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Heaton J, Alshami A, Imburgio S, Upadhyaya V, Saybolt M, Apolito R, Hansalia R, Selan J, Almendral J, Sealove B. Comparison of pooled cohort equation and PREVENT™ risk calculator for statin treatment allocation. Atherosclerosis 2024; 399:118626. [PMID: 39447456 DOI: 10.1016/j.atherosclerosis.2024.118626] [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: 04/16/2024] [Revised: 10/08/2024] [Accepted: 10/10/2024] [Indexed: 10/26/2024]
Abstract
BACKGROUND AND AIMS Effective hypercholesterolemia management is linked to lower all-cause and cardiovascular mortality. The 2018 AHA/ACC guidelines recommended using the Pooled Cohort Equations (PCE) for lipid management, but these may overestimate risk and be less accurate for certain racial groups. The AHA's new PREVENT equation, which omits race and includes cardiometabolic factors, aims to provide a more accurate risk assessment for a diverse population. However, it has not yet been applied to a nationally representative US population, and implementation guidelines are still lacking. Our study aimed to evaluate potential changes in hypercholesterolemia management for primary prevention by using the PREVENT equation instead of the PCE. METHODS Analyzing pre-pandemic NHANES 2017-2020 data, participants aged 40-75 without prior lipid-lowering treatment or other compelling indication were identified for elevated risk (≥7.5 %) using the PCE and PREVENT equations. We assessed risk shifts and indications for statin therapy, comparing the two risk equations. NHANES guidelines with weighting were followed to obtain US nationally representative estimates. RESULTS Out of 77, 647, 807 (unweighted = 2494) participants, 81.0 % had no change in risk. The PCE flagged 18.8 % (n = 14,614,094) of participants at elevated risk not identified by PREVENT, while 0.20 % (n = 107,813) were flagged only by PREVENT. Participants identified solely by the PCE were older, with higher systolic blood pressure and increased estimated glomerular filtration rates. Indications for statin therapy were largely unchanged (81.0 %). PREVENT newly identified (0.20 %) for moderate-intensity therapy and none for high-intensity therapy. Participants qualifying for moderate intensity therapy by the PCE were reclassified to no therapy in 74.59 % of cases, while 25.41 % remained unchanged. Participants qualifying for high-intensity therapy by the PCE were reclassified to moderate therapy in 93.97 % of cases, and 6.03 % were reclassified to no therapy. CONCLUSIONS The PREVENT equation notably differs in identifying hypercholesterolemia candidates compared to the PCE. Its adoption would influence cardiovascular risk reduction therapy recommendations, emphasizing the need for comprehensive studies to understand its long-term impact and reevaluate the threshold of treatment strategies for improved patient outcomes.
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Heaton J, Johal A, Alshami A, Okoh A, Udongwo N, Schoenfeld M, Saybolt M, Almendral J, Sealove B. Effect of Combination Antihypertensive Pills on Blood Pressure Control. J Am Heart Assoc 2024:e036046. [PMID: 39604035 DOI: 10.1161/jaha.124.036046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 09/24/2024] [Indexed: 11/29/2024]
Abstract
BACKGROUND Hypertension is a global health issue causing increased cardiovascular morbidity and mortality. Adherence to prescribed medication is a crucial factor in obtaining targeted outcomes, and fixed-dose combined antihypertensive pills (FCAPs) have been shown to help combat difficulties associated with polypharmacy management. This study investigated the influence of combination antihypertensives on blood pressure (BP) management. METHODS AND RESULTS Data from the 2013 to 2020 NHANES (National Health and Nutrition Examination Survey) were analyzed. Participants were included if between 18 and 79 years of age and were prescribed 2 antihypertensive classes. BP was deemed controlled if <140/<90 mm Hg. Examiner documentation and questionnaire data determined prescription antihypertensive medication usage and the presence of an FCAP. Descriptive statistics and multivariate regression analyses were used to compare the 2 groups. Subgroup analysis was performed for stricter BP goals of <130/<80 mm Hg. A total of 15 927 747 weighted participants met the inclusion criteria, 32.7% of whom were undergoing management with an FCAP. Participants with an FCAP were 1.78 (95% CI, 1.28-2.47, P=0.001) times more likely to have controlled BP (76.4% versus 67.3%) than those without an FCAP. Subgroup analysis revealed that FCAPs were associated with stricter BP goals (odds ratio [OR], 1.65, P=0.008; 87.6% versus 71.2%) compared with those without. CONCLUSIONS Participants with an FCAP were more likely to exhibit controlled BP, including participants with clinical atherosclerotic cardiovascular disease and those targeting stricter control. Clinicians can immediately and meaningfully affect their patient's BP by opting for FCAPs.
