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Background: Heart disease remains the leading cause of death in the United States. Although there are clear indications for revascularization in patients with acute coronary syndromes, there is debate regarding the benefits of revascularization in stable ischemic heart disease. We sought to perform a comprehensive meta-analysis to assess the role of revascularization compared to conservative medical therapy alone in patients with stable ischemic heart disease., Hypothesis: There is no significant difference in all-cause mortality or cardiovascular mortality between invasive and medical arms., Methods: We performed a systematic literature search from January 2000 to June 2020. Our literature search yielded seven randomized controlled trials. We analyzed a total of 12 013 patients (6109 in revascularization arm and 5904 in conservative medical therapy arm). Primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac events (MACE) (death, myocardial infarction [MI], or stroke), cardiovascular mortality, MI, and stroke. Additional subgroup analysis for all-cause mortality was performed comparing percutaneous coronary intervention (PCI) with bare metal stent versus conservative therapy; and PCI with drug eluting stent versus conservative therapy., Results: There was no statistically significant difference in primary outcome of all-cause mortality between either arm (odds ratio [OR] = 0.95; 95% CI [confidence interval], 0.83 to 1.08; p = .84). There were statistically significant lower rates of MACE (death, MI or stroke) in the revascularization arm when compared to conservative arm., Conclusions: Our analysis did not show any survival advantage of an initial invasive strategy over conservative medical therapy in patients with stable coronary artery disease (CAD)., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: Age is the strongest predictor of atrial fibrillation (AF), yet little is known about AF incidence in the oldest old., Hypothesis: AF incidence declines after age 90 years, and morbidity is compressed into a brief period at the end of life., Methods: In this retrospective, longitudinal cohort study of patients (born 1905-1935), we examined cumulative lifetime incidence of AF and its impact on mortality. Data included records from 1 062 610 octogenarians, 317 161 nonagenarians, and 3572 centenarians. Kaplan-Meier curves were used to estimate cumulative incidence of AF by age group, incidence rates were compared using log-rank tests, and Cox proportional hazards model was used to estimate unadjusted hazard ratios. The primary outcome was AF incidence at age > 80 years; the secondary outcome was mortality., Results: The cumulative AF incidence rate was 5.0% in octogenarians, 5.4% in nonagenarians, and 2.3% in centenarians. Octogenarians and nonagenarians had a higher risk of AF incidence compared to centenarians (adjusted hazard ratio 8.74, 95% confidence interval [CI]: 6.31-12.04; and 2.98, 95% CI: 2.17-4.1, respectively). The lowest hazard ratio for mortality in patients with AF compared to those without was 2.3 (95% CI: 2.3-2.4) in patients who were on antiplatelet and anticoagulant medication and had a score of 0 on the Elixhauser comorbidity index score., Conclusions: Although AF incidence increased with age, being a centenarian was associated with reduced incidence and compression of morbidity. Patients with AF had a higher adjusted mortality rate. However, data suggest that a regimen of anticoagulants and antiplatelets may reduce risk of mortality in patients over 80 with an AF diagnosis., (© 2018 Wiley Periodicals, Inc.)

Background: Pericardial effusion is common in hospitalized patients with chronic kidney disease (CKD). We sought to identify predictors and prognostic impact of pericardial effusion in CKD patients., Hypothesis: Clinical and biochemical parameters can predict pericardial effusion in CKD patients., Methods: In a retrospective nested case-control design, we analyzed hospitalized adult patients with CKD stage 4, 5, or end-stage renal disease diagnosed with pericardial effusion. Controls were same-stage CKD patients without effusion., Results: Among 84 cases and 61 controls, 44% and 34% were on dialysis, respectively. The mean creatinine was higher among cases versus controls (8.4±6.0 vs. 6.0±3.4 mg/dL, P = 0.002). Effusion was moderate to large in 46% of cases. Independent predictors of any pericardial effusion were serum potassium (OR: 1.95 per 1-mEq/L increment, 95% CI: 1.21-3.13, P = 0.006), serum corrected calcium (OR: 1.33 per 1-mg/dL decrement, 95% CI: 1.11-1.67, P = 0.015), and admission heart rate (OR: 1.29 per 10-bpm increment, 95% CI: 1.03-1.62, P = 0.027). Corrected calcium level was an independent predictor of moderate to large pericardial effusion (OR: 1.38 per 1-mg/dL decrement, 95% CI: 1.04-1.82, P = 0.023). Corrected calcium <8.0 mg/dL demonstrated 95% specificity for moderate to large effusion. Patients with effusion had no significant difference in the composite endpoint of mortality or cardiovascular rehospitalization (P = 0.408)., Conclusions: In hospitalized CKD patients, hypocalcemia may be useful in identifying those with moderate to large pericardial effusion. In this population, pericardial effusion does not seem to be associated with adverse outcomes., (© 2018 Wiley Periodicals, Inc.)

