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Bansal M, Mehta A, Ahmad K, Bortnick AE, Nagaraja V, Hyder ON, Dawn Abbott J, Vallabhajosyula S. Management and Outcomes of Pulmonary Embolism in Women of Reproductive Age Admitted to Urban Versus Rural Areas Compared to Men. Catheter Cardiovasc Interv 2025; 105:193-199. [PMID: 39659102 DOI: 10.1002/ccd.31344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2024] [Accepted: 11/24/2024] [Indexed: 12/12/2024]
Abstract
There are limited and conflicting data on sex and urban-rural disparities in outcomes of patients with pulmonary embolism (PE) in the reproductive age group. Our object was to assess sex disparities in the reproductive age group cohort. All adult non-elective admissions in the reproductive age group (18-49 years) with a primary diagnosis of PE and with no missing sex/age data were identified using the National Inpatient Sample. Females and males were stratified into rural and urban location based on hospital information. Outcomes of interest included in-hospital mortality, complication rates, variations in management, total hospitalization costs, and length of stay. During 01/01/2016 to 12/31/2020, 180,898 PE admissions aged 18-49 years were identified (rural-12,319 [6.8%]). Females comprised 54.8% and 55.1% of the rural and urban cohorts, respectively. Overall, compared to males, females in urban and rural regions had largely comparable rates of definitive PE interventions, except lower rates of catheter directed therapy (4.7 vs. 3.6%, p < 0.001) in females admitted to urban hospitals. Despite younger age, higher comorbidity, and lower utilization of PE interventions, females in both regions had similar unadjusted in-hospital mortality (rural 1.1% vs. 1.0%; p = 0.93 and urban 1.8% vs. 1.7%; p = 0.78) and hospitalization costs compared to males. In conclusion, females of reproductive age group had comparable in-hospital outcomes to males in both urban and rural areas. Females in urban areas had lower utilization of advanced PE interventions, potentially indicating selective management strategies in different settings.
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Mehta A, Bansal M, Singh A, Kompella R, Chanda A, Mehta C, Mullin CJ, Abbott JD, Vallabhajosyula S. Hospital-Level Disparities in the Management and Outcomes of Pulmonary Embolism. Am J Cardiol 2024; 240:S0002-9149(24)00887-7. [PMID: 39746562 DOI: 10.1016/j.amjcard.2024.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2024] [Revised: 12/13/2024] [Accepted: 12/24/2024] [Indexed: 01/04/2025]
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Carson JL, Fergusson DA, Noveck H, Mallick R, Simon T, Rao SV, Cooper H, Stanworth SJ, Portela GT, Ducrocq G, Bertolet M, DeFilippis AP, Goldsweig AM, Kim S, Triulzi DJ, Menegus MA, Abbott JD, Lopes RD, Brooks MM, Alexander JH, Hébert PC, Goodman SG, Steg PG. Restrictive versus Liberal Transfusion in Myocardial Infarction - A Patient-Level Meta-Analysis. NEJM EVIDENCE 2024:EVIDoa2400223. [PMID: 39714935 DOI: 10.1056/evidoa2400223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2024]
Abstract
BACKGROUND Clinical guidelines have concluded that there are insufficient data to provide recommendations for the hemoglobin threshold for the use of red cell transfusion in patients with acute myocardial infarction (MI) and anemia. After the recent publication of the Myocardial Infarction and Transfusion (MINT) trial, we performed an individual patient-level data meta-analysis to evaluate the effect of restrictive versus liberal blood transfusion strategies. METHODS We conducted searches in major databases. Eligible trials randomly assigned patients with MI and anemia to either a restrictive (i.e., transfusion threshold of 7-8 g/dl) or liberal (i.e., transfusion threshold of 10 g/dl) red cell transfusion strategy. We used individual patient data from each trial. The primary outcome was a composite of 30-day mortality or MI. RESULTS We included 4311 patients from four trials. The primary outcome occurred in 334 patients (15.4%) in the restrictive strategy and 296 patients (13.8%) in the liberal strategy (relative risk [RR] 1.13, 95% confidence interval [CI], 0.97 to 1.30). Death at 30 days occurred in 9.3% of patients in the restrictive strategy and in 8.1% of patients in the liberal strategy (RR 1.15, 95% CI, 0.95 to 1.39). Cardiac death at 30 days occurred in 5.5% of patients in the restrictive strategy and in 3.7% of patients in the liberal strategy (RR 1.47, 95% CI, 1.11 to 1.94). Heart failure (RR 0.89, 95% CI, 0.70 to 1.13) was similar in the transfusion strategies. All-cause mortality at 6 months occurred in 20.5% of patients in the restrictive strategy compared with 19.1% of patients in the liberal strategy (hazard ratio 1.08, 95% CI, 1.05 to 1.11). CONCLUSIONS Pooling individual patient data from four trials did not find a definitive difference in our primary composite outcome of MI or death at 30 days. At 6 months, a restrictive transfusion strategy was associated with increased all-cause mortality. (Partially funded by a grant from the U.S. National Heart, Lung, and Blood Institute [R01HL171977].).