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Heaton J, Imburgio S, Mararenko A, Udongwo N, Alshami A, Schoenfeld M, Apolito R, Selan J, Sealove B, Almendral J. Potential United States Population Impact of the 2023 PREVENT Risk Calculator on Hypertension Management. Hypertension 2024; 81:e88-e90. [PMID: 39018379 DOI: 10.1161/hypertensionaha.124.23013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
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Johal A, Heaton J, Alshami A, Udongwo N, Imburgio S, Mararenko A, Sealove B, Almendral J, Selan J, Hansalia R. Trends in Atrial Fibrillation and Ablation Therapy During the Coronavirus Disease 2019 Pandemic. J Innov Card Rhythm Manag 2024; 15:5955-5962. [PMID: 39011462 PMCID: PMC11238886 DOI: 10.19102/icrm.2024.15074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/19/2024] [Indexed: 07/17/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic affected many aspects of health care and continues to have an impact as waves of COVID-19 cases re-emerge. Many procedures were negatively impacted by the pandemic, and management was primarily focused on limiting exposure to the virus. We present an analysis of the National Inpatient Sample (NIS) to delineate how COVID-19 affected atrial fibrillation (AF) ablation. The NIS was analyzed from 2017-2020 in order to determine the pre- and intra-pandemic impacts on AF ablation procedures. Admissions were identified using the International Classification of Diseases, 10th Revision, Clinical Modification codes with a primary diagnosis of AF (ICD-10 CM code I48.0, I48.1, I48.2, or I48.91). Admissions were also assessed for the use of cardiac ablation therapy. Comorbidity diagnoses were identified using the Elixhauser comorbidity software (Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Rockville, MD, USA); additional ICD-10 codes for diagnoses and procedures used are also provided. The primary outcome of our study was the trend in ablation therapy during AF admissions. Secondary outcomes included health care disparities, inpatient mortality, and length of stay. Ablation therapy was used in 18,885 admissions in 2020, compared to the preceding 3-year average of 20,103 (adjusted Wald test, P = .002). Multivariate logistic regression revealed a greater likelihood of undergoing ablation therapy (odds ratio, 1.24; 95% confidence interval, 1.10-1.40; P < .001) among 2020 admissions compared to 2017 admissions. Inpatient mortality increased in 2020 compared to the preceding average; however, the difference was not significant. The procedural volume of ablation for AF saw a decrease in 2020; however, surprisingly, more patients were likely to undergo ablation during 2020.
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Heaton J, Alshami A, Imburgio S, Mararenko A, Schoenfeld M, Sealove B, Asif A, Almendral J. Current Trends in Hypertension Identification and Management: Insights from the National Health and Nutrition Examination Survey (NHANES) Following the 2017 ACC/AHA High Blood Pressure Guidelines. J Am Heart Assoc 2024; 13:e034322. [PMID: 38563377 PMCID: PMC11262485 DOI: 10.1161/jaha.123.034322] [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: 01/05/2024] [Accepted: 02/14/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Hypertension is a global health issue associated with increased cardiovascular morbidity and mortality. This study aimed to investigate contemporary hypertension identification and management trends following the 2017 American College of Cardiology/American Heart Association guidelines. METHODS AND RESULTS Data from the National Health and Nutrition Examination Survey conducted from 2017 to 2020 were analyzed. Participants between 20 and 79 years of age were included. Participants were stratified into different treatment groups based on indication and guideline adherence. Descriptive statistics were used to compare medication use, diagnosis rates, and blood pressure control. A total of 265 402 026 people met the inclusion criteria, of which 19.0% (n=50 349 209) were undergoing guideline antihypertensive management. In the guideline antihypertensive management group, a single antihypertensive class was used to treat 45.7% of participants, and 55.2% had uncontrolled blood pressure. Participants not undergoing guideline antihypertensive management qualified for primary prevention in 11.5% (n=24 741 999) of cases and for secondary prevention in 2.4% (n=5 070 044) of cases; of these, 66.3% (n=19 774 007) did not know they may have hypertension and were not on antihypertensive medication. CONCLUSIONS Adherence to guidelines for antihypertensive management is suboptimal. Over half of patients undergoing guideline treatment had uncontrolled blood pressure. One-third of qualifying participants may not be receiving treatment. Education and medical management were missing for 2 in 3 qualifying participants. Addressing these deficiencies is crucial for improving blood pressure control and reducing cardiovascular event outcomes.
