Contemporary Features and Management of Endocarditis.

Infective endocarditis is a rare but devastating disease. Morbidity and mortality rates have failed to improve despite new technological advances. The disease has evolved over time with new significant populations at risk-most notably those with prosthetic valves or implantable cardiovascular devices. These devices pose new challenges for achieving a timely and accurate diagnosis of infection. While the modified Duke criteria is accepted as the gold standard for diagnosing native valve endocarditis, it has been shown to have significantly inferior sensitivity when it comes to identifying infections related to right-heart endocarditis, prosthetic valves, and indwelling cardiac devices. Additionally, prosthetic valves and cardiovascular implantable electronic devices can exhibit shadowing and artifact, rendering transthoracic echocardiography and transesophageal echocardiography results inconclusive or even normal. Having a keen awareness of the varying clinical presentations, as well as emerging valvular imaging modalities such as F-fluorodeoxyglucose cardiac positron-emission tomography plus computed tomography, promises to improve the evaluation and diagnosis of infective endocarditis. However, indications for appropriate use of these studies and guidance on modern clinical management are still needed.

Regional Variation in Procedural and Clinical Outcomes Among Patients With ST Elevation Myocardial Infarction With Cardiogenic Shock.

There is limited data on regional differences in patient characteristics, practice patterns, and clinical outcomes in patients with ST elevation myocardial infarction (STEMI) with cardiogenic shock (CS) in the United States (US). We aimed to identify variations in treatment methods and clinical outcomes in patients with STEMI CS between the 4 US regions. Using the National Inpatient Sample database, we identified adult patients admitted with STEMI associated with CS between 2006 and 2015 using ICD-9-DM codes. Based on the US regions (Northeast, Midwest, South, and West), we divided patients in 4 cohorts and compared baseline patient characteristics, clinical outcomes and procedural outcomes. A total of 186,316 patients with STEMI CS were included; 32,303 (17.3%) were hospitalized in the Northeast, 43,634 (23.4%) in the Midwest, 70,036 (37.8%) in the South, and 40,043 (21.5%) in the West. Although nonstatistically significant, the in-hospital mortality was higher in Northeast region (37.7%), followed by the South (36.6%), West (35.7%), and Midwest (35.2%). Rates of percutaneous coronary intervention were higher in the Midwest (68.5%) and lower in the Northeast (56%). The use of percutaneous ventricular assist device and ECMO was higher in the Northeast (3.3% and 2.2%) and lower in the West (2.1% and 0.4%). The median length of stay was similar among all 4 cohorts (6 days) but median hospital costs were higher in the West ($36, 614) and lower in the South ($28,795). In conclusion, there are significant geographic variations in practice patterns, healthcare cost, and in-hospital outcomes in patients with STEMI complicated by CS between 4 US regions.

Frequency of 30-day readmission and its causes after percutaneous coronary intervention in acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Survival after percutaneous coronary intervention (PCI) in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) has increased over the years. Short-term readmission rates in this high-risk population remain unknown. METHODS: We queried the United States (U.S.) Nationwide Readmission Database (NRD) from January 2010 to November 2014 using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9 CM) codes to identify all patients ≥18 years readmitted within 30 days after surviving an index hospitalization for PCI in AMI-CS. Incidence, etiologies, and predictors of 30-day readmission were analyzed. RESULTS: Among 46,435 patients who survived to discharge after PCI in AMI-CS, 9,020 (19.4%) were readmitted within 30 days. Median time to 30-day readmission was 11 days. Cardiac conditions were the most common causes of readmission (57.8%). Heart failure was the leading readmission diagnosis (24.8%). Private insurance including HMO and self-pay were predictive of lower 30-day readmission. Among other covariates, female sex, comorbidities such as heart failure, atrial fibrillation, in-hospital complications such as major bleeding, sepsis, respiratory complications, AKI requiring dialysis, utilization of mechanical circulatory support (IABP and ECMO) were independently predictive of 30-day readmission. Trend analysis showed decline in 30-day readmission rates from 21.9% in 2010 to 17.9% in 2014 (ptrend < 0.001). CONCLUSION: In this large real-world database, one in five patients receiving PCI in AMI-CS was readmitted within 30 days after discharge. Cardiac conditions were the most common causes of readmission. Insurance type had significant influence on 30-day readmission.

Optimal TR-band weaning strategy while minimizing vascular access site complications.

