Mechanical Support in High-Risk Pulmonary Embolism: Review Article.

Acute pulmonary embolism (PE) may manifest with mild nonspecific symptoms or progress to a more severe hemodynamic collapse and sudden cardiac arrest. A substantial thrombotic burden can precipitate sudden right ventricular strain and failure. Traditionally, systemic thrombolytics have been employed in such scenarios; however, patients often present with contraindications, or these interventions may prove ineffective. Outcomes for this medically complex patient population are unfavorable, necessitating a compelling argument for advanced therapeutic modalities or alternative approaches. Moreover, patients frequently experience complications beyond hemodynamic instability, such as profound hypoxia and multiorgan failure, necessitating assertive early interventions to avert catastrophic consequences. The existing data on the utilization of mechanical circulatory support (MCS) devices are not exhaustive. Various options for percutaneous MCS devices exist, each possessing distinct advantages and disadvantages. There is an imminent imperative to develop a tailored approach for this high-risk patient cohort to enhance their overall outcomes.

Heart Failure With Stable Mildly-reduced Ejection Fraction: Prognosis and Predictors of Outcomes.

Heart failure with mildly-reduced ejection fraction (HFmrEF) of 40%-49% is an under-recognized type of heart failure. The prognosis and predictors of outcomes of stable mildly-reduced ejection fraction (EF) of 1 year are unclear. This is a retrospective study. Included patients had stable left ventricular ejection fraction (LVEF) for at least 1 year (n = 609) and were classified into 3 groups based on LVEF. Clinical outcome measures were all-cause mortality, cardiac mortality, and HF hospitalization (HFH). In patients with stable HFmrEF of one year, the predictors of clinical outcomes and hospital length of stay (LOS) were studied. Patients with stable HFmrEF had lower HFH rate compared to stable HFrEF with HR = 0.52 (95% CI = 0.39-0.70), P = 0.0001, and a higher HFH rate compared to stable HFpEF with HR = 1.23 (95% CI = 1.01-1.50), P = 0.032. Mortality rates were similar between all groups. In the stable HFmrEF patients, beta-blockers caused lower cardiac mortality, and CKD had fewer HFH. Unfavorable predictors were loop diuretics for mortality, and higher NYHA class for HFH. Smoking and CKD were associated with a longer hospital stay. Stable HFmrEF patients with at least one HF admission had higher mortality. Patients with stable HFmrEF had a lower HFH rate compared to stable HFrEF and higher HFH rate compared to stable HFpEF. In patients with stable HFmrEF, CKD, NYHA class, beta-blockers, and loop diuretics were predictors of clinical outcomes. Smoking and CKD were predictors of hospital LOS.

Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients <60 Years of Age.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an alternative therapeutic modality to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS). In the current analysis, we compare the characteristics and outcomes of AVR procedures in patients <60 years of age. METHODS: We queried the Nationwide Readmissions Database for all AVR hospitalizations in patients 18-59 years of age between January 2012 and December 2017. We performed a propensity score matching analysis (1:1) and compared baseline characteristics, procedural complications, and outcomes between TAVR and SAVR patients. RESULTS: A total of 72,356 hospitalizations for AVR were identified in patients <60 years of age. Compared to their SAVR counterparts, TAVR patients were older (52.5 ± 7.6) vs. 48.8 ± 9.6, p < 0.001), more likely to be women (37.9% vs. 28.0%, p < 0.001), and have history of prior radiation (8.3% vs. 0.7%, p < 0.001). After propensity score matching, TAVR patients had lower procedural complications, but a similar mortality rate compared to SAVR patients (2.9% vs. 3.0%, p = 0.77). TAVR was associated with a shorter length of hospital stay [4 [2-9] vs. 6 [5-11], p < 0.001), but no significant difference in the 30-day readmission rate was noted (16.2% vs. 16.8%, p-value = 0.49). CONCLUSION: Our study demonstrates favorable short-term outcomes in younger patients undergoing TAVR, which improved over time. Further investigation of long-term outcomes in TAVR performed younger patients is warranted to draw a comprehensive picture of TAVR safety and efficacy in low-risk patients.

Characteristics and Outcomes of Patients With Acute Coronary Syndrome Who Received Percutaneous Coronary Intervention During Snowy Days.

