Optimizing Post-Acute Coronary Syndrome Dyslipidemia Management: Insights from the North American Acute Coronary Syndrome Reflective III.

INTRODUCTION: Despite contemporary practice guidelines, a substantial number of post-acute coronary syndrome (ACS) patients fail to achieve guideline-recommended LDL-C thresholds. Our study aimed to investigate this guideline recommendations-to-practice care gap. Specifically, we aimed to identify opportunities where additional lipid-lowering therapies are indicated and explore reasons for the non-prescription of guideline-recommended therapies. METHODS: ACS patients with LDL-C ≥1.81 mmol/L (70 mg/dL) despite maximally tolerated statin ± ezetimibe therapy (including those intolerant of ≥2 statins) were enrolled 1-12 months post-event from 27 Canadian and US sites from September 2018 to October 2020 and followed up for three visits during the 12 months post-event. We determined the proportion of patients who did not achieve Canadian/US guideline-recommended LDL-C thresholds, the number of patients who would have been eligible for additional lipid-lowering therapies, and reasons behind lack of escalation in lipid-lowering therapies when indicated. Individual patient and aggregate practice feedback, including guideline-recommended intensification suggestions, were provided to each physician. RESULTS: Of the 248 patients enrolled in the pilot study (median age 64 [57, 73] years, 31.5% female and STEMI 27.4%), 75.4% were on high-intensity statins on the first visit. A total of 18.5% of those who attended all 3 visits had an LDL-C measured only at the first visit which was above the threshold. After 1 year of follow-up, 51.9% of patients achieved LDL-C thresholds at either visit 2 or 3. In the context of feedback reminding physicians about guideline-directed LDL-C-modifying therapy in their individual participating patients, we observed an increase in the use of ezetimibe and PCSK9 inhibitor therapy at 3-12 months. This was associated with a significant lowering of the mean LDL-C (from 2.93 mmol/L [baseline] to 2.09 mmol/L [3-6 months] to 1.87 mmol/L [6-12 months]) and a significantly greater proportion of patients (from 0% [baseline] to 38.6% [3-6 months] to 53.4% [6-12 months]) achieving guideline-recommended LDL-C thresholds. The most prevalent reasons behind the non-intensification of LDL-C-lowering therapy with ezetimibe and/or PCSK9i were LDL-C levels being close to target, the pre-existing use of other lipid-lowering therapies, patient refusal, and cost. CONCLUSION: Although most patients post-ACS were on high-intensity statin therapy, almost 50% failed to achieve guideline-recommended LDL-C thresholds by 1-year follow-up. Furthermore, additional lipid-lowering therapies in this high-risk group were underprescribed, and this might be linked to several factors including potential gaps in physician knowledge, treatment inertia, patient refusal, and cost.

Inappropriate noise detection in Tendril family pacing leads.

INTRODUCTION: Noise oversensing encountered in patients with Abbott Tendril leads in our hospital triggered an internal investigation. METHODS: We retrospectively analyzed patients with a Tendril lead model 1688, 1788, 1888, and 2088. Most leads were connected to Abbott generators. To exclude a primary generator issue as the cause of noise oversensing, we enrolled a cohort of patients in whom Medtronic CapSureFix leads model 4076 and 5076 were prospectively connected to similar Abbott generators. RESULTS: A total of 1063 Tendril leads were implanted in 869 patients. Noise was encountered in 66 leads (6.2%) during a follow-up of 3.9 years. Most affected leads had normal impedance and only a few of these patients were symptomatic. Reprogramming was attempted in 44 of 66 (67%), and reduced oversensing in 34 of 44 (77%) of these patients. Seventeen malfunctioning leads (1.5%) were replaced, including 16 of 66 (24%) of those with noise. Of the four leads with noise extracted and returned to the manufacturer, lead to device abrasion was identified in two and inner insulation breach in one. None of the 145 Medtronic CapSureFix leads connected to Abbott generators had noise during a follow-up of 3.6 years. CONCLUSION: Noise oversensing was relatively common in Tendril leads, but was not detected in Medtronic leads despite connecting to Abbott generators. Although the majority of the affected leads did not show abnormal impedance, outer or inner insulation breach was identified in three of the four returned leads. As patients with affected leads are generally asymptomatic, most of them can be managed conservatively.

