Search

Discrepancies in medical care are well known to adversely affect patients with opioid abuse disorders (OUD), including management and outcomes of acute myocardial infarction (AMI) in patients with OUD. We used the National Inpatient Sample was queried from January 2006 to September 2015 to identify all patients ≥18 years admitted with a primary diagnosis of AMI (weighted N = 13,030; unweighted N = 2,670) and concomitant OUD. Patients using other nonopiate illicit drugs were excluded. Propensity matching (1:1) yielded 2,253 well-matched pairs in which intergroup comparison of invasive revascularization strategies and cardiac outcomes were performed. The prevalence of OUD patients with AMI over the last decade has doubled, from 163 (2006) to 326 cases (2015) per 100,000 admissions for AMI. The OUD group underwent less cardiac catheterization (63.2% vs 72.2%; p0.001), percutaneous coronary intervention (37.0% vs 48.5%; p0.001) and drug-eluting stent placement (32.3% vs 19.5%; p0.001) compared with non-OUD. No differences in in-hospital mortality/cardiogenic shock were noted. Among subgroup of ST-elevation myocardial infarction patients (26.2% of overall cohort), the OUD patients were less likely to receive percutaneous coronary intervention (67.9% vs 75.5%; p = 0.002), drug-eluting stent (31.4% vs 47.9%; p0.001) with a significantly higher mortality (7.4% vs 4.3%), and cardiogenic shock (11.7% vs 7.9%). No differences in the frequency of coronary bypass grafting were noted in AMI or its subgroups. In conclusion, OUD patients presenting with AMI receive less invasive treatment compared with those without OUD. OUD patients presenting with ST-elevation myocardial infarction have worse in-hospital outcomes with increased mortality and cardiogenic shock.

Background Left ventricular thrombus (LVT) is not uncommon and pose a risk of systemic embolism, which can be mitigated by adequate anticoagulation. Direct oral anticoagulants (DOACs) are increasingly being used as alternatives to warfarin for anticoagulation, but their efficacy and safety profile has been debated. We aim to compare the therapeutic efficacy and safety of DOACs versus warfarin for the treatment of LVT. Methodology We systematically searched PubMed/Medline, Google Scholar, Cochrane library, and LILCAS databases from inception to 14th August 2020 to identify relevant studies comparing warfarin and DOACs for LVT treatment and used the pooled data extracted from retrieved studies to perform a meta-analysis. Results We report pooled data on 1955 patients from 8 studies, with a mean age of 61 years and 59.7 years in warfarin and DOACs group, respectively. The pooled odds ratio for thrombus resolution was 1.11 (95% CI 0.51–2.39) on comparing warfarin to DOAC, but it did not reach a statistical significance (p = 0.76). The pooled risk ratio (RR) of stroke or systemic embolization and bleeding in patients treated with warfarin vs DOACs was 1.04 (95% CI 0.64–1.68; p = 0.85), and 1.15 (95% CI 0.62–2.13; p = 0.57), respectively; with an overall RR of 1.09 (95% CI 0.70–1.70; p = 0.48) for mortality. Conclusions DOACs appears to be non-inferior or at least as effective as warfarin in the treatment of left ventricular thrombus without any statistical difference in stroke or bleeding complications.

Background Transcatheter mitral valve repair (TMVR) utilization has increased significantly in the United States over the last years. Yet, a risk-prediction tool for adverse events has not been developed. We aimed to generate a machine-learning-based algorithm to predict in-hospital mortality after TMVR. Methods Patients who underwent TMVR from 2012 through 2015 were identified using the National Inpatient Sample database. The study population was randomly divided into a training set (n = 636) and a testing set (n = 213). Prediction models for in-hospital mortality were obtained using five supervised machine-learning classifiers. Results A total of 849 TMVRs were analyzed in our study. The overall in-hospital mortality was 3.1%. A naive Bayes (NB) model had the best discrimination for fifteen variables, with an area under the receiver-operating curve (AUC) of 0.83 (95% CI, 0.80–0.87), compared to 0.77 for logistic regression (95% CI, 0.58–0.95), 0.73 for an artificial neural network (95% CI, 0.55–0.91), and 0.67 for both a random forest and a support-vector machine (95% CI, 0.47–0.87). History of coronary artery disease, of chronic kidney disease, and smoking were the three most significant predictors of in-hospital mortality. Conclusions We developed a robust machine-learning-derived model to predict in-hospital mortality in patients undergoing TMVR. This model is promising for decision-making and deserves further clinical validation.

Purpose of review To review recent evidence evaluating the long-term safety and efficacy outcomes of left atrial appendage occlusion (LAAO), current guideline recommendations for LAAO use, performance of LAAO in comparison with direct oral anticoagulants (DOAC) and recently approved LAAO device. Recent findings The last 18 months have been marked with increasing evidence of the utility of LAAO in patients who are not candidates for long-term oral anticoagulation (OAC). Long-term data from two continued access registries to PROTECT-AF and PREVAIL support LAAO as a safe and effective long-term anticoagulation therapy. This new evidence led to class IIb recommendation for LAAO in nonvalvular atrial fibrillation (NVAF) patients not eligible for long-term OAC. PRAGUE-17 randomized controlled trial showed LAAO is noninferior to DOAC lending support to use of this modality in current era. PINNACLE FLX trial showed improved implant success and adequate closure rate which led to the device's Food and Drug Administration approval. Summary In conclusion, percutaneous LAAO appears to be a promising option for NVAF patients who are not candidates for long-term OAC in the current era. Further evidence guiding optimal patient selection and periprocedural antithrombotic regimen will help identify the patients who would benefit the most from this procedure.