BACKGROUND: Acute coronary syndrome (ACS) is affected by several weather conditions. Studies from different geographical locations have yielded mixed results regarding the outcomes of patients presenting with ACS during snowy days, and we aim to report the Cleveland Clinic experience. METHODS: Patients who presented with an ACS and underwent percutaneous coronary intervention (PCI) from July 1, 2009 to September 30, 2017 were divided into ST-segment elevation myocardial infarction (STEMI), and non-ST segment elevation ACS (NSTE-ACS). According to snowy day arrival, we compared in-hospital mortality, culprit lesion anatomy, and door-to-balloon (DTB) time (in STEMI patients). Findings were confirmed in propensity-score matched cohorts. RESULTS: A total of 6878 patients were included: 1608 patients with STEMI (139 snowy-day vs 1469 non-snowy day PCIs) and 5270 NSTE-ACS (419 snowy-day vs 4851 non-snowy day PCIs). Right coronary artery territories accounted for most of the stented culprit lesions in all STEMI and NSTE-ACS snowy-day PCIs. While left anterior descending artery lesions were predominant in NSTE-ACS non-snowy day PCIs. There was no difference in in-hospital mortality between the snowy-day vs non-snowy day groups (4.3% vs 4.5% in the STEMI group [P=.92] and 1.2% vs 1.7% in the NSTE-ACS group [P=41]). In STEMI patients, mean DTB times were similar (43 ± 55.1 minutes vs 46.7 ± 59.6 minutes; P=.61), which remained true after hours, during weekends and holidays. Outcomes were similar in propensity-score matched cohorts. CONCLUSION: At our institution, snowy days do not seem to affect in-patient mortality. In STEMI patients, DTB times were similar in those who underwent PCI regardless of the snowfall.

Invasive versus echocardiographic gradients in degenerated surgical aortic valve prostheses: A multicenter study.

Objectives: To compare echocardiographic and invasive mean gradients obtained concomitantly in degenerated bioprosthetic surgical aortic valves (SAVRs). Methods: In a multicenter study, we compared concomitant echocardiographic and invasive mean gradients of SAVR, obtained before valve-in-valve transcatheter aortic valve replacement in all patients, patients with primary stenosis (AS), primary aortic regurgitation (AR), and mixed aortic valve disease (MAVD), and in small versus large valves (≤ or >23 mm). Dimensionless index (DI) was calculated in all groups. Results: In total, 74 patients were included and data presented as median (interquartile range). Echocardiography-catheterization mean gradient discordance was observed in all patients (invasive = 22 mm Hg [11-34] vs echocardiographic = 32 mm Hg [21-42], P = .013), small valves (invasive = 15 mm Hg [8-34] vs echocardiographic = 28 mm Hg [21-41], P = .013), and large valves (invasive = 20 mm Hg [8.5-27.13] vs echocardiographic = 32 mm Hg [25.5 - 41.5], P < .0001), with a bias of 8 ± 15 mm Hg and wide limits of agreement (-22 to 39 mm Hg) on Bland-Altman plots, indicating these modalities may not be interchangeable. Discordance occurred in AR (invasive = 3 mm Hg [1-6] vs echocardiographic = 12 mm Hg [7-22], P = .017) and in MAVD (invasive = 19 mm Hg [12-29] vs echocardiographic = 31 mm Hg [23-39], P < .0001) but not in AS (invasive = 35 mm Hg [24-45] vs echocardiographic = 41 mm Hg [30-50], P = .45). A lower DI (0.21 [0.14-0.25]) occurred in AS compared with MAVD (0.31 [0.19-0.39]) and AR (0.55 [0.51-0.69]), P < .0001. Conclusions: Discordance between echocardiography and invasive mean gradients exists in degenerated SAVR, regardless of valve size, but depends on mechanism of failure and DI helps stratify these patients. With a discrepancy between echocardiographic mean gradients AND the patient's symptoms OR the valve leaflet structure and/or mobility on imaging, especially before redo-SAVR or valve-in-valve transcatheter aortic valve replacement, invasive gradients may adjudicate the true valvular hemodynamics.

Prevalence of venous thromboembolism in admissions and readmissions with and without syncope: a nationwide cohort study.