Prevalence and Doppler Echocardiographic Characteristics of Normally Functioning Mitral Prostheses with Mean Gradient ≥10 mmHg.

BACKGROUND: The study aim was to determine the prevalence of normally functioning mitral prostheses with mean gradient ≥10 mmHg, and to identify the characteristics and echocardiographic variables that might be useful to distinguish normal function from dysfunction. METHODS: A total of 56 consecutive patients with a prosthetic mitral valve and mean gradient ≥10 mmHg was retrospectively identified. Nineteen patients without subsequent imaging confirming normal prosthesis function or dysfunction were excluded; hence, 37 patients were classified as obstruction, insufficiency, or normal prosthesis (high-gradient; NPHG). A comparison group of 25 patients with a mean transprosthetic gradient of ≤5 mmHg (low-gradient group) was also identified. RESULTS: Of the 37 patients, seven (19%) had obstruction, 10 (27%) had significant valvular or perivalvular insufficiency, and 20 (54%) were deemed NPHG. NPHG patients had a similar net atrioventricular compliance (Cn) to those with obstruction and insufficiency, which was significantly lower than the low-gradient group. The cardiac index (CI) was significantly higher in the NPHG group (3.4 ± 0.9 l/min/m2) compared to all other groups (p = 0.001). Receiver operator characteristic curves showed that the indexed effective orifice area (EOAi), effective orifice area (EOA) and velocity-time integral ratio distinguished NPHG from abnormal prosthesis function in patients with mean gradients ≥10 mmHg (area under curve = 0.92, 0.86, and 0.82, respectively). CONCLUSIONS: The study data suggested that a plurality of individuals with a mean transprosthetic mitral gradient ≥10 mmHg will be found to have a normally functioning prosthesis. Most of these patients will have a small EOAi, a reduced Cn, and a relatively increased CI.

Normalization of Left Ventricular Ejection Fraction and Incidence of Appropriate Antitachycardia Therapy in Patients With Implantable Cardioverter Defibrillator for Primary Prevention of Sudden Death.

BACKGROUND: Patients with severely depressed left ventricular ejection fractions (LVEFs) receive implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden death. In some patients, however, LVEF may improve or even normalize over time. Limited data are available on the incidence of appropriate antitachycardia therapy, including pacing and shock, in these patients. METHODS AND RESULTS: We retrospectively identified consecutive patients at our institution with an ICD for primary prevention who had LVEF measurement available at initial implantation and at the time of generator replacement. None of these patients had ever received appropriate antitachycardia therapy before generator replacement. The incidence of appropriate antitachycardia therapy after generator replacement was assessed. Of the 125 patients who received generator replacement, 53 (42%) received an ICD and 72 (58%) a cardiac resynchronization therapy-defibrillator (CRT-D). Among them, 30 (21%) had LVEF normalized to ≥50%, 25 (17%) had LVEF partially improved to 36%-49%, and 70 (63%) had LVEF that remained depressed at ≤35%. During an overall follow-up period of 25 ± 18 months, none of the individuals with normalized LVEF experienced appropriate antitachycardia therapy regardless of ICD or CRT-D. Meanwhile, 20% of patients with LVEF at 36%-49% and 14% of patients with LVEF at ≤35% received appropriate ICD therapy. The omnibus P value for any differences among the 3 LVEF groups was 0.046 for the entire cohort, 0.01 for ICD, and 0.15 for CRT-D patients. CONCLUSIONS: These preliminary data suggest that patients with reduced LVEF and primary-prevention ICDs who normalize their LVEF over time may be at lower risk of appropriate antitachycardia therapy.

Sex difference in mitral valve prolapse regurgitant volume is resolved by normalization of regurgitant volume to left ventricular end-diastolic volume.