ImportanceCoronavirus disease 2019 (COVID-19) has been reported to cause worse outcomes in patients with underlying cardiovascular disease, especially in patients with acute cardiac injury, which is determined by elevated levels of high-sensitivity troponin. There is paucity of data on the impact of congestive heart failure (CHF) on outcomes in COVID-19 patients.ObjectiveTo evaluate the occurrence of acute cardiac injury and arrhythmias and to assess the impact of pre-existing CHF and hypertension (HTN) in COVID-19 patients.Data SourcesWe conducted a literature search of PubMed/Medline, EMBASE, and Google Scholar databases from 11/1/2019 till 06/07/2020. databases using following search terms or keywords: “(COVID) AND (Clinical); ((heart) OR (myocard*)) AND (COVID); (COVID) AND (Troponin); (Coronavirus) AND (Heart).”Study SelectionWe identified all relevant studies reporting cardiovascular comorbidities, cardiac biomarkers, disease severity, and survival in COVID-19 patients.Data Extraction and SynthesisWe followed preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for abstracting data. Pooled data was meta-analyzed using random-effects model and between-study heterogeneity was calculated with Higgins I2 statistic.Main outcome and measuresTo assess the impact of HTN and CHF and to evaluate different cardiac biomarkers in COVID-19 patients based on their disease severity.ResultsWe collected pooled data on 5,967 COVID-19 patients from 20 individual studies. We found that both non-survivors and those with severe disease had an increased risk of acute cardiac injury and cardiac arrhythmias, our pooled relative risk (RR) was — 8.52 (95% CI 3.63– 19.98) (pConclusion and RelevanceCardiac involvement in COVID-19 infection appears to significantly adversely impact patient prognosis and survival. Pre-existence of CHF, and high cardiac biomarkers like NT-pro BNP and CK-MB levels in COVID-19 patients correlates with worse outcomes.

Objectives To evaluate whether a preoperative diagnosis of atrial septal defect (ASD) or patent foramen ovale (PFO) is associated with perioperative stroke in noncardiac surgery and their outcomes. Design Retrospective cohort analysis. Setting United States hospitals. Participants Adults patients (≥18 years old) who underwent major noncardiac surgery from 2010 to 2015 were identified using the Healthcare Cost and Utilization Project's National Readmission Database. Interventions Preoperative diagnosis of ASD or patent foramen ovale. Measurements and Main Results Among the 19,659,161 hospitalizations for major noncardiac surgery analyzed, 12,248 (0.06%) had a preoperative diagnosis of ASD/PFO. Perioperative ischemic stroke occurred in 723 (5.9%) of patients with ASD/PFO and 373,291 (0.02%) of those without ASD/PFO (adjusted odds ratio [aOR], 16.7; 95% confidence interval [CI]: 13.9-20.0). Amongst the different types of noncardiac surgeries, obstetric, endocrine, and skin and burn surgery were associated with higher risk of stroke in patients with pre-existing ASD/PFO. Moreover, patients with ASD/PFO also had an increased in-hospital mortality (aOR, 4.6, 95% CI: 3.6-6.0), 30-day readmission (aOR, 1.2, 95% CI: 1.04-1.38), and 30-day stroke (aOR, 7.2, 95% CI: 3.1-16.6). After adjusting for atrial fibrillation, ischemic stroke remained significantly high in the ASD/PFO group (aOR: 23.7, 95%CI 19.4-28.9), as well as in-hospital mortality (aOR: 5.6, 95% CI 4.1-7.7), 30-day readmission (aOR: 1.19, 95%CI 1.0-1.4), and 30-day stroke (aOR: 9.3, 95% CI 3.7-23.6). Conclusions Among adult patients undergoing major noncardiac surgery, pre-existing ASD/PFO is associated with increased risk of perioperative ischemic stroke, in-hospital mortality, 30-day stroke, and 30-day readmission after surgery.

OBJECTIVE The authors sought to evaluate 10-year national trends, incidence and clinical outcomes of stroke in CS-STEMI. BACKGROUND Stroke is a devastating complication among patients with ST-elevation myocardial infarction (STEMI). Concomitant cardiogenic shock (CS) may further increase the risk of stroke. Use of percutaneous mechanical circulatory support (pMCS) devices may further increase stroke risk in CS-STEMI. No studies have evaluated the risk of stroke in contemporary CS-STEMI. METHODS We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database between 2005 and 2014. Previously validated codes for stroke were used to identify events of ischemic or hemorrhagic stroke. They were then divided into different groups: without MCS, with intra-aortic balloon pump, percutaneous ventricular assist device (PVAD, includes Impella or TandemHeart devices), or extracorporeal membrane oxygenation. RESULTS In 172,491 admissions, stroke was noted in 5,613 (3.2%). Between 2005 and 2014, we observed an increase in the events of overall stroke from 3.1% in 2005 to 5.0% in 2014 (p for the trend

Purpose: Septic shock (SS) manifests with profound circulatory and cellular metabolism abnormalities and has a high in-hospital mortality (25%-50%). Congestive heart failure (CHF) patients have underlying circulatory dysfunction and compromised cardiac reserve that may place them at increased risk if they develop sepsis. Outcomes in patients with CHF who are admitted with SS have not been well studied. Materials and Method: Retrospective cross sectional secondary analysis of the Nationwide Readmission Database (NRD) for 2016 and 2017. ICD-10 codes were used to identify patients with SS during hospitalization, and then the cohort was dichotomized into those with and without an underlying diagnosis of CHF. Results: Propensity match analyses were performed to evaluate in-hospital mortality and clinical cardiovascular outcomes in the 2 groups. Cardiogenic shock patients were excluded from the study. A total of 578,629 patients with hospitalization for SS were identified, of whom 19.1% had a coexisting diagnosis of CHF. After propensity matching, 81,699 individuals were included in the comparative groups of SS with CHF and SS with no CHF. In-hospital mortality (35.28% vs 32.50%, P

