Trends and In-Hospital Outcomes of Patients Admitted with ST Elevation Myocardial Infarction and Chronic Total Occlusions: Insights from a National Database.

Chronic total occlusion (CTO) is seen in a minority of ST-elevation myocardial infarction (STEMI) patients and is implicated in poor outcomes due to "double jeopardy." There is no large national data evaluating the trend and outcomes of STEMI patients who have a CTO (STEMI-CTO). We analyzed the Nationwide In-patients sample database from 2008 to 2011 and compared the trends, clinical characteristics, and in-hospital outcomes of STEMI patients with and without CTO. An increasing trend of CTO was seen in STEMI patients from 2008 to 2011. STEMI-CTO patients were younger, more likely develop cardiogenic shock, undergo percutaneous coronary intervention and thrombolysis. In this large, contemporary, national database, we also found that STEMI-CTO patients were more likely to have iatrogenic cardiac & vascular complications and undergo percutaneous mechanical circulatory support. We did not find significant difference in in-hospital deaths between STEMI-CTO patients and those without CTO.

Comparison of Transcatheter Pulmonic Valve Implantation With Surgical Pulmonic Valve Replacement in Adults (from the National Inpatient Survey Dataset).

There are no large reports of comparative outcomes of transcatheter pulmonic valve implantation (TPVI) and surgical pulmonic valve replacement (SPVR). Prospective studies are unlikely to be feasible in the future also. Thus, we utilized a large adult inpatient database to compare the two with respect to temporal trends, in hospital outcomes and costs. Data from the National Inpatient Sample database from 2003 to 2014 was analyzed to extract patients who underwent TPVI and SPVR using unique ICD 9-CM codes. In-hospital outcomes and charges were then analyzed. All charges were converted to 2018 dollars and a loss of wages analysis was performed using the Bureau of Labor Statistics published median weekly wages. A total of 8,449 and 555 SPVR and TPVI discharges were identified. 5.8% SPVR procedures were done in rural setting versus 1.8% of TPVI. Complications including in-hospital mortality (2.3 vs 0.9%; p = 0.02) were higher in SPVR group. Length of stay was significantly shorter for the TPVI group (1 vs 5 days; p <0.001), which also contributed to lower loss of wages ($1028.57 vs $6042.86; p <0.001) with similar hospital charges. In conclusion, volumes of both TPVI and SPVR are increasing across adult hospitals in the United States, reflecting an overall increase in the adult congenital heart disease population. TPVI offers improved short-term outcomes and decreased loss of wages through shorter recovery time in this real-world database analysis.

Incidence and Predictors of Obstructive Coronary Artery Disease and the Role of Cardiac Troponin Assays in Patients with Unstable Angina.

In a time when cardiac troponin assays are widely used to detect myocardial injury, data remain scarce concerning the incidence and predictors of substantial obstructive coronary artery disease that causes unstable angina. This retrospective single-center study included consecutive patients hospitalized for unstable angina from January 2015 through January 2016. Patients with troponin I levels above the upper reference limit and those who did not undergo angiography were excluded. Multivariate logistic regression analysis was used to identify predictors of obstructive coronary artery disease that warranted revascularization and of major adverse cardiac events up to 6 months after discharge from the hospital. Of the 114 patients who met the inclusion criteria, 46 (40%) had obstructive coronary artery disease. In the univariate analysis, male sex, white race, history of coronary artery disease, prior revascularization, hyperlipidemia, chronic kidney disease, aspirin use, long-acting nitrate use, and Thrombolysis in Myocardial Infarction score ≥3 were associated with obstructive coronary artery disease. History of coronary artery disease, prior revascularization, hyperlipidemia, and long-acting nitrate use were associated with major adverse cardiac events. Male sex was an independent predictor of obstructive coronary artery disease (adjusted odds ratio=4.82; 95% CI, 1.79-13; P=0.002) in the multivariate analysis. Our results showed that coronary artery disease warranting revascularization is present in a considerable proportion of patients who have unstable angina. The association that we found between male sex and obstructive coronary artery disease suggests that the risk stratification of patients presenting with unstable angina may need to be refined to improve outcomes.

Association of peripheral artery disease with in-hospital outcomes after endovascular transcatheter aortic valve replacement.