Women with primary mitral insufficiency have a smaller regurgitant volume at the same regurgitant fraction than men. We hypothesized that normalizing regurgitant volume with left ventricular end-diastolic volume or allometric scaling would eliminate the difference in regurgitant volume between women and men. The study cohort consisted of 101 patients with mitral valve prolapse undergoing cardiac MRI. Descriptive statistics and linear regression were performed to assess differences between sexes. Of the 101 patients, 46 (46%) were women. Women had a significantly smaller left and right ventricular end-diastolic volume, end-systolic volume, and stroke volume. While there was no difference in regurgitant fraction between women and men (34 ± 13% vs. 35 ± 14%; p = 0.71), women had a significantly smaller regurgitant volume (36 ± 18 ml vs. 49 ± 26 ml; p = 0.005). The slope-intercept relationship between regurgitant fraction and regurgitant volume revealed unique slopes and y-intercept values for men and women (p-value < 0.0001). Normalizing regurgitant volume to left ventricular end-diastolic volume (RVol/LVEDV), body surface area1.5 (RVol/BSA1.5) and height2.7 (RVol/height2.7) all had essentially identical slope-intercept relationships with regurgitant fraction for men and women, but RVol/LVEDV had the smallest effect size. In mitral insufficiency secondary to mitral valve prolapse women have a significantly smaller regurgitant volume than men despite no difference in regurgitant fraction. The significant difference in regurgitant volume between women and men is secondary to women having a smaller left ventricular end-diastolic volume.

Manufacturer-provided effective orifice area index charts and the prevention of prosthesis-patient mismatch.

Prosthesis-patient mismatch (PPM) occurs when an implanted prosthesis is too small relative to the patient's body surface area (BSA). However, mismatch can often be prevented by indexing the expected effective orifice area (EOA) of a prosthesis to the patient's BSA and then selecting the largest implantable prosthesis to avoid mismatch. Previously, prosthesis manufacturers have attempted to simplify this process by providing charts that include the expected EOA for their prosthesis, already indexed into an array of BSA values. One caveat with these charts is that the expected EOA data must truly be reliable, or the charts will misguide the implanting surgeon. Manufacturer-provided charts could be improved by standardizing the EOA data, with one potential source being the hemodynamic data submitted to the United States Food and Drug Administration. This review discusses PPM, manufacturer-provided EOA charts, and the regulation of EOA data.

Gender differences in primary mitral regurgitant volumes at specific regurgitant fractions as assessed by magnetic resonance imaging.

Guidelines suggest using a regurgitant fraction of 50% and regurgitant volume of 60 ml for determination of severe mitral insufficiency. Recent MRI data has suggested that a regurgitant fraction of 40% defines severe primary mitral insufficiency. We sought to determine whether there were gender differences in primary mitral regurgitant volumes for regurgitant fractions of 40% and 50%. A database search identified 394 patients that had MRI with a mitral regurgitant volume ≥ 10 ml or a study indication of mitral insufficiency. Chart review identified 97 patients with primary mitral insufficiency. Of these patients, 53 (54%) were women. Men had significantly larger left ventricular volumes, myocardial mass, stroke volumes and mitral regurgitant volumes (37 ± 25 ml vs. 24 ± 12 ml). The difference in regurgitant fraction between genders was not significant (27 ± 14% vs. 24 ± 11%; p-value = 0.24). Regurgitant fraction and regurgitant volume had a strong linear correlation in both men (r = .95) and women (r = .92). Despite similar linear correlations, the slope-intercept equations differed significantly between men and women (p < .001). A regurgitant fraction of 40% correlated with a regurgitant volume of 59 ml in men and 39.5 ml in women, while a regurgitant fraction of 50% correlated with a regurgitant volume of 76.2 ml in men and 49.6 ml in women. Regurgitant fraction, determined by cardiac MRI, provides a gender independent assessment of primary mitral insufficiency, and suggests that regurgitant volume thresholds for severe primary mitral insufficiency may be lower in women.

Mitral valve area by the pressure half-time method does not correlate with mean gradient in mitral valve repair patients.

