The 2022 FASEB Virtual Catalyst Conference on the Cardiac Interatrial Septum and Stroke Risk, December 7, 2022.

There is emerging evidence that the cardiac interatrial septum has an important role as a thromboembolic source for ischemic strokes. There is little consensus on treatment of patients with different cardiac interatrial morphologies or pathologies who have had stroke. In this paper, we summarize the important background, diagnostic, and treatment considerations for this patient population as presented during the Federation of American Societies for Experimental Biology (FASEB) Virtual Catalytic Conference on the Cardiac Interatrial Septum and Stroke Risk, held on December 7, 2022. During this conference, many aspects of the cardiac interatrial septum were discussed. Among these were the embryogenesis of the interatrial septum and development of anatomic variants such as patent foramen ovale and left atrial septal pouch. Also addressed were various mechanisms of injury such as shunting physiologies and the consequences that can result from anatomic variants, as well as imaging considerations in echocardiography, computed tomography, and magnetic resonance imaging. Treatment options including anticoagulation and closure were addressed, as well as an in-depth discussion on whether the left atrial septal pouch is a stroke risk factor. These issues were discussed and debated by multiple experts from neurology, cardiology, and radiology.

Systematic review of disparities in continuous glucose monitoring and insulin pump utilization in the United States: Key themes and evidentiary gaps.

AIM: This study aims to provide a comprehensive overview of real-world evidence pertaining to disparities in the utilization of continuous glucose monitors (CGMs)/insulin pumps to highlight potential evidentiary gaps and discern emerging themes from the literature. MATERIALS AND METHODS: A systematic review of published manuscripts and abstracts was conducted from: MEDLINE, EMBASE, Nursing and Allied Health, Web of Science and CINHAL. Attributes related to patients, outcomes, interventions (CGMs/pumps/both) and study type were captured. In addition, factors associated with disparities in device utilization were examined. RESULTS: Thirty-six studies were included in the final analysis; the studies predominantly focused on people living with type 1 diabetes. Only two studies included individuals with type 2 diabetes. Almost two-thirds of the studies reported outcomes associated with disparities (e.g. glycated haemoglobin, diabetic ketoacidosis, resource utilization). Most studies highlighted disparities across race, ethnicity and insurance type. Evidentiary gaps were identified, particularly in the evidence for people with type 2 diabetes, the continuation of CGM/pump use and limited studies addressing disparities among Native Americans/American Indians. CONCLUSION: This study reveals critical disparities in diabetes technology use across race, ethnicity and insurance type, particularly among people with type 1 diabetes. Evidentiary gaps assessing disparities in diabetes technology use persist, particularly concerning people with type 2 diabetes, Native American/American Indian and LGBTQ+ populations, and in outcomes related to continuation of use. Social and digital determinants of health, such as income, transportation, residential location and technological literacy, are crucial to achieving equitable access. Future research should focus on the patient journey to identify opportunities for equitable access to diabetes technology as its use grows.

Association between immune checkpoint inhibitor-induced myocarditis and concomitant use of thiazide diuretics.

Although an association has been reported between diuretics and myocarditis, it is unclear whether the risk of immune checkpoint inhibitor (ICI)-induced myocarditis is affected by concomitant diuretics. Thus, the aim of this work was to evaluate the impact of concomitant diuretics on ICI-induced myocarditis. This cross-sectional study used disproportionality analysis and a pharmacovigilance database to assess the risk of myocarditis with various diuretics in patients receiving ICIs via the analysis of data entered into the VigiBase database through December 2022. Multiple logistic regression analysis was performed to identify risk factors for myocarditis in patients who received ICIs. A total of 90 611 patients who received ICIs, including 975 cases of myocarditis, were included as the eligible dataset. A disproportionality in myocarditis was observed for loop diuretic use (reporting odds ratio 1.47, 95% confidence interval [CI] 1.02-2.04, P = .03) and thiazide use (reporting odds ratio 1.76, 95% CI 1.20-2.50, P < .01) in patients who received ICIs. The results of the multiple logistic regression analysis showed that the use of thiazides (odds ratio 1.67, 95% CI 1.15-2.34, P < .01) was associated with an increased risk of myocarditis in patients who received ICIs. Our findings may help to predict the risk of myocarditis in patients receiving ICIs.

Trends in Time in Range-Related Publications and Clinical Trials: A Bibliometric Review.