OBJECTIVES: The aim of this study was to determine the prevalence of peripheral artery disease (PAD) and its association with in-hospital outcomes after endovascular transcatheter aortic valve replacement (EV-TAVR). BACKGROUND: TAVR is an established treatment for patients at prohibitive, high, or intermediate surgical risk. PAD is a significant comorbidity in the determination of surgical risk. However, data on association of PAD with outcomes after EV-TAVR are limited. METHODS: Patients in the National Inpatient Sample who underwent EV-TAVR between January 1, 2012 and September 30, 2015 were evaluated. The primary outcome was in-hospital mortality. RESULTS: A total of 51,685 patients underwent EV-TAVR during the study period. Of these, 12,740 (24.6%) had a coexisting diagnosis of PAD. The adjusted odds for in-hospital mortality [OR 1.08 (95% CI 0.83-1.41)], permanent pacemaker implantation [OR 0.98 (0.85-1.14)], conversion to open aortic valve replacement [OR 1.05 (0.49-2.26)], or acute myocardial infarction [OR 1.31(0.99-1.71)] were not different in patients with versus without PAD. However, patients with PAD had greater adjusted odds of vascular complications [OR 1.80 (1.50-2.16)], major bleeding [OR 1.20 (1.09-1.34)], acute kidney injury (AKI) [OR 1.19 (1.05-1.36)], cardiac complications [aOR 1.21 (1.01-1.44)], and stroke [OR 1.39(1.10-1.75)] compared with patients without PAD. Length of stay (LOS) was significantly longer for patients with PAD [7.23 (0.14) days vs. 7.11 (0.1) days, p < 0.001]. CONCLUSION: Of patients undergoing EV-TAVR, ~25% have coexisting PAD. PAD was not associated with increased risk of in-hospital mortality but was associated with higher risk of vascular complications, major bleeding, AKI, stroke, cardiac complications, and longer LOS.

Meta-Analysis of Aspirin Versus Dual Antiplatelet Therapy Following Coronary Artery Bypass Grafting.

Although aspirin monotherapy is considered the standard of care after coronary artery bypass grafting (CABG), more recent evidence has suggested a benefit with dual antiplatelet therapy (DAPT) after CABG. We performed a meta-analysis of observational studies and randomized controlled trials comparing outcomes of aspirin monotherapy with DAPT in patients after CABG. Subgroup analyses were conducted according to surgical technique (i.e., on vs off pump) and clinical presentation (acute coronary syndrome vs no acute coronary syndrome). Random effects overall risk ratios (RR) were calculated using the DerSimonian and Laird model. Eight randomized control trials and 9 observational studies with a total of 11,135 patients were included. At a mean follow-up of 23 months, major adverse cardiac events (10.3% vs 12.1%, RR 0.84, confidence interval [CI] 0.71 to 0.99), all-cause mortality (5.7% vs 7.0%, RR 0.67, CI 0.48 to 0.94), and graft occlusion (11.3% vs 14.2%, RR 0.79, CI 0.63 to 0.98) were less with DAPT than with aspirin monotherapy. There was no difference in myocardial infarction, stroke, or major bleeding between the 2 groups. In conclusion, DAPT appears to be associated with a reduction in graft occlusion, major adverse cardiac events, and all-cause mortality, without significantly increasing major bleeding compared with aspirin monotherapy in patients undergoing CABG.

Aortic pseudoaneurysm & endocarditis caused by Aerococcus viridans: A case report and literature review.

Aerococcus viridans is a gram positive microaerophilic lactic acid coccus which is known to cause an infection in lobsters called Gaffkaemia. Consumption of gaffekaemia affected lobsters is considered to be safe if properly cooked even though there hasn't been any research on potential transmission by this route. Though uncommon, A. viridans is capable of causing a virulent endocarditis associated with aortic valve destruction and abscess. There have been 11 worldwide reported cases of infective endocarditis, of which 6 were aortic and only one of them had aortic pseudoaneurysm (APA). We review these cases and also present the case of a 32-year-old young man with no risk factors who presented initially with native valve endocarditis with aerococcus viridans and subsequently with large aortic pseudo-aneurysm.

Trends in the Incidence and In-Hospital Outcomes of Cardiogenic Shock Complicating Thyroid Storm.

BACKGROUND: Thyroid storm (TS) constitutes an endocrine emergency with an incidence of up to 10% of all admissions for thyrotoxicosis. Cardiogenic shock (CS) is a rare complication of TS and very limited data exists on its incidence and outcomes. We aimed to estimate the national trends in incidence and outcomes of CS among patients admitted to US hospitals with TS. MATERIALS AND METHODS: We queried the nationwide inpatient sample for patients with the discharge diagnosis of TS between the years of 2003 and 2011. RESULTS: Based on a weighted estimate, we identified 41,835 patients with a diagnosis of TS, of which 1% developed CS. Patients with CS were more likely to have history of atrial fibrillation, alcohol abuse, preexisting congestive heart failure, coagulopathy, drug use, liver disease, pulmonary circulation disorders, valvular disorders, weight loss, renal failure, fluid and electrolyte disorders as compared to those who did not develop CS (P < 0.001 for all). We observed an increase in incidence of CS from 0.5% in 2003 to 3% in 2011 and a decrease in mortality from 60.5% in 2003 to 20.9% in 2011 (Ptrend < 0.001 for both). CONCLUSIONS: We observed that CS is a rare complication of TS, which occurs more commonly in male patients with preexisting structural and atherosclerotic heart disease, and carries a very poor prognosis. Although incidence has increased over the years, mortality from CS has steadily declined.