AIMS: Pressure half-time is an inaccurate measure of mitral valve area in many clinical situations. The utility of the pressure half-time method to calculate mitral valve area after mitral valve repair is not well defined. METHODS AND RESULTS: Forty-two patients with a repaired mitral valve were identified. Mitral valve area was calculated by both the pressure half-time method and the continuity equation. The two mitral valve areas were then directly compared and also correlated with mean gradient. The two mitral valve areas were significantly different from one another with a mean of 1.81 ± 0.53 cm(2) by continuity equation and 2.65 ± 0.69 cm(2) by pressure half-time. The continuity equation correlated well with mean gradient (ρ = -0.63), whereas the correlation for pressure half-time was weak (r = -0.08). CONCLUSION: A non-linear, inverse correlation was found between mitral valve area by the continuity equation and mean gradient. No correlation was found between the pressure half-time method for mitral valve area and mean gradient. The continuity equation likely provides a better estimate of mitral valve area in repaired mitral valves.

How reliable is an effective orifice area indexed chart?

BACKGROUND AND AIM OF THE STUDY: Patient-prosthesis mismatch (PPM) occurs when a valvular prosthesis is too small relative to the patient's body surface area (BSA). The presence of PPM results in increased transprosthetic gradients and may portend a worse prognosis. It has been shown that reliable effective orifice area (EOA) data can be used to accurately predict PPM, thus preventing its occurrence. The study aim was to assess the predictive abilities of an effective orifice area indexed (EOAI) chart--the Perimount Magna EOAI chart--in the prevention of PPM. METHODS: A retrospective comparison of projected versus calculated EOA values and the predicted versus actual incidence of PPM was conducted. Forty patients with a Perimount Magna aortic bioprosthesis implanted between 1st January 2006 and 31st March 2009, were identified. The sensitivity, specificity, positive-predictive value (PPV) and negative predictive value (NPV) were each calculated using the Perimount Magna EOAI chart, to assess how well it could predict the incidence of postoperative PPM. RESULTS: The Perimount Magna EOAI chart had a sensitivity of 35% for predicting postoperative PPM, and an NPV of 53%. The projected EOA-values were almost invariably larger than those actually measured; this resulted in a higher proportion of patients than in whom PPM was predicted preoperatively. This EOAI chart proved to be very specific, with specificity of 100% and a PPV of 100%. CONCLUSION: The Perimount Magna EOAI chart, based on mean EOA data from a small echocardiographic cohort, represents a poor method of predicting and preventing PPM. Rather, EOAI charts should be based on reliable EOA data that reproducibly predict the expected EOA for that prosthesis.

The Association Between Cardiac Rehabilitation Attendance and Hospital Readmission.

Purpose: Cardiac rehabilitation is associated with improved clinical outcomes, but the impact of individual cardiac rehabilitation sessions on readmission rates is less studied. Methods: A retrospective evaluation of the relationship between the number of cardiac rehabilitation sessions completed and all-cause and cardiac readmission rates at 1 year was conducted. The 1-year cardiac readmission counts were modeled via Poisson regression. Results: Of the 347 patients included in the primary analysis, 227 (65%) completed all assigned cardiac rehabilitation sessions. At 1 year, 135 patients (39%) had at least 1 cardiac readmission, and 155 patients (45%) had at least 1 all-cause readmission. The primary result was that every additional cardiac rehabilitation session completed was associated with a 1.75% lower incidence rate of 1-year cardiac readmission (P = .01) and a 2% lower incidence rate of all-cause hospital readmission (P = .001). Conclusion: Regardless of the number of cardiac rehabilitation sessions assigned, each additional session attended was associated with reduced cardiac readmission by 1.75% and all-cause readmission by 2%.

Predictors of appropriate therapy in patients with implantable cardioverter-defibrillator for primary prevention of sudden cardiac death.

