SARS-COV-ATE risk assessment model for arterial thromboembolism in COVID-19.

Patients with SARS-CoV-2 infection are at an increased risk of cardiovascular and thrombotic complications conferring an extremely poor prognosis. COVID-19 infection is known to be an independent risk factor for acute ischemic stroke and myocardial infarction (MI). We developed a risk assessment model (RAM) to stratify hospitalized COVID-19 patients for arterial thromboembolism (ATE). This multicenter, retrospective study included adult COVID-19 patients admitted between 3/1/2020 and 9/5/2021. Among 3531 patients from the training cohort, 15.5% developed acute in-hospital ATE, including stroke, MI, and other ATE, compared to 13.4% in the validation cohort. The 16-item final score was named SARS-COV-ATE (Sex: male = 1, Age [40-59 = 2, > 60 = 4], Race: non-African American = 1, Smoking = 1 and Systolic blood pressure elevation = 1, Creatinine elevation = 1; Over the range: leukocytes/lactate dehydrogenase/interleukin-6, B-type natriuretic peptide = 1, Vascular disease (cardiovascular/cerebrovascular = 1), Aspartate aminotransferase = 1, Troponin-I [> 0.04 ng/mL = 1, troponin-I > 0.09 ng/mL = 3], Electrolytes derangement [magnesium/potassium = 1]). RAM had a good discrimination (training AUC 0.777, 0.756-0.797; validation AUC 0.766, 0.741-0.790). The validation cohort was stratified as low-risk (score 0-8), intermediate-risk (score 9-13), and high-risk groups (score ≥ 14), with the incidence of ATE 2.4%, 12.8%, and 33.8%, respectively. Our novel prediction model based on 16 standardized, commonly available parameters showed good performance in identifying COVID-19 patients at risk for ATE on admission.

3D-PAST: Risk Assessment Model for Predicting Venous Thromboembolism in COVID-19.

Hypercoagulability is a recognized feature in SARS-CoV-2 infection. There exists a need for a dedicated risk assessment model (RAM) that can risk-stratify hospitalized COVID-19 patients for venous thromboembolism (VTE) and guide anticoagulation. We aimed to build a simple clinical model to predict VTE in COVID-19 patients. This large-cohort, retrospective study included adult patients admitted to four hospitals with PCR-confirmed SARS-CoV-2 infection. Model training was performed on 3531 patients hospitalized between March and December 2020 and validated on 2508 patients hospitalized between January and September 2021. Diagnosis of VTE was defined as acute deep vein thrombosis (DVT) or pulmonary embolism (PE). The novel RAM was based on commonly available parameters at hospital admission. LASSO regression and logistic regression were performed, risk scores were assigned to the significant variables, and cutoffs were derived. Seven variables with assigned scores were delineated as: DVT History = 2; High D-Dimer (>500−2000 ng/mL) = 2; Very High D-Dimer (>2000 ng/mL) = 5; PE History = 2; Low Albumin (<3.5 g/dL) = 1; Systolic Blood Pressure <120 mmHg = 1, Tachycardia (heart rate >100 bpm) = 1. The model had a sensitivity of 83% and specificity of 53%. This simple, robust clinical tool can help individualize thromboprophylaxis for COVID-19 patients based on their VTE risk category.

Venous thromboembolism in COVID-19 patients and prediction model: a multicenter cohort study.

BACKGROUND: Patients with COVID-19 infection are commonly reported to have an increased risk of venous thrombosis. The choice of anti-thrombotic agents and doses are currently being studied in randomized controlled trials and retrospective studies. There exists a need for individualized risk stratification of venous thromboembolism (VTE) to assist clinicians in decision-making on anticoagulation. We sought to identify the risk factors of VTE in COVID-19 patients, which could help physicians in the prevention, early identification, and management of VTE in hospitalized COVID-19 patients and improve clinical outcomes in these patients. METHOD: This is a multicenter, retrospective database of four main health systems in Southeast Michigan, United States. We compiled comprehensive data for adult COVID-19 patients who were admitted between 1st March 2020 and 31st December 2020. Four models, including the random forest, multiple logistic regression, multilinear regression, and decision trees, were built on the primary outcome of in-hospital acute deep vein thrombosis (DVT) and pulmonary embolism (PE) and tested for performance. The study also reported hospital length of stay (LOS) and intensive care unit (ICU) LOS in the VTE and the non-VTE patients. Four models were assessed using the area under the receiver operating characteristic curve and confusion matrix. RESULTS: The cohort included 3531 admissions, 3526 had discharge diagnoses, and 6.68% of patients developed acute VTE (N = 236). VTE group had a longer hospital and ICU LOS than the non-VTE group (hospital LOS 12.2 days vs. 8.8 days, p < 0.001; ICU LOS 3.8 days vs. 1.9 days, p < 0.001). 9.8% of patients in the VTE group required more advanced oxygen support, compared to 2.7% of patients in the non-VTE group (p < 0.001). Among all four models, the random forest model had the best performance. The model suggested that blood pressure, electrolytes, renal function, hepatic enzymes, and inflammatory markers were predictors for in-hospital VTE in COVID-19 patients. CONCLUSIONS: Patients with COVID-19 have a high risk for VTE, and patients who developed VTE had a prolonged hospital and ICU stay. This random forest prediction model for VTE in COVID-19 patients identifies predictors which could aid physicians in making a clinical judgment on empirical dosages of anticoagulation.