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DeFilippis AP, Abbott JD, Herbert BM, Bertolet MH, Chaitman BR, White HD, Goldsweig AM, Polonsky TS, Gupta R, Alsweiler C, Silvain J, de Barros E Silva PGM, Hillis GS, Daneault B, Tessalee M, Menegus MA, Rao SV, Lopes RD, Hébert PC, Alexander JH, Brooks MM, Carson JL, Goodman SG. Restrictive Versus Liberal Transfusion in Patients With Type 1 or Type 2 Myocardial Infarction: A Prespecified Analysis of the MINT Trial. Circulation 2024; 150:1826-1836. [PMID: 39206549 PMCID: PMC11611643 DOI: 10.1161/circulationaha.124.071208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The MINT trial (Myocardial Ischemia and Transfusion) raised concern for harm from a restrictive versus liberal transfusion strategy in patients with acute myocardial infarction (MI) and anemia. Type 1 and type 2 MI are distinct pathophysiologic entities that may respond differently to blood transfusion. This analysis sought to determine whether the effects of transfusion varied among patients with a type 1 or a type 2 MI and anemia. The authors hypothesized that the liberal transfusion strategy would be of greater benefit in type 2 than in type 1 MI. METHODS The authors compared rates of death or MI at 30 days in patients with type 1 (n=1460) and type 2 (n=1955) MI and anemia who were randomly allocated to a restrictive (threshold, 7-8 g/dL) or a liberal (threshold, 10 g/dL) transfusion strategy. RESULTS The primary outcome of death or MI was observed in 16% of type 1 MI and 15.4% of type 2 MI patients. The rate of death or MI was higher in patients with type 1 MI randomized to a restrictive (18.2%) versus liberal (13.8%) transfusion strategy (relative risk [RR], 1.32 [95% CI, 1.04-1.67]) with no difference observed between the restrictive (15.8%) and liberal (15.1%) transfusion strategies in patients with type 2 MI (RR, 1.05 [95% CI, 0.85-1.29]). The test for a differential effect of transfusion strategy by MI type was not statistically significant (Pinteraction = 0.16). CONCLUSIONS The concern for harm with a restrictive transfusion strategy in patients with acute MI and anemia raised in the MINT primary outcome manuscript may be more apparent in patients with type 1 than type 2 MI. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02981407.
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Singh S, Tantry US, Bliden K, Saad M, Gurbel PA, Abbott JD, Garg A. Meta-Analysis of Physiology-Guided Complete or Culprit Lesion-Only Percutaneous Coronary Interventions in Myocardial Infarction. Am J Cardiol 2024; 232:49-56. [PMID: 39299632 DOI: 10.1016/j.amjcard.2024.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/05/2024] [Accepted: 09/10/2024] [Indexed: 09/22/2024]
Abstract
Whether physiology-guided complete revascularization of nonculprit lesions is superior to culprit lesion-only percutaneous coronary intervention (PCI) in patients with myocardial infarction (MI) and multivessel disease remains debated. Online databases were searched for randomized controlled trials comparing physiology-guided complete revascularization and culprit lesion-only PCI in patients with MI. The outcomes of interest were all-cause death, cardiovascular (CV) death, repeat revascularization, MI, stent thrombosis, and contrast-associated nephropathy/acute kidney injury. Pooled odds ratios, along with 95% confidence intervals (CI) were calculated. A total of 4,849 patients (n = 2,288 physiology-guided complete revascularization, n = 2,561 culprit lesion-only PCI) were included. The mean age was 66 years and 76% were men. At a mean follow-up of 2.5 years, physiology-guided complete revascularization was associated with significant reductions in CV death (odds ratio 0.72, 95% CI 0.54 to 0.97, p = 0.03) and repeat revascularizations (0.50, 95% CI 0.38 to 0.66, p <0.00001) compared with culprit lesion-only PCI. There were no differences between the 2 approaches in all-cause death (0.91, 95% CI 0.69 to 1.19, p = 0.50), MI (0.85, 95% CI 0.59 to 1.21, p = 0.36), stent thrombosis (1.24, 95% CI 0.58 to 2.69, p = 0.58), and contrast-associated nephropathy/acute kidney injury (1.07, 95% CI 0.88 to 1.31, p = 0.50). In conclusion, among patients with MI and multivessel disease, physiology-guided complete revascularization was associated with significant reductions in CV death and revascularizations compared with culprit lesion-only PCI.