The purpose of this study was to evaluate predictors of appropriate therapy in patients with implantable cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death. A retrospective cohort of 321 patients with systolic heart failure undergoing ICD placement for primary prevention of sudden cardiac death was queried with a mean follow-up period of 2.6 years. Appropriate ICD therapy was defined as therapy delivered for termination of a ventricular tachyarrhythmia. Appropriate ICD therapy was delivered in 142 (44%) of the patients. In a multivariate model, body mass index ≥28.8 kg/m(2), chronic kidney disease, left ventricular ejection fraction ≤20% and metabolic syndrome were found to be independent predictors of appropriate ICD therapy. Appropriate ICD therapy was associated with higher cardiovascular mortality. These findings show the importance of identification of risk factors, especially metabolic syndrome, in patients following ICD implantation as aggressive treatment of these co-morbidities may decrease appropriate ICD therapy and cardiovascular mortality.

Chronic kidney disease is an independent predictor of pocket hematoma after pacemaker and defibrillator implantation.

INTRODUCTION: The aim of this investigation was to determine additional predisposing factors of pocket hematoma formation in patients undergoing anti-arrhythmic device surgery. METHODS: Initially, we performed a retrospective chart review of 459 patients on warfarin therapy who underwent anti-arrhythmic device surgery (pacemaker or defibrillator implantation, generator replacement, or lead revision) between April 2004 and September 2008 to determine whether continuation of anticoagulation or cessation of anticoagulation, with or without bridging therapy, was the preferred approach. In those patients who developed pocket hematoma, we then analyzed factors that might predispose to hematoma formation. RESULTS: The incidence of pocket hematoma in the entire group was 2.2% (n = 10). Forty-eight percent of the patient group was on continued warfarin (n = 220), 27% on bridging therapy with intravenous heparin or subcutaneous enoxaparin (n = 123) and 66% were on antiplatelet therapy (aspirin or clopidegrol or both; n = 303) at the time of device implantation. Twelve percent of the patients had chronic kidney disease (n = 55). In multivariate regression analysis, after adjusting for anticoagulation and antiplatelet agents, chronic kidney disease was found to be a significant risk factor for pocket hematoma formation after ICD and pacemaker placement. An increase of 1.0 mg/dl in creatinine levels was associated with a nearly twofold increase in hematoma formation (OR, 1.99; 95% CI, 1.22-3.21; p = 0.03). CONCLUSION: Chronic kidney disease is a significant risk factor for pocket hematoma formation after pacemaker and ICD placement, independent of anticoagulation and antiplatelet agents.

Continuing warfarin therapy is superior to interrupting warfarin with or without bridging anticoagulation therapy in patients undergoing pacemaker and defibrillator implantation.

BACKGROUND: Current guidelines recommend stopping oral anticoagulation and starting bridging anticoagulation with intravenous heparin or subcutaneous enoxaparin when implanting a pacemaker or defibrillator in patients at moderate or high risk for thromboembolic events. A limited body of literature suggests that device surgery without cessation of oral anticoagulation may be feasible. OBJECTIVE: The purpose of this study was to evaluate the safety of device surgery in orally anticoagulated patients without interrupting warfarin therapy. METHODS: We performed a retrospective study of 459 consecutive patients on chronic warfarin therapy who underwent device surgery from April 2004 to September 2008. Warfarin was continued in 222 patients during the perioperative period. Warfarin was temporarily held and bridging therapy administered in 123 patients. Warfarin was temporarily held without bridging therapy in 114 patients. RESULTS: There were no significant differences with regard to age, sex, or risk factors for thromboembolism in the three groups. Patients who continued taking warfarin had a lower incidence of pocket hematoma (P = .004) and a shorter hospital stay (P <.0001) than did patients in the bridging group. Holding warfarin without bridging is associated with a higher incidence of transient ischemic attacks (P = .01). CONCLUSION: Temporarily interrupting anticoagulation is associated with increased thromboembolic events, whereas cessation of warfarin with bridging anticoagulation is associated with a higher rate of pocket hematoma and a longer hospital stay. Continuing warfarin with a therapeutic international normalized ratio appears to be a safe and cost-effective approach when implanting a pacemaker or defibrillator in patients with moderate to high thromboembolic risk.

