Evolution and Outcomes of Premature Coronary Artery Disease.

PURPOSE OF REVIEW: The purpose of this review is to explore the evolution and outcomes of premature coronary artery disease (PCAD) while reviewing strategies for effective screening of those at high risk for developing this disease. RECENT FINDINGS: Premature coronary artery disease (PCAD) affects a population of patients not typically identified as high risk by current risk stratification guidelines or traditional risk calculation tools. Not only does PCAD represent a large proportion of overall cardiovascular disease, it also afflicts a population in which the rate of mortality from cardiovascular disease has plateaued despite an overall declining population-wide cardiovascular mortality rate. There is ample opportunity for behavioral change strategies, screening tools, adapted imaging modalities, and precision pharmacotherapies to be more precisely targeted toward those at highest risk for premature coronary artery disease. Premature coronary artery disease (PCAD) is pervasive and not frequently represented within contemporary risk calculation models. Providers should pursue proactive screening and aggressive risk factor modification and deploy appropriate preventative therapies in caring for younger populations.

Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine. Objective: To evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic. Design, Setting, and Participants: In this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record. Main Outcomes and Measures: A successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically. Results: A total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties. Conclusions and Relevance: In this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.

The effect of transfusion of blood products on ventricular assist device support outcomes.

AIMS: Perioperative blood transfusions are common among patients undergoing left ventricular assist device (LVAD) implantation. The association between blood product transfusion at the time of LVAD implantation and mortality has not been described. METHODS AND RESULTS: This was a retrospective cohort study of all patients who underwent continuous flow LVAD implantation at a single, large, tertiary care, academic centre, from 2008 to 2014. We assessed used of packed red blood cells (pRBCs), platelets, and fresh frozen plasma (FFP). Outcomes of interest included all-cause mortality and acute right ventricular (RV) failure. Standard regression techniques were used to examine the association between blood product exposure and outcomes of interest. A total of 170 patients were included in this study (mean age: 56.5 ± 15.5 years, 79.4% men). Over a median follow-up period of 11.2 months, for every unit of pRBC transfused, the hazard for mortality increased by 4% [hazard ratio (HR) 1.04; 95% CI 1.02-1.07] and odds for acute RV failure increased by 10% (odds ratio 1.10; 95% CI 1.05-1.16). This association persisted for other blood products including platelets (HR for mortality per unit 1.20; 95% CI 1.08-1.32) and FFP (HR for mortality per unit 1.08; 95% CI 1.04-1.12). The most significant predictor of perioperative blood product exposure was a lower pre-implant haemoglobin. CONCLUSIONS: Perioperative blood transfusions among patients undergoing LVAD implantation were associated with a higher risk for all-cause mortality and acute RV failure. Of all blood products, FFP use was associated with worst outcomes. Future studies are needed to evaluate whether pre-implant interventions, such as intravenous iron supplementation, will improve the outcomes of LVAD candidates by decreasing need for transfusions.

Management of Acute Pulmonary Embolism.

PURPOSE OF THE REVIEW: Over 100,000 cardiovascular-related deaths annually are caused by acute pulmonary embolism (PE). While anticoagulation has historically been the foundation for treatment of PE, this review highlights the recent rapid expansion in the interventional strategies for this condition. RECENT FINDINGS: At the time of diagnosis, appropriate risk stratification helps to accurately identify patients who may be candidates for advanced therapeutic interventions. While systemic thrombolytics (ST) is the mostly commonly utilized intervention for high-risk PE, the risk profile of ST for intermediate-risk PE limits its use. Assessment of an individualized patient risk profile, often via a multidisciplinary pulmonary response team (PERT) model, there are various interventional strategies to consider for PE management. Novel therapeutic options include catheter-directed thrombolysis, catheter-based embolectomy, or mechanical circulatory support for certain high-risk PE patients. Current data has established safety and efficacy for catheter-based treatment of PE based on surrogate outcome measures. However, there is limited long-term data or prospective comparisons between treatment modalities and ST. While PE diagnosis has improved with modern cross-sectional imaging, there is interest in improved diagnostic models for PE that incorporate artificial intelligence and machine learning techniques. SUMMARY: In patients with acute pulmonary embolism, after appropriate risk stratification, some intermediate and high-risk patients should be considered for interventional-based treatment for PE.

