Transcatheter Aortic Valve Replacement Outcomes in End-Stage Renal Disease Patients on Hemodialysis Requiring Midodrine.

Background: Patients with dialysis-dependent end-stage renal disease (ESRD) taking midodrine may be at high risk for poor outcomes following transcatheter aortic valve replacement (TAVR). We evaluated dialysis-dependent ESRD patients taking midodrine. Methods: We conducted a retrospective analysis of non-clinical trial TAVR patients from February 2012 to December 2020 from 11 facilities in a Western US health system. Patient groups included ESRD patients on midodrine before TAVR (ESRD [+M]), ESRD patients without midodrine (ESRD [-M]), and non-ESRD patients. The endpoints of 30-day and 1-year mortality were represented by Kaplan-Meier survival estimator and compared by log-rank test. Results: Forty-five ESRD (+M), 216 ESRD (-M), and 6898 non-ESRD patients were included. ESRD patients had more comorbid conditions, despite no significant difference in predicted Society of Thoracic Surgeons mortality risk between ESRD (+M) and ESRD (-M) (8.7% vs. 9.2%, p = 0.491). Thirty-day mortality was significantly higher for ESRD (+M) patients vs. ESRD (-M) patients (20.1% vs. 5.6%, p = 0.001) and for ESRD (+M) vs. non-ESRD patients (2.5%, p < 0.001). One-year mortality trended higher for ESRD (+M) vs. ESRD (-M) patients (41.9% vs. 29.8%, p = 0.07), and was significantly higher for ESRD (+M) vs. non-ESRD patients (10.7%, p < 0.001). Compared to ESRD (-M), ESRD (+M) patients had a higher incidence of 30-day stroke (6.7% vs. 1.4%, p = 0.033), 30-day vascular complications (6.7% vs. 0.9%, p = 0.011), and a lower rate of discharge to home (62.2% vs. 84.7%, p < 0.001). In contrast, ESRD (-M) patients had no significant differences from non-ESRD patients for these outcomes. Conclusions: Our experience suggests ESRD patients on midodrine are a higher acuity population with worse survival after TAVR, compared to ESRD patients not on midodrine. These findings may help with risk stratification for ESRD patients undergoing TAVR.

Cardiorespiratory Fitness and Mortality in Patients Aged 60 to 90 Years.

Chronological age alone does not fully reflect a patient's prognosis. We sought to assess the association of cardiorespiratory fitness (quantified by METs) with all-cause mortality among patients aged 60 to 90 years. This retrospective study included patients who underwent exercise treadmill testing at an integrated healthcare system from 2011 to 2019. Patients were categorized into age groups: 60 to <70 years, 70 to <80 years, and 80 to 90 years; and cardiorespiratory fitness level: low (<5 METs), moderate (5 to 10 METs), and high fitness (>10 METs). Mean follow-up was 3.5 years. A total of 40,520 patients were included (mean age 67.7 ± 4.7 years, 48.6% women). Of whom, 27,021 were 60 to <70 years old (66.7%); 12,638 70 to <80 years old (31.2%); and 1,861 80 to 90 years old (4.6%). There were 3,494 patients categorized as low (8.6%), 21,863 as moderate (54%), and 15,163 as high fitness (37.4%). Low fitness level was independently associated with lower survival (hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.15 to 2.24). Using age 60 to 70 group with high fitness level as reference, the age 80 to 90 group with high fitness level had better survival than their younger counterparts with low fitness level (age 80 to 90 years high fitness level: HR 2.9, 95% CI 1.2 to 7.2; age 60 to 70 years low fitness level: HR 4.3, 95% CI 3.1 to 5.9; age 70 to 80 years low fitness level: HR 6.8, 95% CI 5.2 to 8.9) on adjusted analysis. In conclusion, higher cardiorespiratory fitness is associated with better survival. Patients >80 years old with high fitness level have comparable or even better survival than their younger counterparts with submoderate fitness levels. Chronological age alone should not be the only factor when considering prognosis.

The Prognostic Utility of Invasive Right Heart Catheterization in Patients Prior to Transcatheter Aortic Valve Replacement.

