Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care.

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

Physiologic Lesion Assessment to Optimize Multivessel Disease.

PURPOSE OF REVIEW: Multivessel coronary artery disease, defined as significant stenosis in two or more major coronary arteries, is associated with high morbidity and mortality. The diagnosis and treatment of multivessel disease have evolved in the PCI era from solely a visual estimation of ischemic risk to a functional evaluation during angiography. This review summarizes the evidence and discusses the commonly used methods of multivessel coronary artery stenosis physiologic assessment. RECENT FINDINGS: While FFR remains the gold standard in coronary physiologic assessment, several pressure-wire-based non-hyperemic indices of functional stenosis have been developed and validated as well as wire-free angiographically derived quantitative flow ratio. Identifying and treating functionally significant coronary atherosclerotic lesions reduce symptoms and major adverse cardiovascular events. Coronary physiologic assessment in multivessel disease minimizes the observer bias in visual estimates of stenosis, changes clinical management, and improves patient outcomes.

Variations of coronary hemodynamic responses to intravenous adenosine infusion: implications for fractional flow reserve measurements.

BACKGROUND: Continuous intravenous adenosine infusion reportedly produces stable and maximal hyperemia to allow for fractional flow reserve (FFR) measurement; however, several observers have noted variation of the coronary/aortic (Pd/Pa) pressure ratio during the course of an adenosine infusion. METHODS: Pd/Pa pressure recordings during continuous peripheral intravenous adenosine infusion were examined in 51 patients (68 measurements) with data collected for at least 150 sec and for at least 30 sec after the lowest Pd/Pa reading. The lowest recorded Pd/Pa ratio was used as the true FFR value at maximal hyperemia. The highest subsequent Pd/Pa during the remaining period of adenosine infusion was recorded. A separate cohort of 12 patients had Pd/Pa values measured with both peripheral and central infusion. RESULTS: The average FFR value was 0.82 ± 0.10 and was recorded 99 ± 33 sec into the infusion. The Pd/Pa value showed a subsequent average increase of 0.08 ± 0.07 at 135 ± 32 sec. From the lowest measurement, Pd/Pa changed from a ratio ≤0.80 to >0.80 in 28% of recordings. In the cohort with matched recordings, central infusion reduced the severity (mean change of 0.08 vs. 0.11, P = 0.09) but not the incidence of Pd/Pa variability compared with peripheral infusion. CONCLUSION: Instability of Pd/Pa measurements is common over the course of a continuous intravenous adenosine infusion. FFR remains valid as the lowest value of Pd/Pa observed, however, Pd/Pa variability may subsequently occur and complicate pullback measurements for serial or multiple lesions.

Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care.

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

Nanosensor technologies and the digital transformation of healthcare.

Nanosensors are nanoscale devices that measure physical attributes and convert these signals into analyzable information. In preparation, for the impending reality of nanosensors in clinical practice, we confront important questions regarding the evidence supporting widespread device use. Our objectives are to demonstrate the value and implications for new nanosensors as they relate to the next phase of remote patient monitoring and to apply lessons learned from digital health devices through real-world examples.

Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care.

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

The Clinical Importance of Hyponatremia in Patients with Left Ventricular Assist Devices.

Hyponatremia is associated with increased morbidity and mortality in heart failure (HF) patients. The implication of hyponatremia during left ventricular assist device (LVAD) therapy remains unknown. In this retrospective study, consecutive LVAD patients implanted between April 2014 and March 2018 were stratified by the presence of hyponatremia (serum sodium <135 mEq/L) at 30 days post-LVAD. Incidence of HF readmissions and survival during 1-year follow-up were compared between the groups. Of 204 patients identified, 170 were included. Serum sodium levels improved significantly from pre-LVAD to 1-year post-LVAD (136 [133, 139] mEq/L to 137 [135, 140] mEq/L, p < 0.001). At 30 days, 35 patients (21%) were in the hyponatremia group. No difference was observed for 1-year survival between groups (77% vs. 81%, p = 0.66). However, the incidence of HF readmissions was significantly higher in the hyponatremia group (44% vs. 15%, p = 0.001). Among the patients with pre-LVAD hyponatremia (N = 60), those with normalized serum sodium levels (N = 42) had a lower incidence of HF readmissions compared with those with persistent hyponatremia (12% vs. 44%, p = 0.008). Hyponatremia in LVAD patients is associated with a higher incidence of HF readmissions. Further studies are needed to elucidate whether therapies directed at hyponatremia (e.g., vasopressin antagonists) would improve outcomes in LVAD patients.

Cost-utility of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is a resource-intensive tool that provides haemodynamic and respiratory support in patients who have suffered cardiac arrest. In this study, we investigated the cost-utility of ECPR (cost/QALY) in cardiac arrest patients treated at our institution. METHODS: We performed a retrospective review of patients who received ECPR following cardiac arrest between 2012 and 2018. All medical care-associated charges with ECPR and subsequent hospital admission were recorded. The quality-of-life of survivors was assessed with the Health Utilities Index Mark II. The cost-utility of ECPR was calculated with cost and quality-of-life data. RESULTS: ECPR was used in 32 patients (15/32 in-hospital, 47%) with a median age of 55.0 years (IQR 46.3-63.3 years), 59% male and 66% African American. The median duration of ECPR support was 2.1 days (IQR 0.9-3.8 days). Survival to hospital discharge was 16%. The median score of the Health Utilities Index Mark II at discharge for the survivors was 0.44 (IQR 0.32-0.52). The median operating cost for patients undergoing ECMO was $125,683 per patient (IQR $49,751-$206,341 per patient). The calculated cost-utility for ECPR was $56,156/QALY gained. CONCLUSIONS: The calculated cost-utility is within the threshold considered cost-effective in the United States (<$150,000/QALY gained). These results are comparable to the cost-effectiveness of heart transplantation for end-stage heart failure. Larger studies are needed to assess the cost-utility of ECPR and to identify whether other factors, such as patient characteristics, affect the cost-utility benefit.