The 2020 ACC/AHA Guidelines for Management of Patients With Valvular Heart Disease: Highlights and Perioperative Implications.

Valvular heart disease contributes to a large burden of morbidity and mortality in the United States. During the last decade there has been a paradigm shift in the management of valve disease, primarily driven by the emergence of novel transcatheter technologies. In this article, the latest update of the American College of Cardiology/American Heart Association valve heart disease guidelines is reviewed.

Implantable cardiac devices in geriatric patients: a primer for primary and geriatric physicians.

In the next 20 years, the percentage of people older than 65 years of age in the United States is expected to double. Heart disease is the leading cause of mortality in developed nations, including the United States. Due to the increased incidence of cardiac disease in elderly patients, the need for special treatment considerations, including cardiac devices, may be necessary to reduce morbidity and mortality in this patient population. The purpose of this review is to provide a primer of the common cardiac devices used in the management of cardiac disorders in the geriatric patient population. In order to do this, we have performed a literature review for articles related to cardiac devices published between 2000 and 2020, in addition to reviewing guidelines and recommendations from relevant professional societies. We provide readers with an overview of several cardiac devices including implantable loop recorders, pacemakers, cardiac resynchronization therapy, automated implantable cardiac defibrillators, watchman devices, and ventricular assist devices. Indications, contraindications, clinical trial data, and general considerations in the geriatric population were included. Due to the aging population and increased incidence of cardiac disease, clinicians should be aware of the indications and contraindications of cardiac device therapy in the management of various cardiac conditions that afflict the geriatric population.

Sudden cardiac death: epidemiology, pathogenesis and management.

Sudden cardiac death (SCD) is an unexpected sudden death due to a heart condition, that occurs within one hour of symptoms onset. SCD is a leading cause of death in western countries, and is responsible for the majority of deaths from cardiovascular disease. Moreover, SCD accounts for mortality in approximately half of all coronary heart disease patients. Nevertheless, the recent advancements made in screening, prevention, treatment, and management of the underlying causes has decreased this number. In this article, we sought to review established and new modes of screening patients at risk for SCD, treatment and prevention of SCD, and the role of new technologies in the field. Further, we delineate the current epidemiologic trends and pathogenesis. In particular, we describe the advancement in molecular autopsy and genetic testing, the role of target temperature management, extracorporeal membrane oxygenation (ECMO), cardiopulmonary resuscitation (CPR), and transvenous and subcutaneous implantable cardioverter devices (ICDs).

Comparing outcomes of diabetic ketoacidosis hospitalisations in patients with diastolic heart failure: A retrospective propensity matched analysis of the nationwide inpatient sample.

INTRODUCTION: Diabetic ketoacidosis (DKA) is a known complication of patients with diabetes mellitus. The aim of this study was to compare the outcomes of patients admitted with a diagnosis of DKA with, and without, diastolic heart failure (DHF). METHODS: This was a population-based, retrospective, observational study using data from the National Inpatient Sample database for the years 2016 and 2017. The primary outcome was in-hospital mortality. Secondary outcomes were rates of sepsis, non-ST elevation myocardial infarctions (NSTEMI), acute kidney failure, acute respiratory failure (ARF), deep vein thrombosis, pulmonary embolism, mean length of hospital stay (LOS) and total hospital charges (THC). RESULTS: There was no statistically significant difference for the adjusted odds for in-hospital mortality between patients with and without DHF (adjusted odds ratio [aOR]: 0.55, 95% confidence interval [CI] 0.28-1.08, p = 0.081). Patients with DKA and DHF had increased odds of developing an NSTEMI (aOR: 1.31, 95% CI: 1.01-1.70, p = 0.045) or ARF (aOR: 1.82, 95% CI: 1.38-2.40, p < 0.001) during the same admission compared to patients without DHF. Patients with DKA and DHF also had an increased mean THC (6500 CI: 1900-11,200, p = 0.0006) in US dollars and increased LOS (0.7, 95% CI: 0.2-1.3, p = 0.011) in days when compared to patients without DHF. CONCLUSIONS: Patients with DKA showed no statistically significant difference in mortality if they did or did not have a secondary diagnosis of DHF within the same admission.

Predictors of outcomes in hospitalized patients undergoing pacemaker insertion: Analysis from the national inpatient database (2016-2017).