INTRODUCTION: Invasive right heart catheterization (RHC) provides valuable prognostic information in cases of severe aortic stenosis, but is not done routinely prior to transcatheter aortic valve replacement (TAVR). Therefore, we sought to investigate the prognostic utility of pre-TAVR RHC for assessing outcomes post TAVR. METHODS: This is a single-center, retrospective study of patients who underwent RHC prior to TAVR between June 2011 and March 2019. We evaluated abnormalities in the following variables as predictors of poor outcomes post TAVR: pulmonary capillary wedge pressure (PCWP), systolic pulmonary artery pressure (PASP), mixed venous oxygen saturation (MVO2), right ventricular stroke work index (RVSWI), and right atrial pressure (RAP). Cox proportional hazard regression models were used to assess the primary composite outcome of all-cause mortality and hospitalization for heart failure. RESULTS: A total of 522 patients (mean age, 83.5 ± 4.5 years; 49.4% women) with complete invasive hemodynamic data were included. At a median follow-up of 529.5 days, there were 127 deaths and 59 heart failure hospitalizations. On multivariate analysis, PCWP ≥15 mm Hg (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.02-2.07), PASP ≥50 mm Hg (HR, 1.66; 95% CI, 1.17-2.36), MVO2 ≤60% (HR, 1.42; 95% CI, 1.01-1.98), RVSWI ≥12 g•m/m²/beat (HR, 1.40; 95% CI, 1.004-1.94), and RAP ≥10 mm Hg (HR, 1.66; 95% CI, 1.09-2.51) were independent predictors of death or heart failure hospitalization. CONCLUSIONS: Preprocedural invasive RHC provides useful prognostic information. A comprehensive invasive hemodynamic assessment should be considered for risk stratification in patients undergoing TAVR.

Revascularization versus medical therapy in patients aged 80 and older with stable ischemic heart disease.

BACKGROUND: Older patients are underrepresented in landmark randomized trials for stable ischemic heart disease (SIHD). Therefore, we sought to evaluate the benefits of revascularization in patients ≥80 years old with SIHD. METHODS: Retrospective study of patients undergoing invasive coronary angiography (ICA) for SIHD between 2009 and 2019. Patients were grouped according to treatment: revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) versus initial medical therapy alone. Inverse probability of treatment weighting (IPTW)-adjusted Cox proportional hazard regression analyses were performed. Outcomes evaluated were all-cause mortality, non-fatal myocardial infarction (MI), and repeat revascularization. RESULTS: A total of 1015 patients (median age 83.0, interquartile range [IQR] 81.3-85.2 years; 29% female) underwent ICA for SIHD. Of these, 557 (55%) were treated with revascularization and 458 (45%) with initial medical therapy alone. Baseline characteristics were well balanced after IPTW adjustment. At median follow-up of 3.5 years (IQR 1.7-5.9 years), there were no differences in all-cause mortality and non-fatal MI between treatment groups; but there was an increased need for repeat revascularization (IPTW adjusted hazard ratio 2.22, 95% confidence interval 1.53-3.22) with revascularization. Separately comparing PCI or CABG alone versus medical therapy yielded similar results; as well as in subgroup analysis (except for patients ≥90 years old and those without prior CABG). CONCLUSION: There were no differences in all-cause mortality and non-fatal MI with invasive revascularization (either PCI or CABG) versus medical therapy alone in patients ≥80 years old with SIHD. Large randomized trials focusing on older patients are warranted to guide clinical practice in this growing population.

Comparison of a Single Versus Double Perclose Technique for Percutaneous Transfemoral Transcatheter Aortic Valve Replacement.