Data of atrial arrhythmias in hospitalized COVID-19 and influenza patients.

Atrial arrhythmias (AA) are common in hospitalized COVID-19 patients with limited data on their association with COVID-19 infection, clinical and imaging outcomes. In the related research article using retrospective research data from one quaternary care and five community hospitals, patients aged 18 years and above with positive SARS-CoV-2 polymerase chain reaction test were included. 6927 patients met the inclusion criteria. The data in this article provides demographics, home medications, in-hospital events and COVID-19 treatments, multivariable generalized linear regression regression models using a log link with a Poisson distribution (multi-parameter regression [MPR]) to determine predictors of new-onset AA and mortality in COVID-19 patients, computerized tomography chest scan findings, echocardiographic findings, and International Classification of Diseases-Tenth Revision codes. The clinical outcomes were compared to a propensity-matched cohort of influenza patients. For influenza, data is reported on baseline demographics, comorbid conditions, and in-hospital events. Generalized linear regression models were built for COVID-19 patients using demographic characteristics, comorbid conditions, and presenting labs which were significantly different between the groups, and hypoxia in the emergency room. Statistical analysis was performed using R programming language (version 4, ggplot2 package). Multivariable generalized linear regression model showed that, relative to normal sinus rhythm, history of AA (adjusted relative risk [RR]: 1.38; 95% CI: 1.11-1.71; p = 0.003) and newly-detected AA (adjusted RR: 2.02 95% CI: 1.68-2.43; p < 0.001) were independently associated with higher in-hospital mortality. Age in increments of 10 years, male sex, White race, prior history of coronary artery disease, congestive heart failure, end-stage renal disease, presenting leukocytosis, hypermagnesemia, and hypomagnesemia were found to be independent predictors of new-onset AA in the MPR model. The dataset reported is related to the research article entitled "Incidence, Mortality, and Imaging Outcomes of Atrial Arrhythmias in COVID-19" [Jehangir et al. Incidence, Mortality, and Imaging Outcomes of Atrial Arrhythmias in COVID-19, American Journal of Cardiology] [1].

Incidence, Mortality, and Imaging Outcomes of Atrial Arrhythmias in COVID-19.

Atrial arrhythmias (AAs) are common in hospitalized patients with COVID-19; however, it remains uncertain if AAs are a poor prognostic factor in SARS-CoV-2 infection. In this retrospective cohort study from 2014 to 2021, we report in-hospital mortality in patients with new-onset AA and history of AA. The incidence of new-onset congestive heart failure (CHF), hospital length of stay and readmission rate, intensive care unit admission, arterial and venous thromboembolism, and imaging outcomes were also analyzed. We further compared the clinical outcomes with a propensity-matched influenza cohort. Generalized linear regression was performed to identify the association of AA with mortality and other outcomes, relative to those without an AA diagnosis. Predictors of new-onset AA were also modeled. A total of 6,927 patients with COVID-19 were included (626 with new-onset AA, 779 with history of AA). We found that history of AA (adjusted relative risk [aRR] 1.38, confidence interval [CI], 1.11 to 1.71, p = 0.003) and new-onset AA (aRR 2.02, 95% CI 1.68 to 2.43, p <0.001) were independent predictors of in-hospital mortality. The incidence of new-onset CHF was 6.3% in history of AA (odds ratio 1.91, 95% CI 1.30 to 2.79, p <0.001) and 11.3% in new-onset AA (odds ratio 4.01, 95% CI 3.00 to 5.35, p <0.001). New-onset AA was shown to be associated with worse clinical outcomes within the propensity-matched COVID-19 and influenza cohorts. The risk of new-onset AA was higher in patients with COVID-19 than influenza (aRR 2.02, 95% CI 1.76 to 2.32, p <0.0001), but mortality associated with new-onset AA was higher in influenza (aRR 12.58, 95% CI 4.27 to 37.06, p <0.0001) than COVID-19 (aRR 1.86, 95% CI 1.55 to 2.22, p <0.0001). In a subset of the patients with COVID-19 for which echocardiographic data were captured, abnormalities were common, including valvular abnormalities (40.9%), right ventricular dilation (29.6%), and elevated pulmonary artery systolic pressure (16.5%); although there was no evidence of a difference in incidence among the 3 groups. In conclusion, new-onset AAs are associated with poor clinical outcomes in patients with COVID-19.

