Identifying opportunities to advance health equity in interventional cardiology: Structural heart disease.

Health care practices are influenced by variety of factors. These factors that include social determinants, race and ethnicity, and gender not only affect access to health care but can also affect quality of care and patient outcomes. These are a source of health care disparities. This article acknowledges that these disparities exist in getting optimal care in structural heart disease, reviews the literature and proposes steps that can help reduce these disparities on personal and committee levels.

Optimization of reconstruction and quantification of motion-corrected coronary PET-CT.

BACKGROUND: Coronary PET shows promise in the detection of high-risk atherosclerosis, but there remains a need to optimize imaging and reconstruction techniques. We investigated the impact of reconstruction parameters and cardiac motion-correction in 18F Sodium Fluoride (18F-NaF) PET. METHODS: Twenty-two patients underwent 18F-NaF PET within 22 days of an acute coronary syndrome. Optimal reconstruction parameters were determined in a subgroup of six patients. Motion-correction was performed on ECG-gated data of all patients with optimal reconstruction. Tracer uptake was quantified in culprit and reference lesions by computing signal-to-noise ratio (SNR) in diastolic, summed, and motion-corrected images. RESULTS: Reconstruction using 24 subsets, 4 iterations, point-spread-function modelling, time of flight, and 5-mm post-filtering provided the highest median SNR (31.5) compared to 4 iterations 0-mm (22.5), 8 iterations 0-mm (21.1), and 8 iterations 5-mm (25.6; all P < .05). Motion-correction improved SNR of culprit lesions (n = 33) (24.5[19.9-31.5]) compared to diastolic (15.7[12.4-18.1]; P < .001) and summed data (22.1[18.9-29.2]; P < .001). Motion-correction increased the SNR difference between culprit and reference lesions (10.9[6.3-12.6]) compared to diastolic (6.2[3.6-10.3]; P = .001) and summed data (7.1 [4.8-11.6]; P = .001). CONCLUSIONS: The number of iterations and extent of post-filtering has marked effects on coronary 18F-NaF PET quantification. Cardiac motion-correction improves discrimination between culprit and reference lesions.

Looking for the bare necessities.

The authors suggest that the early durability of the CoreValve implant should not be in question based on the results of this modestly sized, but well-done postmortem observational study. Given the ever-expanding knowledge of valvular degeneration, one thing is clear: more research and study is needed before any routine change in clinical practice, such as change it antithrombotic therapy, can be recommended. Further autopsy studies of patients who die outside of typical healthcare settings and who have had a longer median implant time would aid greatly in furthering the understanding of the degeneration and natural history of bioprosthetic transcatheter heart valves.

Spontaneous Coronary Artery Dissection: Insights From Histology and Optical Coherence Tomography.

Spontaneous coronary artery dissection (SCAD) is a well-known but infrequent cause of acute coronary syndrome (ACS), and often goes unrecognized. Although management of SCAD is, at times, controversial, when a patient presents with ACS, percutaneous coronary intervention (PCI) is frequently necessary. We present a patient with ST-segment elevation myocardial infarction (STEMI) with SCAD that illustrates two important points: use of intracoronary optical coherence tomography to guide PCI, and histologic assessment to provide a unique insight into the etiology of SCAD. Following the case, we briefly review the important aspects of the pathophysiology, epidemiology, diagnosis, and interventional management of SCAD.

Two Perspectives of the Appropriate Use Criteria in Cardiology Practice: Advantageous and Useful or Limiting and Harmful?

The appropriate use criteria (AUC) has become an integral part of the cardiologist's daily practice and have evolved greatly since their inception over a decade ago. However, as health care costs continue to rise, the AUC has come to play an even more pivotal role in the way medicine-specifically cardiology-is practiced today. This editorial describes two opposing viewpoints commonly held by practicing clinicians of the AUC. Written from the perspective of two fellows-in-training looking ahead at the challenges and opportunities of clinical practice (under the auspices of several experienced clinicians and leaders of the American College of Cardiology), this article provides a fresh perspective on the impact AUC has on our patients, clinicians, and the health care system.

Dollars and stents: A brave new world.

Reimbursement in the healthcare system is shifting from pure volume to a mixed volume/value-based metric. Using complex statistical modeling to adjust for unknowns, the study provides real world data that the use of Co-Cr EES is more cost effective than BMS assuming that clinicians select clopidogrel for P2Y12 inhibition. More cost-effectiveness analyses should be conducted to guide the use of ever costlier novel medical devices and drugs.

