Regional wall motion abnormalities in transthoracic echocardiography in patients with significant coronary artery disease and coronary collateral circulation in adults.

BACKGROUND: Coronary collateral circulation is a common finding in patients with chronic total occlusions (CTOs) resulting from chronic coronary artery disease (CAD). Regional wall motion abnormalities (RWMA) on transthoracic echocardiography (TTE) can be used for the diagnosis of CAD. However, little work has been done to investigate the impact of collateral vessels on the diagnostic accuracy of resting TTE for CAD. METHODS: A retrospective chart review was conducted of adults who received a resting TTE and cardiac catheterization within 30 days over a 4-year period at the Temple Baylor Scott & White echocardiography laboratory. Exclusion criteria included catheterization without coronary angiography and prior history of CAD, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). We analyzed RWMA on TTE in patients with CAD and coronary collateral circulation on cardiac catheterization to assess for correlation. RESULTS: Of the 753 patients were included in this study, 453 had CAD, 272 had both CAD and RWMA, 111 had collateral circulation, and 73 had collateral circulation and RWMA. There was no significant difference in RWMA in patients with CAD with and without collateral circulation. There was no significant difference in the sensitivity (60.0 % vs 59.2 %) and specificity (78.4 % vs 73.9 %) after collateral-adjusted interpretation of RWMA and CAD (p = 0.3). DISCUSSION: Our results suggest the average coronary collateral system is of insufficient clinical significance to prevent the development of RWMA on resting TTE.

The Positive Impact of Bariatric Surgery on Vascular Health.

BACKGROUND: Obesity is one of the most prevalent medical conditions in the Western world. There are many risk factors associated with obesity, including cardiovascular and pulmonary risk. Vascular health is not studied in obese patients, and whether obesity has an adverse effect on vascular health in these patients remains unknown. OBJECTIVE: The first objective is to find a correlation between vascular health and obesity and whether obesity can be classified as a risk factor for vascular health. The second objective is to see if weight loss leads to an improvement in vascular health in patients. METHODS: The study was conducted with pre- and post-surgical methods at Baylor Scott & White (BSWH) Medical Center, Temple, Texas, USA. Ten patients were approached, consented, and prepared to obtain baseline values through WatchPAT and EndoPAT devices prior to their bariatric surgery. Values obtained include their initial weight, respiratory disturbance index, apnea-hypopnea index, oxygen desaturation index, and degree of endothelial dysfunction via the EndoPAT device. Post-surgery, these values were obtained again and compared using Wilcoxon non-parametric analyses with a level of significance at p < 0.05. RESULTS: Our study results demonstrate a correlation between obesity and vascular health as endothelial dysfunction is widely seen. In our patients, after bariatric surgery, we saw a significant weight change (31.2% +11.2, p < 0.0001). There was a significant degree of endothelial function improvement after the weight loss (31.2% +34.7, p < 0.04). CONCLUSION: Our results indicate that there is a correlation between obesity and vascular health, which also correlates with cardiovascular risk. There is a significant reduction in endothelial dysfunction after weight loss. We believe that obesity is a risk factor for vascular health outcomes.

An interrupted time series study of electronic health record clinical decision support for providers caring for patients with atrial fibrillation at increased stroke risk.

PURPOSE: To measure the effect of clinical decision support (CDS) on anticoagulation rates in patients with atrial fibrillation (AFib) or atrial flutter (AFlut) at high stroke risk and receiving care in outpatient settings, and to assess provider response to CDS. METHODS: This observational, quasi-experimental, interrupted time series study utilized electronic health record data at a large integrated delivery network in Texas from April to November 2020. CDS consisted of an electronic Best Practice Advisory (BPA)/alert (Epic Systems Corporation, Verona, WI) with links to 2 AFib order sets displayed to providers in outpatient settings caring for non-anticoagulated patients with AFib and elevated CHA2DS2VASc scores. Weekly outpatient anticoagulation rates were assessed in patients with high stroke risk before and after implementation of CDS. Alert actions and acknowledgment reasons were evaluated descriptively. RESULTS: Mean (SD) weekly counts of eligible patients were 8,917 (566) before and 8,881 (811) after implementation. Weekly anticoagulation rates increased during the pre-BPA study period (ß1 = 0.07%; SE, 0.02%; P = 0.0062); however, there were no significant changes in the level (ß2 = 0.60%; SE, 0.42%; P = 0.1651) or trend (ß3 = -0.01%; SE, 0.05%; P = 0.8256) of anticoagulation rates associated with CDS implementation. In encounters with the BPA/alert displayed (n = 17,654), acknowledgment reasons were provided in 4,473 (25.3%) of the encounters, with prescribers most commonly citing bleeding risk (n = 1,327, 7.5%) and fall risk (n = 855, 4.8%). CONCLUSION: There was a significant trend of increasing anticoagulation rates during the pre-BPA period, with no significant change in trend during the post-BPA period relative to the pre-BPA period.

