Evaluation of Right-Side Filling Pressure in Patients With Obesity With Heart Failure Using Handheld Ultrasound Score.

The goal of this investigation is to evaluate the accuracy of handheld ultrasound score in assessing right atrial (RA) pressure in patients with obesity with heart failure. We prospectively studied 123 patients with heart failure referred for right-sided cardiac catheterization. Handheld ultrasound was performed before catheterization to evaluate volume status by estimating RA pressure using end-expiratory inferior vena cava (IVC) dimension, IVC respiratory collapsibility, and right internal jugular (RIJ) vein respiratory collapsibility. A 3-point simple score was created using multiple logistic regression. The patients were divided into 2 groups based on body mass index. The performance of this score was assessed using the receiver operating characteristics curve in each subgroup and was compared with the performance of the 2-point score (expiratory IVC dimension, IVC respiratory collapsibility). Median age was 58 years (interquartile range 48 to 65), and 37% were women. The 3-point score including RIJ performed better than did the 2-point score in patients with obesity (area under the curve 0.84 [0.74 to 0.95] vs 0.69 [0.58 to 0.81], p = 0.001). The performance of the scores did not differ in patients without obesity (area under the curve 0.85 [0.74 to 0.95] vs 0.82 [0.71 to 0.93], p = 0.49). In patients with obesity, the 3-point score had a specificity of 100% and sensitivity of 21% (11% to 31%) for elevated RA pressure ≥10 mm Hg. In conclusion, a 3-point score including both RIJ and IVC assessment performed better in patients with obesity with heart failure and highlights the importance of comprehensive evaluation in patients with obesity to achieve an accurate, noninvasive assessment of volume status.

Healthcare and economic burden of heart failure with amyloidosis: An insight from National Readmission Database.

INTRODUCTION: We analyzed trends, causes and predictors of 30-days readmission in cardiac amyloidosis and inspected the impact of these readmissions on mortality, morbidity, and utilization of healthcare resources. METHODS: Heart Failure with cardiac amyloidosis patients were selected from National readmission Database (NRD) using ICD-10 CM codes. Patients younger than 18 years, elective readmissions, readmissions due to trauma, patients with missing data and December 2018 admissions were excluded. Primary outcome was all-cause 30-day readmissions rate, secondary outcomes were factors associated with 30-days readmissions and their effect on morbidity, mortality, and healthcare resource utilization. RESULTS: Out of 4123 total heart failure with cardiac amyloidosis index admissions in 2018, 3374 patients were included in final analysis. 19.6% were readmitted within 30 days. Readmitted patients were younger, sicker, admitted to small or large hospital. Hypertensive heart and Chronic Kidney Disease (CKD Stage I-IV) with Congestive Heart Failure (CHF), hypertensive heart and CKD (Stage V) or End Stage Renal Disease (ESRD) with CHF, hypertensive heart disease with CHF, acute kidney failure, and sepsis were the most common causes of readmissions. Young age, admission to small and large size hospitals were independent predictors of 30-day readmissions. Readmissions had higher mortality, costed 6.6 extra in hospital days to patients and $16380 per admission to healthcare system. CONCLUSIONS: Cardiac amyloidosis readmissions were associated with increased morbidity and mortality of patients and extra burden on the healthcare system. There is a need to identify patients at risk for readmissions to improve patient outcomes and decrease healthcare cost.

Insight on the Etiologies of Chronically Elevated Troponin.

Elevated troponins signify myocardial damage and raise concern for acute coronary syndrome (ACS). However, there are medical conditions that may cause a patient to have chronically elevated troponin levels in the absence of ACS. In our extensive review, we look at the conditions and their mechanisms that cause chronically elevated troponin levels and discuss them comprehensively. We also aim for our review to serve as a guide for physicians evaluating this complex group of patients.

In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Heart failure patients.

In-hospital outcomes of chronic total occlusion Percutaneous Coronary Interventions (CTO PCI) in heart failure patients has not been evaluated on a national base and was the focus of this investigation. We used the Nationwide Inpatient Sample database from 2008 to 2014 to identify adults with single vessel CTO PCI for stable ischemic heart disease (SIHD). Patients were divided into 3 groups: patients without heart failure, heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple logistic regression models were performed to assess in-hospital mortality, acute renal failure, and the use of mechanical support devices. Of 112,061 inpatients with SIHD from 2008 to 2014 undergoing CTO PCI, 21,185 (19%) had HFrEF and 3309 (3%) had HFpEF. Compared to patients without heart failure, HFrEF and HFpEF patients were older (mean age 69.2 vs 66.3, 70.3 vs 66.3 respectively, P < 0.001), had more comorbidities and higher acute in-hospital complications. HFrEF patients had higher adjusted in-hospital mortality [AOR 1.73, 95% CI (1.21-2.48)], acute renal failure [AOR 2.68, 95% CI (2.34-3.06)], and need for mechanical support [AOR 2.76, 95% CI (2.17-3.51)]. Compared to patients without heart failure, HFpEF patients had similar mortality and need for mechanical support, but higher incidence of acute renal failure. Older age was significantly associated with increased in-hospital mortality. chronic total occlusion PCI in patients with heart failure is associated with higher in-hospital morbidity and mortality and warrants further investigation to optimize health care delivery.

