Platelet FcγRIIa expression in patients with stable coronary artery disease.

OBJECTIVES: FcÉ£RIIa amplifies platelet activation and greater expression increases platelet reactivity. In patients with myocardial infarction (MI), high platelet FcÉ£RIIa identifies patients with an approximately 4-fold greater risk of MI, stroke, and death. We compared platelet FcÉ£RIIa in 2 groups: (1) patients who had not had an MI in the previous year and were undergoing cardiac catheterization and percutaneous coronary intervention (PCI) labeled as stable coronary artery disease (CAD), and (2) previously obtained results in patients with MI (n = 197). METHODS: Patients undergoing cardiac catheterization and PCI were enrolled. FcÉ£RIIa expression was quantified with the use of flow cytometry. Comparisons were made with Mann-Whitney Rank Sum Test and Chi Squared analysis. Significance was defined as P less than .05. RESULTS: Compared to patients with MI, patients with stable CAD (n = 49) were older (70 ± 9 years vs 63 ± 12 years) and were more likely to have had prior MI (43% vs 23%), prior revascularization (62% vs 33%), diabetes (35% vs 24%), and hypertension (98% vs 66%). In patients with stable CAD, platelet FcÉ£RIIa was, on average, lower than that seen in patients with acute MI (9746 ± 4316 vs 11 479 ± 2405 molecules/platelet, P less than .001). Patients with stable CAD exhibited a range of platelet FcÉ£RIIa (~4500 to ~27 000 molecules/platelet) similar to that seen in acute MI patients (~6500 to ~30 000 molecules/platelet). CONCLUSIONS: Compared to patients with MI, patients with stable CAD had, on average, lower platelet FcÉ£RIIa. However, the range of platelet FcÉ£RIIa was similar to that seen in patients with MI. These results support future studies designed to assess the prognostic implications of platelet FcÉ£RIIa in patients with stable CAD.

Trends and Predictors of Short Length of Stay Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Minimalist approaches to Transcatheter aortic valve replacement (TAVR) have allowed for improved efficiency in care of patients. We hypothesized that improved efficiencies in care process may have led to increased adoption of a one night length of stay (LOS) in this patient group. OBJECTIVES: The authors aimed to study temporal trends in short length of stay following TAVR. METHODS: This is a nationwide temporal trends study using the 2016-2019 National In Patient Sample (NIS) registry. Short stay was defined as LOS of one night or less. Trends in proportion of patients with short stay were obtained. A multivariate model to identify predictors of short stay was built after adjusting for confounders. Secondary analysis of temporal trends was stratified by presence or absence of major complications (major bleeding requiring transfusion or pacemaker implantation [PPMI]). RESULTS: A total of 217,110 patients were included in the weighted sample. The proportion of patients with short stay significantly increased for those with and without complications (Ptrend < 0.001). The morbidity burden, as defined by the proportion of patients with a Charlson comorbidity index (CCI) score of ≥2 and rate of major complications decreased significantly. On multivariate analysis short stay was predicted by male sex, white ethnicity, Southern/Western regions and lower CCI score. Patients with major bleeding requiring transfusion or PPMI were less likely to have short stay (aOR 0.23 and aOR 0.12, p < 0.001 respectively). CONCLUSION: There is a national trend towards shorter LOS following TAVR. There is a decrease in major post procedural complication rates from 2016 to 2019.

Concordance of Guideline-Based Risk Stratification and Selection of Patients for Transcatheter Aortic Valve Implantation or Surgical Replacement.

The 2020 American Health Association/American College of Cardiology valve guidelines recommend surgical aortic valve replacement (SAVR) for symptomatic patients with aortic stenosis (AS) age <65 years and transcatheter aortic valve implantation (TAVI) for patients with AS age >80 years. We analyzed TAVI versus SAVR practice patterns using age-based recommendations. We compared 2016-to-2019 TAVI and isolated SAVR in northern New England at 5 centers according to guideline-recommended age groups. Multivariable logistic regression was performed to identify independent predictors of TAVI for the intermediate age group. The study was approved by each site's institutional review board in accordance with ongoing participation and quality improvement efforts in the Northern New England Cardiovascular Study Group. Among 4,161 patients with isolated severe AS, TAVI increased from 2016 to 2019: 55.8% versus 76.1%, p <0.01 for trend. SAVR for patients with AS age >80 years was uncommon and decreased over time: 13.1% versus 1.6%, p <0.01. TAVI utilization nearly doubled over time in young patients with AS age <65 years (14.3% vs 26.2%, p <0.01). Preference for SAVR decreased by 50% over time (p <0.01) in the intermediate age group (65 to 80 years). Independent predictors of TAVI among patients aged 65 to 80 years included older age, chronic obstructive pulmonary disease, previous stroke, and coronary artery bypass grafting, whereas vascular disease and clinical urgency favored SAVR. In conclusion, consistent with current American Health Association/American College of Cardiology guidelines, TAVI was the treatment of choice in >97% of severe patients with AS age >80 years by 2019. TAVI utilization in patients <65 years has doubled over time and thus may not reflect current guideline recommendations. TAVI is the preferred choice in those aged 65 to 80 years, especially among patients with previous stroke or coronary artery bypass grafting.