Acute Presentation of Critical Aortic Stenosis, Cardiogenic Shock, and the "Heart Team" Approach to Management.

A 65-year-old male was admitted for cardiogenic shock (ejection fraction: 15%) with severe aortic stenosis and regurgitation. He underwent emergency angiography and mechanical circulatory support. A multidisciplinary heart team discussed treatment options. Ultimately, he underwent successful emergency surgical aortic valve replacement with recovery on extracorporeal membrane oxygenation. (Level of Difficulty: Intermediate.).

An analysis of physician reviews in relation to quality and social media presence.

Press Ganey patient engagement survey scores are used among health care facilities throughout the US to evaluate patients' perception of the quality of care provided. The relation of Press Ganey score to primary quality metrics has not been reported before; thus, we studied it in a cohort of Baylor Scott and White Health primary care physicians. Using simple linear regression, we evaluated Press Ganey scores and compared them with primary care quality metrics associated with improved patient outcomes, including cancer screening, depression screening, blood pressure, and glucose control, in addition to well-child visits. We found that overall quality had a very low linear correlation with Press Ganey survey items, and high-quality performance and increased number of practice years had an overall positive correlation with high survey ratings. We also found that social media presence or total website activity was not an important feature in predicting the top 25 quality performers within the health care system.

Cardiology co-management of rheumatoid arthritis patients with coronary artery disease as an intervention reduces hospitalization rates and adverse event occurrence.

INTRODUCTION: Rheumatoid arthritis (RA) is a systemic autoimmune disease with important cardiovascular (CV) implications. CV disease represents over half of RA patient deaths and causes significant morbidity. CV manifestations in RA can be complex, raising concerns for adequate patient management and provider-dependent roles. METHODS: This is a retrospective study of patients diagnosed with RA and coronary artery disease (CAD). Patients were identified and filtered via EPIC Database search engine. Parameters were set from January 1, 2014, to December 31, 2020. Inclusion criteria consisted of patients who met diagnostic criteria for both RA and CAD. A total of 399 patients met criteria. RESULTS: Of the 399 identified patients, 272 were female (68.2%) and 127 were male (31.8%) with a median age of 73 (range 26-98). The population was further divided into two groups: those with established cardiology care versus those without. Patients without cardiology follow-up experienced significantly more hospitalizations (RR 1.63 95% CI 1.12, 2.38), higher rates of adverse events including myocardial infarction (MI) (RR 4.82 95% CI 1.94, 11.98), heart failure (HF) (OR 15.81 95% CI 3.54, 70.52), and stroke (RR 2.55 95% CI 1.29, 5.03). Patients not followed by cardiology also had numerical increases in CV death (4 deaths compared to none in those with cardiology follow) and all-cause mortality (HR 1.03 95% CI 0.63, 1.67). CONCLUSION: Patients with regular cardiology follow-up demonstrated fewer cardiac-related adverse events. This suggests that co-management may have a role in adverse cardiac event risk reduction and should therefore be an early consideration. Key Points • Rheumatoid arthritis patients demonstrate higher rates of coronary disease compared to the general population. Traditional cardiac risk factors may not be entirely responsible for this phenomenon • Hospitalization rates and adverse event occurrence are significantly higher in patients with single-provider care (rheumatology only) compared to dual provider care (rheumatology and cardiology) • Cardiology co-management should be an early consideration in the management of RA patients • Early screening, risk stratification of coronary disease, and utilization of appropriate treatment algorithms are important to decrease morbidity and mortality.

