Prevalence of Neurovascular Microemboli After Transcatheter Aortic Valve Replacement.

Background: Neurolotic sequelae after transcatheter aortic valve replacement (TAVR) can cause significant morbidity and mortality. Transcranial Doppler (TCD) imaging can show real-time high intensity transient signals (HITS), which reflect active microembolization. Although it is well known that intraprocedural microembolism occurs, it is not known if this embolic phenomenon continues in the postprocedural period. We investigated whether microemboli occur post-TAVR and whether we could determine any clinical, procedural, or echocardiographic predictors. Methods: We evaluated HITS in 51 consecutive patients undergoing unprotected TAVR with low-, intermediate-, or high-risk Society of Thoracic Surgeons score. Patients were excluded if they did not have temporal windows for insonation of the middle cerebral artery or if they were not willing to participate. Primary outcomes of HITS 24 hours post-TAVR were observed using a Philips iU22 TCD. TCD was performed at 3 time points (pre-, peri-, and post-TAVR) for each patient, before, during, and 24 hours postprocedure. Results: While no HITS were detected in any of the patients preoperatively, all patients had HITS during the procedure. Interestingly, 56.8% had HITS 24 hours post-TAVR. One patient with HITS post-TAVR had a stroke 48 hours after TAVR. Conclusion: We observed a high prevalence of microemboli 24 hours post-TAVR. None of the predictors for intraprocedural microembolism seemed to play an important role for post-TAVR microemboli.

Statins for the Primary Prevention of Anthracycline Cardiotoxicity: A Comprehensive Review.

PURPOSE OF REVIEW: The aim of this review is two-fold: (1) To examine the mechanisms by which statins may protect from anthracycline-induced cardiotoxicity and (2) To provide a comprehensive overview of the existing clinical literature investigating the role of statins for the primary prevention of anthracycline-induced cardiotoxicity. RECENT FINDINGS: The underlying cardioprotective mechanisms associated with statins have not been fully elucidated. Key mechanisms related to the inhibition of Ras homologous (Rho) GTPases have been proposed. Data from observational studies has supported the beneficial role of statins for the primary prevention of anthracycline-induced cardiotoxicity. Recently, several randomized controlled trials investigating the role of statins for the primary prevention of anthracycline-induced cardiotoxicity have produced contrasting results. Statins have been associated with a lower risk of cardiac dysfunction in cancer patients receiving anthracyclines. Further investigation with larger randomized control trials and longer follow-up periods are needed to better evaluate the long-term role of statin therapy and identify the subgroups who benefit most from statin therapy.

Disparities in Drug-Eluting Stent Utilization in Patients With Acute ST-Elevation Myocardial Infarction: An Analysis of the National Inpatient Sample.

The superiority of drug-eluting stents (DES) compared with bare-metal stents (BMS) is well-established, but data regarding DES use in ST-elevation myocardial infarction (STEMI) as a function of race is limited. Our goal was to examine stent utilization patterns and disparities based on race, sex, and insurance status in patients with STEMI undergoing percutaneous coronary intervention. The National Inpatient Sample database was used to retrospectively compare DES vs BMS use in patients admitted with STEMI from 2009 to 2018. Multivariable logistic regression was performed to assess the independent predictors of DES use. DES utilization increased significantly from 62.8% in 2009 to 94.0% in 2018. However, African Americans were less likely to receive a DES (odds ratio [OR] .82, 95% confidence interval [CI] .77-.87) compared with Caucasians. Women were more likely to undergo DES implantation (OR 1.07, 95% CI 1.05-1.10). Patients insured by Medicaid (OR .84, 95% CI .80-.89) and those classified as Self-pay (OR .63, 95% CI .61-.66) were less likely to undergo DES implantation compared to those with private insurance (OR 1.33, 95% CI 1.29-1.38). Disparities based on race and insurance status continue to persist despite a significant increase in DES utilization in STEMI patients across the identified subgroups.

Sex Disparities in the Treatment of Aortic Stenosis and Related Outcomes: An Analysis of the National Inpatient Sample.

INTRODUCTION: The impact of transcatheter aortic valve replacement (TAVR) on sex disparities has not been well established. This study sought to examine the impact of sex on outcomes following aortic valve replacement (AVR) for aortic stenosis (AS) in the era of routine TAVR. METHODS: We performed a cross-sectional analysis of the National Inpatient Sample (2009-18) to study AS visits for all AVR and in-hospital outcomes as a function of sex. Survey estimation commands were used to provide national estimates. RESULTS: There were an estimated 431,344 surgical AVR (SAVR) and 189,137 TAVR inpatient visits. Mortality was higher in women after SAVR (3.8% ± 0.1 vs. 2.7% ± 0.07, p < 0.001) and TAVR (2.4% ± 0.1 vs. 1.7% ± 0.1, p < 0.001) compared to men. Female patients undergoing SAVR had higher rates of permanent pacemaker (PPM) implantation, stroke, and bleeding (5.9% ± 0.1 vs. 5% ± 0.1, 2.8% ± 0.1 vs. 2.3% ± 0.07, and 37.8% ± 0.8 vs. 29.8% ± 0.6; p < 0.001, respectively) but lower rates of acute kidney injury (AKI) (16.4% ± 0.3 vs. 20.3% ± 0.3, p < 0.001). Women undergoing TAVR had higher rates of stroke and bleeding (2.4% ± 0.1 vs. 1.6% ± 0.09 and 28.7% ± 0.6 vs. 22% ± 0.5; p < 0.001, respectively) but lower rates of PPM and AKI (9.5% ± 0.3 vs. 10.7% ± 0.2 and 11.3% ± 0.3 vs. 13.4% ± 0.3; p < 0.001, respectively). Compared with isolated SAVR, isolated TAVR was associated with lower mortality in women during 2016-18, both after multivariable adjustment (OR = 0.40; 95% CI, 0.27-0.60) and propensity matching (mean difference 0.66% ± 0.2); however, there was no difference in men. CONCLUSION: Although women continue to have higher in-hospital mortality following both TAVR and SAVR as compared to men, TAVR is associated with a lower in-hospital mortality in women compared to SAVR. Thus, TAVR may represent a potential intervention to narrow the sex-based disparities in the management of AS.