ObjectivesThis study aimed to compare short- and long-term outcomes following various alternative access routes for transcatheter aortic valve replacement (TAVR).MethodsThirty-four studies with a pooled sample size of 30,986 records were selected by searching PubMed and Cochrane library databases from inception through 11thJune 2021 for patients undergoing TAVR via 1 of 6 different access sites: Transfemoral (TF), Transaortic (TAO), Transapical (TA), Transcarotid (TC), Transaxillary/Subclavian (TSA), and Transcaval (TCV). Data extracted from these studies were used to conduct a frequentist network meta-analysis with a random-effects model using TF access as a reference group.ResultsCompared with TF, both TAO [RR 1.91, 95% CI (1.46–2.50)] and TA access [RR 2.12, 95%CI (1.84–2.46)] were associated with an increased risk of 30-day mortality. No significant difference was observed for stroke, myocardial infarction, major bleeding, conversion to open surgery, and major adverse cardiovascular or cerebrovascular events in the short-term (≤ 30 days). Major vascular complications were lower in TA [RR 0.43, (95% CI, 0.28-0.67)] and TC [RR 0.51, 95% CI (0.35-0.73)] access compared to TF. The 1-year mortality was higher in the TAO [RR of 1.35, (95% CI, 1.01–1.81)] and TA [RR 1.44, (95% CI, 1.14–1.81)] groups.ConclusionNon-thoracic alternative access site utilization for TAVR implantation (TC, TSA and TCV) is associated with similar outcomes to conventional TF access. Thoracic TAVR access (TAO and TA) is associated with increased short and long-term mortality.

Background The usefulness of right heart catherization (RHC) has long been debated, and thus, we aimed to study the real‐world impact of the use of RHC in cardiogenic shock. Methods and Results In the Nationwide Readmissions Database using International Classification of Diseases, Tenth Revision ( ICD‐1 0 ), we identified 236 156 patient hospitalizations with cardiogenic shock between 2016 and 2017. We sought to evaluate the impact of RHC during index hospitalization on management strategies, complications, and outcomes as well as on 30‐day readmission rate. A total 25 840 patients (9.6%) received RHC on index admission. The RHC group had significantly more comorbidities compared with the non‐RHC group. During the index admission, the RHC group had lower death (25.8% versus 39.5%, P P P =0.04) and death on readmission (7.9% versus 9.3%, P =0.03) were also lower in the RHC group. After adjustment, RHC was associated with lower index admission mortality (odds ratio, 0.69; 95% CI, 0.66–0.72), lower stroke rate (odds ratio, 0.81; 95% CI, 0.72–0.90), lower 30‐day readmission (odds ratio, 0.83; 95% CI, 0.78–0.88), and higher left ventricular assist device implantations/orthotopic heart transplants (odds ratio, 6.05; 95% CI, 4.43–8.28) during rehospitalization. Results were not meaningfully different after excluding patients with cardiac arrest. Conclusions RHC use in cardiogenic shock is associated with improved outcomes and increased use of downstream advanced heart failure therapies. Further blinded randomized studies are required to confirm our findings.

PURPOSE: To identify racial/ethnic disparities in utilization rates, in-hospital outcomes and health care resource use among Non-Hispanic Whites (NHW), African Americans (AA) and Hispanics undergoing transcatheter aortic valve replacement (TAVR) in the United States (US). METHODS AND RESULTS: The National Inpatient Sample database was queried for patients ≥18 years of age who underwent TAVR from 2012 to 2014. The primary outcome was all-cause in hospital mortality. A total of 36,270 individuals were included in the study. The number of TAVR performed per million population increased in all study groups over the three years [38.8 to 103.8 (NHW); 9.1 to 26.4 (AA) and 9.4 to 18.2 (Hispanics)]. The overall in-hospital mortality was 4.2% for the entire cohort. Race/ethnicity showed no association with in-hospital mortality (P>.05). Though no significant difference were found between AA and NHW in any secondary outcome, being Hispanic was associated with higher incidence of acute myocardial infarction (aOR=2.02; 95%CI, 1.06–3.85; P=.03), stroke/transient ischemic attack (aOR=1.81; 95%CI, 1.04–3.14; P=.04), acute kidney injury (aOR=1.65; 95%CI, 1.23–2.21; P

OBJECTIVES: The aim of this study was to determine the prevalence of peripheral artery disease (PAD) and its association with in-hospital outcomes after endovascular transcatheter aortic valve replacement (EV-TAVR). BACKGROUND: TAVR is an established treatment for patients at prohibitive, high, or intermediate surgical risk. PAD is a significant comorbidity in the determination of surgical risk. However, data on association of PAD with outcomes after EV-TAVR are limited. Methods: Patients in the National Inpatient Sample who underwent EV-TAVR between January 1, 2012 and September 30, 2015 were evaluated. The primary outcome was in-hospital mortality. RESULTS: A total of 51,685 patients underwent EV-TAVR during the study period. Of these, 12,740 (24.6%) had a coexisting diagnosis of PAD. The adjusted odds for in-hospital mortality [OR 1.08 (95% CI 0.83–1.41)], permanent pacemaker implantation [OR 0.98 (0.85–1.14)], conversion to open aortic valve replacement [OR 1.05 (0.49–2.26)], or acute myocardial infarction [OR 1.31(0.99–1.71)] were not different in patients with versus without PAD. However, patients with PAD had greater adjusted odds of vascular complications [OR 1.80 (1.50–2.16)], major bleeding [OR 1.20 (1.09–1.34)], acute kidney injury (AKI) [OR 1.19 (1.05–1.36)], cardiac complications [aOR 1.21 (1.01–1.44)], and stroke [OR 1.39(1.10–1.75)] compared with patients without PAD. Length of stay (LOS) was significantly longer for patients with PAD [7.23 (0.14) days vs. 7.11 (0.1) days, p < 0.001]. CONCLUSION: Of patients undergoing EV-TAVR, ~25% have coexisting PAD. PAD was not associated with increased risk of in-hospital mortality but was associated with higher risk of vascular complications, major bleeding, AKI, stroke, cardiac complications, and longer LOS.