Coronary Artery Disease and Aspirin Intolerance: Background and Insights on Current Management.

Aspirin is one of the most widely used medications across the global healthcare system and is the foundation in treating ischemic heart disease, as well as secondary prevention for ischemic and valvular heart disease. Challenges arise in treating patients with cardiovascular disease who have concomitant aspirin intolerance. Through an extensive review of the literature, we provide a comprehensive background on the pharmacology of aspirin, the mechanisms behind aspirin intolerance, the importance of aspirin in cardiovascular disease, and the management of aspirin intolerance in both acute coronary syndrome and stable coronary artery disease. Our review includes a multidisciplinary approach from the internist, allergist/immunologist, and cardiologist when evaluating this important patient population.

Variability of discharge medical therapy for secondary prevention among patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) in the United States.

BACKGROUND: Optimal medical therapy after myocardial infarction with nonobstructive coronary arteries (MINOCA; <50% stenosis) is uncertain. We evaluated variability in discharge prescription of angiotensin-converting enzyme inhibitors / angiotensin receptor blockers (ACEI/ARB) and beta-blockers (BB) to MINOCA patients between hospitals to assess physician equipoise about secondary prevention. METHODS: Patients with MINOCA between 2007-2014 were identified in the NCDR Chest Pain-MI Registry. Those with prior revascularization or missing demographic, angiographic, or medication data were excluded. Analysis was limited to high-volume hospitals with ≥20 MINOCA total discharges. Discharge prescriptions for ACEI/ARB and BB after MINOCA were analyzed for each hospital. Clinical data on left ventricular ejection fraction (LVEF), glomerular filtration rate (GFR), and diabetes mellitus status were extracted to identify other indications for ACEI/ARB or BB. RESULTS: Clinical data were available for 17,849 MINOCA patients, of whom 8,752 (49%) had LVEF <40%, GFR ≤60 mL/min, and/or diabetes. 5,913 patients without one of these indications for ACEI/ARB or BB were discharged from 156 high-volume hospitals. At discharge, ACEI/ARB was prescribed to between 16.0% and 88.8% of MINOCA patients (median 45.6%, IQR 38.0%-56.5%) and BB to between 28.0% and 97.5% (median 74.1%, IQR 64.7%-80.0%). CONCLUSION: There is marked variability between hospitals in the proportions of patients receiving ACEI/ARB and BB after hospitalization for MINOCA, suggesting clinical equipoise about the routine use of these agents. Randomized clinical trials are necessary to establish the benefit of ACEI/ARB and BB to improve outcomes after MINOCA.

Phytochemicals as Therapeutic Interventions in Peripheral Artery Disease.

Peripheral artery disease (PAD) affects over 200 million people worldwide, resulting in significant morbidity and mortality, yet treatment options remain limited. Among the manifestations of PAD is a severe functional disability and decline, which is thought to be the result of different pathophysiological mechanisms including oxidative stress, skeletal muscle pathology, and reduced nitric oxide bioavailability. Thus, compounds that target these mechanisms may have a therapeutic effect on walking performance in PAD patients. Phytochemicals produced by plants have been widely studied for their potential health effects and role in various diseases including cardiovascular disease and cancer. In this review, we focus on PAD and discuss the evidence related to the clinical utility of different phytochemicals. We discuss phytochemical research in preclinical models of PAD, and we highlight the results of the available clinical trials that have assessed the effects of these compounds on PAD patient functional outcomes.

Pathobiology and evolving therapies of coronary artery vasospasm.

Coronary artery vasospasm is a known cause of chest pain and requires a high level of clinical suspicion for diagnosis. It also remains in the differential diagnosis for patients presenting with type 2 myocardial infarction. There are few randomized controlled trials for guideline-based prevention and treatment for coronary artery vasospasm. In this article, we review updated concepts in coronary artery vasospasm. Specifically, our aim is to provide current evidence of pathophysiology, identify the risk factors, propose a diagnostic algorithm, review available evidence of evolving therapies, and identify patients who would benefit from automatic implantable cardioverter defibrillators.