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Johal A, Udongwo N, Imburgio S, Mararenko A, Akhlaq H, Dandu S, Abe T, Almendral J, Heaton J, Hansalia R. Negative effects of COVID-19 on the implantation rate of cardiac resynchronization therapy with defibrillator device. J Arrhythm 2024; 40:237-246. [PMID: 38586844 PMCID: PMC10995599 DOI: 10.1002/joa3.12994] [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: 11/16/2023] [Revised: 12/29/2023] [Accepted: 01/06/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction COVID-19 drastically impacted the landscape of the United States' medical system. Limited data is available on the nationwide implantation trends in Cardiac Resynchronization Therapy Defibrillator (CRT-D) devices before and during the pandemic. We aimed to explore the impact of the COVID-19 pandemic on CRT-D insertion rates and adverse outcomes related to delays in care. Methods and Results We conducted a retrospective cross-sectional analysis using the National Inpatient Sample database between 2017 and 2020. Variables were identified using their ICD-10 codes. Inclusion criteria: age ≥ 18 years, presenting for a nonelective admission, primary diagnosis of hypertensive heart disease, hypertensive heart, chronic kidney disease, or heart failure, and underwent insertion of a CRT-D. Between 2017 and 2020, CRT-D devices were inserted during 23,635 admissions. On average, 6198 devices were implanted yearly from 2017 to 2019, with only 5040 devices being implanted in 2020. Additionally, reduced implantation rates were noted for every cohort of hospital size, location, and teaching status during this year. The year 2020 also had the highest average death rate at 1.39%, but this difference was statistically insignificant (adjusted Wald test p = .767), and COVID-19 was not associated with an increased risk of inpatient mortality (OR 0.22, 95% CI 0.03-1.82, p = .162). Conclusion The COVID-19 pandemic has affected all facets of the healthcare system, especially surgical volume rates. CRT-D procedures significantly decreased in 2020. This is the first retrospective study highlighting the trend of reduced rates of CRT-D implantation as a response to the COVID-19 pandemic.
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Barrio-Lopez MT, Ruiz-Canela M, Goni L, Valiente AM, Garcia SR, de la O V, Anton BD, Fernandez-Friera L, Castellanos E, Martínez-González MA, Almendral J. Mediterranean diet and epicardial adipose tissue in patients with atrial fibrillation treated with ablation: a substudy of the 'PREDIMAR' trial. Eur J Prev Cardiol 2024; 31:348-355. [PMID: 37950920 DOI: 10.1093/eurjpc/zwad355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/21/2023] [Accepted: 11/07/2023] [Indexed: 11/13/2023]
Abstract
AIMS To analyse the relationship between Mediterranean diet (MedDiet) adherence and epicardial adipose tissue (EAT) in patients with atrial fibrillation (AF) and the association between EAT or MedDiet adherence at baseline with AF recurrence after ablation. METHODS AND RESULTS We included 199 patients from the PREDIMAR trial (PREvención con DIeta Mediterránea de Arritmias Recurrentes), in a single centre in this substudy. All of them had a computed tomography with EAT measurement. Lifestyle and clinical characteristics were obtained at baseline. The traditional MedDiet pattern was defined according to the MedDiet Adherence Screener (MEDAS). Any documented AF > 30 s after ablation was considered a recurrence. Multivariable-adjusted linear and logistic regression models were run to assess the cross-sectional association of MedDiet with EAT, and of EAT with the AF type at baseline. Also, Cox regression models were used to prospectively assess the associations of MedDiet adherence and EAT with AF recurrences after ablation. Median EAT was 135 g (interquartile range: 112-177), and the mean MedDiet score was 7.75 ± 2 points. A higher MEDAS ≥ 7 that was associated with lower odds of an EAT ≥ 135 g [multivariable odds ratio (mOR) = 0.45; 95% CI = 0.22-0.91; P = 0.025] was significantly associated with persistent AF after adjusting for traditional risk factors (mOR: 2.22; 95% CI: 1.03-4.79; P = 0.042). No significant associations were observed between EAT ≥ 135 g and the risk of atrial tachyarrhythmia recurrences after ablation [multivariable-adjusted hazard ratio (mHR) = 1.18; 95% CI: 0.72-1.94; P = 0.512], or between MEDAS ≥ 7 and AF recurrence (mHR = 0.78; 95% CI: 0.47-1.31; P = 0.344). CONCLUSION In patients with AF, higher adherence to MedDiet is associated with a significantly lower amount of EAT. Epicardial adipose tissue ≥ 135 g was significantly associated with persistent AF.
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Imburgio S, Dandu S, Pannu V, Udongwo N, Johal A, Hossain M, Patel P, Sealove B, Almendral J, Heaton J. Sex-based differences in left ventricular assist device clinical outcomes. Catheter Cardiovasc Interv 2024; 103:376-381. [PMID: 37870108 DOI: 10.1002/ccd.30892] [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: 06/25/2023] [Revised: 09/01/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Heart failure (HF) continues to be a significant public health issue, posing a heightened risk of morbidity and mortality for both genders. Despite the widespread use of left ventricular assist device (LVAD), the influence of gender differences on clinical outcomes following implantation remains unclear. OBJECTIVES We investigated the impact of gender differences on readmission rates and other outcomes following LVAD implantation in patients admitted with advanced HF. METHODS We conducted a retrospective study of patients who underwent LVAD implantation for advanced HF between 2014 and 2020, using the Nationwide Readmissions Database. Our study cohort was divided into male and female patients. The primary outcome was 30-day readmission (30-dr), while secondary outcomes were inpatient mortality, length of stay (LOS), procedural complication rates, and periadmission rates. Multivariate linear, Cox, and logistic regression analyses were performed. RESULTS During the study period, 11,492 patients with advanced HF who had LVAD placement were identified. Of these, 22% (n = 2532) were females and 78% (n = 8960) were males. The mean age was 53.9 ± 10.8 years for females and 56.3 ± 10.5 years for males (adjusted Wald test, p < 0.01). Readmissions were higher in females (21% vs. 17%, p = 0.02) when compared to males. Cox regression analysis showed higher readmission events (hazard ratio: 1.24, 95% confidence interval: 1.01-1.52, p = 0.03) in females when compared to males. Inpatient mortality, LOS, and most procedural complication rates were not statistically significantly different between the two groups (p > 0.05, all). CONCLUSION Women experienced higher readmission rates and were more likely to be readmitted multiple times after LVAD implantation when compared to their male counterparts. However, there were no significant sex-based differences in inpatient mortality, LOS, and nearly all procedural complication rates. These findings suggest that female patients may require closer monitoring and targeted interventions to reduce readmission rates.