Coronavirus disease 2019 (COVID-19) is characterized by a clinical spectrum of diseases ranging from asymptomatic or mild cases to severe pneumonia with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. Extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy in appropriate patients with COVID-19 complicated by ARDS refractory to mechanical ventilation. In this study, we review the indications, challenges, complications, and clinical outcomes of ECMO utilization in critically ill patients with COVID-19-related ARDS. Most of these patients required venovenous ECMO. Although the risk of mortality and complications is very high among patients with COVID-19 requiring ECMO, it is similar to that of non-COVID-19 patients with ARDS requiring ECMO. ECMO is a resource-intensive therapy, with an inherent risk of complications, which makes its availability limited and its use challenging in the midst of a pandemic. Well-maintained data registries, with timely reporting of outcomes and evidence-based clinical guidelines, are necessary for the careful allocation of resources and for the development of standardized utilization protocols.

Objective The aim of the study was to examine the effects of the vitamin D (Vit-D) treatment and nontreatment on Vit-D–deficient patients without a prior history of myocardial infarction (MI). Materials and Methods This was a retrospective, observational, nested case–control study of patients (N = 20 025) with low 25-hydroxyvitamin D ([25-OH]D) levels ( Results Among the cohort of 20 025 patients, the risk of MI was significantly lower in Group C than in Group B (hazard ratio [HR] 0.65, 95% CI 0.49-0.85, P = .002) and Group A (HR 0.73, 95% CI 0.55-0.96), P = .02). There was no difference in the risk of MI between Group B and Group A (HR 1.14, 95% CI 0.91-1.42, P = 0.24). Compared with Group A, both Group B (HR 0.59, 95% CI 0.54-0.63, P Conclusions In patients with Vit-D deficiency and no prior history of MI, treatment to the (25-OH)D level of >20 ng/mL and >30 ng/mL was associated with a significantly lower risk of all-cause mortality. The lower risk of MI was observed only in individuals maintaining (25-OH)D levels ≥30 ng/mL.

Adults with congenital heart diseases may not be candidates for conventional therapies to control ventricular systolic dysfunction, including mechanical circulatory support, which moves potential heart-transplantation recipients to a listing status of higher priority. This results in longer waitlist times and greater mortality rates. Exception-status listing allows a pathway for this complex and anatomically heterogenous group of patients to be listed for heart transplantation at appropriately high listing status. Our study queried the United Network for Organ Sharing registry to evaluate trends in the use of exception-status listing among adults with congenital heart diseases awaiting heart transplantation. Uptrend in the use of exception-status listing precedes the new allocation system, but it has been greatest since changes were made in the allocation system. It continues to remain a vital pathway for adults with congenital heart disease (whose waitlist mortality rates are often not characterized adequately by using the waitlist-status criteria) timely access to heart transplantation.

Background Emerging evidence links acute kidney injury (AKI) in patients with COVID‐19 with higher mortality and respiratory morbidity, but the relationship of AKI with cardiovascular disease outcomes has not been reported in this population. We sought to evaluate associations between chronic kidney disease (CKD), AKI, and mortality and cardiovascular outcomes in patients hospitalized with COVID‐19. Methods and Results In a large multicenter registry including 8574 patients with COVID‐19 from 88 US hospitals, data were collected on baseline characteristics and serial laboratory data during index hospitalization. Primary exposure variables were CKD (categorized as no CKD, CKD, and end‐stage kidney disease) and AKI (classified into no AKI or stages 1, 2, or 3 using a modification of the Kidney Disease Improving Global Outcomes guideline definition). The primary outcome was all‐cause mortality. The key secondary outcome was major adverse cardiac events, defined as cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, new‐onset nonfatal heart failure, and nonfatal cardiogenic shock. CKD and end‐stage kidney disease were not associated with mortality or major adverse cardiac events after multivariate adjustment. In contrast, AKI was significantly associated with mortality (stage 1 hazard ratio [HR], 1.72 [95% CI, 1.46–2.03]; stage 2 HR, 1.83 [95% CI, 1.52–2.20]; stage 3 HR, 1.69 [95% CI, 1.44–1.98]; versus no AKI) and major adverse cardiac events (stage 1 HR, 2.17 [95% CI, 1.74–2.71]; stage 2 HR, 2.70 [95% CI, 2.07–3.51]; stage 3 HR, 3.06 [95% CI, 2.52–3.72]; versus no AKI). Conclusions This large study demonstrates a significant association between AKI and all‐cause mortality and, for the first time, major adverse cardiovascular events in patients hospitalized with COVID‐19.

V122I genotype variant (pV142I) is the most common hereditary transthyretin amyloidosis (hATTR) in the USA, with 3–3.5% of African-Americans being the carriers of this mutation. We aimed to compare baseline clinical features, cardiac parameters, and mortality in V122I-ATTR with the wild-type ATTR and other hATTR subtypes. We systematically searched PubMed/Medline and Google Scholar databases to identify relevant studies from inception to 10th September, 2020 reporting phenotypic, echocardiographic, and/or laboratory parameters in patients with hereditary and wild types of cardiac amyloidoses. A total of 2843 patients from 7 individual studies with 67–100% males and an overall follow-up duration of 51.6 ± 30.4 months were identified. The mean age of diagnosis among wild-type ATTR patients was 77 years, followed by 71.2 and 65 years in V122I and T60A group patients, respectively. V122I patients were mostly black, had a poor quality of life, and highest mortality risk compared with other subtypes. Merely, the presence of V122I mutation was identified as an independent predictor of mortality. V30M subtype correlated with the least severe cardiac disease and a median survival duration comparable with T60A subtype. V122I ATTR is an aggressive disease, prevalent in African-Americans, and is associated with a greater morbidity and mortality, which is partly attributed to its misdiagnosis and/or late diagnosis. Current advances in non-invasive studies to diagnose hATTR coupled with concurrent drug therapies have improved quality of life and provide a survival benefit to these patients.