The Lotus Valve System: an In-depth Review of the Technology.

PURPOSE OF REVIEW: Innovation for transcatheter aortic valve replacement (TAVR) has transformed a medically complex treatment into a standardized procedure. While Edwards SAPIEN and Medtronic CoreValve occupy the market for TAVR in the United States (US), additional valve systems are being developed. The Boston Scientific Lotus Valve system was recently FDA-approved and will represent the third valve in the US market. This evidence-based review will summarize advantages, disadvantages, and projected impact of this new TAVR system. RECENT FINDINGS: The Lotus Valve system demonstrates superiority in terms of rates of paravalvular leak, with similar rates of mortality and disabling stroke. This benefit is at the expense of increased pacemaker implantation rates, though preliminary data from subsequent iterations of the Lotus Valve suggest decreasing rates over time. There is much anticipation from ongoing trials utilizing the Lotus Edge system, which may perform best for those with pre-existing pacemakers or anatomy that increases likelihood of paravalvular leak.

Trends in Platelet Adenosine Diphosphate P2Y12 Receptor Inhibitor Use and Adherence Among Antiplatelet-Naive Patients After Percutaneous Coronary Intervention, 2008-2016.

Importance: Current guidelines recommend prasugrel hydrochloride and ticagrelor hydrochloride as preferred therapies for patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). However, it is not well known how frequently these newer agents are being used in clinical practice or how adherence varies among the platelet adenosine diphosphate P2Y12 receptor (P2Y12) inhibitors. Objectives: To determine trends in use of the different P2Y12 inhibitors in patients who underwent PCI from 2008 to 2016 in a large cohort of commercially insured patients and differences in patient adherence and costs among the P2Y12 inhibitors. Design, Setting, and Participants: A retrospective cohort study used administrative claims from a large US national insurer (ie, UnitedHealthcare) from January 1, 2008, to December 1, 2016, comprising patients aged 18 to 64 years hospitalized for PCI who had not received a P2Y12 inhibitor for 90 days preceding PCI. The P2Y12 inhibitor filled within 30 days of discharge was identified from pharmacy claims. Main Outcomes and Measures: Proportion of patients filling prescriptions for P2Y12 inhibitors within 30 days of discharge by year, as well as medication possession ratios (MPRs) and total P2Y12 inhibitor copayments at 6 and 12 months for patients who received drug-eluting stents. Results: A total of 55 340 patients (12 754 [23.0%] women; mean [SD] age, 54.4 [7.1] years) who underwent PCI were included in this study. In 2008, 7667 (93.6%) patients filled a prescription for clopidogrel bisulfate and 521 (6.4%) filled no P2Y12 inhibitor prescription within 30 days of hospitalization. In 2016, 2406 (44.0%) patients filled clopidogrel prescriptions, 2015 (36.9%) filled either prasugrel or ticagrelor prescriptions, and 1045 (19.1%) patients filled no P2Y12 inhibitor prescription within 30 days of hospitalization. At 6 months, mean MPRs for patients who received a drug-eluting stent filling clopidogrel, prasugrel, and ticagrelor prescriptions were 0.85 (interquartile range [IQR], 0.82-1.00), 0.79 (IQR, 0.66-1.00), and 0.76 (IQR, 0.66-0.98) (P < .001), respectively; mean copayments for a 6 months' supply were $132 (IQR, $47-$203), $287 (IQR, $152-$389), and $265 (IQR, $53-$387) (P < .001), respectively. At 12 months, mean MPRs for clopidogrel, prasugrel, and ticagrelor were 0.76 (IQR, 0.58-0.99), 0.71 (IQR, 0.49-0.98), and 0.68 (IQR, 0.41-0.94) (P < .001), respectively; mean total copayments were $251 (IQR, $100-$371), $556 (IQR, $348-$730), and $557 (IQR, $233-$744) (P < .001), respectively. Conclusions and Relevance: Between 2008 and 2016, increased use of prasugrel and ticagrelor was accompanied by increased nonfilling of prescriptions for P2Y12 inhibitors within 30 days of discharge. Prasugrel and ticagrelor had higher patient costs and lower adherence in the year following PCI compared with clopidogrel. The introduction of newer, more expensive P2Y12 inhibitors was associated with lower adherence to these therapies.

