Temporal trends in the prevalence and severity of aortic stenosis within a contemporary and diverse community-based cohort

BACKGROUND

Data on the epidemiology of aortic stenosis (AS) are primarily derived from single center experiences and administrative claims data that do not delineate by degree of disease severity.

METHODS

An observational cohort study of adults with echocardiographic AS was conducted January 1st, 2013-December 31st, 2019 at an integrated health system. The presence/grade of AS was based on physician interpretation of echocardiograms.

RESULTS

A total of 66,992 echocardiogram reports for 37,228 individuals were identified. The mean ± standard deviation (SD) age was 77.5 ± 10.5, 50.5% (N = 18,816) were women, and 67.2% (N = 25,016) were non-Hispanic whites. The age-standardized AS prevalence increased from 589 (95% Confidence Interval [CI] 580-598) to 754 (95% CI 744-764) cases per 100,000 during the study period. The age-standardized AS prevalences were similar in magnitude among non-Hispanic whites (820, 95% CI 806-834), non-Hispanic blacks (728, 95% CI 687-769), and Hispanics (789, 95% CI 759-819) and substantially lower for Asian/Pacific Islanders (511, 95% CI 489-533). Finally, the distribution of AS by degree of severity remained relatively unchanged over time.

CONCLUSIONS AND RELEVANCE

The population prevalence of AS has grown considerably over a short timeframe although the distribution of AS severity has remained stable.

Outcomes of Adults with Severe Aortic Stenosis Undergoing Urgent or Emergent vs. Elective Transcatheter Aortic Valve Replacement Within an Integrated Health Care Delivery System

Background

Transcatheter aortic valve replacement (TAVR) may be used to urgently or emergently treat severe aortic stenosis, but outcomes for this high-risk population have not been well-characterized. We sought to describe the incidence, clinical characteristics, and outcomes of patients undergoing urgent or emergent vs. elective TAVR.

Methods

We identified all adults who received TAVR for primary aortic stenosis between 2013 and 2019 within an integrated health care delivery system in Northern California. Elective or urgent/emergent procedure status was based on standard Society of Thoracic Surgeons definitions. Data were obtained from electronic health records, the Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry, and state/national reporting databases. Logistic regression and Cox proportional hazard models were performed.

Results

Among 1564 eligible adults that underwent TAVR, 81 (5.2%) were classified as urgent/emergent. These patients were more likely to have heart failure (63.0% vs. 47.4%), reduced left ventricular ejection fraction (21.0% vs. 11.8%), or a prior aortic valve balloon valvuloplasty (13.6% vs. 5.0%) and experienced higher unadjusted rates of 30-day and 1-year morbidity and mortality. Urgent/emergent TAVR status was independently associated with non-improved quality of life at 30-days (hazard ratio, 4.87; p < 0.01) and acute kidney injury within 1-year post-TAVR (hazard ratio, 2.11; p = 0.01). There was not a significant difference in adjusted 1-year mortality with urgent/emergent TAVR.

Conclusions

Urgent/emergent TAVR status was uncommon and associated with high-risk clinical features and higher unadjusted rates of short- and long-term morbidity and mortality. Procedure status may be useful to identify patients less likely to experience significant short term improvement in health-related quality of life post-TAVR.

Long-Term Cardiovascular Effects of COVID-19: Emerging Data Relevant to the Cardiovascular Clinician

Purpose of Review

COVID-19 is now a global pandemic and the illness affects multiple organ systems, including the cardiovascular system. Long-term cardiovascular consequences of COVID-19 are not yet fully characterized. This review seeks to consolidate available data on long-term cardiovascular complications of COVID-19 infection.

Recent Findings

Acute cardiovascular complications of COVID-19 infection include myocarditis, pericarditis, acute coronary syndrome, heart failure, pulmonary hypertension, right ventricular dysfunction, and arrhythmia. Long-term follow-up shows increased incidence of arrhythmia, heart failure, acute coronary syndrome, right ventricular dysfunction, myocardial fibrosis, hypertension, and diabetes mellitus. There is increased mortality in COVID-19 patients after hospital discharge, and initial myocardial injury is associated with increased mortality.

Summary

Emerging data demonstrates increased incidence of cardiovascular illness and structural changes in recovered COVID-19 patients. Future research will be important in understanding the clinical significance of these structural abnormalities, and to determine the effect of vaccines on preventing long-term cardiovascular complications.

Abstract 218: Improving Guideline-Directed Medical Therapy Utilization for Heart Failure With Reduced Ejection Fraction Within a Veteran's Affairs Health System

Despite a robust evidence base and well-established clinical guidelines for patients with HFrEF, a significant number of patients with this disease are not currently prescribed ACEI/ARB/ARNI and beta-blocker therapies at or near target doses proven to reduce the risk of cardiovascular events and mortality in randomized clinical trials. Within the VA Palo Alto Health System we found that the minority of patients with HFrEF prescribed these therapies were receiving ACEI/ARB/ARNI (45.2%: 410 of 908) and beta-blockers (45.4%: 458 of 1008) at ≥50% of target doses.

Limited general medicine and cardiology appointment availability as well as clinical inertia were identified as root causes of suboptimal dosing of guideline-directed medical therapy (GDMT). We addressed these with implementation of a pharmacist driven Heart Failure Medication Titration Clinic through a shared practice agreement with general medicine physicians, initially at one clinical site with 190 total HFrEF patients. An academic detailing clinical dashboard including medication prescribing and LV ejection fraction data (obtained via natural language processing of imaging reports) is utilized by the on-site clinical pharmacist to identify actionable HFrEF patients on suboptimal GDMT. If felt appropriate for escalation of therapy, a patient’s primary care physician or cardiologist approves a referral to the clinic. The pharmacist then conducts regular clinic or telephone visits (typically every two weeks) with the patient to assess tolerance of therapy and eligibility for further dose escalation per an established titration algorithm that integrates recent symptoms, vital signs, and lab values.

In three months, patients referred to the Heart Failure Medication Titration Clinic have had their average ACE/ARB/ARNI dose escalated from 21.9% to 42.7% of target dose and their average beta-blocker dose escalated from 56.3% to 81.3% of target dose. No adverse medication events or hospitalizations have occurred. There has been a corresponding increase in the overall percentage of this clinical site’s HFrEF patients on ACEI/ARB/ARNI (36.4% to 43.7%: 55 of 126) and beta-blockers (39.4% to 43.0%: 55 of 128) that are receiving ≥50% of target dose therapy.

These results suggest that clinical pharmacists can play a vital role in identifying and treating patients that are on suboptimal treatment for HFrEF via utilization of an academic detailing dashboard and pharmacist led medication titration clinics. Limitations of this quality improvement initiative include short duration of follow-up to date and performance of these interventions within an integrated health care system, which may not be generalizable to other health care delivery models. Next steps include addition of mineralocorticoid antagonist therapy to our titration algorithm and scaling these interventions to additional clinical sites within our health system.

Enantioselective synthesis of (-)-sclerophytin A by a stereoconvergent epoxide hydrolysis

The cytotoxic natural product (-)-sclerophytin A was constructed in 13 steps from geranial. Highlights from the synthesis are a stereoselective Oshima-Utimoto reaction, a Shibata-Baba indium-promoted radical cyclization, and a novel stereoconvergent epoxide hydrolysis.