The invisible scaffold with invisible benefits?

Authors suggest the use of an investigator-owned and directed, prospective, non-randomized, single-arm multicenter registry at 23 Italian hospitals to follow 500 STEMI patients who receive BVS. Follow-up of patients is out to 5 years to determine how a BVS which has been deployed according to the IFU performs in these ACS patients. There is no comparator arm. Mandate that patients included in this registry follow a strict BVS implantation protocol which is felt to mitigate the not insignificant stent thrombosis rates noted with BVS to date.

Acute and Chronic Cardiovascular Effects of Hyperkalemia: New Insights Into Prevention and Clinical Management.

Hyperkalemia is a common electrolyte disorder associated with life-threatening cardiac arrhythmias and increased mortality. Patients at greatest risk for hyperkalemia include those with diabetes and those with impaired renal function in whom a defect in the excretion of renal potassium may already exist. Hyperkalemia is likely to become more common clinically because angiotensin receptor blockers and angiotensin-converting enzyme inhibitors are increasingly being used in higher doses and are thought to confer cardiovascular and renal protection. Until recently, options for treating hyperkalemia were limited to the use of thiazide and loop diuretics and sodium polystyrene sulfonate. Newer options such as sodium zirconium cyclosilicate will allow for the safe and effective treatment of hyperkalemia while maintaining patients on prescribed renin-angiotensin-aldosterone system inhibitors.

The bare naked truth "excuse me but your metal is showing!".

In 11,181 consecutive STEMI patients, the use of DES increased over time and there were significant differences in patients who received DES versus BMS Using complex statistical modeling to adjust for measured and unmeasured confounders, the study provides real world data that the use of DES in STEMI is associated with reduced TVR and improved long-term survival Overwhelming evidence supports the use of current-generation DES as first line for STEMI.

Medical Malpractice Claims Within Cardiology from 2006 to 2015.

With increasing healthcare costs and the high cost of spending driven by "defensive medicine," shedding light on recent litigation trends is critical for understanding current tort patterns, especially in the field of cardiology, a specialty with higher rates of malpractice suits than average. Understanding the characteristics of these liability claims and common types of patient injuries can aid cardiologists in mitigating malpractice risk and better patient care. Thus, the objective of this study was to characterize current malpractice trends in the field of cardiology and common sources of patient injury. An analysis of malpractice litigation claims from 2006 to 2015 in cardiology was performed on a database of nationwide professional liability insurers, health systems, and community hospitals. Both the total number of claims and annual indemnity payments in cardiology have seen an overall increase from 2006 to 2015. Of the 1,538 claims observed, the leading allegations were improper medical treatment and diagnostic error. However, despite the large number of claims, most cardiology claims during this decade were either decreased, denied, or dismissed (68%) and the plurality of the remainder was settled outside of court (30%). In conclusion, from 2006 to 2015, rates of cardiology malpractice claims and amount paid in compensation have increased substantially in the United States. Further understanding of the characteristics of these lawsuits can aid cardiologists in avoiding common sources of injury to improve patient care.

Multivessel Revascularization in Shock and High-Risk Percutaneous Coronary Intervention.

This review explores the usefulness of multivessel revascularization with percutaneous coronary intervention in patients with multivessel obstructive coronary artery disease (CAD) presenting with and without cardiogenic shock. We also evaluate the literature regarding complete versus incomplete revascularization for patients with cardiogenic shock, acute coronary syndromes, and stable coronary artery disease.

Prevalence of resistant hypertension and eligibility for catheter-based renal denervation in hypertensive outpatients.