BACKGROUND: The optimal strategy for arterial closure in percutaneous transfemoral transcatheter aortic valve replacement (TF-TAVR) remains under debate. METHODS: Single-center, prospective, observational study of consecutive patients undergoing TF-TAVR between March 2018 and December 2019 who underwent closure with an upfront single vs double Perclose device. Device success, access-site vascular, and bleeding complications were defined according to the Valvular Academic Research Consortium (VARC)-2 criteria. Inverse-probability of treatment weighting (IPTW) was used to balance baseline characteristics between groups. RESULTS: A total of 241 patients (mean age, 81.4 ± 8.5 years, 47% women) were included, of which 127 underwent an upfront single-Perclose (SP) strategy and 114 underwent an upfront double-Perclose (DP) strategy. Fifty-six percent of patients were treated with a CoreValve (Medtronic). The SP group was less likely to be on dialysis and on aspirin, but were more likely to receive a CoreValve, with larger valve sizes and larger delivery sheaths. Baseline characteristics were well balanced after IPTW adjustment. Device success rate was comparable between groups (96% in the SP group vs 93% in the DP group; P=.39). The SP technique was associated with fewer vascular complications (8.7% in the SP group vs 26.3% in the DP group; P<.01; IPTW relative risk [RR], 0.34; 95% confidence Interval [CI], 0.16-0.71) and bleeding complications (2.4% in the SP group vs 12.3% in the DP group; P<.01; IPTW RR, 0.21; 95% CI, 0.06-0.76) compared with the DP technique. There were no differences in 30-day mortality. CONCLUSION: An upfront SP technique is equally efficacious and not associated with increased vascular and bleeding complications compared with an upfront DP technique in patients undergoing percutaneous TF-TAVR.

The role of neighborhood disadvantage in predicting mortality in patients after transcatheter aortic valve replacement.

BACKGROUND: Neighborhoods have a powerful impact on health. Prior investigations into disparities associated with transcatheter aortic valve replacement (TAVR) have focused on race and access to the procedure. We sought to investigate the role of neighborhood disadvantage on mortality post-TAVR. METHODS: Patients who underwent TAVR at Kaiser Permanente Los Angeles Medical Center between June, 2011 and March, 2019 were evaluated. Neighborhood disadvantage was defined using the area deprivation index, an established and validated index that considers multiple socioeconomic metrics. Cutoffs used for disadvantage were national percentile ≥25% and state decile ≥6. Cox proportional hazards regression analysis was used to assess outcomes. RESULTS: A total of 668 patients (age 82.1 ± 7.5 years, 49% female) were included, of which 215 (32.2%) were from disadvantaged neighborhoods by state decile, and 167 (25%) by national percentile. At a median follow-up of 18.8 months (interquartile range 8.7-36.5 months), neighborhood disadvantage was independently associated with increased all-cause mortality (National percentile: hazard ratio [HR] 1.91, 95% confidence interval [CI] 1.35-2.69; state decile: HR 1.68, 95% CI 1.21-2.34). On propensity scored analysis, neighborhood disadvantaged remained independently associated with increased all-cause mortality (National percentile: IPTW HR 1.86, 95% CI 1.52-2.28, PSM HR 1.67, 95% CI 1.11-2.51; state decile: IPTW HR 1.55, 95% CI 1.26-1.91, PSM HR 2.0, 95% CI 1.33-2.99). CONCLUSION: Living in a disadvantaged neighborhood was independently associated with increased mortality post-TAVR on multivariate and propensity score matched analysis. Further investigations into the role of neighborhood disadvantage are needed to address disparities and improve outcomes post-TAVR.

Multivessel Spontaneous Coronary Artery Dissection With Coronary Artery Fibromuscular Dysplasia.

A 53-year-old woman underwent a cardiac catheterization for evaluation of acute coronary syndrome. The coronary angiogram revealed evidence of spontaneous coronary artery dissection in multiple coronary arteries including the left anterior descending artery, posterior descending artery, and posterior left ventricular artery. Further diagnostic imaging revealed associated bilateral vertebral artery and renal artery fibromuscular dysplasia (FMD). Follow-up coronary angiogram 6 weeks later revealed a "string of beads" appearance of the posterior descending artery. This case highlights the importance of extra-coronary imaging for FMD and demonstrates angiogram findings suggestive of coronary FMD.