AIMS: The Pulmonary Embolism in Syncope Italian Trial reported 17.3% prevalence of pulmonary embolism (PE) in patients admitted with syncope. We investigated the prevalence of venous thromboembolism [VTE, including PE and deep vein thrombosis (DVT)] in syncope vs. non-syncope admissions and readmissions, and if syncope is an independent predictor of VTE. METHODS AND RESULTS: We conducted an observational study of index admissions of the 2013-14 Nationwide Readmission Database. We excluded patients <18 years, December discharges, died during hospitalization, hospital transfers, and missing length of stay. Encounters were stratified by the presence or absence of DVT/PE and syncope diagnoses. Multivariable logistic regression analysis was used to evaluate the association between syncope and VTE. There were 38 655 570 admissions, of whom 285 511 had syncope. In the overall cohort, syncope occurred in 1.6% of VTE and 1.8% in non-VTE admissions. In a multivariable model, syncope was associated with a lower prevalence of VTE [odds ratio (OR) 0.76, 95% confidence interval (CI) 0.75-0.78; P < 0.001]. In index syncope vs. non-syncope admissions, the prevalence of DVT, PE, and VTE were 0.4 ± 0.06% vs. 1.3 ± 0.12%, 0.2 ± 0.04% vs. 1.2 ± 0.11%, and 0.5 ± 0.07% vs. 2.1 ± 0.14% (all P < 0.001), respectively. At 30 days, the prevalence of DVT, PE, and VTE in syncope vs. non-syncope were 2.2 ± 0.14% vs. 2.1 ± 0.14% (P = 0.38), 1.4 ± 0.12% vs. 1.2 ± 0.11% (P = 0.01), and 2.6 ± 0.17% vs. 3.0 ± 0.17% (P = 0.99), respectively. CONCLUSION: Syncope admissions were associated with a lower prevalence of VTE as compared to non-syncope admissions. Syncope should not trigger an automatic PE workup, rather, should be put into context of patient presentation.

Surgical Versus Transcatheter Aortic Valve Replacement in Patients With Malignancy.

BACKGROUND: Patients with aortic stenosis (AS) and malignancy experience poor clinical outcomes with challenging decisions regarding aortic valve replacement (AVR). We sought to compare the outcomes of transcatheter (TAVR) versus surgical (SAVR) AVR in patients with AS and malignancy. METHODS: Based on the Nationwide Readmission Database, we compared all patients with malignancy who underwent isolated SAVR vs. TAVR in 2016 for severe AS. We performed univariate and multivariate analyses for baseline characteristics and clinical outcomes. A total of 2566 patients were included, 1952 (76%) had TAVR and the remaining 614 (24%) had isolated SAVR. Patients who underwent TAVR were older (82 vs 72 years, p < .001), had more metastasis (19 vs 14%, p = .004), heart failure (72% vs 34%, p < .001), coronary artery disease (72% vs 52%, p < .001), anemia (28% vs 22%, p = .006), chronic lung (30% vs 22%, p < .001) and renal disease (35% vs 14%, p < .001), and shorter length of stay (3 vs 7 days, p < .001). RESULTS: In multivariate regression, TAVR and SAVR had similar in-patient mortality (HR = 1.08; 95%CI 0.61 ̶ 1.94) and 30-day readmission (HR = 1.26; 95%CI 0.95 ̶ 1.67). TAVR was associated with lower vascular complications (HR = 0.59; 95%CI 0.41 ̶ 0.86), acute deep venous thrombosis (HR = 0.25, 95%CI 0.1 ̶ 0.59), acute kidney injury (HR = 0.24, 95%CI 0.17 ̶ 0.33), blood transfusion (HR = 0.22, 95%CI 0.16 ̶ 0.3), cardiogenic shock (HR = 0.48, 95%CI 0.26 ̶ 0.89), and respiratory complications (HR = 0.26, 95%CI 0.2 ̶ 0.35). CONCLUSIONS: In patients with malignancy, TAVR is a viable and safe option compared to SAVR with better clinical outcomes, especially thromboembolic events.

National Trends of Tobacco, Alcohol, and Drug Use in Patients Admitted With Acute Myocardial Infarction.