Left ventricular assist device (LVAD) implantation in patients with advanced heart failure due to hypertrophic or restrictive cardiomyopathy (HCM/RCM) presents technical and physiologic challenges. We conducted a systematic review of observational studies to evaluate the utilization and clinical outcomes associated with LVAD implantation in patients with HCM/RCM and compared these to patients with dilated or ischemic cardiomyopathy (DCM/ICM). We searched MEDLINE, EMBASE, and Scopus from inception through May 2019 and included appropriate studies describing the use of an LVAD in patients with HCM/RCM. We identified six studies with a total of 2,766 patients with HCM/RCM and advanced heart failure, among whom 338 patients (12.2%) underwent LVAD implantation. In patients listed for transplant, the rate of LVAD implantation was significantly lower in patients with HCM/RCM compared to that in patients with DCM/ICM (4.4% vs. 18.2%, p < 0.001). Adverse clinical outcomes were significantly higher in HCM/RCM than in DCM/ICM, including operative/short-term mortality (14.0% vs. 9.0%), right ventricular failure (50.0% vs. 21.0%), infection (15.5% vs. 11.2%), bleeding (40.2% vs. 12.5%), renal failure (15.0% vs. 5.1%), stroke (5.0% vs. 2.4%), and arrhythmias (18.0% vs. 7.7%) (all p values

Objective: Increased red cell distribution width (RDW) has been associated with poor prognosis in patients with heart failure (HF) and coronary heart disease (CHD) in multiple observation studies. We conducted this meta-analysis to determine composite impact of RDW on cardiovascular outcomes in patients with HF and CHD. Methodology: Literature search of databases such as PubMed/Medline, Google Scholar, and Cochrane library was conducted from inception till 16 th August, 2020 to identify all the relevant studies reporting all-cause mortality based on the RDW levels in patients with HF and CHD (ST- elevation & non-ST elevation myocardial infarction, coronary artery disease). The data was extracted from retrieved results for performing this systematic review and meta-analysis. Results: A total of 32 studies were included with a total of 58, 518 patients. The ages ranged from 49-80 years with males being 47%–98% in proportion. We observed that the pooled estimate of hazard ratio (HR) for all-cause mortality among patients with congestive heart failure (CHF) was 1.16 (95% CI 1.10–1.23; p

Introduction: Watchman device is an alternative for anticoagulation in atrial fibrillation (AF) patients for stroke prevention but there is paucity of data on 30-day readmission trends and factors influencing it. Methods: We queried the 2016-2017 National Readmission Database for all adult AF patients, who had procedure done in January to November and discharged alive, using ICD10 code of 02L73DK. We divided the study population into deciles and used the annual procedure volume cut-off of 20 to compare the lowest volume decile with rest of the study population. Hierarchical multivariable logistic regression model was created to identify predictors of 30-day readmission and hospitals were included as random effect. Results: A total of 4565 and 9219 procedures were included for 2016 and 2017; respectively. Overall readmission rate was 1287 (9.3%) and of these 43 (3.3%) died on readmission. The 30-day readmission rate in 2017 was 906 (9.8%) compared to 381 (8.4%) in 2016 (p = 0.053) but the mortality associated with readmission was significantly higher in 2017 at 38 (0.42%) compared to 5 (0.11%) in 2016 (p=0.01). The proportion of patients with Charlson co-morbidity index ≥5 was significantly higher in 2017 at 1177 (12.8%) compared to 384 (8.4%) in 2016 (p Conclusions: Thirty-day readmission rate and mortality has been increasing along with the procedural volume which could be related to patients with higher number of co-morbidities receiving the device. Lower procedural volume of the hospital is an independent predictor of readmission.

Background: Preliminary reports have suggested the role of annular calcium in independently predicting pacemaker implantation after transcatheter aortic valve replacement (TAVR). Data regarding role of calcium in the aortic-valvular complex on pacemaker dependency is lacking. Hypothesis: Calcium volume and score in the aortic annular region predicts RV (right ventricle) pacing burden. Methods: We conducted a retrospective single-center study at our tertiary care center including patients who had new pacemaker implantation after TAVR procedure (n=47). Standard calcium scoring software was used to demarcate and quantify the calcium along the aortic cusps and subvalvular region and dichotomized into septal and non-septal based on proximity to the interventricular septum. Standard statistical tests were used for analysis with two-sided p-value Results: The mean age was 78.6 ± 10.3 years and females were 42.6%. At baseline, 44.7% had narrow QRS complex, with 31.9% had right bundle branch block (RBBB), 8.5% had left bundle branch block (LBBB). Median Pre-TAVR QRS duration was 112 ms. Median septal and non-septal calcium score were 646 and 474 with a volume of 441 mm 3 and 327.2 mm 3 , respectively. Patients with progression to complete heart block (CHB) during index admission had significantly higher non-septal volume (650 mm 3 vs 344 mm 3 ;p=0.01) and score (892 vs 485;p=0.01) when compared to progression after discharge. Similarly, the high burden of RV pacing (>40%) was associated with lower septal calcium score (989 vs 552, p= 0.03) and volume (717 mm 3 vs 385 mm 3 , p=0.03) within 3 months of TAVR. No septal or non-septal parameters were predictive of pacing burden for mid-term (3-12 months) and long-term (>12 months) follow up. Septal calcium parameters were not predictive of RV pacing burden or progression to CHB. Conclusion: Quantitative calcium in the non-septal and septal regions were predictive of early progression to CHB and a higher burden of RV pacing, respectively. Larger scale studies on calcium distribution and the burden should be performed to validate our findings.