Reversible complete heart block in a patient with coronavirus disease 2019.

Patients infected with novel coronavirus (SARS-CoV-2) can present with a variety of arrhythmias. We report an unusual case of reversible complete heart block (CHB) in the setting of acute coronavirus disease 2019 (COVID-19). A 23-year-old male with a history of Hodgkin's Lymphoma presented with dizziness and syncope. He was found to be in CHB associated with hypotension requiring a transvenous pacemaker. Methylprednisolone and remdesivir were started with rapid resolution of the CHB. Further study is needed to determine the mechanism of CHB in COVID-19. This case underscores the importance of including COVID-19 in one's differential diagnosis for acute CHB.

Impact of Percutaneous Coronary Intervention on Outcomes in Patients With Heart Failure: JACC State-of-the-Art Review.

Coronary artery disease (CAD) is highly prevalent in patients with heart failure (HF) and accounts for nearly two-thirds of cases. The use of percutaneous coronary intervention (PCI) in HF patients with CAD has markedly increased and has been suggested to be associated with improved outcomes in numerous observational studies. Randomized data comparing the impact of PCI with that of coronary artery bypass graft (CABG) or contemporary guideline-directed medical therapy alone on clinical outcomes and myocardial recovery in patients with HF are lacking. The purpose of this review is to describe the available evidence regarding the impact of PCI in acute HF (in the presence and absence of an acute coronary syndrome), chronic HF with reduced ejection fraction, and HF with preserved ejection fraction. Adequately-powered randomized clinical trials examining the outcomes with PCI in these distinct HF populations are warranted.

Predictors of Aspirin Nonadherence in Adults With Prior Myocardial Infarction.

BACKGROUND: Medication nonadherence is an alarming public health concern due to its effect on both individual treatment success and overall health care costs. This study sought to identify the predictors of aspirin nonadherence in adults with prior myocardial infarction (MI). METHODS: The 2017 Centers for Disease Control's Behavioral Risk Factor Surveillance Survey, a nationally representative, cross-sectional survey, was utilized to identify a cohort of community-dwelling adults (age ≥ 18 years) with prior MI (n = 2173). The primary outcome of interest was presence of self-reported aspirin nonadherence. RESULTS: Among 2173 participants with prior MI studied, a total of 550 participants (25.3%) reported aspirin nonadherence, whereas 1623 participants (74.7%) reported adherence to aspirin. Adults with aspirin nonadherence were younger and more likely to be female, Black, and of Hispanic ethnicity. They also had lower annual income and were less likely to have health insurance or own a home. Participants with aspirin nonadherence had less frequent medical checkups and lower rates of multiple comorbidities including diabetes mellitus, hypertension, hyperlipidemia, and obesity. In multivariable analysis, independent predictors of aspirin nonadherence included female sex [odds ratio (OR), 1.42; 95% confidence interval (CI), 1.14-1.83], Black race (OR, 1.64; 95% CI, 1.19-2.26), Hispanic ethnicity (OR, 2.27; 95% CI, 1.60-3.21), current employment (OR, 1.74; 95% CI, 1.28-2.36), and absence of homeowner status (OR, 0.71; 95% CI, 0.55-0.93). CONCLUSIONS: In this observational contemporary study of adults with prior MI, predictors of aspirin nonadherence included female sex, Black race, Hispanic ethnicity, currently employed status, and absence of homeowner status.

Comparing the Modified History, Electrocardiogram, Age, Risk Factors, and Troponin Score and Coronary Artery Disease Consortium Model for Predicting Obstructive Coronary Artery Disease and Cardiovascular Events in Patients With Acute Chest Pain.

The objective of this study was to compare the History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) score and clinical coronary artery disease (CAD) consortium (CADC) model for predicting obstructive CAD (≥50% stenosis on coronary computed tomographic angiography) and 30-day major adverse cardiovascular events (MACE, composite of acute myocardial infarction, revascularization, and mortality). We studied 1981 patients with no known CAD who presented with acute chest pain and had negative initial troponin and electrocardiogram. Chest pain was classified as typical, atypical, and nonanginal and used to score the history component of the modified HEART score. The C-statistic for predicting obstructive CAD was 0.747 [95% confidence interval (CI), 0.712-0.783] for the HEART score and 0.792 (95% CI, 0.762-0.823) for the CADC model (P = 0.0005). The C-statistic for predicting 30-day MACE was 0.820 (95% CI, 0.774-0.864) for the HEART score and 0.850 (95% CI, 0.800-0.891) for the CADC model (P = 0.11). Among the 48.3% of patients for whom the CADC model predicted ≤5% probability of obstructive CAD, the observed 30-day MACE was 0.6%; among the 48.9% of patients for whom the HEART score was ≤2, the 30-day MACE was 0.6%. In conclusion, the CADC model was more effective at predicting obstructive CAD compared to the HEART score. The HEART score and CADC model were equally effective to safely identify low-risk patients by achieving <1% missed 30-day MACE.