BACKGROUND: Acute myocardial infarction (AMI) is a significant health and economic burden in the US. Tobacco, alcohol, and drug use are established risk factors. We sought to evaluate the national trend of use of each substance in patients admitted with AMI. METHODS: We used the National Inpatient Sample between 2005 and 2017. We included adult patients hospitalized with AMI. International Classification of Diseases, Ninth and Tenth Revisions codes were used to define tobacco, alcohol, cocaine, opioid, cannabis and other drug use. Trends of each substance use were assessed using multivariable Poisson regression, and were expressed as annual percent change (APC) with their 95% confidence intervals (CIs). RESULTS: A total of 10,796,844 hospitalizations with AMI were included. Among all substances used, tobacco was the most common (32.7%), followed by alcohol (3.2%). Between 2005 and 2017, the prevalence ratio of tobacco use increased from 21.5% to 44.5% with an APC +6.2% (95%CI 6.2%-6.2%). Tobacco users had more percutaneous coronary intervention (41%vs25%) and coronary artery bypass surgery (6.9%vs4.9%), p < 0.001. Further, there were positive trends in alcohol (APC +3.1%; 95%CI 3.0%-3.2%), opioid (APC +9.0%; 95%CI 8.7%-9.2%), cannabis (APC + 7.2; 95% CI 7%-7.4%), and combined all drug use (+7.1%; 95%CI 7%-7.2%). Meanwhile, there was a slight negative trend in cocaine use. CONCLUSIONS: This analysis outlines the national trends of substance use in patients admitted with AMI and reveals an increasing prevalence of tobacco use, alcohol and drug use. More effective cessation measures are necessary to reduce the risk for AMI and its burden on the healthcare system and economy.

Comparison of acute recoil after valve deployment and after post-dilation in patients undergoing transfemoral-transcatheter aortic valve replacement with SAPIEN-3 valve.

BACKGROUND: Transcatheter aortic valves are prone to acute recoil similar to the metal-based coronary stents. However, it is not clear if recoil remains a factor only after the initial valve deployment or also after post-dilation. METHODS: We conducted a retrospective observational study of patients who underwent transfemoral transcatheter aortic valve replacement (TAVR) with SAPIEN-3 valve. Acute recoil at the upper, central, and lower levels of the valve was calculated in both anteroposterior right anterior oblique (RAO) and lateral left anterior oblique (LAO) views after initial deployment as well as after post-dilation. The average recoil of the RAO and LAO views was also calculated and described as RAO/LAO. RESULTS: The acute recoil in the RAO/LAO views (mean ± SD) was 3.9 ± 1.1% after valve deployment in the whole study population (n = 257). Among the subset of patients who required post-dilation (n = 133), the mean acute recoil in the RAO/LAO views was found to be greater after initial valve deployment as compared with after post-dilation (3.8 ± 1.1% vs. 3.0 ± 0.9%; p < .001). Further, acute recoil was significantly greater in the RAO view than the LAO view and at the central level of the prosthesis as compared with the upper and lower levels. Those findings were consistent after initial deployment as well as after post-dilation. Clinical outcomes were similar between patients who required post-dilation compared to those who did not. In multivariable logistic regression analysis, only smaller valve cover index was found to be an independent predictor of 30-day mild or greater aortic regurgitation (OR 0.007; 95% CI 0.0001-0.707; p = .035). CONCLUSION: Acute elastic recoil of the SAPIEN-3 valve was significantly less after post-dilation as compared with after deployment. It was also greater when measured in the RAO view as compared with the LAO view. Furthermore, acute recoil was not homogenous across the height of the valve stent frame.

Outcomes of Transcatheter Aortic Valve Replacement in Mixed Aortic Valve Disease.

OBJECTIVES: The aim of this study was to compare outcomes after transcatheter aortic valve replacement (TAVR) in patients with pure aortic stenosis (AS) (i.e., no or trivial associated aortic regurgitation [AR]) with those in patients with AS and mild or more severe AR (i.e., mixed aortic valve disease [MAVD]). BACKGROUND: TAVR is indicated in treating patients with severe AS. Limited data exist regarding the outcomes of TAVR in patients with MAVD. METHODS: A total of 1,133 patients who underwent TAVR between January 2014 and December 2017 were included. The primary outcome was all-cause mortality. The comparison was adjusted to account for post-TAVR AR development in both groups. The secondary outcomes included composite endpoints of early safety and clinical efficacy as specified in the Valve Academic Research Consortium-2 criteria. Variables were compared using Mann-Whitney, chi-square, and Fisher exact tests, while Kaplan-Meier analyses were used to compare survival. RESULTS: A total of 688 patients (61%) had MAVD (median age 83 years , 43% women). Among these, 17% developed mild, 2% moderate, and <1% severe post-TAVR AR. Overall, patients with MAVD had better survival compared with patients with pure AS (p = 0.03). Among patients who developed post-TAVR AR, those in the MAVD group had better survival (p = 0.04). In contrast, in patients who did not develop post-TAVR AR, pre-TAVR AR did not improve survival (p = 0.11). CONCLUSIONS: Patients with MAVD who underwent TAVR had better survival compared with patients with pure AS. This is explained by the better survival of patients with MAVD who developed post-TAVR AR, likely due to left ventricular adaptation to AR.