Une femme de 53 ans a été soumise à un examen par cathétérisme cardiaque afin d'évaluer le syndrome coronarien aigu dont elle est atteinte. L'angiographie coronarienne a révélé des signes de dissection spontanée de l'artère coronaire dans de multiples artères coronaires, y compris l'artère interventriculaire antérieure, l'artère interventriculaire postérieure et l'artère ventriculaire gauche postérieure. D'autres images diagnostiques ont révélé la présence d'une dysplasie fibromusculaire (DFM) bilatérale connexe des artères rénales et vertébrales. L'artère interventriculaire postérieure avait l'aspect d'un « collier de perles ¼ à l'angiographie coronarienne de suivi effectué six semaines plus tard. Ce cas souligne l'importance de l'imagerie extracoronaire pour la détection d'une DFM et montre que les résultats de l'angiographie sont indicatifs d'une DFM coronaire.

Association between mid-term worsening renal function and mortality after transcatheter aortic valve replacement in patients with chronic kidney disease.

INTRODUCTION: Chronic kidney disease (CKD), acute kidney injury (AKI) and worsening renal function at 30 days after transcatheter aortic valve replacement (TAVR) portend poor outcomes. We sought to evaluate the association between worsening renal function at 3-6 months and mortality among patients with baseline renal dysfunction undergoing TAVR. METHODS: This is a retrospective study of patients with glomerular filtration rate (GFR) < 60 ml/min undergoing TAVR between June 2011 and March 2019 at the Regional Cardiac Catheterization Lab at Kaiser Permanente Los Angeles. Worsening renal function at 3-6 months post-TAVR was defined as: increase in serum creatinine >1.5 times compared to baseline, absolute increase of ≥0.3 mg/dl, or initiation of dialysis. RESULTS: Of 683 patients reviewed, 176 were included in the analysis (median age 84 [IQR 79-88] years, 56% female). Of these, 27 (15.3%) had worsening renal function. AKI post-TAVR (OR 2.9, 95% CI 1.1-7.4, p = .03) and transfusion of ≥4 units red blood cells (OR 8.4, 95% CI 1.2-59, p = .03) were independent predictors of worsening renal function. Worsening renal function increased risk for mortality (HR 2.2, 95% CI 1.17-4.27, p = .015) at a median follow-up of 691 days. Those with improved/stable function with baseline GFR < 60 ml/min had comparable mortality risk to those with baseline GFR ≥ 60 ml/min (18% vs. 16.5%; HR 1.1, 95% CI 0.72-1.75, p = .62). CONCLUSION: Among patients with baseline renal dysfunction, only 15% developed worsening renal function at 3-6 months after TAVR, which was associated with increased mortality. Predictors for worsening renal function include AKI and blood transfusions. Preventative measures peri-procedurally and continued monitoring post-discharge are warranted to improve outcomes.

Characteristics and outcomes of patients with spontaneous coronary artery dissection who suffered sudden cardiac arrest.

PURPOSE: Spontaneous coronary artery dissection (SCAD) can cause life-threatening ventricular arrhythmias, but the characteristics and outcomes of this population are not well characterized. We sought to determine the characteristics and outcomes of patients with SCAD who suffered sudden cardiac arrest, whether treated with or without an implantable cardioverter-defibrillator (ICD). METHODS: Retrospective cohort study of patients diagnosed with SCAD between 2006 and 2016. RESULTS: Eleven of 208 SCAD patients suffered sudden cardiac arrest (5.3%). Those who suffered cardiac arrest were more likely to have pregnancy-associated SCAD (27.3% vs 7.1%, p = 0.018). They were more likely to have left main (18.2% vs 1.0%, p = 0.01) or proximal coronary vessel involvement (36.4% vs 8.1%, p = 0.002), and with left ventricular ejection fraction of < 50% (45.5% vs 13.2%, p = 0.013). Percutaneous coronary intervention was more commonly performed in patients who suffered cardiac arrest (54.6% vs 8.6%, p < 0.001). Left main or proximal LAD involvement increased the odds of cardiac arrest by over 6-fold (OR 6.2, 95% CI 1.2-32.9, p = 0.03). Eight of the 11 patients suffered VT/VF arrest, of which one was treated with an ICD and one with a wearable cardioverter-defibrillator. Of these, no shocks were reported at follow-up and no ventricular arrhythmic events were reported in those not receiving defibrillator treatment. CONCLUSION: Sudden cardiac arrest in SCAD patients is associated with left main or proximal coronary lesions. Secondary prevention ICD did not show benefit in this cohort. Future larger studies are needed to determine the role of ICD therapy in SCAD patients who suffer cardiac arrest.