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Heaton J, Imburgio S, Dandu S, Johal A, Udongwo N, Mararenko A, Asif A, Almendral J, Sealove B, Selan J, Kiss D, Saybolt M. Geographic variability and operator trends of transcatheter edge-to-edge repair in the United States. Catheter Cardiovasc Interv 2024; 103:147-152. [PMID: 37855205 DOI: 10.1002/ccd.30857] [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: 06/12/2023] [Revised: 08/10/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUNDS Transcatheter edge-to-edge repair (TEER) devices are used for primary mitral regurgitation (MR) and secondary MR. Despite the growing use of TEER devices, there have not been many studies on operator experience or procedure volumes by state. AIMS We aimed to investigate nationwide operator volume trends and geographic variation in access to TEER. METHODS The United States Center for Medicare and Medicaid Services (CMS) National Medicare Provider Utilization and Payment Database (MPUPD) was analyzed between 2015 and 2020 for initial TEER procedures. RESULTS Procedure volume and total operators increased yearly from 2015 to 2019 but declined in 2020. Mean annual procedure volume per operator varied significantly by state, between 0 in multiple states and 35 in North Dakota. In 2019, 994 unique operators were identified, with 295 operators documented performing 10 or more procedures (29.68%). Operators performing 10 or more TEER procedures provided 68.46% of all operations in 2019, averaging 20.94 procedures per operator. CONCLUSIONS TEER procedures are becoming increasingly common as more operators are being trained. However, significant variability exists in the procedural volume per operator.
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Imburgio S, Udongwo N, Mararenko A, Johal A, Tafa M, Akhlaq H, Dandu S, Hossain M, Alshami A, Sealove B, Almendral J, Heaton J. Impact of Frailty on Left Ventricular Assist Device Clinical Outcomes. Am J Cardiol 2023; 207:69-74. [PMID: 37734302 DOI: 10.1016/j.amjcard.2023.08.171] [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: 08/13/2023] [Revised: 08/26/2023] [Accepted: 08/26/2023] [Indexed: 09/23/2023]
Abstract
Frailty is a clinical syndrome prevalent in older adults and carries poor outcomes in patients with heart failure. We investigated the impact of frailty on left ventricular assist device (LVAD) clinical outcomes. The Nationwide Readmission Database was used to retrospectively identify patients with a primary diagnosis of heart failure who underwent LVAD implantation during their hospitalization from 2014 to 2020. Patients were categorized into frail and nonfrail groups using the Hospital Frailty Risk Score. Cox and logistic regression were used to predict the impact of frailty on inpatient mortality, 30-day readmissions, length of stay, and discharge to a skilled nursing facility. LVADs were implanted in 11,465 patients who met the inclusion criteria. There was more LVAD use in patients who were identified as frail (81.6% vs 18.4%, p <0.001). The Cox regression analyses revealed that LVAD insertion was not associated with increased inpatient mortality in frail patients (hazard ratio 1.15, 95% confidence interval 0.81 to 1.65, p = 0.427). Frail patients also did not experience a higher likelihood of readmissions within 30 days (hazard ratio 1.15, 95% confidence interval 0.91 to 1.44, p = 0.239). LVAD implantation did not result in a significant increase in inpatient mortality or readmission rates in frail patients compared with nonfrail patients. These data support continued LVAD use in this high-risk patient population.