Geographic Trends, Patient Characteristics, and Outcomes of Infective Endocarditis Associated With Drug Abuse in the United States From 2002 to 2016.

Background There has been an increase in the prevalence of drug abuse (DA) in the national opioid epidemic. With increasing DA, there is an increased risk of infective endocarditis (IE). There are limited recent data evaluating national trends on the incidence and geographical distribution of DA-IE. We aim to investigate those numbers as well as the determinants of outcome in this patient population. Methods and Results Hospitalized patients with a primary or secondary diagnosis of IE based on the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9, ICD-10) were included. We described the national and geographical trends in DA-IE. We also compared DA-IE patients' characteristics and outcomes to those with IE, but without associated drug abuse (non-DA-IE) using Poisson regression models. Incidence of DA-IE has nearly doubled between 2002 and 2016 All US regions were affected, and the Midwest had the highest increase in DA-IE hospitalizations (annual percent change=4.9%). Patients with DA-IE were younger, more commonly white males, poorer, had fewer comorbidities, and were more likely to have human immunodeficiency virus, hepatitis C, concomitant alcohol abuse, and liver disease. Their length of stay was longer (9 versus 7 days; P<0.001) and were more likely to undergo cardiac surgery (7.8% versus 6.2%; P<0.001), but their inpatient mortality was lower (6.4% versus 9.1%; P<0.001). Conclusions DA-IE is rising at an alarming rate in the United States. All regions of the United States are affected, with the Midwest having the highest increase in rate. Young-adult, poor, white males were the most affected.

Outcomes of patients with severe tricuspid regurgitation and congestive heart failure.

OBJECTIVES: A substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not. METHODS: Retrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes. RESULTS: Among a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71). CONCLUSION: Although corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.

Impact of Tricuspid Regurgitation in Patients With Heart Failure and Mitral Valve Disease from a Nationwide Cohort Study.

Concomitant heart failure (HF) and mitral valve disease (MVD) portend significant morbidity and mortality. Although associated Tricuspid regurgitation (TR) is a common occurrence in this scenario, it is not well known whether there are additional prognostic implications. We sought to assess whether coexistent TR is associated with higher readmission rates or increased mortality in patients with HF and MVD. We identified 1,520,871 encounters with a primary diagnosis of HF in the 2013 to 2014 Nationwide Readmission Database. We excluded patients without MVD, patients <18 years old, those with rheumatic heart disease and infective endocarditis. We also excluded patients who were discharged in December, hospital transfers, and cases where follow-up or outcomes were missing. Logistic regression was used to evaluate the association between baseline characteristics (including the presence of tricuspid valve disease), mortality as well as 30-day readmission rates. A total of 221,127 admissions with HF and MVD were identified. Median age was 79 years (IQR, 67 to 87), 55% were female, 2.7% died during hospitalization, and the 30-day readmission rate was 20.3%. Nearly 1/3 had concomitant TR (n = 78,356, 35%). The presence of TR was neither associated with elevated risk of mortality (hazard ratio 0.98, 95% confidence interval 0.93 to 1.04) nor 30-day readmission rate (odds ratio 1.01, 95% confidence interval 0.98 to 1.03). HF accounted for 33% of 30-day readmissions, while combined cardiac causes accounted for 54%. In conclusion concomitant TR in patients with HF and MVD was not associated with worse short-term outcomes in terms of inpatient hospital mortality and 30-day readmission rates.

An Interesting Case of Atherosclerotic Occlusion of the First Septal Perforator in a Physically Young and Fit Individual Causing Complete Heart Block.