Predicting Long Term Outcome in Patients Treated With Continuous Flow Left Ventricular Assist Device: The Penn-Columbia Risk Score.

BACKGROUND: Predicting which patients are unlikely to benefit from continuous flow left ventricular assist device (LVAD) treatment is crucial for the identification of appropriate patients. Previously developed scoring systems are limited to past eras of device or restricted to specific devices. Our objective was to create a risk model for patients treated with continuous flow LVAD based on the preimplant variables. METHODS AND RESULTS: We performed a retrospective analysis of all patients implanted with a continuous flow LVAD between 2006 and 2014 at the University of Pennsylvania and included a total of 210 patients (male 78%; mean age, 56±15; mean follow-up, 465±486 days). From all plausible preoperative covariates, we performed univariate Cox regression analysis for covariates affecting the odds of 1-year survival following implantation (P<0.2). These variables were included in a multivariable model and dropped if significance rose above P=0.2. From this base model, we performed step-wise forward and backward selection for other covariates that improved power by minimizing Akaike Information Criteria while maximizing the Harrell Concordance Index. We then used Kaplan-Meier curves, the log-rank test, and Cox proportional hazard models to assess internal validity of the scoring system and its ability to stratify survival. A final optimized model was identified based on clinical and echocardiographic parameters preceding LVAD implantation. One-year mortality was significantly higher in patients with higher risk scores (hazard ratio, 1.38; P=0.004). This hazard ratio represents the multiplied risk of death for every increase of 1 point in the risk score. The risk score was validated in a separate patient cohort of 260 patients at Columbia University, which confirmed the prognostic utility of this risk score (P=0.0237). CONCLUSION: We present a novel risk score and its validation for prediction of long-term survival in patients with current types of continuous flow LVAD support.

In-hospital mortality and morbidity after robotic coronary artery surgery.

OBJECTIVES: The objective of this study was to assess the impact of robotic approaches on outcomes of coronary bypass surgery. DESIGN: Retrospective national database analysis. SETTING: United States hospitals. PARTICIPANTS: A weighted sample of 484,128 patients undergoing isolated coronary artery surgery identified from the Nationwide Inpatient Sample from 2008 through 2010. INTERVENTIONS: Robotically assisted coronary artery bypass surgery versus conventional bypass surgery. MEASUREMENTS AND MAIN RESULTS: Robotic approaches were used in 2,582 patients (0.4%). Patients undergoing robotic surgery were less likely to be female (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.57-0.87), present with acute myocardial infarction (OR 0.53, 95% CI 0.38-0.73), or have cerebrovascular disease (OR 0.41, 95% CI 0.23-0.71) compared to patients undergoing conventional surgery. In 59% of robotic cases, a single bypass was performed, and 2 bypasses were performed in 25% of cases. After adjusting for comorbidity, reduced postoperative stroke (0.0% v 1.5%, p = 0.045) and transfusion (13.5% v 24.4%, p = 0.001) rates were observed in patients who underwent robotic single-bypass surgery compared to conventional surgery. In patients undergoing multiple bypass grafts, higher mortality (1.1% v 0.5%), and cardiovascular complications (12.2% v 10.6%) were observed when robotic assistance was used, but the differences were not statistically significant (p = 0.5). The mean number of robotic cases carried out annually at institutions sampled was 6. CONCLUSIONS: Robotic assistance is associated with lower rates of postoperative complications in highly selected patients undergoing single coronary artery bypass surgery, but the benefits of this approach are reduced in patients who require multiple coronary artery bypass grafts.