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Mehta A, Bansal M, Mehta C, Pillai AA, Allana S, Jentzer JC, Ventetuolo CE, Abbott JD, Vallabhajosyula S. Utilization of inpatient palliative care services in cardiac arrest complicating acute pulmonary embolism. Resusc Plus 2024; 20:100777. [PMID: 39314255 PMCID: PMC11417587 DOI: 10.1016/j.resplu.2024.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 09/02/2024] [Accepted: 09/06/2024] [Indexed: 09/25/2024] Open
Abstract
Introduction The role of palliative care services in patients with cardiac arrest complicating acute pulmonary embolism has been infrequently studied. Methods All adult admissions with pulmonary embolism complicating cardiac arrest were identified using the National Inpatient Sample (2016-2020). The primary outcome of interest was the utilization of palliative care services. Secondary outcomes included predictors of palliative care utilization and its association of with in-hospital mortality, do-not-resuscitate status, discharge disposition, length of stay, and total hospital charges. Multivariable regression analysis was used to adjust for confounding. Results Between 01/01/2016 and 12/31/2020, of the 7,320 admissions with pulmonary embolism complicating cardiac arrest, 1229 (16.8 %) received palliative care services. Admissions receiving palliative care were on average older (68.1 ± 0.9 vs. 63.2 ± 0.4 years) and with higher baseline comorbidity (Elixhauser index 6.3 ± 0.1 vs 5.6 ± 0.6) (all p < 0.001). Additionally, this cohort had higher rates of non-cardiac organ failure (respiratory, renal, hepatic, and neurological) and invasive mechanical ventilation (all p < 0.05). Catheter-directed therapy was used less frequently in the cohort receiving palliative care, (2.8 % vs 7.9 %; p < 0.001) whereas the rates of systemic thrombolysis, mechanical and surgical thrombectomy were comparable. The cohort receiving palliative care services had higher in-hospital mortality (85.7 % vs. 69.1 %; adjusted odds ratio 2.20 [95 % CI 1.41-3.42]; p < 0.001). This cohort also had higher rates of do-not-resuscitate status and fewer discharges to home, but comparable hospitalization costs and length of hospital stay. Conclusions Palliative care services are used in only 16.8 % of admissions with cardiac arrest complicating pulmonary embolism with significant differences in the populations, suggestive of selective consultation.
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Callegari S, Romain G, Cleman J, Scierka L, Peri-Okonny PA, Spertus J, Labrosciano C, Beltrame JF, Abbott JD, Fitridge R, Mena-Hurtado C, Smolderen KG. Association of social support and health status outcomes in peripheral artery disease. J Vasc Surg 2024; 80:1824-1835.e7. [PMID: 39151740 PMCID: PMC11585422 DOI: 10.1016/j.jvs.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/10/2024] [Accepted: 08/04/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE A critical goal in the care of patients with peripheral artery disease (PAD) is to optimize their health status; that is, their symptoms, function, and quality of life. Social support has been proposed to be a predictor of disease-specific health status in patients with PAD. However, the prevalence of low perceived social support, the association with health status outcomes, and the interaction with other biopsychosocial variables, is unknown. Our aim was to assess the association of baseline perceived social support with health status at 12 months in patients with PAD. METHODS The Patient-Centered Outcomes Related Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) registry, which enrolled patients with PAD in the United States, the Netherlands, and Australia from 2011 to 2015, was used. Perceived social support was assessed at baseline with the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Inventory (ESSI), and disease-specific (Peripheral Artery Disease Questionnaire [PAQ]) and generic health status (Euro-Quality of Life Visual Analog Scale [VAS] and EQ-5D-3L Index) questionnaires were assessed at baseline and 12 months. Low social support was defined as a score of ≤3 on two items and an ESSI score of ≤18. A hierarchical mixed level linear regression model adjusting for biopsychosocial variables was used to assess the association between low perceived social support and the ESSI score with health status at 12 months. RESULTS A total of 949 patients were included (mean age, 67.64 ± 9.32 years; 37.9% female), with low social support being present in 18.2%. Patients with low social support were more likely to not be married or to be living alone (50.0% vs 77.5%; P < .001); have more financial constraints; have more depressive, stress, and anxiety symptoms; and have lower disease-specific and generic health status at baseline and at 12 months. In the unadjusted model, low social support was associated with a -7.02 (95% confidence interval [CI], -10.97 to -3.07) point reduction in the PAQ, -7.43 (95% CI, -10.33 to -4.54) in the VAS, and -0.06 (95% CI, -0.09 to -0.03) in the EQ-5D-3L Index. Adjusting for biopsychosocial factors minimally attenuated these associations (PAQ: -6.52; 95% CI, -10.55 to -2.49; P = .002; VAS: -5.39; 95% CI, 8.36 to -2.42; P < .001; EQ-5D-3L Index: -0.04; 95% CI, -0.07 to 0.01; P = .022). The ESSI per-point score was associated with a decrease of 0.51 (95% CI, 0.18-0.85; P = .003) in PAQ and 0.46 (95% CI, 0.12-0.61; P = .004) in the VAS. CONCLUSIONS Among patients with PAD, low social support was frequent and associated with a lower health status at 1 year independent of other biopsychosocial variables. Improving social support could improve health status and outcomes in PAD.