Predictors of conduction recovery after permanent pacemaker implantation following transcatheter aortic valve replacement.

PURPOSE: Conduction disturbances after transcatheter aortic valve replacement (TAVR) requiring pacemaker (PPM) implantation are a known complication and may be reversible. Therefore, we sought to evaluate the incidence and predictors for atrioventricular (AV) conduction recovery after TAVR. METHODS: A single-center, retrospective study of patients undergoing PPM implantation for conduction disorders after TAVR between June 2011 and March 2019. Conduction recovery was defined as ≤ 1% ventricular pacing (VP) on follow-up PPM interrogation. RESULTS: A total of 110 patients (mean age 83.6 ± 6.6 years, 46.8% female) were included. At a median follow-up of 438 days (interquartile range [IQR] 111-760 days), 35 patients (32%) had conduction recovery, with 50% of these occurring within the first 6 months. On multivariate analysis, predictors of conduction recovery include female sex (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.01-6.4, p = 0.048), non-VP/non-complete heart block rhythm immediately post-TAVR (HR 5.2, 95% CI 1.5-18.1, p = 0.011), normal sinus rhythm 7 days post-TAVR (HR 3.9, 95% CI 1.7-9.2, p = 0.002), and smaller valve size (mm) (HR 0.81, 95% CI 0.7-0.996, p = 0.045). Significant narrowing of the QRS and resolution of new-onset left bundle branch block within 1 month post-TAVR occurred in those with conduction recovery on PPM interrogation. CONCLUSIONS: One-third of patients receiving new PPM implantation have conduction recovery after TAVR, with 50% occurring within the first 6 months. Patient gender, valve size, and rhythm on serial ECGs after TAVR can help identify patients that may recover AV conduction. A conservative approach rather than immediate PPM implantation may be considered in these patients.

Revascularization Versus Medical Therapy in Patients Aged 80 Years and Older with Acute Myocardial Infarction.

BACKGROUND/OBJECTIVES: Older patients are underrepresented in acute coronary syndrome clinical trials. We sought to evaluate the benefits of revascularization in patients aged 80 years and older presenting with acute myocardial infarction (AMI). DESIGN: Retrospective study utilizing inverse probability of treatment weighting (IPTW). SETTING: Single tertiary referral center for an integrated healthcare system in southern California. PARTICIPANTS: Patients undergoing invasive coronary angiography for AMI between 2009 and 2019, and subsequently treated with percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or medical therapy alone. MEASUREMENTS: All-cause mortality, nonfatal myocardial infarction (MI), and repeated revascularization. RESULTS: A total of 1,433 patients aged 80 years or older (median age = 83.5 years; 66% male) presenting with AMI who underwent treatment with PCI (50%), CABG (12%), or medical therapy alone (38%) were included. Those treated with medical therapy were more likely to be Black, had one or more chronic total occlusions in any vessel, had more comorbidities, and had lower left ventricular ejection fraction. Baseline characteristics were well balanced after IPTW adjustment. Median follow-up was 2.6 years. Revascularization (PCI or CABG) was associated with reduced mortality (hazard ratio (HR) = 0.66; 95% confidence interval (CI) = 0.60-0.73) and nonfatal MI (HR = 0.68; 95% CI = 0.58-0.78), but an increased need for repeated revascularization (HR = 1.60; 95% CI = 1.15-2.23). Separately comparing PCI or CABG alone versus medical therapy yielded similar results. Revascularization was associated with lower mortality in all subgroups, except in Black patients and those with prior CABG. CONCLUSION: Revascularization is superior to medical therapy in reducing all-cause mortality and nonfatal MI in patients aged 80 years and older with AMI. Age alone should not preclude patients from potentially beneficial invasive therapies.

Characteristics and outcomes of pregnant women with cardiomyopathy stratified by etiologies: A population-based study.