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Mararenko A, Udongwo N, Pannu V, Miller B, Alshami A, Ajam F, Odak M, Tavakolian K, Douedi S, Mushtaq A, Asif A, Sealove B, Almendral J, Zacks E, Heaton J. Intracardiac leadless versus transvenous permanent pacemaker implantation: Impact on clinical outcomes and healthcare utilization. J Cardiol 2023; 82:378-387. [PMID: 37196728 DOI: 10.1016/j.jjcc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Transvenous permanent pacemakers are used frequently to treat cardiac rhythm disorders. Recently, intracardiac leadless pacemakers offer potential treatment using an alternative insertion procedure due to their novel design. Literature comparing outcomes between the two devices is scarce. We aim to assess the impact of intracardiac leadless pacemakers on readmissions and hospitalization trends. METHODS We analyzed the National Readmissions Database from 2016 to 2019, seeking patients admitted for sick sinus syndrome, second-degree-, or third-degree atrioventricular block who received either a transvenous permanent pacemaker or an intracardiac leadless pacemaker. Patients were stratified by device type and assessed for 30-day readmissions, inpatient mortality, and healthcare utilization. Descriptive statistics, Cox proportional hazards, and multivariate regressions were used to compare the groups. RESULTS Between 2016 and 2019, 21,782 patients met the inclusion criteria. The mean age was 81.07 years, and 45.52 % were female. No statistical difference was noted for 30-day readmissions (HR 1.14, 95 % CI 0.92-1.41, p = 0.225) and inpatient mortality (HR 1.36, 95 % CI 0.71-2.62, p = 0.352) between the transvenous and intracardiac groups. Multivariate linear regression revealed that length of stay was 0.54 (95 % CI 0.26-0.83, p < 0.001) days longer for the intracardiac group. CONCLUSION Hospitalization outcomes associated with intracardiac leadless pacemakers are comparable to traditional transvenous permanent pacemakers. Patients may benefit from using this new device without incurring additional resource utilization. Further studies are needed to compare long-term outcomes between transvenous and intracardiac pacemakers.
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Heaton J, Udongwo N, Mararenko A, Imburgio S, Johal A, Singh S, Asif A, Sealove B, Almendral J, Selan J. Utilization of percutaneous coronary intervention during the COVID-19 pandemic. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 51:75-76. [PMID: 36804306 PMCID: PMC9902339 DOI: 10.1016/j.carrev.2023.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/20/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
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Diaz-Gutierrez J, Baron-Esquivias G, Martinez-Gonzalez MA, Sayon-Orea C, Bazal P, Almendral J, Barrio-Lopez MT, Amigo-Otero E, Fruhbeck G, Ruiz-Canela MA. Body adiposity estimated with CUN-BAE predicts atrial fibrillation: the SUN cohort. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Obesity is widely recognised as a strong risk factor for atrial fibrillation and recent interest has focused on epicardial fat. Although body mass index is commonly used in the clinical practice, it doesn't precisely estimate adiposity. The Clínica Universidad de Navarra-Body Adiposity Estimator (CUN-BAE) is an equation developed for body fat calculation, that has been previously associated with cardiometabolic disease. Our objective was to assess the association between body fat, as captured by the CUN-BAE index, and the incidence of atrial fibrillation in a prospective cohort.
Methods
The SUN project is a dynamic, prospective cohort of Spanish university graduates. A total of 20.136 participants, free of atrial fibrillation at baseline, were followed-up for a median time of 12 years, with a retention proportion of 91%. CUN-BAE was calculated for each participant taking into account only sex, age and body mass index. Incident cases of atrial fibrillation were confirmed by a cardiologist according to a prespecified protocol. Multivariable Cox regression models were used to estimate hazard ratios (HR) of atrial fibrillation according to calculated body fat.
Results
During follow-up, we identified 128 incident cases of atrial fibrillation. There was a strong direct association between a higher CUN-BAE index at baseline and incident atrial fibrillation during follow-up. In comparison to participants with a lower body fat category (median 21.3%), those with a higher category of body fat (median 34.8%) exhibited a significant 118% higher relative risk of incident atrial fibrillation (adjusted HR=2.18; 95% CI: 1.22, 3.90). For each 2-unit increase in the CUN-BAE index, atrial fibrillation risk significantly increased by 10%. The risk of incident atrial fibrillation remained significantly associated with adiposity even after further adjustment for obesity (body mass index ≥30 kg/m2) and in repeated measures analysis of the CUN-BAE index every other year.
Conclusions
Increased body adiposity, as captured by CUN-BAE index, was strongly and independently associated with a higher risk of atrial fibrillation in a Spanish cohort. These findings support the hypothesis that adiposity is closely related with arrhythmogenic mechanisms that could lead to atrial fibrillation and may be predicted using an equation to estimate body fat.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Spanish Ministry of Health and European Regional Development Fund (FEDER)
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Rao PN, Deo DD, Gaur A, Baran DA, Zucker MJ, Kapoor S, Marchioni MA, Almendral J, Kandula P, Patel A. A new flow cytometry assay identifies recipient IgG subtype antibodies binding donor cells: increasing donor availability for highly sensitised patients. Clin Transl Immunology 2022; 11:e1415. [PMID: 36092480 PMCID: PMC9446897 DOI: 10.1002/cti2.1415] [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: 12/08/2021] [Revised: 07/13/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives There are four immunoglobulin (IgG) subtypes that have varying complement‐activating ability: strong (IgG3 and IgG1) and weak (IgG2 and IgG4). The standard flow cytometric crossmatch (FCM) assay does not distinguish between the various subtypes of the IgG molecule. This study outlines the development and use of a novel cell‐based IgG subtype‐specific FCM assay that is able to detect the presence of and quantitate the IgG subtypes bound to donor cells. Methods A six‐colour lyophilised reagent was designed that specifically detects the four IgG subtypes, as well as distinguishes between T cells and B cells in the lymphocyte population. To test the efficacy of this reagent, a retrospective evaluation of a group of highly sensitised patients awaiting heart and kidney transplant was carried out, who, because of positive standard FCM results, had been deemed incompatible with numerous prior potential donors. Results Observations in this study demonstrate that the positive standard FCM results were mainly because of the presence of noncomplement‐activating IgG2 or IgG4 antibodies. The results were supported by the absence of C3d‐binding donor‐specific antibodies (DSA) and a negative complement‐dependent cytotoxicity crossmatch (CDC). Conclusion Preliminary data presented in this study demonstrate the reliability of the novel IgG subtype assay to detect the presence of pretransplant, complement‐activating antibodies bound to donor cells. The knowledge gained from the IgG subtype assay and the C3d‐binding specificities of DSAs provides improved identification of donor suitability in pretransplant patients, potentially increasing the number of transplants.