Complete heart block (CHB) is an unfortunate complication of an anterior and inferior myocardial infarction (MI). We present a case of an atherosclerotic occlusion of the first septal perforator leading to CHB requiring permanent pacemaker placement in a young patient. A 33-year-old healthy white male presented to the emergency department with an episode of syncope. His vitals were stable, and his physical exam was unremarkable. His electrocardiogram (EKG) showed CHB and ST elevations in V1, V2, and V3 suggestive of septal MI. He underwent emergent left heart catheterization which revealed significant stenosis of the proximal left anterior descending (LAD) artery, proximal diagonal artery, and the first septal perforator. An intervention was done with stent placement in the LAD and insertion of a temporary pacemaker. After removal of the temporary pacemaker two days later, the patient developed asystole with alternating bundle branch block which prompted immediate reinsertion of the temporary pacemaker which was replaced later with a permanent pacemaker. The patient was stable afterward and discharged. The persistent atherosclerotic occlusion of the first septal perforator prevented adequate perfusion of the conduction system, even after revascularization of the proximal LAD. In conclusion, it is essential to acknowledge that difficulty to revascularize an occluded septal perforator raises the need for a permanent pacemaker to prevent a CHB.

Cardiovascular mortality among patients with non-Hodgkin lymphoma: Differences according to lymphoma subtype.

Survival rates of patients with non-Hodgkin lymphoma (NHL) have improved over the last decade. However, cardiotoxicities remain important adverse consequences of treatment with chemotherapy and radiation, although the burden of cardiovascular mortality (CVM) in such patients remains unknown. We conducted a retrospective cohort study of patients greater than or equal to 20 years of age diagnosed with diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) between 2000 and 2013 using data extracted from the United States Surveillance, Epidemiology, and End Results (SEER) database. Our primary endpoint was CVM. The association between NHL and CVM was evaluated using multivariable Cox regression analysis after adjusting for other patient characteristics. We calculated standardized mortality ratios (SMRs) for CVM, comparing NHL patients with the general population. We identified 153 983 patients who met the inclusion criteria (69 329 with DLBCL, 48 650 with CLL/SLL, and 36 004 with FL). The median follow-up was 37 months (interquartile range, 10-78 months); the mean patient age was 66.24 (±14.69) years; 84 924 (55.2%) were men; 134 720 (87.5%) were White, and 131 912 (85.7%) did not receive radiation therapy. Overall, 9017 patients (5.8%) died from cardiovascular disease, and we found that NHL patients had a higher risk of CVM than the general population, after adjusting for age (SMR 15.2, 95% confidence interval: 14.89-15.52). The rates of CVM were 5.1%, 8%, and 4.4% in patients with DLBCL, CLL/SLL, and FL, respectively. Furthermore, across all NHL subtypes, older age, higher stage at the time of diagnosis (particularly stage 4), male sex, and living in the south were associated with higher risks of CVM. Our data suggest that risk assessment and careful cardiac monitoring are recommended for NHL patients, particularly those with the CLL/SLL subtypes.

Effect of Citalopram for the Treatment of Neurocardiogenic Syncope.

BACKGROUND: Neurocardiogenic syncope (NCS) is a common form of syncope. Although selective serotonin reuptake inhibitors and other medications have been used to treat NCS with variable success, there is no consensus regarding a first-line therapy. STUDY QUESTION: To assess the effects of citalopram in NCS and to examine the effect of diagnostic use of the head-up tilt table (HUTT) versus empirical diagnosis on patient outcome. STUDY DESIGN: A retrospective case series of 1000 consecutive patients who were diagnosed with NCS and treated with citalopram. MEASURES AND OUTCOMES: The primary outcome measure was well-being score (WS) recorded at each outpatient visit. RESULTS: After excluding patients who had other comorbidities, were taking daily medication, or did not attend a follow-up visit within 1 month after treatment initiation, data from 186 patients were included. Thirty-five patients were diagnosed empirically, and 151 patients were diagnosed with the HUTT. All 186 patients were followed up within 1 month (early follow-up); of these, 92 patients attended a second follow-up after 1 month (late follow-up). The early follow-up group showed a significant improvement in mean WS (7.35 vs. 4.46, P < 0.001) and only 5 patients discontinued therapy because of intolerability. The late follow-up group also showed significant improvements in mean WS at the early follow-up (7.42 vs. 4.43, P < 0.001) and late follow-up (7.42 vs. 4.26, P < 0.001). Of 186 patients who were treated with citalopram, only 11 reported the development of undesirable side effects. There was no significant difference in the outcome of patients who were diagnosed empirically versus those who were diagnosed with the HUTT. CONCLUSIONS: Citalopram seems to have desirable effects on NCS and patient well-being. Diagnostic use of the HUTT is useful for confirming diagnoses of NCS but is not likely to improve patient outcome.