BACKGROUND: Heart failure is an uncommon diagnosis among pregnant women with limited data on this condition. We sought to describe the characteristics and outcomes of pregnant women with heart failure stratified by etiologies of cardiomyopathy. METHODS: This is a retrospective population-based cohort study across medical centers in Southern California in the United States. Pregnant women with heart failure were identified using ICD-9 codes and adjudicated by manual review of the medical records. Obstetric complications, fetal birthweight, and maternal mortality outcomes were evaluated. RESULTS: Between 2003 and 2014, there were 488 pregnancies (0.1% of all pregnancies) complicated by heart failure, of which 333 (68.2%) were due to peripartum cardiomyopathy (PPCM) and 155 (31.8%) were due to other etiologies (non-PPCM). Compared to patients with non-PPCM, patients with PPCM were more likely to be Black Americans (26.7% vs 15.5%) or Asian Americans (16.8% vs 7.1%). A high proportion of PPCM patients had preeclampsia (11.1% vs 5.2%, p = 0.04). Infants born to mothers with non-PPCM were more likely to be small for gestational age (SGA) (SGA <3% 4.1% vs 9.7%, p < 0.001; SGA <10% 20% vs 8.8%, p = 0.001). No significant difference in maternal mortality was observed between PPCM and non-PPCM patients. CONCLUSIONS: PPCM is the most common etiology of HF during pregnancy. Infants born to mothers with PPCM were likely to be small for gestational age.

Exposures to Single-Use Detergent Sacs Reported to a Statewide Poison Control System, 2013-2015.

BACKGROUND: Single-use detergent sacs (SUDSs) represent a relatively new household hazard to children. Brand differences and packaging changes may contribute to differential risks with accidental exposure. We sought to identify high-risk features from SUDS exposures in children and to assess whether product packaging changed trends in SUDS exposures reported to poison centers. METHODS: In this institutional review board-approved, retrospective chart review of SUDS exposures from January 2013 to August 2015, deidentified case records of a large statewide poison control system were extracted and analyzed for clinical associations and trends. Clinical and demographic data were gathered, and outcomes were analyzed for differences by brand type, presenting complaints, and occurrence in relation to SUDS packaging changes. RESULTS: There were 3502 SUDS exposures, with 3343 (95%) in children 5 years or younger. Metabolic, central nervous system, and pulmonary effects were significantly associated with moderate or severe outcome (P < 0.05). Forty patients received invasive procedures such as endoscopy, bronchoscopy, and/or endotracheal intubation, and more than half had mucosal lesions discovered by the diagnostic procedure. The presence of stridor, wheezing, drooling, lethargy, and exposure to the brand All Mighty Pacs were all significant predictors of moderate or severe outcome (P < 0.05). After the implementation of packaging changes, there was a transient decline in the number of exposures to the Tide Pods product. CONCLUSION: Central nervous system and respiratory effects as well as certain brand types predict serious outcomes from SUDS exposures. Manufacturing changes had a brief beneficial effect on the volume of SUDS exposures reported between 2013 and 2015.

Frequency of Utilization of Beta Blockers in Patients With Heart Failure and Depression and Their Effect on Mortality.

Beta blockers reduce mortality and morbidity in patients with heart failure. Early reports linking ß-blockers with depression may have limited their use in heart failure patients with co-morbid depression. Although more recent studies have challenged the association between ß-blocker therapy and depression, patient and physicians remain concerned. The goal of this study is to evaluate the utilization and outcomes of ß-blocker therapy in heart failure patients with depression. This is a retrospective cohort study of patients at a multicenter integrated healthcare system with a diagnosis of heart failure from 2008 to 2014. Among 6,915 patients with heart failure with left ventricular ejection fraction of <50%, 1,252 (18.1%) had a diagnosis of depression. Patients with depression were more likely to be women and had a higher prevalence of cardiovascular risk factors. Depression was associated with decreased odds of ß-blocker treatment (adjusted odds ratio [OR], 0.77; 95% confidence interval [CI], 0.62 to 0.95; p = 0.016). During a mean follow-up of 2.6 years, 439 (35.1%) patients with depression died compared with 1,549 (27.4%) patients without depression. Depressed patients not treated with ß-blocker had higher mortality compared with nondepressed patients (adjusted hazard ratio [HR], 1.4, 95% CI 1.09 to 1.7, p = 0.005). When treated with ß-blockers, their risk of mortality was attenuated (HR 1.1, 95% CI 0.97 to 1.2, p = 0.14). In conclusion, ß-blocker therapy remains underutilized in heart failure patients with depression, and its underutilization contributes to the reduced survival rate observed in this cohort.