INTRODUCTION: The purpose of the study is to develop an optimal TR-Band weaning strategy while minimizing vascular access site complications of hematoma or radial artery occlusion (RAO). METHODS: The trial was a randomized, prospective, single center study of 129 patients who underwent cardiac catheterization via the radial artery. Group A was an accelerated protocol in which weaning was initiated 20 min after sheath removal. Group B was an adjusted protocol, in which weaning was dependent on the amount of anti-platelet or anti-coagulation used. All patients underwent radial artery ultrasound to demonstrate arterial patency. RESULTS: Baseline characteristics were similar in both groups, and PCI was performed in 36.7% of patients in Group A and 37.7% of patients in Group B. RAO occurred in 7.7% of patients overall, with no statistical difference between groups (Group A 5% versus Group B 10.1%, p-value = 0.337). Hematoma formation >5 cm in diameter occurred in 4.6% of patients in the overall cohort, without statistical difference between groups (Group A 5% versus Group B 4.3%, p-value = 1). The TR-Band duration was significantly shorter in Group A compared to Group B (112.9 ±â€¯50.7 versus 130.7 ±â€¯51.1 in minutes, respectively, p-value = 0.013). CONCLUSION: We have demonstrated an accelerated weaning protocol is simple to utilize for nursing staff without increased vascular site complications of RAO or hematoma formation.

Clinical Updates in Women's Health Care Summary: Ischemic Heart Disease: Primary and Preventive Care Review.

Cardiovascular disease is the leading cause of death among women in the United States. Obstetrician-gynecologists often are the sole health care providers for otherwise healthy women. Therefore, they must be aware of risk factors, signs, and symptoms of cardiovascular disease and be prepared to recognize and treat this condition in patients as well as provide referrals when specialized care is indicated. Women with cardiac problems typically present with chest discomfort; however, they also are more likely than healthy women to present with other common symptoms, such as shortness of breath, back pain, jaw pain, or nausea and vomiting. This monograph, with a primary focus on ischemic heart disease (IHD), discusses the basic anatomy of the heart and coronary arteries; vascular biology; pathogenesis of atherosclerosis; and the screening, prevention, diagnosis, and treatment of IHD as well as the multiple risk factors associated with the development of IHD that contribute to both increased morbidity and mortality.

Clinical Updates in Women's Health Care Summary: Arrhythmias: Primary and Preventive Care Review.

Obstetrician-gynecologists often are the sole providers of health care to female patients. Because cardiovascular disease is the leading cause of death in women in the United States, obstetrician- gynecologists must be aware of the risk factors, symptoms, and signs of cardiovascular disease and arrhythmia. Furthermore, they must be prepared to identify and treat common types of arrhythmia in this population and refer patients to cardiology for specialized care. Understanding the role of pregnancy among women with arrhythmia is critically important to optimize both maternal and fetal outcomes. This monograph discusses the cardiac conduction system and addresses the assessment, diagnosis, and treatment of both pregnant and nonpregnant patients with heart rhythm disorders.

Clinical Updates in Women's Health Care Summary: Structural Heart Disease: Primary and Preventive Care Review.

Reproductive-aged women with structural heart disease who become pregnant as well as postreproductive-aged women with this condition represent a significant proportion of patients seen by obstetrician- gynecologists. Usually, their conditions are complex, and a basic knowledge of the anatomy and physiology of the heart is required. Additionally, understanding the effect of pregnancy on women with structural heart disease is critically important to optimizing maternal and fetal outcomes. This monograph addresses the pathophysiology, signs and symptoms, screening and diagnosis, basic management, and suggested counseling for an obstetric-gynecologic patient with structural heart disease.

Cangrelor in patients undergoing cardiac surgery: the BRIDGE study.

The benefit of long-term dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes, drug-eluting stents and those at high risk for thromboembolic events has been well established in a number of well-designed randomized controlled studies. Current research in this area has focused on the development of novel antiplatelet agents for clinical use. The BRIDGE trial evaluated the use of cangrelor as a bridge to coronary artery bypass graft surgery in patients receiving extended DAPT. The BRIDGE trial results confirm the efficacy and safety of cangrelor in this population. This study is novel as it attempts to address the lapse in thienopyridine therapy required for many surgical and invasive procedures. The future of antiplatelet agents, particularly cangrelor, must also focus on bridging for high-risk patients undergoing noncoronary artery bypass graft surgical procedures. Overall, the BRIDGE trial represents a significant advance for patients appropriate for long-term DAPT.

Safety and efficacy of cangrelor, an intravenous, short-acting platelet inhibitor in patients requiring coronary artery bypass surgery.