Causes and Predictors of 30-Day Readmission in Patients With Syncope/Collapse: A Nationwide Cohort Study.

Background Syncope accounts for 0.6% to 1.5% of hospitalizations in the United States. We sought to determine the causes and predictors of 30-day readmission in patients with syncope. Methods and Results We identified 323 250 encounters with a primary diagnosis of syncope/collapse in the 2013-2014 Nationwide Readmissions Database. We excluded patients younger than 18 years, those discharged in December, those who died during hospitalization, hospital transfers, and those whose length of stay was missing. We used multivariable logistic regression analysis to evaluate the association between baseline characteristics and 30-day readmission. A total of 282 311 syncope admissions were included. The median age was 72 years (interquartile range, 58-83), 53.9% were women, and 9.3% had 30-day readmission. The most common cause of 30-day readmissions was syncope/collapse, followed by cardiac, neurological, and infectious causes. Characteristics associated with 30-day readmissions were age 65 years and older (odds ratio [OR], 0.7; 95% confidence interval [ CI ], 0.6-0.7), female sex (OR, 0.9; 95% CI, 0.8-0.9), congestive heart failure (OR, 1.5; 95% CI, 1.2-1.9), atrial fibrillation/flutter (OR, 1.3; 95% CI, 1.3-1.4), diabetes mellitus (OR, 1.2; 95% CI, 1.2-1.3), coronary artery disease (OR, 1.2; 95% CI, 1.2-1.3), anemia (OR, 1.4; 95% CI, 1.4-1.5), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.3-1.4), home with home healthcare disposition (OR, 1.5; 95% CI, 1.5-1.6), leaving against medical advice (OR, 1.7; 95% CI, 1.6-1.9), length of stay of 3 to 5 days (OR, 1.5; 95% CI, 1.4-1.6) or >5 days (OR, 2; 95% CI, 1.8-2), and having private insurance (OR, 0.6; 95% CI, 0.6-0.7). Conclusions The 30-day readmission rate after syncope/collapse was 9.3%. We identified causes and risk factors associated with readmission. Future prospective studies are needed to derive risk-stratification models to reduce the high burden of readmissions.

The role of B-type natriuretic peptide in diagnosing acute decompensated heart failure in chronic kidney disease patients.

INTRODUCTION: Chronic kidney disease (CKD) and congestive heart failure (CHF) patients have higher serum B-type natriuretic peptide (BNP), which alters the test interpretation. We aim to define BNP cutoff levels to diagnose acute decompensated heart failure (ADHF) in CKD according to CHF subtype: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). MATERIAL AND METHODS: We reviewed 1,437 charts of consecutive patients who were admitted for dyspnea. We excluded patients with normal kidney function, without measured BNP, echocardiography, or history of CHF. BNP cutoff values to diagnose ADHF for CKD stages according to CHF subtype were obtained for the highest pair of sensitivity (Sn) and specificity (Sp). We calculated positive and negative likelihood ratios (LR+ and LR-, respectively), and diagnostic odds ratios (DOR), as well as the area under the receiver operating characteristic curves (AUC) for BNP. RESULTS: We evaluated a cohort of 348 consecutive patients: 152 had ADHF, and 196 had stable CHF. In those with HFpEF with CKD stages 3-4, BNP < 155 pg/ml rules out ADHF (Sn90%, LR- = 0.26 and DOR = 5.75), and BNP > 670 pg/ml rules in ADHF (Sp90%, LR+ = 4 and DOR = 6), with an AUC = 0.79 (95% CI: 0.71-0.87). In contrast, in those with HFrEF with CKD stages 3-4, BNP < 412.5 pg/ml rules out ADHF (Sn90%, LR- = 0.19 and DOR = 9.37), and BNP > 1166.5 pg/ml rules in ADHF (Sp87%, LR+ = 3.9 and DOR = 6.97) with an AUC = 0.78 (95% CI: 0.69-0.86). All LRs and DOR were statistically significant. CONCLUSIONS: BNP cutoff values for the diagnosis of ADHF in HFrEF were higher than those in HFpEF across CKD stages 3-4, with moderate discriminatory diagnostic ability.