BACKGROUND: Pacemaker implantation in the U.S. is rising due to an aging population. The aim of this analysis was to identify risk factors associated with increased mortality and complications in hospitalized patients requiring pacemaker implantation. METHODS: We performed a retrospective analysis using the National Inpatient Sample database, identifying hospitalized patients who underwent pacemaker implantation using International Classification of Disease, Tenth Revision, Clinical Modification codes. Independent predictors of inpatient mortality were identified using multivariate logistic regression analysis. RESULTS: There were 242,980 hospitalizations with pacemaker implantation during 2016 and 2017. The most frequently encountered indications for hospitalizations involving pacemaker insertion included sick sinus syndrome (SSS) (27.60%), complete atrioventricular (AV) block (21.57%), and second-degree AV block (7.83%). Chronic liver disease was associated with the highest adjusted odds of inpatient mortality (aOR = 5.76, 95% CI: 4.46 to 7.44, p < .001). Comorbid anemia had the highest statistically significant adjusted odds ratio (aOR) for predictors of post-procedural cardiac complications (aOR = 3.17, 95% CI: 2.81 to 3.58, p < .001). Mortality in hospitalized patients needing pacemaker implantation was 1.05%. About 3.36% of hospitalizations developed post procedural circulatory complications (PPCC), 2.45% developed sepsis, and 1.84% developed mechanical complications of cardiac electronic devices. CONCLUSIONS: We identified several predictors of inpatient mortality in hospitalized patients undergoing pacemaker implantation, including chronic liver disease, protein-calorie malnutrition, chronic heart failure, anemia, and history of malignancy. Anemia, chronic liver disease, and congestive heart failure were independent predictors of adverse outcomes in such patients.

Increased inpatient mortality in patients hospitalized for atrial fibrillation and atrial flutter with concomitant amyloidosis: Insight from National Inpatient Sample (NIS) 2016-2017.

PURPOSE: Using National Inpatient Database (NIS), comparison of clinical outcomes for patients primarily admitted for atrial fibrillation/flutter with and without a secondary diagnosis of amyloidosis was done. Inpatient mortality was the primary outcome and hospital length of stay (LOS), mean total hospital charges, odds of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block, cardiogenic shock and cardiac arrest were secondary outcomes. METHODS: NIS database of 2016, 2017 was used for only adult hospitalizations with atrial fibrillation/flutter as principal diagnosis with and without amyloidosis as secondary diagnosis using ICD-10 codes. Multivariate logistic with linear regression analysis was used to adjust for confounders. RESULTS: 932,054 hospitalizations were for adult patients with a principal discharge diagnosis of atrial fibrillation/flutter. 830 (0.09%) of these hospitalizations had amyloidosis. Atrial fibrillation/flutter hospitalizations with co-existing amyloidosis have higher inpatient mortality (4.22% vs 0.88%, AOR: 3.92, 95% CI 1.81-8.51, p = 0.001) and likelihood of having a secondary discharge diagnosis of cardiac arrest (2.40% vs 0.51%, AOR: 4.80, 95% CI 1.89-12.20, p = 0.001) compared to those without amyloidosis. CONCLUSIONS: Hospitalizations of atrial fibrillation/flutter with co-existing amyloidosis have higher inpatient mortality and odds of having a secondary discharge diagnosis of cardiac arrest compared to those without amyloidosis. However, LOS, total hospital charges, likelihood of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block and cardiogenic shock were similar between both groups.

Prevalence, Predictors, and Outcomes of Type 2 NSTEMI in Hospitalized Patients With COVID-19.

BACKGROUND: Data on the incidence of type 2 non-ST-segment-elevation myocardial infarction (T2MI) in hospitalized patients with COVID-19 has been limited to single-center studies. Given that certain characteristics, such as obesity and type 2 diabetes, have been associated with higher mortality in COVID-19 infections, we aimed to define the incidence of T2MI in a national cohort and identify pre-hospital patient characteristics associated with T2MI in hospitalized patients with COVID-19. METHODS AND RESULTS: Using the national American Heart Association COVID-19 Cardiovascular Disease Quality Improvement Registry, we performed a retrospective 4:1 matched (age, sex, race, and body mass index) analysis of controls versus cases with T2MI. We performed (1) conditional multivariable logistic regression to identify predictive pre-hospital patient characteristics of T2MI for patients hospitalized with COVID-19 and (2) stratified proportional hazards regression to investigate the association of T2MI with morbidity and mortality. From January 2020 through May 2021, there were 709 (2.2%) out of 32 015 patients with T2MI. Five hundred seventy-nine cases with T2MI were matched to 2171 controls (mean age 70; 43% female). Known coronary artery disease, heart failure, chronic kidney disease, hypertension, payor source, and presenting heart rate were associated with higher odds of T2MI. Anti-hyperglycemic medication and anti-coagulation use before admission were associated with lower odds of T2MI. Those with T2MI had higher morbidity and mortality (hazard ratio, 1.40 [95% CI, 1.13-1.74]; P=0.002). CONCLUSIONS: In hospitalized patients with COVID-19, those with a T2MI compared with those without had higher morbidity and mortality. Outpatient anti-hyperglycemic and anti-coagulation use were the only pre-admission factors associated with reduced odds of T2MI.