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Portela GT, Carson JL, Swanson SA, Alexander JH, Hébert PC, Goodman SG, Steg PG, Bertolet M, Strom JB, Fergusson DA, Simon T, White HD, Cooper HA, Abbott JD, Rao SV, Chaitman BR, Fordyce CB, Lopes RD, Daneault B, Brooks MM. Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia : A Target Trial Emulation Using MINT Trial Data. Ann Intern Med 2024; 177:1489-1498. [PMID: 39348705 DOI: 10.7326/m24-0571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2024] Open
Abstract
BACKGROUND The optimal hemoglobin threshold to guide red blood cell (RBC) transfusion for patients with acute myocardial infarction (MI) and anemia is uncertain. OBJECTIVE To estimate the efficacy of 4 individual hemoglobin thresholds (<10 g/dL [<100 g/L], <9 g/dL [<90 g/L], <8 g/dL [<80 g/L], and <7 g/dL [<70 g/L]) to guide transfusion in patients with acute MI and anemia. DESIGN Prespecified secondary analysis of the MINT (Myocardial Ischemia and Transfusion) trial using target trial emulation methods. (ClinicalTrials.gov: NCT02981407). SETTING 144 clinical sites in 6 countries. PARTICIPANTS 3492 MINT trial participants with acute MI and a hemoglobin level below 10 g/dL. INTERVENTION Four transfusion strategies to maintain patients' hemoglobin concentrations at or above thresholds of 10, 9, 8, or 7 g/dL. Protocol exceptions were permitted for specified adverse clinical events. MEASUREMENTS Data from the MINT trial were leveraged to emulate 4 transfusion strategies and estimate per protocol effects on the composite outcome of 30-day death or recurrent MI (death/MI) and 30-day death using inverse probability weighting. RESULTS The 30-day risk for death/MI was 14.8% (95% CI, 11.8% to 18.4%) for a <10-g/dL strategy, 15.1% (CI, 11.7% to 18.2%) for a <9-g/dL strategy, 15.9% (CI, 12.4% to 19.0%) for a <8-g/dL strategy, and 18.3% (CI, 14.6% to 22.0%) for a <7-g/dL strategy. Absolute risk differences and risk ratios relative to the <10-g/dL strategy for 30-day death/MI increased as thresholds decreased, although 95% CIs were wide. Findings were similar and imprecise for 30-day death. LIMITATION Unmeasured confounding may have persisted despite adjustment. CONCLUSION The 30-day risks for death/MI and death among patients with acute MI and anemia seem to increase progressively with lower hemoglobin concentration thresholds for transfusion. However, the imprecision around estimates from this target trial analysis precludes definitive conclusions about individual hemoglobin thresholds. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Elkaryoni A, Hyder O, Saad M, Darki A, Elgendy IY, Mamdani ST, Bunte MC, Aronow HD, Soukas PA, Abbott JD. Trends in Transcatheter Mechanical Thrombectomy for Management of Acute Pulmonary Embolism. Circ Cardiovasc Qual Outcomes 2024; 17:e011038. [PMID: 39492716 DOI: 10.1161/circoutcomes.124.011038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2024]
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Tamis-Holland JE, Abbott JD, Al-Azizi K, Barman N, Bortnick AE, Cohen MG, Dehghani P, Henry TD, Latif F, Madjid M, Yong CM, Sandoval Y. SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102294. [PMID: 39649824 PMCID: PMC11624394 DOI: 10.1016/j.jscai.2024.102294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2024]
Abstract
ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality in the United States. Timely reperfusion with primary percutaneous coronary intervention is associated with improved outcomes. The Society for Cardiovascular Angiography & Interventions puts forth this expert consensus document regarding best practices for cardiac catheterization laboratory team readiness, arterial access with an algorithm to help determine proper arterial access in STEMI, and diagnostic angiography. This consensus statement highlights the strengths and limitations of various diagnostic and therapeutic interventions to access and treat a patient with STEMI in the catheterization laboratory, reviews different options to manage large thrombus burden during STEMI, and reviews the management of STEMI across the spectrum of various anatomical and clinical circumstances.
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Imran HM, Has P, Kassis N, Shippey E, Elkaryoni A, Gordon PC, Sharaf BL, Soukas PA, Hyder ON, Sellke F, Ehsan A, Sodha N, Mentias A, Elgendy IY, Alkhouli M, Abbott JD, Aronow HD, Saad M. Characteristics, Trends, and Outcomes of Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Replacement in United States. JACC Cardiovasc Interv 2024; 17:2367-2376. [PMID: 39477639 DOI: 10.1016/j.jcin.2024.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 08/19/2024] [Accepted: 08/22/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND Transfemoral (TF) access is the preferred approach for transcatheter aortic valve replacement (TAVR). Limited data exist regarding the outcomes of intravascular lithotripsy (IVL)-assisted TF TAVR in patients with peripheral artery disease. OBJECTIVES This study sought to examine contemporary characteristics, trends, and outcomes of IVL TAVR in the United States. METHODS The Vizient Clinical Database was queried for patients who underwent percutaneous TAVR between October 1, 2020, and November 30, 2023. Outcomes with IVL TAVR vs non-IVL TAVR were examined after propensity score matching. The primary outcome was a composite of in-hospital death, stroke, vascular complications, surgical vascular intervention, and major bleeding. RESULTS Over the study period, 129,655 patients (mean age of 78.4 years, 42.2% women, 87.1% White) underwent percutaneous TAVR at 361 hospitals, 1,242 (0.96%) of whom underwent IVL TAVR. There was an uptrend in IVL TAVR, but the frequency remained low. IVL TAVR patients had a higher median Elixhauser comorbidity score (5 [Q1-Q3: 4-7] vs 4 [Q1-Q3: 3-6]) compared to non-IVL TAVR. TAVR was completed via the TF approach in 1,238 (99.7%) IVL TAVR patients. In a 3:1 propensity score matching analysis, IVL TAVR was associated with a higher rate of the primary composite outcome (21.9% vs 13.7%; P < 0.001) driven by higher rates of vascular complications, surgical vascular intervention, and major bleeding. In-hospital death and stroke were similar in both groups. CONCLUSIONS In the United States, IVL is increasingly adopted to facilitate TF TAVR. IVL TAVR patients exhibited a higher burden of comorbidities and experienced more complications compared to non-IVL TAVR patients. Further studies are needed to identify appropriate anatomical and clinical use criteria for IVL TAVR and to compare its outcomes vs alternative non-TF TAVR.