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Venkatesh Prasad K, Bonso A, Woods CE, Goya M, Matsuo S, Padanilam BJ, Kreis I, Yang F, Williams CG, Tranter JH, Verbick LZ, Sarver AE, Almendral J. Lesion Index–guided workflow for the treatment of paroxysmal atrial fibrillation is safe and effective – Final results from the LSI Workflow Study. Heart Rhythm O2 2022; 3:526-535. [PMID: 36340486 PMCID: PMC9626745 DOI: 10.1016/j.hroo.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pulmonary vein isolation (PVI) ablation is a standard therapy for paroxysmal atrial fibrillation (PAF). Lesion Index (LSI) is a metric to guide radiofrequency (RF) ablation using the TactiCath Ablation Catheter, Sensor Enabled with the EnSite Cardiac Mapping System (Abbott). Objective This study (NCT-03906461) was designed to capture best practices using LSI-guided catheter ablation to treat PAF subjects in a real-world setting. Methods This prospective single-arm observational study enrolled 143 PAF subjects in the United States, Europe, and Japan undergoing de novo PVI with RF ablation. PVI lesions were assigned to 10 anatomically defined segments. Mean LSIs achieved for all lesions were analyzed. Follow-up was conducted between 3–6 months and 12 months after the procedure. Results Pulmonary veins were isolated in all subjects. The mean achieved LSI was 4.9, with lower values in Europe (4.4) and Japan (4.5) than the United States (5.5). First-pass success, defined as no gaps requiring touch-up ablation after 20 minutes post isolation, was achieved in 76.2% of subjects. Use of high LSI (≥5) resulted in shorter procedure, RF, and fluoroscopy times and fewer touch-up ablations compared to low LSI (<5). At 12 months, 99.3% of subjects were free from procedure- or device-related serious adverse events and 95.7% (112/117) (35.0% on antiarrhythmic drugs) were free from recurrence and/or a repeat ablation procedure for atrial fibrillation / atrial flutter / atrial tachycardia. Conclusion LSI-guided ablation strategies proved safe and effective despite differences in LSI workflows. Use of high LSI values resulted in shorter procedure, RF, and fluoroscopy times and fewer touch-up ablations compared to low LSI.
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Adelino Recasens R, Bazan V, Sarrias A, Jimenez J, Rodriguez Garcia J, Bisbal F, Aranyo J, Villuendas R, Almendral J. Negative SA-VA difference during entrainment of a supraventricular tachycardia: a new criterion for the diagnosis of focal atrial tachycardia. Europace 2022. [DOI: 10.1093/europace/euac053.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Ventricular overdrive pacing during tachycardia is one of the most common and useful maneuvers to assess de differential diagnosis of supraventricular tachycardia (SVT). Focal atrial tachycardia (FAT) usually presents long ventriculo-atrial (VA) interval, which is a passive interval since FAT is not an atrio-ventricular reentry. Therefore, during ventricular entrainment of a FAT, the stimulus-atrial (SA) interval will depend solely on the retrograde VA conduction time, if retrograde conduction exists. This retrograde conduction time is usually shorter than the VA Interval during tachycardia, thus being able to cause a negative SA-VA difference. This does not occur in other types of SVT, where the SA-VA difference helps to differential diagnosis, but positive values have been described.
Purpose
Our aim was to analyze whether the SA-VA value discriminates FAT from the other types of SVT, in patients with SVT and VA conduction when stimulating the ventricle during tachycardia.
Methods
Multicenter data of SVT entrainment were collected retrospectively, including FAT, atrioventricular nodal reentry tachycardia (AVNRT), and atrioventricular reciprocating tachycardia (AVRT). The numeric value of SA-VA difference was calculated for each case. The best SA-VA cut-off point for the diagnosis of TAF was determined, evaluating the sensitivity and specificity of this value for the diagnosis of TAF with respect to the gold standard (classical criteria).