Elevated risk of venous thromboembolism in patients undergoing therapeutic hypothermia after cardiac arrest.

INTRODUCTION: Targeted Temperature Management (TTM) reduces mortality and improves neurological outcomes after cardiac arrest. Cardiac arrest is considered a pro-thrombotic state. Endovascular cooling catheters may increase the risk of thrombosis. Targeted Temperature Management, however, increases fibrinolysis. The net outcome of these opposing effects remains largely unexplored. Moreover, the exact rate of venous thromboembolism (VTE) is uncertain in these patients. We sought to determine the incidence and potential predictors of VTE in patients undergoing TTM. METHODS: Single center retrospective analysis. Participants were age ≥18 years old, admitted with out-of-hospital or in-hospital cardiac arrest, underwent TTM between January 1, 2007 and April 30, 2019 with endovascular cooling catheter. A total of 562 patients who underwent TTM (Study group) were compared to 562 patients treated for ARDS (control group). This control group was based on presumed similarities in factors affecting VTE: intensive care setting, immobility, length of stay and likely presence of central venous catheters. RESULTS: Patients who underwent TTM had a significantly higher rate of VTE (6.6% vs 2.3%, p = 0.006) and deep vein thrombosis (DVT) (4.6% vs 1.3%, p = 0.011) when compared to control group. In multivariate analysis age, gender, race and hospital length of stay were not associated with development of VTE in the study group. CONCLUSION: Patients undergoing TTM after cardiac arrest have statistically higher incidence of VTE and DVT compared to patients with ARDS. This risk is independent of age, gender, race or length of stay.

Patient Attributes Associated With Better Long-Term Outcomes on Palliative Milrinone.

Milrinone is a phosphodiesterase three inhibitor used as an inotrope in patients with advanced heart failure with reduced ejection fraction (HFrEF). Its action is independent of ß-receptor stimulation, which makes it preferable in patients who are on ß blockers as part of a guideline-directed neurohormonal blockade. There have been numerous studies evaluating the risks, benefits, and mortality associated with milrinone in the management of chronic heart failure patients. Time and again, there has been concern regarding the undesirable outcomes associated with it, including higher mortality and cardiac arrhythmias. Additionally, it has been difficult to determine whether milrinone or disease progression is responsible for adverse outcomes and mortality. In light of such discrepancy, the selection of patients for milrinone remains challenging. We hypothesized that there are underlying patient characteristics that influence the response to milrinone and may predict milrinone's adverse outcomes in spite of milrinone. A retrospective study review of 10 patients on palliative milrinone was conducted to identify these factors with a mean follow-up of 36 months. During the study period, four of 10 patients died. These four patients were on milrinone for a mean of 11.5 months. The attributes of the survivors compared to the deceased included lower age at start of therapy (67.5 vs 79 y), female gender (66% vs 33%), non-ischemic cardiomyopathy (33% vs 50%), associated diagnosis of atrial fibrillation/flutter(50% vs 25%), hyperlipidemia (66% vs 50%), or anemia (83% vs 75%), presence of chronic resynchronization therapy (CRT) (66% vs 25%), and implantable cardioverter-defibrillator (ICD) (16% vs 0%), as well as lower sodium (136 vs 140 mEq), chloride (101.5 vs 104.5 mEq), potassium (4.07 vs 4.23 mEq), and creatinine (1.3 vs 1.8 mg/dL)  Conversely, the deceased patients were more likely to have coronary artery disease (75% vs 33%), diabetes mellitus (50% vs 16%), hypertension (100% vs 83%), chronic kidney disease (75% vs 66%), peripheral vascular disease (25% vs zero), higher pulmonary artery pressures (54 vs 50.5%), and history of percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) (50% vs 16%). These trends exhibit patient characteristics that may predict better outcomes on long-term milrinone although larger studies are needed to assess the statistical significance of these findings.

Cocaine-induced Thrombosis: Review of Predisposing Factors, Potential Mechanisms, and Clinical Consequences with a Striking Case Report.