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Asaker JC, Bansal M, Mehta A, Joice MG, Kataria R, Saad M, Abbott JD, Vallabhajosyula S. Short-term and long-term outcomes of cardiac arrhythmias in patients with cardiogenic shock. Expert Rev Cardiovasc Ther 2024; 22:537-551. [PMID: 39317223 DOI: 10.1080/14779072.2024.2409437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 09/09/2024] [Accepted: 09/23/2024] [Indexed: 09/26/2024]
Abstract
INTRODUCTION Cardiogenic shock is severe circulatory failure that results in significant in-hospital mortality, related morbidity, and economic burden. Patients with cardiogenic shock are at high risk for atrial and ventricular arrhythmias, particularly within the subset of patients with an overlap of cardiogenic shock and cardiac arrest. AREAS COVERED This review article will explore the prevalence, definition, management, and outcomes of common arrhythmias in patients with cardiogenic shock. This review will describe the pathophysiology of arrhythmia in cardiogenic shock and the impact of inotropic agents on increased arrhythmogenicity. In addition to medical management, focused assessment of mechanical circulatory support, radiofrequency ablation, deep sedation, and stellate ganglion block will be provided. EXPERT OPINION We will navigate the limited data and describe the prognostic impacts of arrhythmia. Finally, we will conclude the review with a discussion of prevention strategies, research limitations, and future research directions.
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Mehta C, Osorio B, Sodha NR, Gibson HC, Clancy A, Poppas A, Hyder ON, Saad M, Kataria R, Abbott JD, Vallabhajosyula S. Anticoagulation Medications, Monitoring, and Outcomes in Patients with Cardiogenic Shock Requiring Temporary Mechanical Circulatory Support. J Card Fail 2024; 30:1343-1354. [PMID: 39389745 DOI: 10.1016/j.cardfail.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/07/2024] [Accepted: 07/11/2024] [Indexed: 10/12/2024]
Abstract
Cardiogenic shock (CS) is a syndrome of low cardiac output resulting in critical end-organ hypoperfusion and hypoxia. The mainstay of management involves optimizing preload, afterload and contractility. In medically refractory cases, temporary percutaneous mechanical support (MCS) is used as a bridge to recovery, surgical ventricular assist device, or transplant. Anticoagulation is recommended to prevent device-related thromboembolism. However, MCS can be fraught with hemorrhagic complications, compounded by incident multisystem organ failure often complicating CS. Currently, there are limited data on optimal anticoagulation strategies that balance the risk of bleeding and thrombosis, with most centers adopting local antithrombotic stewardship practices. In this review, we detail anticoagulation protocols, including anticoagulation agents, therapeutic monitoring, and complication mitigation in CS requiring MCS. This review is intended to provide an evidence-based framework in this population at high risk for in-hospital bleeding and mortality.
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Vallabhajosyula S, Ogunsakin A, Jentzer JC, Sinha SS, Kochar A, Gerberi DJ, Mullin CJ, Ahn SH, Sodha NR, Ventetuolo CE, Levine DJ, Abbott BG, Aliotta JM, Poppas A, Abbott JD. Multidisciplinary Care Teams in Acute Cardiovascular Care: A Review of Composition, Logistics, Outcomes, Training, and Future Directions. J Card Fail 2024; 30:1367-1383. [PMID: 39389747 DOI: 10.1016/j.cardfail.2024.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/27/2024] [Accepted: 06/21/2024] [Indexed: 10/12/2024]
Abstract
As cardiovascular care continues to advance and with an aging population with higher comorbidities, the epidemiology of the cardiac intensive care unit has undergone a paradigm shift. There has been increasing emphasis on the development of multidisciplinary teams (MDTs) for providing holistic care to complex critically ill patients, analogous to heart teams for chronic cardiovascular care. Outside of cardiovascular medicine, MDTs in critical care medicine focus on implementation of guideline-directed care, prevention of iatrogenic harm, communication with patients and families, point-of-care decision-making, and the development of care plans. MDTs in acute cardiovascular care include physicians from cardiovascular medicine, critical care medicine, interventional cardiology, cardiac surgery, and advanced heart failure, in addition to nonphysician team members. In this document, we seek to describe the changes in patients in the cardiac intensive care unit, health care delivery, composition, logistics, outcomes, training, and future directions for MDTs involved in acute cardiovascular care. As a part of the comprehensive review, we performed a scoping of concepts of MDTs, acute hospital care, and cardiovascular conditions and procedures.