In-Hospital Outcomes of Transcatheter Aortic Valve Implantation in Patients With End-Stage Renal Disease on Dialysis from a Large National Database.

The outcomes of patients with end-stage renal disease on dialysis (chronic kidney disease stage 5 on dialysis [CKD 5D]) who undergo transcatheter aortic valve implantation (TAVI) are not well described due to the exclusion of this group in randomized trials. We analyzed the National Inpatient Sample database and compared clinical characteristics and in-hospital outcomes for patients with CKD 5D versus those without CKD 5D (nondialysis group) who underwent TAVI in 2011 to 2014 in the United States. The study population included 1,708 patients (4%) with CKD 5D and 40,481 patients (96%) without CKD 5D who underwent TAVI. Patients with CKD 5D were younger (75.3 ± 9.9 vs 81.4 ± 8.4 years, p <0.001), more likely to be men (62.8% vs 52%, p <0.001), and less likely to be Caucasian (73.6% vs 87.8%, p <0.001). Patients with CKD 5D were more likely to have congestive heart failure (16% vs 11.7%, p <0.001), diabetes with chronic complications (19% vs 5.4%, p <0.001), hypertension (86.5% vs 79.3%, p <0.001), and peripheral vascular disease (34.5% vs 29.4%, p <0.001), but were less likely to have atrial fibrillation (38.6% vs 44.8%, p <0.001) and chronic pulmonary disease (27.5% vs 33.6%, p <0.001). In-hospital mortality was significantly higher in the dialysis group (8.2% vs 4%; adjusted odds ratio 2.21, 95% confidence interval1.81 to 2.69, p <0.001) after adjusting for age, gender, co-morbidities, and hospital characteristics in a robust multivariate regression model. In conclusion, patients with CKD 5D who undergo TAVI have a higher in-hospital mortality than those without CKD 5D.

Staged versus index procedure complete revascularization in ST-elevation myocardial infarction: A meta-analysis.

BACKGROUND: Complete revascularization of patients with ST-elevation myocardial infarction and multivessel coronary artery disease reduces adverse events compared to infarct-related artery only revascularization. Whether complete revascularization should be done as multivessel intervention during index procedure or as a staged procedure remains controversial. METHOD: We performed a meta-analysis of randomized controlled trials comparing outcomes of multivessel intervention in patients with ST-elevation myocardial infarction and multivessel coronary artery disease as staged procedure versus at the time of index procedure. Composite of death or myocardial infarction was the primary outcome. Mantel-Haenszel risk ratios were calculated using random effect model. RESULTS: Six randomized studies with a total of 1126 patients met our selection criteria. At a mean follow-up of 13 months, composite of myocardial infarction or death (7.2% vs 11.7%, RR: 1.66, 95%CI: 1.09-2.52, P = 0.02), all cause mortality (RR: 2.55, 95%CI: 1.42-4.58, P < 0.01), cardiovascular mortality (RR: 2.8, 95%CI: 1.33-5.86, P = 0.01), and short-term (<30 days) mortality (RR: 3.54, 95%CI: 1.51-8.29, P < 0.01) occurred less often in staged versus index procedure multivessel revascularization. There was no difference in major adverse cardiac events (RR: 1.14, 95%CI: 0.88-1.49, P = 0.33), repeat myocardial infarction (RR: 1.14, 95%CI: 0.68-1.92, P = 0.61), and repeat revascularization (RR: 0.92, 95%CI: 0.66-1.28, P = 0.62). CONCLUSION: In patients with ST-elevation myocardial infarction and multivessel coronary artery disease, a strategy of complete revascularization as a staged procedure compared to index procedure revascularization results in reduced mortality without an increase in repeat myocardial infarction or need for repeat revascularization.

Pre-existing medical comorbidity is not associated with neurological outcomes in patients undergoing targeted temperature management following cardiac arrest.