Statin Adherence and Mortality in Patients Aged 80 Years and Older After Acute Myocardial Infarction.

BACKGROUND/OBJECTIVES: The goal of this study was to describe the pattern of statin adherence in older patients, aged 80 years or older; identify factors associated with high adherence; and determine the association between statin adherence and all-cause mortality. DESIGN: Retrospective population-based cohort study. SETTING: An integrated healthcare system in Southern California. PARTICIPANTS: Patients hospitalized with a principal diagnosis of acute myocardial infarction (MI) between January 1, 2006, and December 31, 2016. MEASUREMENTS: Statin adherence, as measured using pharmacy dispensing records over the 365 days following hospital discharge, based on proportion of days covered (PDC). Adherence levels were categorized as high (PDC 80% or higher), partial (PDC 40% or higher and lower than 80%), and low (PDC lower than 40%). RESULTS: Between 2006 and 2016, 5629 patients, 80 years or older, hospitalized for acute MI met the inclusion criteria. Among this group, 68.8% were highly adherent to statin therapy, 20.4% were partially adherent, and 10.8% were not adherent. Male sex (odds ratio [OR] = 1.42; 95% confidence interval [CI] = 1.25-1.62) and white race (OR = 1.35; 95% CI = 1.18-1.55) were associated with high statin adherence. Follow-up was 4.3 ± 2.6 years. Both low and partial adherence were associated with increase mortality (low adherence: adjusted hazard radio [HR] = 1.12; 95% CI = 1.01-1.25; partial adherence: adjusted HR = 1.22; 95% CI = 1.12-1.32). CONCLUSIONS: In older patients, aged 80 years or older, high adherence to statins after MI was associated with improved survival. This association may not have been due only to adherence to statins but to other related factors as well. Findings from this study may inform discussions on the potential benefits of statin adherence. J Am Geriatr Soc 67:2045-2049, 2019.

Characteristics and Clinical Outcomes of Patients With Spontaneous Coronary Artery Dissection.

Background The goal of this study is to report the characteristics and long-term clinical outcomes of patients with spontaneous coronary artery dissection (SCAD) and to identify factors associated with recurrent SCAD . Methods and Results This is a retrospective cohort study that included patients who underwent coronary angiography for evaluation of acute myocardial infarction between 2006 and 2016. Among 26 598 patients hospitalized with a principal diagnosis of acute myocardial infarction, 208 (0.78%) were diagnosed with SCAD . Patients with SCAD were younger (49.0±11.6 versus 65.6±12.2 years) and more likely to be women (88.9% versus 31.6%). Atherosclerotic risk factors, such as hypertension, hyperlipidemia, obesity, and diabetes mellitus, were less prevalent. Median follow-up was 4.7 years. Mortality was lower in patients with SCAD (1-year mortality: 2.4% versus 8.8%; P<0.001). After using propensity score matching to control for differences in age, sex, and comorbidities, the difference in mortality was no longer present, suggesting that lower mortality in patients with SCAD is attributed primarily to their baseline characteristics. Recurrent SCAD occurred in 22 patients (10.6%). Multivariate Cox regression modeling showed concomitant fibromuscular dysplasia (hazard ratio, 5.1; 95% CI , 1.6-15.8; P=0.005) and migraine headaches (hazard ratio, 3.4; 95% CI , 1.4-8.4; P=0.008) to be associated with increased risk of recurrent SCAD . Conclusions Among patients with acute myocardial infarction, patients with SCAD have a lower risk of mortality, which is attributed primarily to their younger age, female sex, and low prevalence of atherosclerotic risk factors. Risk of recurrent SCAD persists years after the initial presentation. Patients with fibromuscular dysplasia and migraine are at higher risk for recurrent SCAD .