Safety of Transcatheter Aortic Valve Replacement in Patients with Aortic Aneurysm: A Propensity-Matched Analysis.

INTRODUCTION: There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) among patients with thoracic or abdominal aortic aneurysms (AA). Using the Nationwide Inpatient Sample (NIS) database, we explored the safety of TAVR among patients with a diagnosis of AA. METHODS: We queried the National Inpatient Sample database (2012-2017) for hospitalized patients undergoing TAVR, using ICD-9 and ICD-10 codes for endovascular TAVR. Reports show that > 95% of endovascular TAVR in the US is via transfemoral access, so our population are mostly patients undergoing transfemoral TAVR. Using propensity score matching, we compared the trends and outcomes of TAVR procedures among patients with versus without AA. RESULTS: From a total sample of 29,517 individuals who had TAVR procedures between January 2012 and December 2017, 910 had a diagnosis of AA. In 774 matched-pair analysis, all-cause in-hospital mortality was similar in patients with and without AA OR 0.63 [(95% CI 0.28-1.43), p = 0.20]. The median length of stay was higher in patients with AA: 4 days (IQR 2.0-7.0) versus 3 days (IQR 2.0-6.0) p = 0.01. Risk of AKI [OR 1.01 (0.73-1.39), p = 0.87], heart block requiring pacemaker placement [OR 1.17 (0.81-1.69), p = 0.40], aortic dissection [OR 2.38 (0.41-13.75), p = 0.25], acute limb ischemia [OR 0.46 (0.18-1.16), p = 0.09], vascular complications [OR 0.80 (0.34-1.89), p = 0.53], post-op bleeding [OR 1.12 (0.81-1.57), p = 0.42], blood transfusion [OR 1.20 (0.84-1.70), p = 0.26], and stroke [OR 0.58 (0.24-1.39), p = 0.25] were similar in those with and without AA. CONCLUSIONS: Data from a large nationwide database demonstrated that patients with AA undergoing TAVR are associated with similar in-hospital outcomes compared with patients without AA.

Outcomes in Hospitalization in Patients with Heart Failure Undergoing Remote Pulmonary Artery Pressure Monitoring: A Systematic Review and Meta-Analysis of Major Trials.

Heart failure is a leading global pandemic and a cause of economic burden. Although, treatments exist to help symptomatic alleviation, patient compliance and monitoring is the basis of ensuring efficacy. With devices that allow for remote wireless PA pressure monitoring such as CardioMEMS, the inconsistency in patient reporting and factors such as symptoms and hospitalizations can be reduced. A systematic review and meta-analysis utilizing the MEDLINE, Cochrane, and Scopus database was performed to identify randomized and non-randomized clinical trials evaluating baseline characteristics and hospitalizations. Five trials for the systematic review and 2 trials for the meta-analysis meeting the inclusion and exclusion criteria were included. Baseline characteristics included an average age of 64.6 years, male predominance, mean BMI of 29.6, predominance of HFrEF, hypertension the most prevalent comorbidity, and a mean PA pressure of 27.2 mm Hg. The follow-up periods ranged from 90 days to 12 months. There was a total of 64 adverse events, mostly non-serious. Patients who underwent remote PA monitoring were less likely to be hospitalized compared with patients who did not (Odds Ratio: 0.52; 95% Confidence Interval 0.39, 0.69). Remote PA pressure monitoring allows for reduced hospitalizations. With the recent and now resurging SARS-CoV-2 pandemic, devices such as CardioMEMS can allow for heart failure patients to be managed from home to not only reduce hospitalizations but for symptom prevention and management.

Outcomes With sGC Therapy in Patients With HFpEF: A Meta-Analysis of Prior Trials.