Use of Web-Based Patient Portals in Patients With Atrial Fibrillation Is Associated With Higher Readmissions.

Background: The impact of web-based patient portals on patient outcomes-specifically hospital readmissions in patients with atrial fibrillation (AF)-remains understudied. Methods: This single-center retrospective cohort study investigated the use of an online portal system (MyChart) by patients hospitalized from January 1, 2014 to June 30, 2017 for AF. During the study period, 11,334 unique AF admissions were identified; 50.3% were MyChart users and 49.7% were non-MyChart users. Patients who experienced inpatient mortality were excluded. The study groups were analyzed for demographic variables, comorbidities, readmission rates, and the frequency of MyChart use during the 3.5-year time frame. Results: MyChart users were younger (median age, 74 years, interquartile range [IQR] 66-82 vs 77 years, IQR 68-85; P<0.0001) and more likely to be white (91.9% vs 84.6%; P<0.0001), but the sex distribution was similar between groups, with 51.8% males in the MyChart group vs 53.2% in the non-MyChart group. MyChart users had a significantly higher rate of readmission compared to non-MyChart users at 1 year (43.0% vs 32.0%, respectively; P<0.0001). MyChart users who were readmitted had a higher median number of logins to MyChart (121 [IQR 32-270.5]) than MyChart users who were not readmitted (91 [IQR 26-205]; P<0.0001). Multivariable regression analysis demonstrated that MyChart use was associated with readmission (odds ratio 1.57, 95% CI 1.49-1.70; P<0.0001). Conclusion: Among patients with AF, MyChart use was associated with higher readmissions in this single-center cohort. Use and benefit of bespoke portals require further study.

Predictive value of vascular response to cuff inflation-induced pain in the control arm for adverse cardiovascular events.

BACKGROUND: The high incidence rate of cardiovascular (CV) events had led to a comprehensive appraisal for identifying patients who are at risk for CV disease. However, CV traditional risk factors, such as Framingham risk score (FRS), failed exhaustively to predict CV events. METHODS: 402 participants (mean age, 58 [12] years; 45% male) using fingertip peripheral artery tonometry at Mayo Clinic in Rochester, Minnesota, were recruited in the present study. Measurements included reactive hyperemia index (RHI) and pain-induced peripheral artery tonometry (PIPAT). RESULTS: After a median follow-up of 3.8 (2.7-7.7) years, 95 CV events occurred. Both first minute PIPAT and RHI were independently associated with events (hazard ratio [HR], 0.77 [95% CI, 0.61-0.98]; P = 0.038 and HR, 0.75 [95% CI, 0.59-0.96]; P = 0.019, respectively). The C statistic values of FRS, FRS + first minute PIPAT, FRS + RHI, and FRS + RHI + first minute PIPAT were 0.704, 0.722, 0.694, and 0.726, respectively. Furthermore, the addition of first minute PIPAT, RHI, and first minute PIPAT + RHI to FRS results in net reclassification improvement (NRI) in the intermediate-risk group (18.1%, P = 0.031; 18.1%, P = 0.035; 21%, P = 0.013). CONCLUSION: First minute PIPAT is a risk marker for adverse CV. Addition of first minute PIPAT to FRS increased the discrimination in the receiver operating characteristic analysis. It also increased NRI compared with FRS alone.

Assessment and pathophysiology of microvascular disease: recent progress and clinical implications.

The development of novel, non-invasive techniques and standardization of protocols to assess microvascular dysfunction have elucidated the key role of microvascular changes in the evolution of cardiovascular (CV) damage, and their capacity to predict an increased risk of adverse events. These technical advances parallel with the development of novel biological assays that enabled the ex vivo identification of pathways promoting microvascular dysfunction, providing novel potential treatment targets for preventing cerebral-CV disease. In this article, we provide an update of diagnostic testing strategies to detect and characterize microvascular dysfunction and suggestions on how to standardize and maximize the information obtained from each microvascular assay. We examine emerging data highlighting the significance of microvascular dysfunction in the development CV disease manifestations. Finally, we summarize the pathophysiology of microvascular dysfunction emphasizing the role of oxidative stress and its regulation by epigenetic mechanisms, which might represent potential targets for novel interventions beyond conventional approaches, representing a new frontier in CV disease reduction.