Cocaine is associated with a wide array of complications through a number of different mechanisms. Although the majority of cocaine-related morbidity has been attributed to complications in arterial vasculature, the deleterious impact of venous complications appears to be largely unrepresented in current literature as well as clinical practice despite emerging evidence of the high prevalence and annual incidence of deep vein thrombosis (DVT) in illicit drug users. Our case report illustrates an uncharacteristic presentation of cocaine-related widespread thrombotic cascade involving both arterial and venous circulations causing significant morbidity. The complex pathophysiology of widespread prothrombotic state caused by cocaine includes endothelial damage promoting the increase of fibrinogen and Von Willebrand factor to platelet aggregation and clot formation. It is important to identify the impact cocaine-induced venous thrombosis can mount, especially in the form of potentially fatal complications like pulmonary embolism. Although recent studies have focused on increased incidence and prevalence of venous thrombosis in the setting of cocaine abuse, ours is the first case of a documented pulmonary embolism caused by cocaine-related venous thrombosis. Further studies are needed to identify patients at higher risk for this complication like rare thrombotic disorders.

Clinical Overlap Between Myopericarditis and Stress Induced Cardiomyopathy: A Diagnostic and Therapeutic Challenge.

BACKGROUND Stress induced cardiomyopathy (SIC) is characterized by non-obstructive coronary arteries and characteristic ventricular apical ballooning. The exact pathogenesis of SIC is not well recognized. We present an unusual case of SIC that mimicked acute myopericarditis and discuss the effect of this masquerading presentation of SIC in recognizing pathophysiological association between myopericarditis and SIC and limitations of current diagnostic criteria. CASE REPORT A 47-year-old female presented with flu-like illness and pleuritic chest pain. An electrocardiogram (ECG) showed diffuse PR depressions and ST elevations, troponin 5 ng/mL, hemoglobin 14.2 mg/dL, leukocytosis (white blood cell count of 15.1×103/uL) and erythrocyte sedimentation rate (ESR) of 22.4 mm/hour. Echocardiogram showed reduced ejection fraction (EF) with apical ballooning. Catheterization showed non-obstructive coronary disease. The patient was given colchicine and ibuprofen for 1 day with symptom resolution over the next 2 days and repeat echocardiogram with preserved EF. Troponin trended down to 3.24 ng/mL and 0.44 ng/mL, 6 hours apart. ECG showed resolution of PR depressions and subsequent T wave inversions in 1, AVl, V1-V6 by day 3. The diagnosis of myopericarditis was favored by viral prodrome, fever, pleuritic pain, pericardial rub, ECG findings, and elevated ESR. History of emotional stress, characteristic ballooning of left ventricle apex with rapid resolution favored SIC. CONCLUSIONS This case showed that SIC and myocarditis need not be mutually exclusive and differentiating clinically between these 2 entities can be difficult. Alternatively, SIC can accompany other cardiac conditions like myocardial infarction, pericarditis, and myocarditis making diagnosis and management challenging. Clinicians need to be cautious while making this differentiation as duration and type of therapy may be significantly different. SIC can be considered a variant of regional inflammatory myocarditis wherein pericarditis may result secondary to extension of myocardial inflammation to overlying pericardium. The current Mayo Clinic criteria for diagnosis of SIC appears to be outdated, not accounting for such atypical presentations, and therefore needs to be revised.

Role of Niacin in Current Clinical Practice: A Systematic Review.

BACKGROUND: Niacin, a potent high-density lipoprotein cholesterol-raising drug, seems an attractive approach to reduce cardiac events in patients with or at risk of atherosclerotic cardiovascular disease. However, previous evidence for niacin has been challenged recently by negative outcomes in 2 large, randomized, controlled trials comparing niacin to placebo with background statin therapy. We studied the currently available evidence for the role of niacin treatment for reducing the risk of cardiovascular events in current practice. METHODS: A systematic review of randomized controlled trials in the MEDLINE, EMBASE, CINAHL, and Cochrane databases comparing niacin alone or combined with statin therapy was performed. We extracted trial level data, including basic characteristics and number of patients enrolled, duration of follow up, occurrence of adverse events, and cardiovascular-related outcomes. Random effects meta-analysis was conducted to estimate the risk ratio (RR) for individual trial endpoints. RESULTS: Thirteen trials (N = 35,206) were selected for final analysis. The mean follow-up duration was 32.8 months. Overall, niacin led to significant increases in serum high-density lipoprotein cholesterol levels from baseline trial enrolment by 21.4%, 9.31 (95% confidence interval [CI] 5.11-13.51) mg/dL. However, we did not observe any differences in all-cause mortality rates (RR 0.99; 95% CI 0.88-1.12) between niacin and control arms. Further, niacin treatment was associated with a trend toward lower risk of cardiovascular mortality (RR 0.91; 95% CI 0.81-1.02), coronary death (RR 0.93; 95% CI 0.78-1.10), nonfatal myocardial infarction (RR 0.85; 95% CI 0.73-1.0), revascularization (coronary and noncoronary) (RR 0.83; 95% CI 0.65-1.06), and stroke (RR 0.89; 95% CI 0.72-1.10), compared with control. CONCLUSION: Niacin therapy does not lead to significant reductions in total or cause-specific mortality or recurrent cardiovascular events among persons with or at risk of atherosclerotic cardiovascular disease.