Changes in Plasma Renin Activity After Renal Artery Sympathetic Denervation.

BACKGROUND: The renin-angiotensin-aldosterone system plays a key role in blood pressure (BP) regulation and is the target of several antihypertensive medications. Renal denervation (RDN) is thought to interrupt the sympathetic-mediated neurohormonal pathway as part of its mechanism of action to reduce BP. OBJECTIVES: The purpose of this study was to evaluate plasma renin activity (PRA) and aldosterone before and after RDN and to assess whether these baseline neuroendocrine markers predict response to RDN. METHODS: Analyses were conducted in patients with confirmed absence of antihypertensive medication. Aldosterone and PRA levels were compared at baseline and 3 months post-procedure for RDN and sham control groups. Patients in the SPYRAL HTN-OFF MED Pivotal trial were separated into 2 groups, those with baseline PRA ≥0.65 ng/ml/h (n = 110) versus <0.65 ng/ml/h (n = 116). Follow-up treatment differences between RDN and sham control groups were adjusted for baseline values using multivariable linear regression models. RESULTS: Baseline PRA was similar between RDN and control groups (1.0 ± 1.1 ng/ml/h vs. 1.1 ± 1.1 ng/ml/h; p = 0.37). Change in PRA at 3 months from baseline was significantly greater for RDN compared with control subjects (-0.2 ± 1.0 ng/ml/h; p = 0.019 vs. 0.1 ± 0.9 ng/ml/h; p = 0.14), p = 0.001 for RDN versus control subjects, and similar differences were seen for aldosterone: RDN compared with control subjects (-1.2 ± 6.4 ng/dl; p = 0.04 vs. 0.4 ± 5.4 ng/dl; p = 0.40), p = 0.011. Treatment differences at 3 months in 24-h and office systolic blood pressure (SBP) for RDN versus control patients were significantly greater for patients with baseline PRA ≥0.65 ng/ml/h versus <0.65 ng/ml/h, despite similar baseline BP. Differences in office SBP changes according to baseline PRA were also observed earlier at 2 weeks post-RDN. CONCLUSIONS: Plasma renin activity and aldosterone levels for RDN patients were significantly reduced at 3 months when compared with baseline as well as when compared with sham control. Higher baseline PRA levels were associated with a significantly greater reduction in office and 24-h SBP. (SPYRAL PIVOTAL - SPYRAL HTN-OFF MED Study; NCT02439749).

Periprocedural and long-term outcomes of endovascular abdominal aortic aneurysm repair in cardiology practice.

BACKGROUND: Endovascular repair of abdominal aortic aneurysm (AAA) has recently been made a class I indication in the treatment of AAA. In comparison to the conventional open surgical treatment, endovascular AAA repair (EVAR) is associated with equivalent long-term morbidity and mortality rates. Vascular surgeons perform majority of EVAR. There are no reports for the long-term results of this intervention performed by interventional cardiologists. We present one of the first reports of periprocedural and long-term outcomes of EVAR performed by interventional cardiologists. METHODS: Retrospective chart review on patients with attempted EVAR between September 2005 and January 2011 was performed. Included cases were all consecutive patients who had attempted EVAR by interventional cardiologists. RESULTS: During the study period EVAR was attempted in 170 patients, with 27% being women. The mean age was 74 years (range 52-93). The endovascular graft placement was successful in 96% (163/170) of patients. Procedure failures were more common in women (6 of 46 vs 1 of 124, P = 0.003). The 30-day mortality was 1.8 % (3 of 170). In patients with successful EVAR the mean follow-up was 30 months and mean length of hospital stay was 3.5 ± 3.2 days. Major periprocedural complications were noted in 9% patients (15 of 167). During follow-up, six patients (3.5%) required re-intervention and additional 16 patients died with no aneurysm related deaths. CONCLUSION: EVAR primarily performed by interventional cardiologists demonstrates high periprocedural and long-term success rates. A higher EVAR failure rate has been observed in women.