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Simon T, Herbert BM, Brooks MM, Goodman SG, Alexander JH, Steg PG, Lopes RD, Ghafghazi S, Bouleti C, Cooper HA, McCamant EL, Bainey KR, Aronow HD, Abbott JD, Alsweiler C, Bertolet M, Fergusson DA, Goldsweig AM, Hébert PC, Carson JL. Restrictive or Liberal Transfusion Strategy in Patients With Acute Myocardial Infarction and Anemia: 6-Month Mortality in the MINT Trial. Circulation 2024; 150:1064-1066. [PMID: 39221566 PMCID: PMC11548830 DOI: 10.1161/circulationaha.124.069917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/30/2024] [Indexed: 09/04/2024]
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Belur AD, Mehta A, Bansal M, Wieruszewski PM, Kataria R, Saad M, Clancy A, Levine DJ, Sodha NR, Burtt DM, Rachu GS, Abbott JD, Vallabhajosyula S. Palliative care in the cardiovascular intensive care unit: A systematic review of current literature. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 66:68-73. [PMID: 38531709 DOI: 10.1016/j.carrev.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND There has been an evolution in the disease severity and complexity of patients presenting to the cardiac intensive care unit (CICU). There are limited data evaluating the role of palliative care in contemporary CICU practice. METHODS PubMed Central, CINAHL, EMBASE, Medline, Cochrane Library, Scopus, and Web of Science databases were evaluated for studies on palliative care in adults (≥18 years) admitted with acute cardiovascular conditions - acute myocardial infarction, cardiogenic shock, cardiac arrest, advanced heart failure, post-cardiac surgery, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and pulmonary embolism - admitted to the CICU, coronary care unit or cardiovascular intensive care unit from 1/1/2000 to 8/8/2022. The primary outcome of interest was the utilization of palliative care services. Secondary outcomes of included studies were also addressed. Meta-analysis was not performed due to heterogeneity. RESULTS Of 5711 citations, 30 studies were included. All studies were published in the last seven years and 90 % originated in the United States. Twenty-seven studies (90 %) were retrospective analyses, with a majority from the National Inpatient Sample database. Heart failure was the most frequent diagnosis (47 %), and in-hospital mortality was reported in 67 % of studies. There was heterogeneity in the timing, frequency, and background of the care team that determined palliative care consultation. In two randomized trials, there appeared to be improvement in quality of life without an impact on mortality. CONCLUSIONS Despite the growing recognition of the role of palliative care, there are limited data on palliative care consultation in the CICU.
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Elkaryoni A, Huded CP, Saad M, Altibi AM, Chhatriwalla AK, Abbott JD, Arnold SV. Normal-Flow Low-Gradient Aortic Stenosis: Comparing the U.S. and European Guidelines. JACC Cardiovasc Imaging 2024; 17:926-936. [PMID: 38703172 DOI: 10.1016/j.jcmg.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 05/06/2024]
Abstract
Patients with normal-flow low-gradient (NFLG) severe aortic stenosis present both diagnostic and management challenges, with debate about the whether this represents true severe stenosis and the need for valve replacement. Studies exploring the natural history without intervention have shown similar outcomes of patients with NFLG severe aortic stenosis to those with moderate aortic stenosis and better outcomes after valve replacement than those with low-flow low-gradient severe aortic stenosis. Most studies (all observational) have shown that aortic valve replacement was associated with a survival benefit vs surveillance. Based on available data, the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines and European Association of Cardiovascular Imaging/American Society of Echocardiography suggest that these patients are more likely to have moderate aortic stenosis. This clinical entity is not mentioned in the American Heart Association/American College of Cardiology guidelines. Here we review the definition of NFLG severe aortic stenosis, potential diagnostic algorithms and points of error, the data supporting different management strategies, and the differing guidelines and outline the unanswered questions in the diagnosis and management of these challenging patients.
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Jhand AS, Abusnina W, Tak HJ, Ahmed A, Ismayl M, Altin SE, Sherwood MW, Alexander JH, Rao SV, Abbott JD, Carson JL, Goldsweig AM. Impact of anemia on outcomes and resource utilization in patients with myocardial infarction: A national database analysis. Int J Cardiol 2024; 408:132111. [PMID: 38697401 DOI: 10.1016/j.ijcard.2024.132111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/29/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Although anemia is common in patients with myocardial infarction (MI), management remains controversial. We quantified the association of anemia with in-hospital outcomes and resource utilization in patients admitted with MI using a large national database. METHODS All hospitalizations with a primary diagnosis code for acute MI in the National Inpatient Sample (NIS) between 2014 and 2018 were identified. Among these hospitalizations, patients with anemia were identified using a secondary diagnosis code. Data on demographic and clinical variables were collected. Outcomes of interest included in-hospital adverse events, length of stay (LOS), and total cost. Multivariable logistic regression and generalized linear models were used to evaluate the relationship between anemia and outcomes. RESULTS Among 1,113,181 MI hospitalizations, 254,816 (22.8%) included concomitant anemia. Anemic patients were older and more likely to be women. After adjustment for demographics and comorbidities, anemia was associated with higher mortality (7.1 vs. 4.3%; odds ratio 1.09; 95% confidence interval [CI] 1.07-1.12, p < 0.001). Anemia was also associated with a mean of 2.71 days longer LOS (average marginal effects [AME] 2.71; 95% CI 2.68-2.73, p < 0.05), and $ 9703 mean higher total costs (AME $9703, 95% CI $9577-$9829, p < 0.05). Anemic patients who received blood transfusions had higher mortality as compared with those who did not (8.2% vs. 7.0, p < 0.001). CONCLUSION In MI patients, anemia was associated with higher in-hospital mortality, adverse events, total cost, and length of stay. Transfusion was associated with increased mortality, and its role in MI requires further research.