Clinical Implications of COVID-19-Related Endothelial Dysfunction.

Endothelial dysfunction represents a measurable and early manifestation of vascular disease. Emerging evidence suggests cardiovascular risk remains elevated after COVID-19 infection for at least 12 months, regardless of cardiovascular disease status prior to infection. We review the relationship between the severity of endothelial dysfunction and the severity of acute COVID-19 illness, the degree of impairment following recovery in both those with and without postacute sequalae SARS-CoV-2 infection, and current therapeutic efforts targeting endothelial function in patients following COVID-19 infection. We identify gaps in the literature to highlight specific areas where clinical research efforts hold promise for progress in understanding the connections between endothelial function, COVID-19, and clinical outcomes that will lead to beneficial therapeutics.

Cirrhosis: Primary care approaches to screening, immunization, and lifestyle modifications.

For patients with decompensated cirrhosis, health maintenance is critical to improve survival rates and prevent adverse outcomes. We review the primary care management of cirrhosis and its complications, such as esophageal varices, hepatocellular carcinoma, and chemical or medication exposures. We also highlight specific immunizations and lifestyle modifications to prevent decompensation, and we summarize current screening guidelines.

Trends in the Use and Complications of Cardiac Resynchronization Therapy Device Implantation in Chronic Kidney Disease Patients.

Large-scale multi-hospital data on cardiac resynchronization therapy (CRT) device implantation in patients with chronic kidney disease (CKD) are currently lacking. The purpose of this study was to examine the incidence of CRT device implantation in patients hospitalized with CKD and the impact of CRT device implantation on hospital complications and outcomes. We analyzed the Nationwide Inpatient Sample from 2008-2014 to identify yearly trends in CRT device implantation during CKD hospitalizations. We compared CRT biventricular pacemakers (CRT-Ps) and CRT defibrillators (CRT-Ds). We also obtained rates of comorbidities and complications associated with CRT device implantations. From 2008-2014, the proportion of hospitalized patients with a concurrent diagnosis of CKD receiving CRT-P devices consistently went up from 2008 to 2014 (from 12.3% to 23.8%, P < .0001) compared to the number of hospitalized patients with a concurrent diagnosis of CKD receiving CRT-D devices, which showed a consistent downward trend (from 87.7% to 76.2%, P < .0001). During CKD hospitalizations, most CRT device implantations were performed in patients aged 65-84 years (68.6%) and in men (74.3%). The most common complication of CRT device implantation during hospitalizations involving CKD was hemorrhage or hematoma (2.7%). Patients hospitalized with CKD who developed any complication associated with CRT device implantation had 3.35-fold increased odds of mortality compared to those without complications (odds ratio, 3.35; 95% confidence interval, 2.18-5.16; P < .0001). In summary, this study shows that CRT-P implantations became more common in CKD patients, while the rate of CRT-D implantations decreased over time. Hemorrhage or hematoma was the most common complication (2.7%), and the mortality risk was increased by 3.35 times in patients who developed periprocedural complications.

Collagen-Specific HSP47+ Myofibroblasts and CD163+ Macrophages Identify Profibrotic Phenotypes in Deceased Hearts With SARS-CoV-2 Infections.