Operative mortality and stroke after on-pump vs off-pump surgery in high-risk patients: an analysis of 83,914 coronary bypass operations.

OBJECTIVES: The objective of this study was to compare the early outcomes of off-pump and on-pump surgeries in high-risk patient groups. METHODS: The outcomes of 83,914 high-risk patients undergoing off-pump or on-pump isolated coronary bypass surgery identified from the Nationwide Inpatient Sample from 2005 to 2010 were compared using propensity analysis. RESULTS: Off-pump surgery was associated with a significant reduction in stroke rates compared with on-pump surgery in propensity-matched patients ≥ 80 years (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.52-0.93, P = 0.02), those with peripheral vascular disease (OR 0.53, 95% CI 0.36-0.77, P = 0.001) and those with aortic atherosclerosis (OR 0.30, 95% CI 0.13-0.72, P = 0.007). In these high-risk subgroups, off-pump surgery was associated with an absolute risk reduction in stroke rates of 0.5, 0.5 and 1.2%, respectively: the minimum number needed to treat to prevent one stroke is 200 patients. There was no significant difference in in-hospital mortality or the incidence of postoperative renal failure or respiratory failure between off-pump and on-pump surgeries in these patient subgroups, or in patients with preoperative renal failure, or chronic obstructive airways disease. CONCLUSIONS: High-risk patients undergoing coronary artery bypass surgery gain a short-term benefit from off-pump approaches due to a small absolute reduction in the risk of postoperative stroke.

Incidence and outcomes of heparin-induced thrombocytopenia in patients undergoing cardiac surgery in North America: an analysis of the nationwide inpatient sample.

OBJECTIVES: The objective of this study was to quantify the impact of heparin-induced thrombocytopenia (HIT) on outcomes after cardiac surgery. DESIGN: Retrospective analysis of national database. SETTING: United States hospitals. PARTICIPANTS: Patients identified from 186,771 discharge records undergoing cardiac surgery from the Nationwide Inpatient Sample between 2009 and 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Heparin-induced thrombocytopenia was diagnosed in 506 (0.3%), and secondary thrombocytopenia was diagnosed in 16,809 (8.7%). Operative mortality was 11.1% in patients with HIT compared to 4.5% for patients without thrombocytopenia (p<0.001) and 4.0% for patients with a diagnosis of secondary thrombocytopenia (p<0.001). After adjusting for baseline patient comorbidity, the strongest independent predictors of HIT in patients undergoing cardiac surgery were female gender (OR 1.4, 95% confidence interval [CI] 1.28-1.48), congestive heart failure (OR 1.8, 95% CI 1.71-1.98), cardiac insufficiency (OR 2.2, 95% CI 1.97-2.39), atrial fibrillation (OR 1.4, 95% CI 1.30-1.51), liver disease (OR 2.2, 95% CI 1.96-2.50), and chronic renal failure (OR 1.4, 95% CI 1.30-1.51). HIT was associated with significantly increased risk of major adverse postoperative outcomes including death (OR 1.5, 95% CI 1.3-1.7), stroke (OR 2.4, 95% CI 1.9-3.1), amputation (OR 7.46, 95% CI 4.0-14.0), and acute renal failure (OR 2.3, 95% CI 2.1-2.5), respiratory failure (OR 1.9, 95% CI 1.8-2.1), and need for tracheostomy (OR 2.7, 95% CI 2.3-3.1). CONCLUSIONS: Heparin-induced thrombocytopenia is associated with a 50% increase in early mortality, and most patients with this diagnosis experience major postoperative morbidity or functional deficits.

National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality.