OBJECTIVE: Oral P2Y12 platelet receptor inhibitors are a cornerstone of reducing complications in patients with acute coronary syndromes or coronary stents. Guidelines advocate discontinuing treatment with P2Y12 platelet receptor inhibitors before surgery. Cangrelor, a short-acting, reversible, intravenously administered P2Y12 platelet inhibitor is effective in achieving appropriate platelet inhibition in patients who are awaiting coronary artery bypass grafting (CABG) and require P2Y12 inhibition. The objective of this study was to assess the effects of preoperative cangrelor on the incidence of perioperative complications, which are currently unknown. METHODS: Patients (n = 210) requiring preoperative clinical administration of thienopyridine therapy were randomized in a multicenter, double-blinded study to receive cangrelor or placebo while awaiting CABG after discontinuation of the thienopyridine. Optimal platelet reactivity, which was defined as <240 P2Y12 platelet reaction units, was measured with serial point-of-care testing (VerifyNow). Pre- and postoperative outcomes, bleeding values, and transfusion rates were compared. To quantify potential risk factors for bleeding, we developed a multivariate logistic model. RESULTS: The differences between the groups in bleeding and perioperative transfusion rates were not significantly different. The rate of CABG-related bleeding was 11.8% (12/102) in cangrelor-treated patients and 10.4% (10/96) in the placebo group (P = .763). Transfusion rates for the groups were similar. Serious postoperative adverse events for the cangrelor and placebo groups were 7.8% (8/102) and 5.2% (5/96), respectively (P = .454). CONCLUSIONS: Compared with placebo, bridging patients with cangrelor prior to CABG effectively maintains platelet inhibition without increasing post-CABG complications, including bleeding and the need for transfusions. These data suggest cangrelor treatment is a potential strategy for bridging patients requiring P2Y12 receptor inhibition while they await surgery.

Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial.

CONTEXT: Thienopyridines are among the most widely prescribed medications, but their use can be complicated by the unanticipated need for surgery. Despite increased risk of thrombosis, guidelines recommend discontinuing thienopyridines 5 to 7 days prior to surgery to minimize bleeding. OBJECTIVE: To evaluate the use of cangrelor, an intravenous, reversible P2Y(12) platelet inhibitor for bridging thienopyridine-treated patients to coronary artery bypass grafting (CABG) surgery. DESIGN, SETTING, AND PATIENTS: Prospective, randomized, double-blind, placebo-controlled, multicenter trial, involving 210 patients with an acute coronary syndrome (ACS) or treated with a coronary stent and receiving a thienopyridine awaiting CABG surgery to receive either cangrelor or placebo after an initial open-label, dose-finding phase (n = 11) conducted between January 2009 and April 2011. Interventions Thienopyridines were stopped and patients were administered cangrelor or placebo for at least 48 hours, which was discontinued 1 to 6 hours before CABG surgery. MAIN OUTCOME MEASURES: The primary efficacy end point was platelet reactivity (measured in P2Y(12) reaction units [PRUs]), assessed daily. The main safety end point was excessive CABG surgery-related bleeding. RESULTS: The dose of cangrelor determined in 10 patients in the open-label stage was 0.75 µg/kg per minute. In the randomized phase, a greater proportion of patients treated with cangrelor had low levels of platelet reactivity throughout the entire treatment period compared with placebo (primary end point, PRU <240; 98.8% (83 of 84) vs 19.0% (16 of 84); relative risk [RR], 5.2 [95% CI, 3.3-8.1] P < .001). Excessive CABG surgery-related bleeding occurred in 11.8% (12 of 102) vs 10.4% (10 of 96) in the cangrelor and placebo groups, respectively (RR, 1.1 [95% CI, 0.5-2.5] P = .763). There were no significant differences in major bleeding prior to CABG surgery, although minor bleeding episodes were numerically higher with cangrelor. CONCLUSIONS: Among patients who discontinue thienopyridine therapy prior to cardiac surgery, the use of cangrelor compared with placebo resulted in a higher rate of maintenance of platelet inhibition. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00767507.

Localization of culprit lesions in coronary arteries of patients with ST-segment elevation myocardial infarctions: relation to bifurcations and curvatures.

BACKGROUND: Although culprit lesions in ST-segment elevation myocardial infarction (STEMI) cluster in the proximal coronary arteries, their relationship to bifurcations and curvatures, where blood flow is disturbed, is unknown. We hypothesized that (a) culprit lesions localize to disturbed flow distal to bifurcations and curvatures and (b) the distribution of culprit lesions in the left (LCA) and right coronary arteries (RCA) and resulting infarct size are related to the location of bifurcations and curvatures. METHODS: Emory University's contribution to the National Cardiovascular Data Registry was queried for STEMIs. Using quantitative coronary angiography, the distances from the vessel ostium, major bifurcations, and major curvatures to the culprit lesion were measured in 385 patients. RESULTS: Culprit lesions were located within 20 mm of a bifurcation in 79% of patients and closer to the bifurcation in the LCA compared with the RCA (7.4 ± 7.3 vs 17.7 ± 14.8 mm, P < .0001). Of RCA culprit lesions, 45% were located within 20 mm of a major curvature. Compared with those in the RCA, culprit lesions in the LCA were located more proximally (24.4 ± 16.5 vs 44.7 ± 28.8 mm, P = .0003) and were associated with larger myocardial infarctions as assessed by peak creatine kinase-MB (208 ± 222 vs 140 ± 153 ng/dL, P = .001) and troponin I (59 ± 62 vs 40 ± 35 ng/dL, P = .0006) and with higher in-hospital mortality (5.2% vs 1.1%, P = .04). CONCLUSIONS: In patients with STEMI, culprit lesions are frequently located immediately distal to bifurcations and in proximity to major curvatures where disturbed flow is known to occur. This supports the role of wall shear stress in the pathogenesis of STEMI.