Introduction: Acute pericarditis accounts for one in every twenty emergency department visits for chest pain and a majority of these patients get admitted to a hospital. However, apart from small studies, there is a lack of data regarding the incidence and predictors of readmissions in these patients. Methodology: A secondary analysis of the Nationwide Readmission Database for years 2016-2017 was performed. Patients who were admitted with a primary diagnosis of acute pericarditis in the first six months of each year were identified based on International Classification of Diseases (ICD-10), Clinical Modification codes, and were followed for 180 days. A multivariate cox-regression model was utilized to delineate the predictors of pericarditis related readmissions. Results: A total of 21,115 patients were admitted with a primary diagnosis of acute pericarditis. The mean age was 53.3+19 years and 60.83% were males. About 23% of patients had pericardial effusion or tamponade and 19.4% of patients presenting with pericarditis required pericardiocentesis. The mortality rate during index admission was 3.21% and the mean length of stay was 6.4+9 days. The rate of all-cause readmission was 30.8% within 180 days, of which 23.8% were pericarditis related. The mean time to readmission for pericarditis was 37.7+41 days. Females were at higher risk of readmission for pericarditis [OR 1.66, CI (1.38-1.99), p Conclusion: Even though the mortality during index admission in patients admitted with pericarditis is low, about 1 in every 3 patients will be readmitted within 180 days. While females account for a minority of initial admissions for pericarditis, their risk of readmission is significantly higher.

Introduction: Extracorporeal membrane oxygenation (ECMO) is being increasingly used for acute support in patients with cardiogenic shock (CS). Data regarding the indications, outcomes, and readmissions in these patients from a nationally representative sample is lacking. Methods: A secondary analysis of the Nationwide Readmission Database for years 2016-2017 was performed. Patients who were admitted with a primary diagnosis of CS were identified using ICD-10, Clinical Modification codes and were sub-grouped into those with acute coronary syndrome (ACS) and without ACS (non-ACS). Any readmission within 30 days of discharge was considered for analysis. Results: A total of 6,126 patients with CS received ECMO support, among which 35% had concurrent acute coronary syndrome (ACS). Patients on ECMO who had ACS were significantly older (60.5±11 vs 45.1±11 years, p Conclusions: Only 1 in every 2 patients with CS on ECMO survives to discharge. Survival to discharge in these patients differs significantly according to the presence or absence of ACS. Among the patients who survive to discharge, 18% of patients are readmitted within 30 days.

Background Left ventricular assist devices (LVAD) have been increasingly used in the treatment of end-stage heart failure. While warfarin has been uniformly recommended in the long-term as anticoagulation strategy, no clear recommendation exists for the post-operative period. We sought to evaluate the feasibility of enoxaparin in the immediate and early postoperative period after LVAD implantation. Methods This is a two-center, retrospective analysis of 250 consecutive patients undergoing LVAD implantation between January 2017 and December 2018. Patients were bridged postoperatively to therapeutic INR by either receiving unfractionated heparin (UFH) or low molecular weight heparin (LMWH). Patients were followed while inpatient and for 3 months after LVAD implantation. The efficacy outcome was occurrence of first and subsequent cerebrovascular accident while safety outcome was the occurrence of bleeding events. Length of stay (LOS) was also assessed. Results Two hundred fifty and 246 patients were analyzed for index admission and 3-month follow up respectively. No statistically significant differences were found between the two groups in CVA (OR = 0.67; CI = 0.07–6.39, P = 0.73) or bleeding events (OR = 0.91; CI = 0.27–3.04, P = 0.88) during index admission. Similarly, there were no differences at 3 months in either CVAs or bleeding events (OR = 0.85; 0.31–2.34; p = 0.76). No fatal events occurred during the study follow-up period. Median LOS was significantly lower (4 days; p = 0.03) in the LMWH group. Conclusions LMWH in the immediate and early postoperative period after LVAD implantation appears to be a concurrently safe and efficacious option allowing earlier postoperative discharge and avoidance of recurrent hospitalizations due to sub-therapeutic INR.

Papillary muscle rupture (PMR) or chordae tendinae rupture (CTR) is a rare but lethal complication after ST elevation myocardial infarction (STEMI). Due to the rarity of this condition, there are limited studies defining its epidemiology and outcomes. This is a retrospective study from Nationwide Inpatient Sample database from 2002 to 2014 of patients with STEMI and PMR/CTR. Outcomes of interest were incidence of in-hospital mortality, cardiogenic shock (CS), utilization of mechanical circulatory support (MCS) devices and mitral valve procedures (MVPs) among patients with and without rupture. We also performed simulation using the cardiovascular model to better understand the hemodynamics of severe mitral regurgitation and effects of different medications and device therapy. We identified 1,888 patients with STEMI complicated with PMR/CTR. Most of the patients were >65 years of age (65.3%), male (63.6%), and white (82.3%). They had significantly higher incidence of CS, cardiac arrest, and utilization of MCS devices. In-hospital mortality was higher in patients with rupture (41% vs. 7.40%, p < 0.001) which remained unchanged over the study period. Hospitalization cost and length of stay was also higher in them. MVP and revascularization led to better survival rates (27.9% vs. 60.6%, adjusted OR: 0.14; 95% CI: 0.10-0.19; p < 0.001). Despite significant advancement in the revascularization strategy, PMR/CTR after STEMI continues to portend poor prognosis with high inpatient mortality. Cardiogenic shock is a common presentation and is associated with significantly inpatient mortality. Future studies are needed determine the best strategies to improve outcomes in patients with STEMI with PMR/CTR and CS.