Results
Continuous ventricular pacing during tachycardia succeeded in accelerating the atrium to the pacing rate in 80 cases out of the total studied cases: 32 (40%) AVNRT, 28 (35%) AVRT and 20 (25%) FAT. All FAT cases had a negative SA-VA value and all AVNRT and AVRT cases obtained positive SA-VA (Figure 1). SA-VA value lower than 0 ms was the best cut-off point (using ROC curve, Figure 2) with an area under the curve of 1. SA-VA difference lower than 0 ms (or negative SA-VA difference) showed 100% sensitivity and specificity for the diagnosis of FAT.
Conclusions
Negative SA-VA difference is a new and accurate criterion for the diagnosis of focal atrial tachycardia.
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Alam A, Doshi H, Patel DN, Patel K, James D, Almendral J. Myocardial infarction and factor VIII elevation in a 36-year-old man. Proc AMIA Symp 2022; 35:93-95. [PMID: 34970049 DOI: 10.1080/08998280.2021.1973285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
An association has been reported between factor VIII and arterial thrombosis such as ischemic stroke and myocardial infarction. We report a 36-year-old man who had a myocardial infarction despite lacking traditional cardiac risk factors. He developed end-stage heart failure and renal insufficiency necessitating a HeartMate II left ventricular assist device (LVAD). While on the transplant list, he experienced two episodes of LVAD thrombosis 6 months apart, prompting device exchange and escalation of anticoagulation therapy. He eventually underwent a successful heart-kidney transplant before suffering an extensive left lower extremity deep vein thrombosis 6 weeks later. A thrombophilia workup revealed elevated factor VIII activity of 319% (normal range, 50%-150%). He was placed on indefinite anticoagulation with apixaban with no further thrombotic episode in 18 months of follow-up to date.
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Goni L, de la O V, Barrio-López MT, Ramos P, Tercedor L, Ibañez-Criado JL, Castellanos E, Ibañez Criado A, Macias Ruiz R, García-Bolao I, Almendral J, Martínez-González MÁ, Ruiz-Canela M. A Remote Nutritional Intervention to Change the Dietary Habits of Patients Undergoing Ablation of Atrial Fibrillation: Randomized Controlled Trial. J Med Internet Res 2020; 22:e21436. [PMID: 33284131 PMCID: PMC7752535 DOI: 10.2196/21436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/12/2020] [Accepted: 10/28/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Prevention With Mediterranean Diet (PREDIMED) trial supported the effectiveness of a nutritional intervention conducted by a dietitian to prevent cardiovascular disease. However, the effect of a remote intervention to follow the Mediterranean diet has been less explored. OBJECTIVE This study aims to assess the effectiveness of a remotely provided Mediterranean diet-based nutritional intervention in obtaining favorable dietary changes in the context of a secondary prevention trial of atrial fibrillation (AF). METHODS The PREvention of recurrent arrhythmias with Mediterranean diet (PREDIMAR) study is a 2-year multicenter, randomized, controlled, single-blinded trial to assess the effect of the Mediterranean diet enriched with extra virgin olive oil (EVOO) on the prevention of atrial tachyarrhythmia recurrence after catheter ablation. Participants in sinus rhythm after ablation were randomly assigned to an intervention group (Mediterranean diet enriched with EVOO) or a control group (usual clinical care). The remote nutritional intervention included phone contacts (1 per 3 months) and web-based interventions with provision of dietary recommendations, and participants had access to a web page, a mobile app, and printed resources. The information is divided into 6 areas: Recommended foods, Menus, News and Online resources, Practical tips, Mediterranean diet classroom, and Your personal experience. At baseline and at 1-year and 2-year follow-up, the 14-item Mediterranean Diet Adherence Screener (MEDAS) questionnaire and a semiquantitative food frequency questionnaire were collected by a dietitian by phone. RESULTS A total of 720 subjects were randomized (365 to the intervention group, 355 to the control group). Up to September 2020, 560 subjects completed the first year (560/574, retention rate 95.6%) and 304 completed the second year (304/322, retention rate 94.4%) of the intervention. After 24 months of follow-up, increased adherence to the Mediterranean diet was observed in both groups, but the improvement was significantly higher in the intervention group than in the control group (net between-group difference: 1.8 points in the MEDAS questionnaire (95% CI 1.4-2.2; P<.001). Compared with the control group, the Mediterranean diet intervention group showed a significant increase in the consumption of fruits (P<.001), olive oil (P<.001), whole grain cereals (P=.002), pulses (P<.001), nuts (P<.001), white fish (P<.001), fatty fish (P<.001), and white meat (P=.007), and a significant reduction in refined cereals (P<.001), red and processed meat (P<.001), and sweets (P<.001) at 2 years of intervention. In terms of nutrients, the intervention group significantly increased their intake of omega-3 (P<.001) and fiber (P<.001), and they decreased their intake of carbohydrates (P=.02) and saturated fatty acids (P<.001) compared with the control group. CONCLUSIONS The remote nutritional intervention using a website and phone calls seems to be effective in increasing adherence to the Mediterranean diet pattern among AF patients treated with catheter ablation. TRIAL REGISTRATION ClinicalTrials.gov NCT03053843; https://www.clinicaltrials.gov/ct2/show/NCT03053843.