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Singh S, Garg A, Tantry US, Bliden K, Abbott JD, Gurbel PA. P2Y12 Inhibitor Monotherapy After Short-Term Dual Antiplatelet Therapy in Acute Coronary Syndrome. Am J Cardiol 2024; 224:1-8. [PMID: 38734399 DOI: 10.1016/j.amjcard.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/20/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
Recent studies have shown similar safety and efficacy of short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor (P2Y12i) monotherapy when compared with standard DAPT. However, the optimal DAPT duration and regimen in acute coronary syndrome (ACS) patients who underwent percutaneous coronary intervention is still unclear. Online databases were searched for randomized controlled trials evaluating P2Y12i monotherapy after short DAPT (≤3 months) versus standard DAPT (≥12 months) in ACS patients. The outcomes of interest were all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, target-vessel revascularization, and major bleeding. Random-effects model was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI). Six randomized controlled trials with a total of 23,884 patients (n = 11,904 P2Y12i monotherapy, n = 11,980 standard DAPT) were included. Compared with standard DAPT, P2Y12i monotherapy after short DAPT was associated with similar odds of all-cause death (OR 0.86, 95% CI 0.65 to 1.12, p = 0.26) and cardiovascular death (OR 0.75, 95% CI 0.43 to 1.29, p = 0.29) at 1 year. Similarly, there were no significant differences in rates of myocardial infarction (OR 1.09, 0.83 to 1.43, p = 0.53), stent thrombosis (OR 1.09, 95% CI 0.71 to 1.67, p = 0.70) and target-vessel revascularization (OR 0.81, 95% CI 0.65 to 1.01, p = 0.07) between the P2Y12i monotherapy and standard DAPT arms. The P2Y12i monotherapy group had significantly lower major bleeding (OR 0.49, 95% CI 0.38 to 0.64, p < 0.001) when compared with standard DAPT. In conclusion, in patients with ACS who underwent percutaneous coronary intervention, P2Y12i monotherapy after short DAPT significantly reduces bleeding without increasing ischemic risk when compared with standard DAPT therapy.
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Vallabhajosyula S, Abbott JD, Kapur NK. The Need to Define High-Dose Pharmacological Circulatory Support in Cardiogenic Shock. Mayo Clin Proc 2024; 99:1035-1037. [PMID: 38960493 DOI: 10.1016/j.mayocp.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 07/05/2024]
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Abbott JD, Adams G, Amoroso N, Aronow H, Ben-Dor I, Conaway S, Coylewright M, Dippel E, Feldman D, Garratt K, Greenbaum A, Hanzel G, Kerrigan J, Magd A, Mishra S, Musialek P, Mustapha J, Nikol S, O'Neill W, Patel R, Rihal C, Rinaldi M, Rogers T, Saddekni S, Schwartz J, Smalling R, Szerlip M, Tamis-Holland J, Truesdell A, Weiner B, Wood D. Clinical conference proceedings: 17th biennial International Andreas Gruentzig Society meeting. THE JOURNAL OF INVASIVE CARDIOLOGY 2024; 36. [PMID: 38959474 DOI: 10.25270/jic/24.10000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
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Drachman DE, Addo T, Applegate RJ, Bartel RC, Bortnick AE, Dea FM, Helmy T, Henry TD, Khalif A, Kirtane AJ, Levy M, Lim MJ, Mahmud E, Mihatov N, Parikh SA, Porter L, Prasad A, Rao SV, Razzouk L, Shah S, Shroff A, Tamis-Holland JE, Velagapudi P, Welt FG, Abbott JD. The Path to a Match for Interventional Cardiology Fellowship: A Major SCAI Initiative. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101980. [PMID: 39131996 PMCID: PMC11307460 DOI: 10.1016/j.jscai.2024.101980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
The field of interventional cardiology (IC) has evolved dramatically over the past 40 years. Training and certification in IC have kept pace, with the development of accredited IC fellowship training programs, training statements, and subspecialty board certification. The application process, however, remained fragmented with lack of a universal process or time frame. In recent years, growing competition among training programs for the strongest candidates resulted in time-limited offers and high-pressure situations that disadvantaged candidates. A grassroots effort was recently undertaken by a Society for Cardiovascular Angiography & Interventions task force, to create equity in the system by establishing a national Match for IC fellowship. This manuscript explores the rationale, process, and implications of this endeavor.