Predictors of inotrope use in patients undergoing concomitant coronary artery bypass graft (CABG) and aortic valve replacement (AVR) surgeries at separation from cardiopulmonary bypass (CPB).

BACKGROUND: Left ventricular dysfunction is common after coronary artery bypass graft and valve replacement surgeries and is often treated with inotropic drugs to maintain adequate hemodynamic status. In this study, we aimed to identify the demographic, clinical, laboratory, echocardiographic and hemodynamic factors that are associated with use of inotropic drugs in patients undergoing concomitant coronary artery bypass graft and aortic valve replacement surgery. METHODS: The study included 97 patients who had undergone concomitant coronary artery bypass graft and aortic valve replacement at Regions Hospital, University of Minnesota Medical School from January 2006 to December 2008. All data were collected retrospectively after reviewing electronic medical records. Inotropic support was defined as the use of dopamine [greater than or equal to] 5 ug/kg/min; any dose of epinephrine, norepinephrine, dobutamine, and milrinone at the separation from cardiopulmonary bypass. RESULTS: Inotropic support was used in a total of 50 patients (52%) at the separation from cardiopulmonary bypass. Average age of the patients requiring inotropic support was 72.2 +/- 8.8 years. The study identified four significant, independent predictors of inotrope use: (1) Cardiac index [less than or equal to] 2.5 L/min/m2, (2) LVEDP [greater than or equal to] 20 mm Hg, (3) LVEF [less than or equal to] 40%, and (4) CKD stage 3 to 5. CONCLUSION: We identified four independent risk factors for postoperative use of inotropic support in patients undergoing concomitant coronary artery bypass graft and arotic valve replacement surgery at the separation from cardiopulmonary bypass. The study results will be helpful to prospectively identify patients who will likely to require inotropic support at the separation from cardiopulmonary bypass.

Acute coronary thrombosis in a patient with septic shock without any evidence of disseminated intravascular coagulation.

The case report describes an interesting and unusual finding of acute coronary artery thrombosis in a patient presenting with septic shock without any clinical and laboratory evidence of disseminated intravascular coagulation (DIC). The patient presented with leucocytosis and refractory hypotension requiring pressor support and found to have anterior and inferior ST-elevation in 12-lead electrocardiogram. Coronary angiogram revealed acute thrombotic occlusions in the proximal right coronary artery and the proximal left anterior descending coronary artery. There was no occlusive atherosclerotic coronary artery disease. The patient underwent mechanical thrombectomy. Haemodynamic parameters obtained from right heart catheterisation confirmed sepsis as the aetiology of hypotension. The patient was treated successfully with broad spectrum antibiotics, pressors and intravenous fluid.Acute myocardial infarctions as a complication secondary to disseminated intravascular coagulation in patients with sepsis and septic shock have been described in the literature. To our knowledge, this is the first reported case of acute coronary artery thrombosis in patient with septic shock without DIC and without any underlying occlusive coronary artery disease.

Sudden cardiac arrest in apical hypertrophic cardiomyopathy.

We present two cases of cardiac arrest, presumably attributable to apical hypertrophic cardiomyopathy(HCM). The first case was a 37-year-old Asian man known to have an apical HCM and was successfully resuscitated from an "out of hospital" ventricular fibrillation arrest. He underwent an electrophysiological study that was unable to induce tachyarrhythmias, which may not be surprising. He did receive an automated internal cardioverter defibrillator (AICD) in compliance with his class I indication for an implantable defibrillator. The second patient was an 86-year-old Caucasian woman with a cardiac history significant for apical HCM, coronary artery disease, diastolic heart failure, and monomorphic ventricular tachycardia. She underwent electrophysiological testing for frequent dizziness and monomorphic ventricular tachycardia of a right ventricular origin was induced. She received an AICD for sudden cardiac death prevention. Though lethal ventricular arrhythmias have been reported in patients with apical HCM, the prevailing consensus is that the prognosis of apical HCM is benign. Whether these accounts are truly exceptional occurrences for this rare and conventionally regarded benign condition or whether they represent an under-appreciated risk for sudden cardiac arrest is an intriguing question.