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Alam A, Pepe R, Iyer D, Mody K, Salahuddin A, Bhatti S, Hakeem A, Almendral J. A Case of Extended Mechanical Circulatory Support with Impella 5.0 in a Patient with Cardiogenic Shock Secondary to Left Ventricular Aneurysm. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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De Diego C, Zaballos M, Quintela O, Sevilla R, Callejo D, González-Panizo J, Anadón MJ, Almendral J. Bupivacaine Toxicity Increases Transmural Dispersion of Repolarization, Developing of a Brugada-like Pattern and Ventricular Arrhythmias, Which is Reversed by Lipid Emulsion Administration. Study in an Experimental Porcine Model. Cardiovasc Toxicol 2019; 19:432-440. [DOI: 10.1007/s12012-019-09515-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Alam A, Mukherjee A, Xu J, Pagan E, Hiltner E, Rios E, Pollack S, Iyer D, Mody K, Kassotis J, James D, Jermyn R, Almendral J. Validating the Newly Reported ASA Score. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Alam A, Doshi H, Hiltner E, Rios E, Kassotis J, Mody K, Iyer D, Almendral J. Efficacy and Safety of Short-Term Universal Prophylaxis for Invasive Aspergillosis after Heart Transplantation. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Carpio EF, Gomez JF, Sebastian R, Lopez-Perez A, Castellanos E, Almendral J, Ferrero JM, Trenor B. Optimization of Lead Placement in the Right Ventricle During Cardiac Resynchronization Therapy. A Simulation Study. Front Physiol 2019; 10:74. [PMID: 30804805 PMCID: PMC6378298 DOI: 10.3389/fphys.2019.00074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
Patients suffering from heart failure and left bundle branch block show electrical ventricular dyssynchrony causing an abnormal blood pumping. Cardiac resynchronization therapy (CRT) is recommended for these patients. Patients with positive therapy response normally present QRS shortening and an increased left ventricle (LV) ejection fraction. However, around one third do not respond favorably. Therefore, optimal location of pacing leads, timing delays between leads and/or choosing related biomarkers is crucial to achieve the best possible degree of ventricular synchrony during CRT application. In this study, computational modeling is used to predict the optimal location and delay of pacing leads to improve CRT response. We use a 3D electrophysiological computational model of the heart and torso to get insight into the changes in the activation patterns obtained when the heart is paced from different regions and for different atrioventricular and interventricular delays. The model represents a heart with left bundle branch block and heart failure, and allows a detailed and accurate analysis of the electrical changes observed simultaneously in the myocardium and in the QRS complex computed in the precordial leads. Computational simulations were performed using a modified version of the O'Hara et al. action potential model, the most recent mathematical model developed for human ventricular electrophysiology. The optimal location for the pacing leads was determined by QRS maximal reduction. Additionally, the influence of Purkinje system on CRT response was assessed and correlation analysis between several parameters of the QRS was made. Simulation results showed that the right ventricle (RV) upper septum near the outflow tract is an alternative location to the RV apical lead. Furthermore, LV endocardial pacing provided better results as compared to epicardial stimulation. Finally, the time to reach the 90% of the QRS area was a good predictor of the instant at which 90% of the ventricular tissue was activated. Thus, the time to reach the 90% of the QRS area is suggested as an additional index to assess CRT effectiveness to improve biventricular synchrony.
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Xu J, Patel KV, Dsouza M, Almendral J, Mody K, Iyer D. Disseminated adenovirus infection in heart and kidney transplant. Turk Kardiyol Dern Ars 2018; 46:231-233. [PMID: 29664432 DOI: 10.5543/tkda.2017.74957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Presently described is a case of disseminated adenovirus infection in a heart-kidney transplant recipient that was successfully treated with cidofovir. There are several reports of adenovirus infections in adult solid organ transplant recipients and the prognosis is usually poor, with mortality rates of 40% to 60%. Severe disseminated adenovirus infections have been associated with increased risk of adverse transplant events, such as rejection, ventricular dysfunction, allograft vasculopathy, graft loss, and the need for re-transplantation. The patient's lack of clinical improvement, the onset of hemorrhagic cystitis and acute kidney injury were factors in our decision to temporarily discontinue administration of immunosuppressive agents and start an antiviral agent. It is important to suspect adenovirus in transplant patients when they do not respond to antibiotics and cultures are negative. Early diagnosis and treatment are critical to improving outcomes in immunocompromised patients.
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Hiltner EP, Alam A, James D, Iyer D, Almendral J, Mody K. Premature Myocardial Infarction as the Presenting Sign of Hypercoagulable Syndrome. J Card Fail 2018. [DOI: 10.1016/j.cardfail.2018.07.356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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