BACKGROUND: Studies of endovascular renal denervation (RDN) have demonstrated significant blood pressure reduction in eligible patients with resistant hypertension. These trials have used stringent inclusion and exclusion criteria in patient enrollment, potentially selecting for a small subset of patients with resistant hypertension. In this study, we examined the changes in estimated prevalence of resistant hypertension when using increasingly stringent definitions of resistant hypertension in a fixed population and assessed the generalizability of RDN when applying study criteria to a community-based hypertensive population. METHODS: A retrospective chart review was done of hypertensive outpatients. Four increasingly stringent interpretations of the American Heart Association definition of resistant hypertension were used to calculate prevalence estimates. Patients eligible for RDN were identified using criteria from SYMPLICITY HTN-3. Demographic and clinical characteristics were compared. RESULTS: We identified 1,756 hypertensive outpatients; 55.0% were male, 53.9% were white, and subjects had a mean age of 66.6 ± 12.5 years and a body mass index (BMI) of 30.1 ± 10.7 kg/m(2). Only 14 (0.8%) were eligible for RDN. Among these patients, 10 (71.4%) were female and all were black, with a mean age of 69.9 ± 8.8 and BMI of 35.7 ± 6.6. Congestive heart failure was more common in patients eligible for RDN. CONCLUSIONS: Patients eligible for RDN based on published studies represent an exceedingly small proportion of the total hypertensive population. Further studies are necessary to determine if the benefits of RDN can be generalized to a broader range of hypertensive patients than those included in previous trials.

Effect of intensive atorvastatin therapy on coronary atherosclerosis progression, composition, arterial remodeling, and microvascular function.

BACKGROUND: There is a discrepancy between the marked reduction in adverse events with statins and their modest effect on atheroma regression. We hypothesized that, in a Western population, high-dose atorvastatin will result in alterations in coronary atheroma composition, phenotype, and microvascular function. METHODS: Serial coronary radiofrequency intravascular ultrasound (VH-IVUS), coronary flow reserve (CFR), and hyperemic microvascular resistance (HMR) were performed at baseline and after 6 months of treatment with 80 mg atorvastatin in 20 patients with moderate coronary artery disease (CAD). For each VH-IVUS frame (n = 2249), changes in total plaque atheroma, composition, and phenotype (pathological intimal thickening, fibrotic plaque, fibroatheroma), and serial remodeling were assessed. RESULTS: Total serum cholesterol decreased from 186.0 mg/dL (interquartile range [IQR], 168.0 to 212.5 mg/dL) to 139.0 mg/dL (IQR, 124.3 to 151.3 mg/dL). Percent atheroma volume did not change significantly (-0.5% [IQR, -2.8% to 3.7%]; P=.90) and serial remodeling analysis demonstrated 40% constrictive, 24% incomplete, and 36% expansive patterns. There was a trend toward lower percent fibrous tissue (-3.47 ± 1.78%; P=.07) and percent fibro-fatty tissue (-2.52 ± 1.24%; P=.06) and increase in percent necrotic core (+2.74 ± 1.65%; P=.11) and percent dense calcium (+1.99 ± 0.81; P=.02), which translated into significantly less pathological intimal thickening (4% vs 12%; P<.0001) and more fibroatheromas (67% vs 57%; P<.0001) at follow-up compared to baseline. There were modest non-significant improvements in CFR (+0.26 [IQR, -0.37 to 0.76]; P=.23) and HMR (-0.22 [IQR, -0.56 to 0.28]; P=.12). CONCLUSIONS: In this pilot study of Western patients with moderate CAD, high-dose atorvastatin resulted in alterations in coronary atheroma composition with corresponding changes in plaque phenotype and modest improvement in coronary microvascular function.

Comparative analysis of secreted enzymes between the anthropophilic-zoophilic sister species Trichophyton tonsurans and Trichophyton equinum.

Trichophyton tonsurans (TT) and Trichophyton equinum (TE) are two closely related dermatophytes with very different host preferences. This study was designed to examine the genetic and transcript level variations of secreted enzymes between TT and TE. Thirty-one genes representing 10 gene families were selected for comparison and complete genomic and cDNA sequences were elucidated. Sequence analyses of the selected genes identified 104 polymorphisms between the two dermatophytes, 37 of which are expected to encode changes in their polypeptide sequence. Quantitative RT-PCR was used to examine the differences in levels of transcript between TT and TE grown over 14d in aqueous keratin medium. Differences in transcript expression between TT and TE were gene specific and ranged from 1.1-fold to 33-fold. Intra-specific variability across all genes ranged from 41% to 250%. Despite their overall genetic similarity, TT and TE exhibit a moderate degree of variability in the genomic make-up of their secreted enzymes and the extent to which they are transcribed when grown in an aqueous keratin medium. Such differences may contribute to how these genetically similar organisms have adapted to infect divergent host organisms.