Decreased readmissions and improved quality of care with the use of an inexpensive checklist in heart failure.

Providing effective discharge instructions, appropriate dose uptitration, education regarding heart failure (HF) monitoring, and strict follow-up have all been shown to decrease readmissions for HF but are all underutilized. The authors developed and evaluated the impact of a quality-improvement HF checklist as a tool to remind physicians to improve quality of care in HF patients. The checklist was used in randomly selected patients admitted with a primary diagnosis of acute decompensated HF. It included documentation regarding medications and dose uptitration, relevant counseling, and follow-up instructions at discharge. The checklist was used in 48 patients, and this checklist group was compared with 48 patients as a randomly selected control group. Higher proportions of patients were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the checklist group compared with the control group (40 of 48 vs 23 of 48, P<.001). Compared with the controls, the rate of dose uptitration for ß-blockers and/or ACE inhibitors/ARBs was more common in the checklist group (4 of 48 vs 21 of 48, P<.001). Both 30-day (19% to 6%) and 6-month (42% to 23%) readmissions were lower in the checklist group. The use of an HF checklist was associated with better quality of care and decreased readmission rates for patients admitted with HF.

No Racial Disparities in the Treatment of ST Elevation Myocardial Infarction - A Community-based Experience.

Whether racial disparities exist in the treatment of ST elevation myocardial infarction (STEMI) is not exactly known. We report a retrospective chart review of patients with first event of STEMI, in two groups separated by one decade. Results revealed that hospital mortality in the 2007 and 1997 groups for African Americans versus Caucasians was one of 22 versus 21 of 170, 95 % confidence interval (CI) -0.178 to 0.022, p=0.48 and four of 41 versus 39 of 402, 95 % CI -0.095 to 0.096, p=1.00, respectively. The mean length of stay (LOS) for African Americans and Caucasians in the 2007 and 1997 groups was 5.7 versus 4.1 days (p=0.09) and 7.3 versus 6.6 days (p=0.42), respectively. During follow-up, a total of 40 patients needed re-intervention in the 2007 group. The re-intervention rate in African American patients being 13.6 % (three of 22) versus 21.2 % (36 of 170) in Caucasians, 95 % CI -0.231 to 0.081, with p=0.57. In conclusion, there was no evidence of racial disparity in the treatment of STEMI in terms of hospital mortality, length of hospital stay and re-intervention rate.

Minimally invasive retrieval of patent foramen ovale closure device after device migration to the descending aorta.

Percutaneous treatment of patent foramen ovale with a septal closure device has become a common procedure, but it is associated with various complications. Migration of the device is uncommon, and migration through the aortic valve into the aorta is rare. Managing the migration of a patent foramen ovale occluder can be challenging; it usually requires surgical retrieval of the foreign body. We report a rare case in which a patient experienced migration of a large patent foramen ovale closure device to the descending aorta. Rarer still was its successful percutaneous management.

High prevalence of obesity in young patients with ST elevation myocardial infarction.

BACKGROUND: There is growing concern about increasing rates of obesity in young people, and increasing ST elevation myocardial infarction (STEMI) at a younger age. There are only a few studies performed to study the risk factors in STEMI among young populations. METHODS: Retrospective chart reviews on all first event STEMI patients between December 2005 and July 2007 were performed. A young population was defined as: men <45 years of age and women <55 years of age. RESULTS: Among 206 patients with STEMI, 36 were young. In young patients with STEMI, 78 % were obese compared with 35 % obese, non-young (p<0.001). Also, among young patients with STEMI, family history of coronary heart disease (CHD) was positive in 39 %, compared with 19 % in non-young patients (p=0.009). This significance for obesity and family history persisted after adjusting for other risk factors using logistic regression (OR 2.96 to 17.75, 95 % CI, p<0.0001 and OR 1.36 to 7.47, 95 % CI, p=0.008, respectively). CONCLUSION: Obesity and family history of CHD were major risk factors with a higher prevalence in young patients with STEMI than non-young patients.

Endovascular abdominal aortic aneurysm repair by interventional cardiologists--a community-based experience.