Background: Hypertensive emergency (HTNE) diagnostic code was introduced, in the US, in October 2016 to improve identification of patients with end-organ damage due to high blood pressure but its impact is unclear. Objective: To assess the accuracy of HTNE code using administrative data. Methods: We used National Inpatient Sample 2017 to identify adult patients, age ≥18 years, with International Classification of Disease-10th Clinical modification (ICD-10-CM) code of I16.1. We used the presence of end-organ damage diagnostic codes to identify true HTNE. Results: A total of 194,495 patients had a diagnosis of HTNE. Of these only 144,070 (74.1%) had a concomitant diagnosis of end-organ damage. Baseline characteristics of entire cohort stratified by presence of target organ damage (Table 1A) and frequency of end-organ damage in true HTNE patients (Table 1B) are shown. Patients with true HTNE were likely to be older and male with higher co-morbidity burden. There was also significant difference in outcomes between two groups with a higher proportion of true HTNE patients experiencing longer length of stay and increased mortality which is in-line with previous studies. Conclusions: The accuracy of hypertensive emergency diagnosis code is low with positive predictive value of 74.1% and caution is advised when using with administrative data. Further studies, using individual patient discharge records, are required to validate HTNE code.

INTRODUCTION Ultrasound guided axillary vein access (UGAVA) is an emerging approach for cardiac implantable electronic device (CIED) implantation not widely utilized. METHODS AND RESULTS This is a retrospective, age and sex-matched cohort study of CIED implantation from January 2017 to July 2019 comparing UGAVA before incision to venous access obtained after incision without ultrasound (conventional). The study population included 561 patients (187 with attempted UGAVA, 68 ± 13 years old, 43% women, body mass index (BMI) 30 ± 8 kg/m2 , 15% right-sided, 43% implantable cardioverter-defibrillator, 15% upgrades). UGAVA was successful in 178/187 patients (95%). In nine patients where UGAVA was abandoned, the vein was too deep for access before incision. BMI was higher in abandoned patients than successful UGAVA (38 ± 6 vs. 28 ± 6 kg/m2 , p

Background Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI). Objective We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI. Methods We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation. Results Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs. Conclusions Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.

Background: Prior studies have shown that WATCHMAN device can be an alternative for anticoagulation in atrial fibrillation (AF) patients for stroke reduction. Its impact on healthcare utilization in AF population remains unknown. Methods: We queried the 2016-2017 National Readmission Database for all adult AF patients undergoing WATCHMAN procedure using ICD10 codes. All patients discharged alive from February to November were included (N = 13192), and their bleeding/thrombosis related admissions pre- and post-index procedure were recorded. Hierarchical longitudinal negative binomial regression was done to calculate incidence rate ratios (IRR) of admissions pre- and post-procedure with patient and hospital as level 2 and 3 variables, respectively. Person-time was included as an offset variable to account for variation in pre and post-procedure time contribution by each patient. A second model was created that included a blanking period of 2 months post-procedure to account for continued anticoagulation after the procedure. For this analysis, patients who received the procedure in October and November (N = 3265) and also patients who died within 2 months of the procedure (N = 49) were excluded. Results: For 13192 patients, the mean age was 77 years and 39% were female. Overall, we found a decrease of ~23% in all-cause readmissions after the procedure (IRR = 0.77; 95% CI = 0.74-0.81; p Conclusions: AF patients undergoing WATCHMAN procedure have a significantly lower readmission rate, especially for thromboembolic/bleeding related readmissions. Thus, there is a trend towards decrease in healthcare utilization post-procedurally. Further studies are needed to confirm and evaluate the reasons for these findings.

Coronavirus disease 2019 (COVID-19) predominantly presents with symptoms of fever, fatigue, cough and respiratory failure. However, it appears to have a unique interplay with cardiovascular disease (CVD); patients with pre-existing CVD are at highest risk for mortality from COVID-19, along with the elderly. COVID-19 contributes to cardiovascular complications including arrhythmias, myocardial dysfunction and myocardial inflammation. Although the exact mechanism of myocardial inflammation in patients with COVID-19 is not known, several plausible mechanisms have been proposed based on early observational reports. In this article, the authors summarise the available literature on mechanisms of myocardial injury in COVID-19.

Programmed cell death ligand 1 (PD-L1) is part of an immune checkpoint system that is essential for preventing autoimmunity and cancer. Recent approaches in immunotherapy that target immune checkpoints have shown great promise in a variety of cancers, including metastatic melanoma. The use of targeted molecular imaging would help identify patients who will best respond to anti-PD-L1 treatment while potentially providing key information to limit immune-related adverse effects. Recently, we developed an antibody-based PD-L1–targeted SPECT agent—111In-diethylenetriaminepentaacetic acid (DTPA)-anti-PD-L1—to identify PD-L1–positive tumors in vivo. To best use such PD-L1–targeted imaging agents, it is important, as a first step, to understand how the signal is affected by different parameters. Methods: We evaluated the impact of protein concentration on the distribution of 111In-DTPA-anti-PD-L1 in a murine model of aggressive melanoma. Results: 111In-DTPA-anti-PD-L1 (dissociation constant, 0.6 ± 0.1 nM) demonstrated increased uptake in B16F10 tumors at protein concentrations equaling or exceeding 1 mg/kg at 24 h and 3 mg/kg at 72 h. At 24 h, the PD-L1–rich spleen and lungs demonstrated decreasing uptake with increasing protein concentration. At 72 h, uptake in the thymus was significantly increased at protein concentrations of 3 mg/kg or greater. Both time points demonstrated increased tracer amounts remaining in circulation as the amount of cold antibody was increased. Conclusion: These studies demonstrate that 111In-DTPA-anti-PD-L1 is capable of identifying tumors that overexpresses PD-L1 and monitoring the impact of PD-L1–rich organs on the distribution of anti-PD-L1 antibodies.