BACKGROUND: Despite clinical and technical advances, acute aortic dissection carries high operative mortality. This study was designed to establish whether this is influenced by institution and surgeon volume. METHODS: Outcomes of 5,184 patients (mean age, 60.3 years; 65.9% male) diagnosed with acute aortic dissection from the Nationwide Inpatient Sample from 2003 to 2008 were analyzed with risk-adjustment for preoperative comorbidity using multivariate logistic regression analysis. RESULTS: Overall operative mortality was 21.6%, with similar preoperative patient risk profile across institutions and individual surgeons. A strong inverse relationship was observed between operative mortality and both institution and surgeon volume: surgeons who averaged less than 1 aortic dissection repair annually had a mean operative mortality of 27.5%, compared with 17.0% for those averaging 5 or more annually (odds ratio, 1.78; 95% confidence interval, 1.39 to 2.29; p < 0.001). This was similar to the relationship seen between institution volume and mortality: operative mortality was 27.4% in institutions performing 3 or fewer acute aortic dissections a year, compared with 16.4% in those performing more than 13 annually (p < 0.001). Nationally, operative mortality decreased steadily from 23% in 1998-2000 to 19% in 2005-2008, with no significant decrease in patient risk profile. CONCLUSIONS: Patients undergoing emergency repair of acute aortic dissection by lower-volume surgeons and centers have approximately double the risk-adjusted mortality of patients undergoing repair by the highest volume care providers. Routine involvement, whenever feasible, of teams experienced in acute aortic dissection repair may be a strategy to reduce operative mortality and major morbidity.

Incidence and risk factors for the development of anemia following gastric bypass surgery.

AIM: To evaluate the incidence and risk factors for the development of anemia after Roux-en-Y gastric bypass (RYGB). METHODS: A retrospective analysis of patients undergoing RYGB from January 2003 to November 2007 was performed. All patients had a preoperative body mass index > 40 kg/m(2). A total of 206 patients were evaluated. All patients were given daily supplements of ferrous sulfate tablets for 2 wk following their operation. Hematological and metabolic indices were routinely evaluated following surgery. Patients were followed for a minimum of 86 wk. RESULTS: There were 41 males and 165 females with an average age of 40.8 years. 21 patients (10.2%) developed post-operative anemia and 185 patients (89.8%) did not. Anemia was due to iron deficiency in all cases. The groups had similar demographics, surgical procedure and co-morbidities. Menstruation (P = 0.02) and peptic ulcer disease (P = 0.01) were risk factors for the development of post-operative anemia. CONCLUSION: Iron deficiency anemia is frequent. RYGB surgery compounds occult blood loss. Increased ferrous sulfate supplementation may prevent iron depletion in populations at increased risk.

Can interval appendectomy be justified following conservative treatment of perforated acute appendicitis?

BACKGROUND: There continues to be controversy about the necessity of interval appendectomy for delayed presentation of acute appendicitis. While recent studies suggest that the risk of recurrent disease is small, the risk of interval appendectomy is also small and does provide histologic identification and usually definitive treatment of the right lower quadrant inflammatory process. METHODS: A retrospective analysis of medical records gathered from 2002 to 2007 at a major teaching hospital of 986 adult patients over the age of 13 with appendicitis were analyzed. Forty-six patients (5%) were found to have right lower quadrant abscess or phlegmon, and were managed with intravenous antibiotics. Some patients also underwent percutaneous drainage. These patients were then readmitted 6 to 26 wk later for an elective laparoscopic interval appendectomy. RESULTS: There were 19 males and 27 females with an average age of 43 y. Ninety-four percent of the appendectomies were completed laparoscopically; 16% of patients were found to have a normal or obliterated appendix on pathologic evaluation and likely did not benefit from interval appendectomy. On the other hand, 84% of patients had persistent acute appendicitis, chronic appendicitis, evidence of inflammatory bowel disease, or neoplasm identified, and likely benefited from surgical appendectomy. CONCLUSIONS: Interval appendectomy provides diagnostic and therapeutic benefit to patients who present with a right lower quadrant abdominal inflammatory focus, and should be carefully considered in all adult patients.