Utility of Coronary Artery Calcium Scores in Predicting Risk of Subclinical Cardiovascular Atherosclerotic Disease: An Analysis of Limitations to its Adoption With Policy Recommendations.

This survey-based analysis aims to highlight key limitations to a wider adoption of coronary artery calcium (CAC) scoring as a means of screening asymptomatic individuals for atherosclerotic cardiovascular disease. The need for a screening tool that adds objective anatomical information to historically established risk scores in the aforementioned population has been met by this imaging modality. Despite that, there has been a hesitance towards frequent usage of these scans. Within the pre-set sampling frame of the University of Toledo, a convenience sampling technique was used to reach out to 60 health care providers. The resultant responses were analyzed and discussed. In addition to identifying patients who need to be worked up further, CAC scans can also help re-stratify patients within-risk groups and inform decision-making regarding the use of lipid-lowering therapies. The public health impact of a greater but appropriate utilization of this diagnostic tool will be impactful. This analysis seeks to better understand real-life obstacles to a wider adoption of these scans and attempts to lay out policy recommendations to address these issues.

Incidence, outcomes, and predictors of in-hospital acute coronary syndrome following endovascular transcatheter aortic valve replacement in the United States.

BACKGROUND: Incidence and outcomes of acute coronary syndrome (ACS) immediately following transcatheter aortic valve replacement (TAVR) remain largely unknown. OBJECTIVES: This study sought to assess the incidence, clinical characteristics, and outcomes of ACS following TAVR. METHODS: We queried the National Readmission Database from January 2012 to September 2015 for TAVR admissions with and without ACS, creating a propensity-matched cohort to compare outcomes. RESULTS: A total of 48,454 patients underwent TAVR, with 1,332 (2.75%) developing ACS. TAVR patients with ACS compared to those without ACS had a significantly higher incidence of acute kidney injury (24.7 vs. 19.2%; p = .001), ischemic stroke (3.7 vs. 2.3%; p = .04), vascular complications (8.6 vs. 5.8%; p = .008), cardiogenic shock (9.8 vs. 1.9%; p < .001), cardiac arrest (5.1 vs. 2.8%; p = .002), mechanical circulatory support (8.1 vs. 1.5%; p < .001), and in-hospital mortality (9.6 vs. 3.4%; p < .001). Additionally, TAVR with ACS had longer lengths of stay (median 10 days vs. 6 days; p < .001) and hospital charges (median $23,200 vs. $19,000; p < .001). Positive predictors of ACS were history of PCI (odds ratio, 1.43; 95% CI: 1.25-1.63), hyperlipidemia (odds ratio, 1.20; 95% CI: 1.07-1.34), chronic blood loss anemia (odds ratio, 2.16; 95% CI: 1.54-3.03), chronic kidney disease (odds ratio, 1.17; 95% CI: 1.04-1.31), fluid and electrolyte disorders (odds ratio, 1.65; 95% CI: 1.47-1.85), and weight loss (odds ratio, 1.53; 95% CI: 1.22-1.91). Heart failure (34%) was the most common reason for readmission in the ACS cohort. CONCLUSION: ACS after TAVR is uncommon but is associated with worse clinical outcomes and increased healthcare resource utilization.

Appropriateness of Prescription and Safety of Wearable Cardioverter Defibrillators: A Single-center Experience.