Effect of Warfarin on Ischemic Stroke, Bleeding, and Mortality in Patients with Atrial Fibrillation Receiving Peritoneal Dialysis.

BACKGROUND: There is limited information on the risks and benefits of anticoagulation in patients with atrial fibrillation receiving peritoneal dialysis. OBJECTIVE: The aim was to determine the risk of mortality, ischemic stroke, and bleeding associated with warfarin use in patients with atrial fibrillation receiving peritoneal dialysis. PATIENTS AND METHODS: This is a retrospective observational study of a multi-ethnic cohort of patients with atrial fibrillation receiving peritoneal dialysis in the United States. Using a dialysis registry, we identified 476 patients with atrial fibrillation receiving peritoneal dialysis. Among these patients, 115 (24%) were treated with warfarin. Cox proportional hazard models were used to compare risks of mortality, ischemic stroke and bleeding between the groups. RESULTS: Compared to untreated patients, patients receiving warfarin were older (67.3 ± 10.8 vs 62.9 ± 13.3 years) and more likely to be white (42% vs 31%). Prevalence of comorbidities including hypertension, hyperlipidemia, diabetes, heart failure, and prior ischemic stroke were similar between the two groups. All cause mortality rates were 19.9 per 100 person-years in the warfarin group and 21.0 per 100 person-years in the untreated group. There was no difference between groups in the risk of mortality [hazard ratio (HR) 0.8, 95% confidence interval (CI) 0.53-1.2, p = 0.28], ischemic stroke (HR 2.3, 95% CI 0.94-5.4, p = 0.07), hemorrhagic stroke (HR 2.0, 95% CI 0.32-12.8, p = 0.46), gastrointestinal bleeding (HR 0.92, 95% CI 0.39-2.2, p = 0.86), or any bleeding (HR 1.2, 95% 0.60-2.3, p = 0.65). Even in the subgroup of patients with > 70% time in therapeutic range, no association was seen between warfarin treatment and mortality. CONCLUSION: There is no significant association between warfarin treatment with risks of mortality, ischemic stroke or bleeding in patients with atrial fibrillation receiving peritoneal dialysis.

Immediate Improvement in Left Atrial Function After Transcatheter Aortic Valve Replacement on Doppler Echocardiography.

BACKGROUND: More than 50% of embolic strokes occur >24 hours after transcatheter aortic valve replacement (TAVR) and are therefore not directly procedure related. We aimed to determine immediate changes in left atrial (LA) function after TAVR, that may alter short-term and long-term stroke risk after TAVR. METHODS: Transesophageal and transthoracic echocardiography were performed before and immediately after TAVR to evaluate left atrial appendage (LAA) velocities and Doppler echocardiographic markers of LA function. RESULTS: Eighty-five patients (mean age, 83.1 ± 7.5 years; 54% male) underwent TAVR. Patients in sinus rhythm (n = 57) during TAVR had immediate improvement of LA function, with an increase in A-wave velocity (92.3 ± 33.7 cm/s to 104.9 ± 34.6 cm/s), mitral inflow velocity time integral (VTI; 27.8 ± 3.6 to 29.6 ± 9.5), A-wave VTI (10.8 ± 4.1 to 12.8 ± 4.2), and lateral A´ velocity (8.8 ± 3.6 cm/s to 9.7 ± 3.6 cm/s; P<.05 for all), and a decrease in E/A ratio (1.2 ± 0.73 to 1.05 ± 0.59; P<.01) after TAVR. Low baseline LAA emptying velocities were common (53%), and velocities significantly increased after TAVR (mean change, +4.9 cm/s; P<.01). We identified several clinical and echocardiographic determinants of low LAA emptying velocity at baseline (<35 cm/s). CONCLUSIONS: There is immediate improvement in LA function and an increase in LAA velocities after TAVR. This improvement may benefit hemodynamics immediately after TAVR, but may also increase the short-term stroke risk (as recently shown in two independent studies) in patients with LAA thrombus or low emptying velocities. Therefore, evaluation of LA function and LAA thrombus may be warranted to identify patients at high risk for periprocedural stroke and guide the need for anticoagulation therapy.