Anemia, hemorrhage, and transfusion in percutaneous coronary intervention, acute coronary syndromes, and ST-segment elevation myocardial infarction.

Advances in antithrombotic and antiplatelet therapies have led to a reduction in ischemic event rates in percutaneous coronary intervention (PCI), acute coronary syndromes (ACS), and ST-segment elevation myocardial infarction (STEMI) but have generally resulted in an increased risk of hemorrhagic complications. In these settings, both baseline anemia and acute hemorrhage occur with relative frequency and are associated with increased morbidity and mortality. Although commonly treated with blood transfusion, this intervention may accentuate rather than attenuate both short-term and long-term risk. This review discusses the pathophysiology of anemia and the impact of anemia and transfusion on morbidity and mortality in PCI, ACS, and STEMI.

Predictors and impact of major hemorrhage on mortality following percutaneous coronary intervention from the REPLACE-2 Trial.

Patients undergoing percutaneous coronary intervention (PCI) have a significant risk of hemorrhagic complications. Predictors of major hemorrhage and its relation to mortality in PCI are not well defined. Baseline and periprocedural predictors of major hemorrhage and its impact on mortality in patients undergoing elective or urgent PCI randomly assigned to heparin plus planned glycoprotein IIb/IIIa inhibitor (GPI) versus bivalirudin plus provisional GPIs in the REPLACE-2 Trial were determined. Of 6,001 patients, 3.2% experienced a major hemorrhage. Independent baseline predictors of major hemorrhage included advanced age, female gender, impaired creatinine clearance, and anemia. Independent periprocedural predictors of major hemorrhage included treatment with heparin plus GPI, increased procedural duration, provisional use of GPI, increased time to sheath removal, length of intensive care unit stay, and use of an intra-aortic balloon pump (all p <0.05). Mortality rates were higher in patients with than without major hemorrhage at 30 days (5.1% vs 0.2%), 6 months (6.7% vs 1.0%), and 1 year (8.7% vs 1.9%; p <0.001 for all). Furthermore, major hemorrhage was an independent predictor of 1-year mortality (odds ratio 2.66, 95% confidence interval 1.44 to 4.92, p = 0.002). In conclusion, in patients undergoing elective or urgent PCI, major hemorrhage was an independent predictor of 1-year mortality. A number of baseline and periprocedural factors independently predicted major hemorrhage, including treatment with heparin plus GPI.

Effect of anemia on hemorrhagic complications and mortality following percutaneous coronary intervention.

The relation across anemia, hemorrhagic complications, and mortality associated with percutaneous coronary intervention (PCI) is unclear. We reviewed the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)-2 Trial, which compared bivalirudin plus provisional glycoprotein IIb/IIIa blockade with heparin plus planned glycoprotein IIb/IIIa blockade in patients undergoing urgent or elective PCI. Of the 6,010 patients randomized in REPLACE-2, 1,371 (23%) were anemic. Major bleeding was more common in anemic than in nonanemic patients (4.9% vs 2.8%, p = 0.0001). In anemic patients, treatment with bivalirudin (n = 678) resulted in a lower risk of major bleeding versus heparin plus glycoprotein IIb/IIIa blockade (n = 693, 3.5% vs 6.2%, p = 0.0221). Mortality was higher in anemic patients than in nonanemic patients at 30 days (0.9% vs 0.2%, p <0.0001), 6 months (2.6% vs 0.7%, p <0.0001), and 1 year (4.3% vs 1.5%, p <0.0001). There were no differences between anemic and nonanemic patients with regard to ischemic complications at 30 days. Although anemic patients had higher mortality rates, proportions of cardiovascular and noncardiovascular mortalities were equal in anemic and nonanemic patients. In conclusion, anemic patients undergoing PCI have an increased risk of mortality and major bleeding, but not of ischemic events, and the use of bivalirudin with provisional glycoprotein IIb/IIIa blockade decreases the risk of hemorrhagic complications compared with heparin plus planned glycoprotein IIb/IIIa blockade.