Chronic thromboembolic pulmonary hypertension (CTEPH) is rare but complex pathophysiological disease with hallmark features of chronic thrombotic mechanical obstruction, right ventricular dysfunction, and secondary pulmonary arteriopathy. It increasingly is being understood that chronic infection/inflammation, abnormal fibrinolysis, and cytokines play an important role in pathogenesis such that only a subset of patients with pulmonary embolism develop CTEPH. Diagnosis remains challenging given the lack of early clinical signs and overlap with other cardiopulmonary conditions. Pulmonary endarterectomy is the surgical procedure of choice with good postoperative survival and functional outcomes, especially when done at high-volume centers with a multidisciplinary approach. There has been a resurgence of balloon pulmonary angioplasty (BPA) as salvage therapy for inoperable CTEPH or in its newfound hybrid role for persistent postoperative pulmonary hypertension with excellent 1-year and 3-year survival. Use of riociguat has shown promising improvements in functional outcomes up to 2 years after initiation. Endothelin receptor antagonists serve a supplemental role postoperatively or in inoperable CTEPH. The role of drug therapy preoperatively or in tandem with BPA is currently under investigation.

Background Benefits of temporary mechanical circulatory support has not been demonstrated successfully in clinical trials despite their increased widespread use in the real-world management of patients with cardiogenic shock (CS). Methods Using the Nationwide Readmissions Database from Jan 2016 to Nov 2017, we identified all patients admitted with CS requiring either only intra-aortic balloon pump (IABP) or Impella device implantation (IM) with 30-day follow up. Patients with combined devices or undergoing medical management only were excluded. Propensity matched (1:1) was performed based on demographics and comorbidities to compare the survival, complications, and use of advanced heart failure therapies. Results Out of a total of 236156 patients, 32850(13.9%) had IABP and 8389(3.5%; unweighted n= 4504) patients had IM implantation. Well-matched 4411-pairs of matched IABP vs IM patients had mean similar age (65 vs 64.9 years), women (29.2% vs 28.6%), and acute myocardial infarction (75.7% vs 75.8%). In terms of therapy, no differences in use of right heart catheterization/pulmonary catheter placement or vasopressor use(p>0.05 for all). IM group had higher mortality (45.8% vs. 28.6%, p Conclusion Significant number of CS patients undergo IM implantations with widely different survival as well as candidacy for a heart transplant. The underlying patient- and physician-related differences need to further be explored prior to widespread use of this powerful technology.

Background: The usefulness of the Right Heart Catherization/Pulmonary Artery Catheterization (RHC/PAC) has been long debated. Previous evidence has shown the lack of additive benefit of RHC/PAC use in various clinical settings. However, current evidence of RHC/PAC utility in the setting of cardiogenic shock (CS) is scarce. Methods: In the Nationwide Readmissions Database (NRD) using International Classification of Diseases, Tenth revision we identified 269,475 patient hospitalizations with cardiogenic shock between 2016-2017. We sought to evaluate the impact of RHC/PAC on in-hospital and readmission outcomes. Results: Approximately 25,840 patients received a RHC/PAC on index admission. The RHC/PAC group had significantly more comorbidities and higher AKI rates (73% vs 60.4%; p

Myocarditis may be associated with hemodynamic instability and portends a poor prognosis when associated with cardiogenic shock (CS). There are limited data available on the incidence of in-hospital mortality, CS, and utilization of mechanical circulatory support (MCS) devices in these patients.We queried the 2005-2014 National Inpatient Sample databases to identify all patients aged18 years with myocarditis in the United States.The number of reported cases of myocarditis per 1 million gradually increased from 95 in 2005 to 144 in 2014 (Pfor trend.01). The trend and incidence of endomyocardial biopsy remained the same despite the increase in clinical diagnosis. Overall, in-hospital mortality was 4.43% of total admissions without a change in overall trend over the study period. We also observed a significant increase in the incidence of CS from 6.94% in 2005 to 11.99% in 2014 (Pfor trend.01). There was a parallel increase in the utilization of advanced MCS devices during the same time period such as extracorporeal membrane oxygenation or percutaneous cardiopulmonary support (0.32% in 2005 to 2.1% in 2014; P.01) and percutaneous ventricular assist devices such as Impella/tandem heart (0.176% in 2005 to 1.75% in 2014; P.01).Although the incidence of myocarditis has increased in the last decade, the in-hospital mortality has remained the same despite increases in the incidence of CS, possibly reflecting the benefits of increased usage of advanced MCS devices. We noted that increasing age, presence of multiple comorbidities and CS were associated with an increase in in-patient mortality.

Drug-induced liver injury (DILI) is the most common cause of early termination of clinical drug trials, and it accounts for more than 33% of cases of acute liver failure in clinical practice. DILI can occur through dose-dependent mechanisms, although the majority of cases (>90%) are dose-independent (i.e., idiosyncratic reactions). Important risk factors for the development of DILI are elderly age, polypharmacy, preexisting liver damage, and genetic predisposition. It is very difficult to identify objectively the offending drug as a cause of liver damage; thus current practice commonly relies on expert consensus to identify the offending agent. The most common presentation of the liver damage is an asymptomatic rise in liver enzymes without overt signs of liver failure, although occasional patients may have symptomatic jaundice with subsequent signs of liver failure. Commonly used health and dietary supplements have become the second most common cause of DILI. Classification of DILI into three categories—cholestatic, hepatocellular, or mixed patterns—based on the ratio of serum alanine aminotransferase to alkaline phosphatase levels (called the R ratio) helps narrow the causative agent of liver damage. The management of DILI is dependent on the severity of liver damage and based principally upon early discontinuation of the inciting agent along with supportive care. Transplant-free survival is poor (approximately 40%) in patients who develop acute liver failure. Specific cases may benefit from the use of antidotes if applicable. The most well-known antidote is N-acetylcysteine for acetaminophen toxicity, which accounts for a large number of cases of DILI. Recent studies have proven its usefulness even in cases of nonacetaminophen–associated cases of DILI.

Left atrial appendage occlusion device implantation (LAOD) is an option to prevent stroke in patients with atrial fibrillation (AF). Though sex and race have implications on stroke risk in AF patients, this is not well studied in patients undergoing LAOD. We studied the sex and racial differences in