In-hospital outcomes and trends of patients with autoimmune diseases undergoing percutaneous coronary intervention. A nationwide analysis.

BACKGROUND: The risk of coronary artery disease is exaggerated in patients with autoimmune diseases (AID). A higher risk of complications has been reported during and after percutaneous coronary intervention (PCI) in these patients. We aimed to analyze the in-hospital outcomes and trends of patients with AID, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD) undergoing PCI. METHOD: We identified all PCI procedures using the National In-patient Sample database from 2016 to 2020. Stratified them into cohorts with RA, SLE and IBD and compared them to cohorts without AID. The Chi-square test and multivariate logistic regression were used for analysis. A p-value <0.005 was considered statistically significant. RESULT: We identified 2,367,475 patients who underwent PCI. Of these, 1.6 %, 0.5 %, and 0.4 % had RA, IBD and SLE respectively. The odds of mortality were lower among patients with IBD (aOR: 0.56; CI 0.38-0.81, p = 0.002) but patients with RA had higher odds of having composite major complications [(MC) including cerebrovascular accident (CVA), cardiac arrest, acute heart failure (AHF), ventricular arrhythmia (VA), major bleeding, and acute kidney injury (AKI)] (aOR: 0.90; CI 0.83-0.98, p = 0.013). Our SLE cohort had higher rates of CVA (p = 0.017) and AKI (p = 0.002). Our cohort with IBD had lower rates of cardiac arrest but had longer hospital length of stay (4.9 days vs 3.9 days) and they incurred higher hospital charges compared to cohort without IBD. CONCLUSION: This study depicts the immediate adverse outcomes observed in patients with AID undergoing PCI. In contrast to those without AID, our cohorts with RA exhibited worse outcomes, as indicated by the higher odds of major complications. IBD is associated with lower risks of in-hospital adverse outcomes but with higher resource utilization.

Coronary Artery Calcium and Cognitive Decline in the Diabetes Prevention Program Outcomes Study.

Background Our aim was to investigate the association of coronary artery calcium (CAC) with cognitive function in adults with impaired glucose tolerance or type 2 diabetes. Methods and Results The Diabetes Prevention Program was a randomized controlled trial comparing an intensive lifestyle intervention, metformin, or placebo for prevention of type 2 diabetes among patients with prediabetes. After 3 years, intensive lifestyle intervention and placebo were stopped, the metformin arm was unmasked, and participants continued in the DPPOS (Diabetes Prevention Program Outcomes Study). Approximately 14 years after randomization (Y14), CAC (Agatston score) was assessed with computed tomography, and cognitive performance was assessed with the Spanish English Verbal Learning Test (SEVLT) and Digit Symbol Substitution Test. SEVLT and Digit Symbol Substitution Test were reassessed 5 years later (Y19) along with the Modified Mini-Mental State Exam. We examined cross-sectional and longitudinal associations between CAC and cognition among 1931 participants using linear and logistic regression. In unadjusted analyses, compared with no calcification, CAC score >300 was associated with decreased performance on all cognitive tests at Y14 in both sexes. Additionally, CAC >300 was associated with a greater 5-year decline in SEVLT Immediate Recall in both sexes and SEVLT Delayed Recall in women. After adjustment for demographic, genetic, metabolic, vascular, and behavioral covariates, CAC score >300 remained associated with greater decline in only SEVLT Delayed Recall in women. Conclusions In women with prediabetes or diabetes, CAC >300, compared with no calcification, was independently associated with greater decline in verbal memory. Registration information clinicaltrials.gov. Identifier: NCT00038727.

Unraveling the Link Between Fibromuscular Dysplasia and Acute Coronary Syndrome: A Comprehensive Case Report and Analysis.

We present a rare case of fibromuscular dysplasia (FMD) manifesting in the mid to distal segment of the left anterior descending (LAD) artery, which led to the development of acute coronary syndrome (ACS) in our patient, highlighting the severe consequences of this vascular disorder. During the investigation of the patient's clinical symptoms, an unexpected incidental finding emerged, indicating bilateral FMD involvement of the renal arteries. This serendipitous discovery underscores the importance of comprehensive evaluation and thorough exploration when managing patients with FMD. We aim to shed light on the intriguing nature of FMD and emphasize the need for vigilant assessment to identify potential multi-vessel abnormalities, even beyond the primary affected site. We also aim to highlight the coronary artery manifestation of FMD as ACS and discuss its medical management.

Assessing and Addressing Social Determinants of Cardiovascular Health: JACC State-of-the-Art Review.

Social determinants of health (SDOH) are the social conditions in which people are born, live, and work. SDOH offers a more inclusive view of how environment, geographic location, neighborhoods, access to health care, nutrition, socioeconomics, and so on are critical in cardiovascular morbidity and mortality. SDOH will continue to increase in relevance and integration of patient management, thus, applying the information herein to clinical and health systems will become increasingly commonplace. This state-of-the-art review covers the 5 domains of SDOH, including economic stability, education, health care access and quality, social and community context, and neighborhood and built environment. Recognizing and addressing SDOH is an important step toward achieving equity in cardiovascular care. We discuss each SDOH within the context of cardiovascular disease, how they can be assessed by clinicians and within health care systems, and key strategies for clinicians and health care systems to address these SDOH. Summaries of these tools and key strategies are provided.