Soluble guanylate cyclase (sGC) agents have been shown to have possible beneficial effects in heart failure treatment. Unfortunately, the role of sGC in HFpEF has not been shown to be efficacious based on recent trials. The CAPACITY HFpEF and VITALITY-HFpEF trials independently showed that sGC does not improve 6-minute walk test (6MWT) distance or the Kansas City Cardiomyopathy Questionnaire (KCCQ) physical limitation score (PLS). The objective of this study was to analyze current data on the 6MWT and KCCQ PLS score from trials that included patients with HFpEF treated with sGC. Using MEDLINE and Cochrane databases, meta-analysis and systematic review was performed looking at data in the CAPACITY HFpEF and VITALITY-HFpEF trials.  For safety analysis we evaluated serious adverse events between the CAPACITY HFpEF, VITALITY-HFpEF, SOCRATES-PRESERVED, and DILATE-1trials. A total of 2 trials were analyzed to assess 6MWT and KCCQ score. The total number of combined patients from both trials assessing 6MWT distance in sGC vs placebo therapy were 620 with 309 in the treatment group and 311 in the placebo group. The total number of combined patients from both trials assessing KCCQ score outcomes were 583 with 280 in the treatment group and 303 in the placebo group. A total of 4 trials were evaluated for safety analysis with a total of 987 patients with 529 in the treatment group and 458 in the placebo group. The analysis did not demonstrate significant difference in 6MWT (P = 0.97), KCCQ PLS (P = 0.83), or serious adverse events (P = 0.67).

Comparison of Coronary Artery Involvement and Mortality in STEMI Patients With and Without SARS-CoV-2 During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis.

BACKGROUND: Cardiovascular injury with SARS-CoV-2 infection is well known. Several studies have outlined baseline characteristics in patients presenting with STEMI and SARS-CoV-2. Paucity in data exists in selective coronary involvement in patients with STEMI and SARS-CoV-2 during the COVID-19 pandemic. METHODS: A systematic search and meta-analysis of studies meeting the inclusion and exclusion criteria obtained from MEDLINE, Scopus, and Cochrane databases was performed utilizing PRISMA criteria. The main outcome was likelihood of coronary artery involvement among patients with STEMI and SARS-CoV-2 versus without SARS-CoV-2. The primary adverse outcome measured was in-hospital mortality. RESULTS: The final analysis included 5 observational studies with a total of 2,266 patients. There was no statistical significance in LM (OR 1.40; 95% CI: 0.68, 2.90), LAD (OR 1.09; 95% CI 0.83, 1.43), LCX (OR 1.17; 95% CI: 0.75, 1.85), or RCA (OR 0.59; 95% CI: 0.30, 1.17) disease among the 2 groups. LAD disease was the most prevalent coronary involvement among patients with STEMI and SARS-CoV-2 (49.6%). Higher in-hospital mortality was observed in the STEMI and SARS-CoV-2 group (OR 5.24; 95% CI: 3.63, 7.56). CONCLUSIONS: Our analysis demonstrated no statistical significance in selective coronary involvement in patients with STEMI and SARS-CoV-2 during the COVID-19 pandemic. The higher mortality among patients with SARS-CoV-2 and STEMI has been noted in prior studies with concerns being late presentation due to fear of infection, delayed care time, and poor resource allocation. Focus should be placed on identifying and managing comorbidities to reduce mortality.

Percutaneous Mitral Valve Repair in Cardiac Amyloidosis and Severe Mitral Regurgitation.

Amyloidosis is an infiltrative disease with severe impact on the cardiac anatomy resulting in structural changes1. Mitral valve insult from the infiltrative process, although rare, has been known to cause severe mitral regurgitation4. Due to underlying comorbidities these patients may not be surgical candidates.17,18,19,20 The role of percutaneous mitral valve repair in cardiac amyloidosis has been described in a few prior cases.4,15 We review the epidemiology, diagnosis, and treatment of cardiac amyloidosis. We also highlight prior cases described in the literature of cardiac amyloidosis and severe mitral regurgitation, while discussing the role of percutaneous mitral valve repair in these patients.

Clinical Characteristics and Outcomes in Immune Checkpoint Inhibitor Therapy-Associated Myocarditis.

Immune checkpoint inhibitor (ICI) therapy has played an important role in the treatment of several groups of cancers. Although a life prolonging treatment, many side effects have been shown with ICI therapy. This study looked at individual level clinical characteristics and outcomes with ICI therapy in patients who developed ICI-related myocarditis. A comprehensive review of the National Library of Medicine PubMed database was performed. Inclusion criteria were all studies that were composed of case reports and case series of individual patients undergoing ICI therapy that developed myocarditis. To appreciate individual patient level data, observational studies, clinical trials, systematic reviews, and meta-analyses were excluded. Our search yielded 333 results with 71 cases reviewed of ICI therapy-related myocarditis. The findings included an average age of 68 years, higher incidence in men, and pretreatment cardiac history of hypertension. Melanoma was the most prevalent malignancy with nivolumab being the most used ICI therapy. Heart failure was the most prevalent adverse event that was co-prevalent with myocarditis. Corticosteroid therapy alone was the most utilized therapy to treat ICI-related myocarditis. Mortality was seen in nearly half of the patient population. Our study reviewed the preexisting literature of prior reported myocarditis secondary to ICI therapy. Periodic surveillance should be performed by the cardio-oncologist and internist. Due to the expanding role of ICI therapy in treating a variety of cancer patients, appreciation of its impact on the development of myocarditis is needed.