Background: In patients with acute pulmonary embolism (PE), detectable levels of cardiac troponin I (cTnI) using a highly sensitive assay have been associated with increased in-hospital mortality. We sought to investigate the impact of detectable cTnI on long-term survival following acute PE., Hypothesis: Detectable cTnI levels in patients presenting with acute PE predict increased long-term mortality following hospital discharge., Methods: In a retrospective cohort study, we analyzed consecutive patients with confirmed acute PE and cTnI assay available from the index hospitalization. The detectable cTnI level was ≥0.012 ng/mL. Patients were classified into low and high clinical risk groups according to the Pulmonary Embolism Severity Index (PESI) at presentation. Subjects were followed for all-cause mortality subsequent to hospital discharge using chart review and Social Security Death Index., Results: A cohort of 289 acute PE patients (mean age 56 years, 51% men), of whom 152 (53%) had a detectable cTnI, was followed for a mean of 3.1 ± 1.8 years after hospital discharge. A total of 71 deaths were observed; 44 (29%) and 27 (20%) in the detectable and undetectable cTnI groups, respectively (P = 0.05). Detectable cTnI was predictive of long-term survival among low-risk (P = 0.009) but not high-risk patients (P = 0.78) who had high mortality rates irrespective of cTnI status., Conclusions: In patients with acute PE, detectable cTnI is predictive of long-term mortality, particularly among patients who were identified as low risk according to PESI score., (© 2017 Wiley Periodicals, Inc.)

Background: Approximately 20% of the population has elevated circulating levels of lipoprotein(a) (Lp[a]), one of the most robust predictors of cardiovascular disease risk. This is particularly true for women., Hypothesis: Many female patients with "normal" traditional risk factors or low atherosclerotic cardiovascular disease (ASCVD) risk scores may harbor high risk related to elevated levels of Lp(a)., Methods: A retrospective, cross-sectional study of consecutive female patients presenting to Heart Centers for Women was performed. Discordance between low-density lipoprotein cholesterol (LDL-C) and Lp(a) was determined. The ASCVD risk and Reynolds Risk Score models A (RRS-A) and B (RRS-B) were calculated, and level of agreement in patients meeting treatment threshold (≥7.5% for ASCVD, ≥10% for RRS-A and RRS-B) were compared., Results: Among 713 women, 290 (41%) had elevated Lp(a); however, LDL-C and Lp(a) were weakly correlated (r = 0.08). Significant discordance was observed between abnormal LDL-C and Lp(a) levels (McNemar P = 0.03). There was moderate correlation between RRS-A and ASCVD risk (r = 0.71, P < 0.001), and Bland-Altman plot showed diminished correlation with increased risk. More patients met treatment threshold by ASCVD risk estimation, but nearly 1 out of 20 patients met treatment threshold by RRS-A but not ASCVD score., Conclusions: There is high prevalence of elevated Lp(a) among women presenting to Heart Centers for Women. Although traditional risk markers such as elevated LDL-C or high ASCVD risk may be absent in some women, elevated Lp(a) may identify patients who may benefit from aggressive risk-factor modification and pharmacologic therapy., (© 2016 Wiley Periodicals, Inc.)

Background: The impact of health insurance carrier and socioeconomic status (SES) on the adherence to appropriate use criteria (AUC) for radionuclide myocardial perfusion imaging (MPI) is unknown., Hypothesis: Health insurance carrier's prior authorization and patient's SES impact adherence to AUC for MPI in a fee-for-service setting., Methods: We conducted a prospective cohort study of 1511 consecutive patients who underwent outpatient MPI in a multi-site, office-based, fee-for-service setting. The patients were stratified according to the 2009 AUC into appropriate/uncertain appropriateness and inappropriate use groups. Insurance status was categorized as Medicare (does not require prior authorization) vs commercial (requires prior authorization). Socioeconomic status was determined by the median household income in the ZIP code of residence., Results: The proportion of patients with Medicare was 33% vs 67% with commercial insurance. The rate of inappropriate use was higher among patients with commercial insurance vs Medicare (55% vs 24%; P < 0.001); this difference was not significant after adjusting for confounders known to impact AUC determination (odds ratio: 1.06, 95% confidence interval: 0.62-1.82, P = 0.82). The mean annual household income in the residential areas of patients with inappropriate use as compared to those with appropriate/uncertain use was $72 000 ± 21 000 vs $68 000 ± 20 000, respectively (P < 0.001). After adjusting for covariates known to impact AUC determination, SES (top vs bottom quartile income area) was not independently predictive of inappropriate MPI use (odds ratio: 0.9, 95% confidence interval: 0.53-1.52, P = 0.69)., Conclusions: Insurance carriers prior authorization and SES do not seem to play a significant role in determining physicians adherence to AUC for MPI., (© 2015 Wiley Periodicals, Inc.)