Outcomes of Impella compared with intra-aortic balloon pump in ST-elevation myocardial infarction complicated by cardiogenic shock.

Background: Despite limited randomized trial data demonstrating clinical efficacy, the utilization of Impella in ST-elevation myocardial infarction (STEMI) patients complicated with cardiogenic shock (CS) has increased over time. Methods: We identified 75,769 hospitalizations with STEMI complicated by CS between October 2015 and December 2018 using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. From this cohort, hospitalizations were stratified according to IABP or Impella placement. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were divided into efficacy, safety, and device-related complications. Propensity-score matching was used to account for differences in the baseline characteristics between the groups. Logistic regression was performed to get the odds ratio and confidence intervals. Results: Among 75,769 admissions with STEMI and CS, hospitalizations with <18 years old, both IABP and Impella placement, and who underwent ECMO and/or LVAD implantation were excluded. After the exclusion, out of 72,791 admissions, 25,260 (34.70%) hospitalizations received IABP, and 7825 (10.75%) received Impella support. After propensity score-matched analysis, 7345 hospitalizations were included in each group. All-cause in-hospital mortality was higher in the hospitalizations requiring Impella support as compared to IABP (42.10% vs. 31.54%, adjusted OR 1.71; 95% confidence interval (CI) 1.60-1.84, P < 0.0001). Impella was associated with a higher risk of in-hospital complications and hospitalization cost compared with IABP. Conclusion: Impella compared with IABP in STEMI patients with CS was associated with higher in-hospital mortality and other adverse clinical and procedural outcomes.

Comprehensive Geriatric Assessment in the Management of Older Patients With Cardiovascular Disease.

Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.

A Digital Health Weight Loss Program in 250,000 Individuals.

Importance: Obesity is a worsening epidemic worldwide. Effective and accessible weight loss programs to combat obesity on a large scale are warranted, but a need for frequent face-to-face care might impose a limitation. Objective: To evaluate whether individuals following a weight loss program based on a mobile application, wireless scale, and nutritional program but no face-to-face care can achieve clinically significant weight loss in a large cohort. Design: Retrospective observational analysis. Setting. China from October 2016 to December 2017. Participants. Mobile application users with a minimum of 2 weights (baseline and ≥35 days). Intervention. A commercial (Weijian Technologies) weight loss program consisting of a dietary replacement, self-monitoring using a wireless home scale, and frequent guidance via mobile application. Main Outcome. Mean weight change around 42, 60, 90, and 120 days after program initiation with subgroup analysis by gender, age, and frequency of use. Results: 251,718 individuals, with a mean age of 37.3 years (SD: 9.86) (79% female), were included with a mean weight loss of 4.3 kg (CI: ±0.02) and a mean follow-up of 120 days (SD: 76.8 days). Mean weight loss at 42, 60, 90, and 120 d was 4.1 kg (CI: ±0.02), 4.9 kg (CI: ±0.02), 5.6 kg (CI: ±0.03), and 5.4 kg (CI: ±0.04), respectively. At 120 d, 62.7% of participants had lost at least 5% of their initial weight. Both genders and all usage frequency tertiles showed statistically significant weight loss from baseline at each interval (P < 0.001), and this loss was greater in men than in women (120 d: 6.5 vs. 5.2 kg; P < 0.001). The frequency of recording (categorized as high-, medium-, or low-frequency users) was associated with greater weight loss when comparing high, medium, and low tertile use groups at all time intervals investigated (e.g., 120 d: -8.6, -5.6, and -2.2 kg, respectively; P < 0.001). Conclusions: People following a commercially available hybrid weight loss program using a mobile application, wireless scale, and nutritional program without face-to-face interaction on average achieved clinically significant short- and midterm weight loss. These results support the implementation of comparable technologies for weight control in a large population.