Introduction Wearable cardioverter defibrillators (WCD) are recommended for patients with a high risk of sudden cardiac death (SCD) secondary to arrhythmia that have not qualified for placement of an implantable cardiac defibrillator (ICD). This study provides insights into a single-center experience with WCD in terms of its usage and safety. Materials and methods We studied all patients that were prescribed a WCD in the Fairview Hospital in Cleveland Clinic Health System, from January 2014 to June 2016. Institutional Review Board of the Cleveland Clinic approved the study. A retrospective chart review was performed to collect data regarding demographics and baseline comorbidities including age, gender, history of hypertension, diabetes, coronary artery disease, and chronic kidney disease. The patients that were lost to follow up in our electronic medical record (EMR) were excluded. Ejection fraction (EF) at the time of diagnosis and follow-up was recorded. The primary outcome was ICD placement at follow up focusing on appropriate use while the secondary outcome was delivery of shock (appropriate or inappropriate) focusing on efficacy and safety of the device. Patients were stratified based on ICD placement. Statistical Package for the Social Sciences (SPSS), version 23 (IBM Corp., NY, USA) was used for the statistical analysis. Results We identified 73 patients with WCD placement. After the exclusion of 23/73 (31.5%) patients due to loss of follow-up, 50 patients were included in the study (n=50). Clinical characteristics showed 66% patients were males, 76% had hypertension, 40% had diabetes, 34% had chronic kidney disease, 56% patient had a New York Heart Association functional status of >II and 34% were on anti-arrhythmic medication. Indication for WCD use was ischemic cardiomyopathy in 23/50 (46%) patients and non-ischemic cardiomyopathy in 27/50 (54%) patients. No ICD was placed in 39/50 (78%) patients and ICD was placed in 11/50 (22%) patients at end time of follow up. Mean age was 59.9 years (95% confidence interval (CI), 55.9 - 63.9 years) in the group with no ICD placement and 63.5 years (95% CI, 56.5 - 70.6 years) in the group with ICD placement. Mean EF in the group with no ICD placement at the time of diagnosis was 25.8% (95% CI, 23.8% - 27.9%) which improved by 18.8% to a mean EF of 44.6% (41.1% - 48.1%) at the follow-up. Mean EF in the group with ICD placement was 32.7% (95% CI, 27.6% - 37.9%) which reduced by 4.1% to mean EF of 28.6% (95% CI, 12.2% - 44.9%) which was statistically significant (p<0.0001). Patients who had no ICD placement were followed for an average of 162 days and with ICD placement for 78 days. There was no difference between ischemic or nonischemic groups in getting the ICD. There were no shocks delivered whether appropriate or inappropriate in our population. Conclusion Almost a quarter of the patients that were prescribed WCD in our center ended up with an implanted device which demonstrates appropriate use. Equally important was the observed safety of WCDs as a treatment modality with no inappropriate shocks recorded in the followed cohort.

Recurrent Bacteremia with Corynebacterium Striatum After Prosthetic Valve Replacement: A Case Report.

Infective endocarditis is typically caused by Staphylococcus aureus (S. aureus), coagulase-negative staphylococci and streptococci but infection with Corynebacterium striatum (C. striatum) is also becoming prominent. We present the case of a 65-year-old female with a recent history of the coronary artery bypass graft with bioprosthetic aortic valve replacement. The surgery was complicated by sternal wound dehiscence with methicillin-sensitive S. aureus (MSSA) for which she was treated for six weeks with intravenous antibiotics. Two months later, she was found to have C. striatum which was treated. A transesophageal echocardiogram was done as well which did not show any vegetation. She presented to the hospital with vomiting, cough, fever, and shortness of breath. She had pyuria on urinalysis and was started on empiric antibiotics after taking blood cultures. She decompensated soon after admission and was transferred to the intensive care unit where she had a pulseless ventricular tachycardia and was resuscitated but required vasopressor support. The blood cultures from admission started growing C. striatum again. Daptomycin was added to the empiric antibiotics and supportive care was continued, but the family decided to make her 'do not resuscitate - comfort care only'. The support was withdrawn and she passed away.

Percutaneous Coronary Intervention for Iatrogenic Right Coronary Artery Dissection Post Bentall Procedure: A Case Report and Minireview.

Iatrogenic coronary artery dissection is a potentially life-threatening complication of cardiovascular interventions. The optimal management of iatrogenic coronary artery dissection is not clear; however, both conservative management and percutaneous or surgical revascularization have been performed depending on the patient's clinical status and the extent of dissection. We present the first reported case of right coronary artery dissection after Bentall procedure performed for ascending aortic aneurysm. Urgent percutaneous intervention using adjunctive coronary imaging was performed with excellent clinical recovery. In this article, we highlight coronary artery dissection after Bentall procedure as a possible complication, provide an insight into various options in its management, and review published data on iatrogenic coronary artery dissection. We also discuss the challenges in percutaneous treatment of coronary artery dissection with special focus on intracoronary imaging for accurate diagnosis and guidance in the management of this complex lesion.