The prognostic significance of chronic medical illness in comatose survivors of cardiac arrest who undergo targeted temperature management (TTM) remains largely unknown. We sought to assess the association between overall burden of pre-existing medical comorbidity and neurological outcomes in survivors of cardiac arrest undergoing TTM. We analyzed a prospectively collected cohort of 314 patients treated with TTM following cardiac arrest at a tertiary care hospital between 2007 and 2014. Overall burden of medical comorbidity was approximated with the use of the Charlson Comorbidity Index (CCI). Poor neurological outcome at hospital discharge, defined as a cerebral performance category (CPC) score >2, was the primary outcome. Secondary outcomes included death prior to hospital discharge and at 1 year following cardiac arrest. Multivariable logistic regression was used to assess the association between CCI scores and outcomes. A poor neurological outcome at hospital discharge was observed in 193 (61%) patients. One hundred and seventy-nine (57%) patients died prior to hospital discharge and a total of 195 (62%) patients had died at 1-year post-arrest. In multivariable logistic regression, elevated CCI scores were not associated with increased odds of poor neurological outcomes (OR 1.04, 95% CI 0.90-1.19, p = 0.608) or death (OR 0.99, 95% CI 0.86-1.13, p = 0.816) at hospital discharge. No association was seen between CCI scores and death at 1-year post-arrest (OR 1.09, 95% CI 0.95-1.26, p = 0.220). Increasing burden of medical comorbidity, as defined by CCI scores, is not associated with neurological outcomes or survival in patients treated with TTM.

Effect of Chronic Obstructive Pulmonary Disease on In-Hospital Mortality and Clinical Outcomes After ST-Segment Elevation Myocardial Infarction.

There is controversy regarding in-hospital mortality, revascularization, and other adverse outcomes in patients with ST-segment elevation (STEMI) and chronic obstructive pulmonary disease (COPD). We queried the 2003 to 2011 Nationwide Inpatient Sample databases to identify patients aged ≥18 years with a primary diagnosis of STEMI. Univariate and multivariate analyses were performed to evaluate the association of COPD with in-hospital clinical outcomes. Patients with COPD comprised 13.2% of 2,120,005 patients with STEMI. COPD was associated with older age, Medicare insurance, greater co-morbidities, and lower socioeconomic status. Compared with non-COPD patients, patients with COPD had higher inpatient mortality even after adjustment for multiple potential other factors (12.5% vs 8.6%, adjusted odds ratio [AOR] 1.13, 95% CI 1.11 to 1.15, p <0.001). Patients with COPD were more likely to develop new-onset heart failure (AOR 2.01, 95% CI 1.99 to 2.03), cardiogenic shock (AOR 1.24, 95% CI 1.22 to 1.26), and acute respiratory failure (AOR 2.46, 95% CI 2.43 to 2.50) during their hospital stay. Patients with COPD were less likely to undergo diagnostic angiographies and any revascularization procedures. The mean length of stay (6.0 vs 4.6 days; p <0.001) was greater in patients with COPD, as were hospital average hospital charges ($63,956 vs $58,536; p <0.001). In conclusion, among patients with STEMI, COPD is associated with a greater risk of in-hospital mortality, new-onset heart failure, acute respiratory failure, and cardiogenic shock.

Prognostic Significance of Early Rehospitalization After Takotsubo Cardiomyopathy.

Short-term complications, particularly rehospitalization, after a diagnosis of takotsubo cardiomyopathy (TTC) are poorly described. We sought to characterize the rates, causes, clinical associations, and prognostic implications of early rehospitalization in this patient population. We performed a retrospective observational study of all adult subjects diagnosed with TTC at an academic tertiary care hospital from 2005 to 2015. The primary outcome was rehospitalization within 30 days of index discharge. Multivariable logistic regression was used to test for association between clinical variables and rehospitalization. Association between rehospitalization and survival after index discharge was assessed as a secondary outcome using a multivariable Cox proportional hazard model. Two hundred sixty-three subjects met the inclusion criteria for the study. There were 38 rehospitalizations among 32 subjects (12%). Ninety-five percent of rehospitalizations were due to nonheart failure causes, and 76% were related to noncardiovascular complaints. In multivariable analysis, recent hospitalization before TTC diagnosis and increased length of index hospitalization were associated with greater risk of rehospitalization (odds ratio 4.58, 95% CI 1.97 to 10.65, p <0.001 and odds ratio 1.05, 95% CI 1.01 to 1.10, p = 0.026, respectively). Early rehospitalization after TTC was associated with decreased survival (hazard ratio 3.17, 95% CI 1.53 to 6.56, p = 0.002).

Trends and outcomes of infective endocarditis in patients on dialysis.