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Berkowitz JL, Kennedy KF, Font C, Nerenz DR, Abbott JD, Aronow HD. Limited English proficiency, cardiovascular risk factors, cardiovascular disease, and in-hospital COVID-19 outcomes. THE AMERICAN JOURNAL OF MANAGED CARE 2024; 30:251-256. [PMID: 38912951 DOI: 10.37765/ajmc.2024.89560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
OBJECTIVES Cardiovascular risk factors and history of cardiovascular disease are associated with greater morbidity and mortality in patients hospitalized with COVID-19. Limited English proficiency (LEP) has also been associated with worse outcomes in this setting, including requiring intensive care unit (ICU) level of care and in-hospital death. Whether non-English-language preference (NELP) modifies the association between cardiovascular risk factors or disease and outcomes in patients hospitalized with COVID-19 is unknown. STUDY DESIGN Retrospective cohort study of adult patients admitted to a large New England health system between March 1 and December 31, 2020, who tested positive for COVID-19. NELP was defined as having a preferred language that was not English noted in the electronic health record. METHODS Cardiovascular risk factors, history of cardiovascular disease, and NELP were related to the primary composite clinical outcome-death or ICU admission-using multivariable binary logistic regression adjusted for demographic and clinical characteristics. Interaction terms for NELP and model covariates were evaluated. RESULTS Of 3582 patients hospitalized with COVID-19, 1024 (28.6%) had NELP; 812 (79.3%) of the patients with NELP received interpreter services. Death or ICU admission occurred in 794 (22.2%) of the hospitalized patients. NELP was not significantly associated with the primary composite outcome in unadjusted or adjusted analyses. In the adjusted analyses, only male gender, coronary artery disease, pulmonary circulatory disease, and liver disease significantly predicted the primary outcome. NELP did not modify the effect of these associations. CONCLUSIONS NELP was not significantly associated with odds of death or ICU admission, nor did it modify the association between cardiovascular risk factors or history of cardiovascular disease and this composite outcome. Because most patients with NELP received interpreter services, these findings may support the role of such services in ensuring equitable outcomes.
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Ogunsakin A, Abbott JD. REGROUPing on the Importance of Complete Revascularization in Patients Referred for Coronary Artery Bypass Grafting. Am J Cardiol 2024; 217:156-157. [PMID: 38401655 DOI: 10.1016/j.amjcard.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/12/2024] [Indexed: 02/26/2024]
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Yeh RW, Shlofmitz R, Moses J, Bachinsky W, Dohad S, Rudick S, Stoler R, Jefferson BK, Nicholson W, Altman J, Bateman C, Krishnaswamy A, Grantham JA, Zidar FJ, Marso SP, Tremmel JA, Grines C, Ahmed MI, Latib A, Tehrani B, Abbott JD, Batchelor W, Underwood P, Allocco DJ, Kirtane AJ. Paclitaxel-Coated Balloon vs Uncoated Balloon for Coronary In-Stent Restenosis: The AGENT IDE Randomized Clinical Trial. JAMA 2024; 331:1015-1024. [PMID: 38460161 PMCID: PMC10924708 DOI: 10.1001/jama.2024.1361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 03/11/2024]
Abstract
Importance Drug-coated balloons offer a potentially beneficial treatment strategy for the management of coronary in-stent restenosis. However, none have been previously evaluated or approved for use in coronary circulation in the United States. Objective To evaluate whether a paclitaxel-coated balloon is superior to an uncoated balloon in patients with in-stent restenosis undergoing percutaneous coronary intervention. Design, Setting, and Participants AGENT IDE, a multicenter randomized clinical trial, enrolled 600 patients with in-stent restenosis (lesion length <26 mm and reference vessel diameter >2.0 mm to ≤4.0 mm) at 40 centers across the United States between May 2021 and August 2022. One-year clinical follow-up was completed on October 2, 2023. Interventions Participants were randomized in a 2:1 allocation to undergo treatment with a paclitaxel-coated (n = 406) or an uncoated (n = 194) balloon. Main Outcomes and Measures The primary end point of 1-year target lesion failure-defined as the composite of ischemia-driven target lesion revascularization, target vessel-related myocardial infarction, or cardiac death-was tested for superiority. Results Among 600 randomized patients (mean age, 68 years; 157 females [26.2%]; 42 Black [7%], 35 Hispanic [6%] individuals), 574 (95.7%) completed 1-year follow-up. The primary end point at 1 year occurred in 17.9% in the paclitaxel-coated balloon group vs 28.6% in the uncoated balloon group, meeting the criteria for superiority (hazard ratio [HR], 0.59 [95% CI, 0.42-0.84]; 2-sided P = .003). Target lesion revascularization (13.0% vs 24.7%; HR, 0.50 [95% CI, 0.34-0.74]; P = .001) and target vessel-related myocardial infarction (5.8% vs 11.1%; HR, 0.51 [95% CI, 0.28-0.92]; P = .02) occurred less frequently among patients treated with paclitaxel-coated balloon. The rate of cardiac death was 2.9% vs 1.6% (HR, 1.75 [95% CI, 0.49-6.28]; P = .38) in the coated vs uncoated balloon groups, respectively. Conclusions and Relevance Among patients undergoing coronary angioplasty for in-stent restenosis, a paclitaxel-coated balloon was superior to an uncoated balloon with respect to the composite end point of target lesion failure. Paclitaxel-coated balloons are an effective treatment option for patients with coronary in-stent restenosis. Trial Registration ClinicalTrials.gov Identifier: NCT04647253.
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