Background Cardiac fibrosis complicates SARS-CoV-2 infections and has been linked to arrhythmic complications in survivors. Accordingly, we sought evidence of increased HSP47 (heat shock protein 47), a stress-inducible chaperone protein that regulates biosynthesis and secretion of procollagen in heart tissue, with the goal of elucidating molecular mechanisms underlying cardiac fibrosis in subjects with this viral infection. Methods and Results Using human autopsy tissue, immunofluorescence, and immunohistochemistry, we quantified Hsp47+ cells and collagen α 1(l) in hearts from people with SARS-CoV-2 infections. Because macrophages are also linked to inflammation, we measured CD163+ cells in the same tissues. We observed irregular groups of spindle-shaped HSP47+ and CD163+ cells as well as increased collagen α 1(I) deposition, each proximate to one another in "hot spots" of ≈40% of hearts after SARS-CoV-2 infection (HSP47+ P<0.05 versus nonfibrotics and P<0.001 versus controls). Because HSP47+ cells are consistent with myofibroblasts, subjects with hot spots are termed "profibrotic." The remaining 60% of subjects dying with COVID-19 without hot spots are referred to as "nonfibrotic." No control subject exhibited hot spots. Conclusions Colocalization of myofibroblasts, M2(CD163+) macrophages, and collagen α 1(l) may be the first evidence of a COVID-19-related "profibrotic phenotype" in human hearts in situ. The potential public health and diagnostic implications of these observations require follow-up to further define mechanisms of viral-mediated cardiac fibrosis.

A Triad of Pericarditis, Pericardial Effusion, and Pleural Effusion as the Predominant Presentation of Rheumatoid Arthritis - A Case Report.

We describe a case of a 67-year-old African American man who presented to the emergency department with a sharp, pleuritic chest pain and shortness of breath. After several admissions and extensive workup, he ultimately was diagnosed with a persistent pleural effusion, pericardial effusion, and secondary constrictive pericarditis due to rheumatoid arthritis. By highlighting immunological disorders such as rheumatoid arthritis in the differential diagnosis, in the setting of a refractory pericardial effusion and serositis, this case report addresses key aspects of the presentation both in the emergency and inpatient settings, reviews the criteria for a rheumatoid arthritis diagnosis, and emphasizes areas of importance in predominantly cardiopulmonary extra-articular manifestations of a typically musculoskeletal disease.

Outcomes of hospitalizations with acute respiratory distress syndrome with and without atrial fibrillation - Analyses from the National Inpatient Sample (2004-2014).

BACKGROUND: Acute respiratory distress syndrome (ARDS) is associated with high mortality. Atrial fibrillation (AF) is a common arrhythmia seen in critically ill patients. The impact of AF on the outcomes in patients with ARDS is less understood. In this analysis we attempt to evaluate the association of concurrent AF and various clinical outcomes in patients with ARDS. METHODS: We conducted a retrospective analysis of adult discharges from the National Inpatient Sample (NIS) between 2004 and 2014. International Classification of Disease codes were used to identify those with ARDS and AF. RESULTS: We found 1,200,737 hospitalizations with ARDS, out of which 238,455 had concomitant diagnosis of AF. Hospitalizations with AF had higher prevalence of comorbidities including chronic pulmonary disease, diabetes mellitus, hypertension, obesity, congestive heart failure and renal failure. On adjusted analysis, AF was associated with increased odds of acute myocardial infarction, cardiogenic shock, pressor use, acute kidney injury, permanent pacemaker implantation, cardiac arrest, mechanical circulatory support use and higher length of stay and inflation-adjusted cost in hospitalizations with ARDS. However, there was no significant difference in adjusted all-cause mortality in ARDS with and without AF (25.42% vs 20.23%, p=0.53). CONCLUSIONS: AF is associated with worse clinical outcomes, higher length of stay and cost in ARDS hospitalizations as compared to those without AF.

Management of Postural Orthostatic Tachycardia Syndrome in the Absence of Randomized Controlled Trials.

Postural orthostatic tachycardia syndrome (POTS) is a clinical syndrome causing patients to experience light-headedness, palpitations, tremors, and breathlessness upon assuming an upright posture. Despite the absence of available long-term, multicenter, randomized controlled trial data, this literature review aims to concisely present the nonpharmacological and pharmacological interventions that have been used in the treatment of POTS reported to date by cross-sectional studies, cohort studies, and retrospective studies. We attempt to classify treatments as first-, second-, and third-line therapies based on our own experience and available data.

ST-segment elevation during arrhythmia ablations-A review.

Coronary injury presenting as ST segment elevation (STE) during ablation procedures for different arrhythmias is a rare and most feared complication. There have been multiple reports on STE during various ablation procedures in the recent past. Herein, we review various mechanisms, presentations, and management of STE observed during various ablations, including atrial fibrillation ablation cavotricuspid isthmus and ablation, supraventricular tachycardia ablations, coronary sinus ablation, and ventricular arrhythmia ablations.