Disparities in Drug-Eluting Stent Utilization in Patients With Acute ST-Elevation Myocardial Infarction: An Analysis of the National Inpatient Sample.

The superiority of drug-eluting stents (DES) compared with bare-metal stents (BMS) is well-established, but data regarding DES use in ST-elevation myocardial infarction (STEMI) as a function of race is limited. Our goal was to examine stent utilization patterns and disparities based on race, sex, and insurance status in patients with STEMI undergoing percutaneous coronary intervention. The National Inpatient Sample database was used to retrospectively compare DES vs BMS use in patients admitted with STEMI from 2009 to 2018. Multivariable logistic regression was performed to assess the independent predictors of DES use. DES utilization increased significantly from 62.8% in 2009 to 94.0% in 2018. However, African Americans were less likely to receive a DES (odds ratio [OR] .82, 95% confidence interval [CI] .77-.87) compared with Caucasians. Women were more likely to undergo DES implantation (OR 1.07, 95% CI 1.05-1.10). Patients insured by Medicaid (OR .84, 95% CI .80-.89) and those classified as Self-pay (OR .63, 95% CI .61-.66) were less likely to undergo DES implantation compared to those with private insurance (OR 1.33, 95% CI 1.29-1.38). Disparities based on race and insurance status continue to persist despite a significant increase in DES utilization in STEMI patients across the identified subgroups.

In-Hospital Outcomes of Surgical Aortic Valve Replacement at Transcatheter Valve Implantation Centers.

The availability of transcatheter aortic valve implantation (TAVI) has led to the development of a multidisciplinary team, the "heart team," at institutions offering both TAVI and surgical aortic valve replacement (SAVR). Whether this approach has improved in-hospital outcomes in patients who underwent SAVR at institutions offering TAVI versus those not offering TAVI is largely unknown. The National Inpatient Sample (2011 to 2018) was used to study trends in visits for SAVR and in-hospital outcomes at TAVI and non-TAVI centers. Survey estimation commands were used to determine weighted national estimates. There were 559,365 inpatient visits during 2011 to 2018 for aortic valve replacement, with 65.9 ± 0.8% and 34.0 ± 0.8% at TAVI and non-TAVI centers, respectively. Patients who underwent SAVR at TAVI hospitals had more co-morbidities and were less likely to receive mechanical prosthesis (24.7 ± 0.5% vs 35.5 ± 0.6%). Adjusted in-hospital mortality was lower among any SAVR (odds ratio 0.84, 95% confidence interval 0.75 to 0.94) and isolated SAVR (odds ratio 0.83, 95% confidence interval 0.70 to 0.98) recipients at TAVI centers. There was no difference in the incidence of stroke, permanent pacemaker placement, and acute kidney injury after SAVR in TAVI and non-TAVI centers. Although patients who underwent SAVR at TAVI centers had more co-morbidities, in-hospital mortality was lower at TAVI centers than non-TAVI centers. This may be attributable to several factors, including but not limited to experience, resource availability, and operative volumes and the use of the heart team.

Contemporary trends and in-hospital outcomes of mechanical and bioprosthetic surgical aortic valve replacement in the United States.

INTRODUCTION: The choice between a mechanical versus a bioprosthetic valve in aortic valve replacement (AVR) is based on life expectancy, bleeding risk and comorbidities, since bioprosthetic AVR (bAVR) are associated with a more rapid structural deterioration compared to mechanical AVR (mAVR). The impact of widespread transcatheter valve replacements, on the decision to use bAVR versus mAVR, in the contemporary era and subsequent outcomes remain to be determined. METHODS: The National Inpatient database (2009-2018) was used to study trends in admissions for bAVR and mAVR and in-hospital mortality and outcomes over time. Survey estimation commands were used to determine weighted national estimates. RESULTS: There were 700,896 ± 18,285 inpatient visits for AVR with 70.1% (95% CI 69.2%-71.1%) and 29.9% (95% CI 28.9%-30.8%) visits for bAVR and mAVR, respectively. Those undergoing bAVR were significantly older (bAVR [69.8 years] vs. mAVR [62.7 years] p < .001]. The rates of mAVR decreased across all age groups during the study period (ptrend < .001), including patients ≤50 years (ptrend < .001). In-hospital mortality for mAVR recipients was higher, both after multivariable adjustment (OR 1.35 95% CI 1.26-1.45 p < .001) and propensity matching (mean difference 0.846% ± 0.19%). CONCLUSION: In the contemporary era, the utilization of mAVR has decreased across all age groups, including those younger than 50 years old. Although mAVR recipients were healthier with less comorbidities, inpatient mortality was higher after mAVR compared to bAVR. In addition to understanding causes for higher in-hospital mortality after mAVR, future research should focus on developing transcatheter valve replacement friendly bAVR.

A Broken Heart: Cardiac Arrest As the Initial Presentation of Myasthenic Crisis.

Myasthenic crisis is a life-threatening condition commonly associated with respiratory failure and may present in unusual ways. However, there is paucity in the literature about the cardiac manifestations of myasthenia gravis. We present a case of a 61-year-old male who presented to the emergency room with upper respiratory infection symptoms who soon thereafter suffered sudden cardiac arrest. He was found to have shortened PR interval pre and post arrest onelectrocardiogram (EKG). Only past medical history, discovered post cardiac arrest, was myastenia gravis. All other causes of cardiac arrest were ruled out, and it was deemed to be due to a manifestation of myastenia gravis. The patient was treated with intravenous steroids and plasmapheresis with resolution of shortened PR interval. It is hypothesized that striatial muscle antibodies may trigger inflammation in cardiac muscle and cause conduction abnormalities. In addition, anti-Kv1.4 antibodies have been associated with EKG abnormalities, including QT prolongation and T-wave inversion. To our knowledge, we are the first to report myasthenic crisis manifesting with isolated cardiac arrest with pulseless electrical activity and a shortened PR interval.