Dialysis patients are at high risk for infective endocarditis (IE); however, no large contemporary data exist on this issue. We examined outcomes of 44 816 patients with IE on dialysis and 202 547 patients with IE not on dialysis from the Nationwide Inpatient Sample database from 2006 thorough 2011. Dialysis patients were younger (59 ± 15 years vs 62 ± 18 years) and more likely to be female (47% vs 40%) and African-American (47% vs 40%; all P < 0.001). Hospitalizations for IE in the dialysis group increased from 175 to 222 per 10 000 patients (P trend = 0.04). Staphylococcus aureus was the most common microorganism isolated in both dialysis (61%) and nondialysis (45%) groups. IE due to S aureus (adjusted odds ratio [aOR]: 1.79, 95% confidence interval [CI]: 1.73-1.84), non-aureus staphylococcus (aOR: 1.72, 95% CI: 1.64-1.80), and fungi (aOR: 1.4, 95% CI: 1.12-1.78) were more likely in the dialysis group, whereas infection due to gram-negative bacteria (aOR: 0.85, 95% CI: 0.81-0.89), streptococci (aOR: 0.38, 95% CI: 0.36-0.39), and enterococci (aOR: 0.78, 95% CI: 0.74-0.82) were less likely (all P < 0.001). Dialysis patients had higher in-hospital mortality (aOR: 2.13, 95% CI: 2.04-2.21), lower likelihood of valve-replacement surgery (aOR: 0.82, 95% CI: 0.76-0.86), and higher incidence of stroke (aOR: 1.08, 95% CI: 1.03-1.12; all P < 0.001). We demonstrate rising incidence of IE-related hospitalizations in dialysis patients, highlight significant differences in baseline comorbidities and microbiology of IE compared with the general population, and validate the association of long-term dialysis with worse in-hospital outcomes.

Temperature variability during targeted temperature management is not associated with neurological outcomes following cardiac arrest.

INTRODUCTION: Recent studies on comatose survivors of cardiac arrest undergoing targeted temperature management (TTM) have shown similar outcomes at multiple target temperatures. However, details regarding core temperature variability during TTM and its prognostic implications remain largely unknown. We sought to assess the association between core temperature variability and neurological outcomes in patients undergoing TTM following cardiac arrest. METHODS: We analyzed a prospectively collected cohort of 242 patients treated with TTM following cardiac arrest at a tertiary care hospital between 2007 and 2014. Core temperature variability was defined as the statistical variance (i.e. standard deviation squared) amongst all core temperature recordings during the maintenance phase of TTM. Poor neurological outcome at hospital discharge, defined as a Cerebral Performance Category (CPC) score>2, was the primary outcome. Death prior to hospital discharge was assessed as the secondary outcome. Multivariable logistic regression was used to examine the association between temperature variability and neurological outcome or death at hospital discharge. RESULTS: A poor neurological outcome was observed in 147 (61%) patients and 136 (56%) patients died prior to hospital discharge. In multivariable logistic regression, increased core temperature variability was not associated with increased odds of poor neurological outcomes (OR 0.38, 95% CI 0.11-1.38, p=0.142) or death (OR 0.43, 95% CI 0.12-1.53, p=0.193) at hospital discharge. CONCLUSION: In this study, individual core temperature variability during TTM was not associated with poor neurological outcomes or death at hospital discharge.

Acute Mitral Regurgitation After Removal of an Impella Device.

Acute mitral regurgitation is a very rare complication of an Impella device. We report a case of a 52-year-old man who had an Impella CP device placed for cardiogenic shock and developed acute mitral regurgitation after removal of the Impella. This was managed with the placement of TandemHeart device.

Beyond Anthracyclines: Preemptive Management of Cardiovascular Toxicity in the Era of Targeted Agents for Hematologic Malignancies.

Advances in drug discovery have led to the use of effective targeted agents in the treatment of hematologic malignancies. Drugs such as proteasome inhibitors in multiple myeloma and tyrosine kinase inhibitors in chronic myeloid leukemia and non-Hodgkin lymphoma have changed the face of treatment of hematologic malignancies. There are several reports of cardiovascular adverse events related to these newer agents. Both "on-target" and "off-target" effects of these agents can cause organ-specific toxicity. The need for long-term administration for most of these agents requires continued monitoring of toxicity. Moreover, the patient population is older, often over 50 years of age, making them more susceptible to cardiovascular side effects. Additional factors such as prior exposure to anthracyclines often add to this toxicity. In light of their success and widespread use, it is important to recognize and manage the unique side effect profile of targeted agents used in hematologic malignancies. In this article, we review the current data for the incidence of cardiovascular side effects of targeted agents in hematologic malignancies and discuss a preemptive approach towards managing these toxicities.