling weights were used in all statistical analyses to account for complex sampling design and nonresponse.If the Friedewald method is replaced by the novel method for analysis of the fasting samples, 0.2% (95% confidence interval [CI], 0.0-0.8) and 0.4% (95% CI, 0.3-0.6) of the population would no longer be eligible or would become newly eligible for statin treatment, respectively. Among the individuals with a TG level ≥150 mg/dL and LDL-C level estimated using the Friedewald method <70 mg/dL, 11.6% (95% CI, 4.0-29.3) would become newly eligible for the statin treatment when using the novel method.The use of the novel method for estimating LDL-C instead of the Friedewald method would be associated with a small net increase in statin eligible/needed US adults for primary prevention based on the 2013 ACC/AHA guidelines. Reassessment of individuals' statin eligibility using the novel method may be beneficial, particularly when their TG level is 150 mg/dL or higher and LDL-CF level is lower than 70 mg/dL.

Progressive Multifocal Leukoencephalopathy and Monoclonal Antibodies: A Review

Progressive multifocal leukoencephalopathy (PML) is a viral infection predominantly seen in patients with HIV infection. However, with the increased use of monoclonal antibodies (MAB) for various lymphoproliferative disorders, we are now seeing this infection in non-HIV patients on drugs such as natalizumab, rituximab, and so on. The aim of this article is to review the relationship between the occurrence of PML and MAB used in the treatment of hematological malignancies and autoimmune diseases. Review of articles from PubMed-indexed journals which study PML in relation to the use of MAB. Relevant literature demonstrated an increased risk of reactivation of latent John Cunningham polyomavirus (JCV) resulting in development of PML in patients on long-term therapy with MAB. The highest incidence of 1 PML case per 1000 treated patients and 1 case per 32 000 was observed in patients treated with natalizumab and rituximab, respectively. Serological and polymerase chain reaction tests for the detection of JCV can be helpful in risk stratification of patients for the development of PML before and during therapy with MAB. Treatment with MAB can result in development of PML. Clinicians should include PML in differential diagnosis in patients treated with these agents if they manifest central nervous system symptoms.

A single-center study of cancer and chemotherapy-induced kidney disease

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Background: It is clinically understood that chronic kidney disease (CKD) and cancer are interrelated. Yet, few studies measure how renal outcomes vary according to common malignancies and common therapeutic agents. We report the incidence and the nature of CKD among cancer patients from a single institution. Methods: A retrospective chart review of cancer patients managed in the onconephrology clinic at the Moffitt Cancer Center from 05/01/2015 to 07/31/2016 was conducted. Patients with acute or chronic kidney disease secondary to a malignancy or side effect of chemotherapy were included in this study. Renal function outcomes were recorded at three-month follow-up intervals from the 15-month duration. Results: Out of the total 88 patients with median age of 68 years, 63 patients were diagnosed with chronic kidney disease, whereas the remaining had acute kidney injury. Kidney cancer and multiple myeloma represented the largest proportion with 12 patients each. Patients with kidney cancer had a mean creatinine of (2.35, 1.74) mg/dl compared to patients without kidney cancer with creatinine (1.97, 1.07) mg/dl. Abdominal cancers had the highest proportion of chronic kidney disease (84.21%) whereas 81.48% of patients with genitourinary cancers had chronic kidney disease. Patients prescribed tyrosine kinase inhibitors had a lower average estimated glomerular filtration rate (28.37, 9.86) mL/min/1.73 m2 compared to other chemotherapeutic agents, though this was a weakly significant relationship (p-value = 0.07). Similar renal outcomes according to malignancy and chemotherapy are reported. Conclusions: This group of patients demonstrated the frequency of chronic kidney disease differs depending on the type of malignancy or chemotherapy. A multidisciplinary approach involving oncologists and nephrologists should be adopted to prevent further renal damage from cancer and its therapies.

Marijuana Smoking in Patients With Leukemia

Worldwide, marijuana (cannabis) is a widely used drug. The incidence of marijuana smoking is increasing and is second only to tobacco as the most widely smoked substance in the general population. It is also the second most commonly used recreational drug after alcohol. Some adverse effects of marijuana smoking have been documented; however, the number of studies on the pulmonary effects of marijuana in individuals with leukemia is limited. In our case series, we report on 2 men with acute myeloid leukemia with miliary nodular lung patterns on computed tomography of the chest due to heavy marijuana use. We also report on 2 patients with acute lymphocytic leukemia who had a history of smoking marijuana and then developed lung opacities consistent with mold infection.

Primary Gangrenous Cutaneous Mold Infections in a Patient With Cancer and Neutropenia

BACKGROUND

Opportunistic fungal infections caused by Aspergillus and Candida followed by infections with Fusarium, Rhizopus, Mucor, and Alternaria species are an important cause of morbidity and mortality in patients with hematological malignancies. Cutaneous mucormycosis infections are rare, and the incidence, outcomes, and factors associated with survival in the setting of hematological malignancies are not clear.

METHODS

A literature search was conducted for all cases of primary cutaneous mold infections in patients with hematological malignancy, of which 50 cases were found. Our case of a patient with a hematological malignancy who sustained a cat bite that in turn caused a primary cutaneous mold infection is also included.

RESULTS

In the 51 cases identified, 66.7% were neutropenic upon presentation, and 54.9% were male with an average age of 32 years. Aspergillus species (33.3%) was the most cited followed by Rhizopus species (19.6%). Overall mortality rate was 29.4% and was observed more frequently in patients with neutropenia (60.0%) and without surgical intervention (73.3%). Survival rate was higher (35.3%) for cases utilizing both antifungal and surgical intervention. The antifungal agent with the highest survival rate was amphotericin B and its formulations (58.8%).

CONCLUSIONS

Neutropenia within hematological malignancies demonstrate a risk for developing severe cutaneous fungal infections, of which primary cutaneous mucormycosis can carry significant mortality. Combination antifungal therapy and surgical debridement appears to be associated with higher survival outcomes and warrants further investigation.