INTRODUCTION: Endovascular repair of abdominal aortic aneurysm (AAA) is a relatively recent technology. In comparison to the conventional open surgical treatment for AAA, endovascular AAA repair (EVAR) combines a less-invasive approach with lower morbidity and mortality. There have been few studies regarding the performance of this procedure in a community-based setting. We report our experience of EVAR performed primarily by interventional cardiologists in a community hospital. METHODS: In our community hospital setting, between September 2005 and November 2007, we included all patients who underwent EVAR by interventional cardiologists, with available on-site vascular surgical support. Clinical and serial computed angiographic imaging outcomes were followed by a retrospective chart review. Data collection tools included demographic and clinical characteristics, anatomical aneurysm features, length of stay, peri- and postprocedural complications, and mortality. RESULTS: A total of 71 consecutive patients had EVAR attempted. The endovascular stent placement was successful in 67 (93%) patients. Thirty-day mortality in this study was 1 of 71 (1.4%). All four procedural failures and the single periprocedural mortality occurred in women. Mean follow-up was 12 months. There were a total of six mortalities and among these four were women (P ≤ 0.001); however, multivariate analysis revealed loss of significant difference in mortality (P = 0.16). Major complications following EVAR were noted in 10 of 71 (14%) patients. CONCLUSION: EVAR can be successfully performed by experienced interventional cardiologists with vascular surgical support in a community-based setting. In our experience, there is acceptable rate of complications and mortality in a carefully selected patient population.

Outcomes with retrievable inferior vena cava filters.

This was a retrospective study of 144 patients with retrievable inferior vena cava (IVC) filters inserted between 2004 and 2008 at a community/teaching hospital. The purpose was to evaluate the incidence of complications and the rate and success of retrieval. Retrieval of IVC filters was attempted in 14 of 144 (10%) patients at an average of 4.6 months. Retrieval was successful in 10 of 14 (71%). Within 6 months of insertion, retrieval was successful in 10 of 12 (83%). Unsuccessful attempts were at 3, 6, 8 and 9 months. Non-bleeding complications of IVC filters occurred in 12 of 144 (8.3%). Half (6 of 12) of the complications occurred after 3 months of insertion. Complications included IVC thrombosis in 3 (2.1%) (1 also had a new deep venous thrombosis [DVT]), a new DVT alone in 6 patients (4.2%), a new DVT with new pulmonary embolism (PE) in 1 patient (0.7%) and filter migration in 2 patients (1.3%). In conclusion, retrieval was attempted in only a small proportion of patients at a community/teaching hospital. Formalized guidelines for follow up may increase the proportion of patients in whom retrieval is attempted. Half of the complications of IVC filters could have been avoided with retrieval within 3 months.

Development of a multicenter peripheral arterial interventional database: the PVD-QI2.

BACKGROUND: The number of peripheral vascular intervention (PVI) procedures performed is steadily increasing in the United States. PVD-QI 2 is a prospective, multicenter observational study designed to improve the quality of care for patients undergoing PVI and to better understand the effectiveness and appropriateness of PVI in improving outcomes of peripheral arterial disease. The registry aims to elucidate which comorbid conditions and procedure-related variables are associated with beneficial or adverse outcomes after vascular interventions. METHODS: Five centers are currently prospectively collecting data on consecutive PVIs performed at their institutions and will include patients with both claudication and critical limb ischemia. A common data collection form and a standard set of definitions were developed during several planning meetings. Information on patient demographics, clinical history, comorbid conditions, treatment approaches, and in hospital outcomes are being collected. Patients will be followed up at 30 days, 6 months, and 1 year after each procedure to identify recurrent vascular events, medication use, lifestyle modifications (regular exercise, dietary modification), self-reported walking scores, and mortality. Data validity will be assured through review of data form accuracy by a trained nurse, by automatic database diagnostic routines, and by site visits that include review of angiography suite logs and randomly selected charts. CONCLUSIONS: The development of a quality-controlled PVI registry requires the commitment and collaboration of clinician-investigators and hospital systems devoted to understanding factors that contribute to quality outcomes. Central to achievement of this goal is the creation of a careful diagnostic and data quality assessment system. This registry will provide important clinical insights into patient demographic and clinical characteristics, procedural characteristics, and current practice patterns that foster or impede achievement of long-term quality-based clinical outcomes for patients with peripheral arterial disease.

Outcome and complications of retrievable inferior vena cava filters.

The results and risks of retrievable inferior vena cava filters were reviewed. Systematic review identified 6 prospective case series with broad ranges of indications for filters. In these case series, 4 different types of retrievable filters were inserted in 284 patients. The longest reported duration of insertion was 134 days. Among patients in whom percutaneous removal of the filter was attempted, the filter was successfully removed in 144 of 159 (91%). Surgery was necessary to remove the filter from 1 patient (1%), and filters could not be removed because of large trapped thrombi in 14 patients (9%).