Locking the Revolving Door: Racial Disparities in Cardiovascular Disease.

Racial disparities in cardiovascular disease are unjust, systematic, and preventable. Social determinants are a primary cause of health disparities, and these include factors such as structural and overt racism. Despite a number of efforts implemented over the past several decades, disparities in cardiovascular disease care and outcomes persist, pervading more the outpatient rather than the inpatient setting, thus putting racial and ethnic minority groups at risk for hospital readmissions. In this article, we discuss differences in care and outcomes of racial and ethnic minority groups in both of these settings through a review of registries. Furthermore, we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.

Best Practices for Cardiac Catheterization Laboratory Morbidity and Mortality Conferences.

Cardiac catheterization laboratory (CCL) morbidity and mortality conferences (MMCs) are a critical component of CCL quality improvement programs and are important for the education of cardiology trainees and the lifelong learning of CCL physicians and team members. Despite their fundamental role in the functioning of the CCL, no consensus exists on how CCL MMCs should identify and select cases for review, how they should be conducted, and how results should be used to improve CCL quality. In addition, medicolegal ramifications of CCL MMCs are not well understood. This document from the American College of Cardiology's Interventional Section attempts to clarify current issues and options in the conduct of CCL MMCs and to recommend best practices for their conduct.

Same day discharge after structural heart disease interventions in the era of the coronavirus-19 pandemic and beyond.

With recent advancements in imaging modalities and techniques and increased recognition of the long-term impact of several structural heart disease interventions, the number of procedures has significantly increased. With the increase in procedures, also comes an increase in cost. In view of this, efficient and cost-effective methods to facilitate and manage structural heart disease interventions are a necessity. Same-day discharge (SDD) after invasive cardiac procedures improves resource utilization and patient satisfaction. SDD in appropriately selected patients has become the standard of care for some invasive cardiac procedures such as percutaneous coronary interventions. This is not the case for the majority of structural heart procedures. With the coronavirus disease 2019 pandemic, safely reducing the duration of time spent within the hospital to prevent unnecessary exposure to pathogens has become a priority. In light of this, it is prudent to assess the feasibility of SDD in several structural heart procedures. In this review we highlight the feasibility of SDD in a carefully selected population, by reviewing and summarizing studies on SDD among patients undergoing left atrial appendage occlusion, patent foramen ovale/atrial septal defect closure, Mitra-clip, and trans-catheter aortic valve replacement procedures.

Ventricular Arrhythmias in Seniors with Heart Failure: Present Dilemmas and Therapeutic Considerations: A Systematic Review.

BACKGROUND: Heart Failure (HF) is a global public health problem, which affects over 23 million people worldwide. The prevalence of HF is higher among seniors in the USA and other developed countries. Ventricular Arrhythmias (VAs) account for 50% of deaths among patients with HF. We aim to elucidate the factors associated with VAs among seniors with HF, as well as therapies that may improve the outcomes. METHODS: PubMed, Web of Science, Scopus, Cochrane Library databases, Science Direct, and Google Scholar were searched using specific keywords. The reference lists of relevant articles were searched for additional studies related to HF and VAs among seniors as well as associated outcomes. RESULTS: The prevalence of VAs increases with worsening HF. A 24-hour Holter electrocardiogram may be useful in risk stratifying patients for device therapy if they do not meet the criterion of low ventricular ejection fraction. Implantable Cardiac Defibrillators (ICDs) are superior to anti-arrhythmic drugs in reducing mortality in patients with HF. Guideline-Directed Medical Therapy (GDMT) together with device therapy may be required to reduce symptoms. In general, the proportion of seniors on GDMT is low. A combination of ICDs and cardiac resynchronization therapy may improve outcomes in selected patients. CONCLUSION: Seniors with HF and VAs have high mortality even with the use of device therapy and GDMT. The holistic effect of device therapy on outcomes among seniors with HF is equivocal. More studies focused on seniors with advanced HF as well as therapeutic options are, therefore, required.

Aortic stenosis and Heyde's syndrome: A comprehensive review.

Heyde's syndrome is an under reported systemic disease of gastrointestinal and cardiac manifestation in older adults. It is characterized by a triad of aortic stenosis, angiodysplasia with bleeding and acquired von Willebrand syndrome. It is characterized by proteolysis of high molecular weight multimers of von Willebrand Factor and loss of platelet mediated homeostasis. Heyde's syndrome is a treatable condition in most cases, especially in the current era of evolution in interventional cardiology and gastroenterology. There are currently no established guidelines in the management of this condition due to paucity of high quality studies, which warrant future trials. High index of suspicion and increasing the awareness of the syndrome among the general practitioners and sub-specialists will improve the diagnostic potential of Heyde's syndrome. Future studies may change the management aspect of Heyde's syndrome and pave a path for drawing specific guidelines and algorithms. The aim of our review article is to summarize the basic pathophysiology, diagnostics and management of Heyde's syndrome with a special attention to Transcatheter aortic valve replacement.

Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review.

Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.

Review of Hypothermia Protocol and Timing of the Echocardiogram.

Targeted temperature management, also known as therapeutic hypothermia (TH), is recommended for out-of-hospital cardiac arrest (OHCA). Both internal or external methods of cooling can be applied. Individuals resuscitated from OHCA frequently develop postarrest myocardial dysfunction resulting in decreased cardiac output and left ventricular systolic function. This dysfunction is usually transient and improves with spontaneous recovery over time. Echocardiogram (ECHO) can be a vital tool for the assessment and management of these patients. This manuscript reviewed methods available for TH after OHCA and reviews role of ECHO in the diagnosis and prognosis in this setting.

Renal Sympathetic Denervation: A Comprehensive Review.

In 2017, the American College of Cardiology and American Heart Association released its updated blood pressure guidelines, redefining hypertension to be any systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg. Among United States adults, these new parameters increased the prevalence of hypertension from 72.2 million (31.9%) to 103.3 million (45.6%) adults and decreased the rate of medication-controlled hypertension from 53.4% to 39% with the prevalence of resistant hypertension ranging from 12% to 18%. Results of the pivotal SPRINT trial showed that more intensive blood pressure control in diabetic patients decreased both cardiovascular events and all-cause mortality. However, even with ideal goals in mind, compliance remains an issue due to multiple causes, and approximately half of study participants had stopped taking their antihypertensive drug within a year. Renal sympathetic denervation is a process in which catheter-based techniques are used to ablate specific portions of the renal artery nerves with the goal of decreasing sympathetic nerve activity and reducing blood pressure. Several studies using renal artery denervation have already shown benefit in patients with resistant hypertension, and now newer trials are beginning to focus on those with stage II hypertension as an additional potential treatment population. This review will seek to summarize the current evidence surrounding renal artery denervation and discuss some of its future trials, current issues, and potential roles both in hypertension and other comorbidities.

Correlation Between Aortic Angulation and Outcomes of Transcatheter Aortic Valve Replacement With New-Generation Valves.

The aim of this study was to assess the correlation of aortic angulation (AA) on immediate postprocedural and long-term outcomes following transcatheter aortic valve replacement (TAVR) with new-generation valves. There is limited and conflicting data on the impact of AA on short- and long-term outcomes in patients undergoing TAVR. Available studies to date were done with first-generation valves. We assessed 179 patients who underwent TAVR with either a balloon-expandable or self-expandable valve at our institute from May 2014 to June 2017 and had multislice computed tomography scans available for AA evaluation. All included patients received a second- or third-generation valve. TAVR endpoints, device success, and adverse events were defined according to the Valve Academic Research Consortium-2 criteria. The mean AA of the study population was 49.05 ± 10.07. Patients were divided into 2 groups: AA <49 and AA ≥49, and then further subdivided by valve type. There were no difference in mean age, The Society for Thoracic Surgery (STS) score, or race distribution between the AA <49 and AA ≥49 groups. The preimplantation balloon valvuloplasty rate was higher in patients with AA ≥ 49 compared to patients with AA <49, (70% vs 55.1%, P = 0.04). There was no difference in re-hospitalization, pacemaker implantation, postprocedural aortic regurgitation or mortality between patients with AA <49 and AA ≥49 irrespective of valve type (P < 0.05). AA does not significantly affect short- or long-term outcomes in patients who undergo TAVR with new-generation balloon-expandable or self-expandable valves.

Invasive Strategies for the Treatment of Pulmonary Embolism. Where Are We in 2020?

Pulmonary Embolism (PE) is the third most common cause of cardiovascular mortality in the United States, with 60,000-100,000 deaths per year following myocardial infarction and stroke. During the past 5 years, there has been an introduction of novel interventions as a result of a renewed interest in optimizing PE management, particularly among those individuals with more severe disease of hemodynamic significance. The cornerstone treatment for PE is anticoagulation. More aggressive alternatives have been considered for patients with intermediate and high-risk PE. In general, these options can be grouped into 3 different categories: systemic thrombolysis, catheter-directed interventions, and surgical embolectomy. Systemic thrombolysis has shown statistical benefit in several randomized trials for intermediate- and high-risk PE, however, this benefit has been offset by an elevated risk of major bleeding and intracerebral hemorrhage, limiting their use in clinical practice. Catheter-directed thrombolysis refers to catheter-directed injection of a thrombolytic drug directly into the pulmonary artery. Three interventional devices (EKOSonic endovascular system, FlowTriever embolectomy device and the Indigo thrombectomy system) have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. As of today, catheter-based interventions are limited to small randomized trials and single arm-prospective studies focused on short-term surrogate endpoints. Although single arm studies carry some value establishing the preliminary safety and effectiveness of these devices, they are not sufficient to stratify risk and guide clinical practice. Furthermore, no trials have been performed with enough power to assess potential mortality benefit with the use of catheter-directed thrombolysis or catheter-based embolectomy devices, hence treatment decisions continue to be influenced by individual risk of bleeding, the location of thrombus and operator expertise until additional evidence becomes available.