Objective: The goal of this article was to describe trends in publications (including conference abstracts) and clinical trials that report on glycemic time in range (TIR). Data sources: Reviewed databases included but were not limited to MEDLINE and Embase. Clinical trial registries were also sourced. Study selection: All studies reporting TIR published between 2010 and 2021 were included. Clinical trials reporting TIR that started in or after 2010 were also included. Non-English publications, abstracts, and clinical trials were excluded. Book chapters, nonhuman studies, and studies not reporting TIR were excluded. Data extraction: Manuscript/abstract category, publication year, study region, interventional versus observational role of continuous glucose monitoring (CGM), and clinical trial start and completion dates were captured. Glycemic outcomes reported in publications or trials, including TIR as a primary outcome, A1C, time below range (TBR), and time above range (TAR), were also captured. Results: A total of 373 clinical trials, 531 publications, and 620 abstracts were included in the review. The number of trials, publications, and abstracts reporting TIR significantly increased, particularly between 2018 and 2021, during which time the number of clinical trials, publications, and conference abstracts reporting TIR increased by 6-fold, 12-fold, and 4.5-fold, respectively. About 35-44% of studies reported TIR as a primary outcome. Approximately 54% of clinical trials, 47% of publications, and 47% of conference abstracts reported the role of CGM to be observational. TBR was reported more often than TAR. Conclusion: The marked increase in the number of trials, publications, and abstracts reporting TIR highlights the increasing significance and acceptance of TIR as an outcome measure in diabetes management.

Determining patient preferences of community pharmacy attributes: A systematic review.

OBJECTIVE: Patient selection of community pharmacy is based on a multitude of factors. With increasing competition and rapidly changing face of pharmacy, identification of these factors is critical for patient satisfaction and financial success. This systematic review summarizes patient preferences for different attributes of community pharmacy. DATA SOURCES: Systematic review of peer-reviewed studies conducted on U.S. population, published from 2005 to 2018 in EBSCO, PubMed, and EMBASE, was conducted to identify attributes of community pharmacy that determine patient patronage. STUDY SELECTION: Studies conducted between 2005 and 2018 on U.S. population that examined attributes in choosing a pharmacy were eligible for this systematic review. DATA EXTRACTION: Data were independently extracted, assessed, and evaluated by 2 reviewers. Any disagreements were resolved by the third reviewer. Data obtained included year, setting, number of patients, data collection and evaluation methods, and relevant results and outcomes. RESULTS: Of the 713 papers identified, 10 articles met the inclusion criteria and were included in this systematic review. Majority of the studies used surveys to examine key attributes that influence patients' selection of a pharmacy. Pharmacist traits like friendly, helpful, trustworthy, professional, competent, caring, knowledgeable, responsive, and approachable are critical attributes that influence a patient's selection of pharmacy. Convenience (i.e., location, hours of operation, wait time, stock availability) also influenced patients' selection of pharmacy. Cost and contract with insurance were other important factors. Availability of auto-refills appeared consistently in the studies. Medication safety (detecting drug interactions) quality metrics also appeared high among patients' preferences. CONCLUSION: The results of this review found that a relationship with a respectful, friendly, competent pharmacist represents important pharmacist-related attributes in the process of pharmacy selection. Important pharmacy-related attributes include cost, convenience, and wait times. Availability of auto-refill service was also a frequently reported attribute in this review.

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.

Defining the common femoral artery: Insights from the femoral arterial access with ultrasound trial.

OBJECTIVE: We sought to establish the typical location of the common femoral artery (CFA) bifurcation, the origin and most inferior reflection of the inferior epigastric artery (IEA) relative to the femoral head (FH) and whether patient demographics predicted anatomical variations. BACKGROUND: In the absence of ultrasound guidance or prior imaging, the precise location of the CFA bifurcation and IEA can only be determined following access site angiography. Fluoroscopic landmarks are commonly used to estimate the location of the CFA bifurcation, but the position of the IEA is less well characterized. METHODS: Prospectively collected data on 989 patients with femoral angiography in the FAUST trial were analyzed. The level of CFA bifurcation and the origin and most inferior reflection of the IEA were classified by angiography. Logistic regression was used to explore whether baseline demographics were associated with anatomic variations. RESULTS: The CFA bifurcation occurs below the middle 1/3rd of the femoral head in 95% of patients, and no patient factors are predictive of a high bifurcation. The IEA origin has a more variable anatomically pattern, with high BSA, male gender, and white race associated with a low IEA origin. CONCLUSION: Operators should attempt to access the CFA at the level of the middle 1/3rd of the FH to maximize the chance of CFA cannulation. However, this location carries an 11% risk of being at or above the IEA origin. Baseline demographics were of limited utility for predicting anatomic variants of the CFA bifurcation and the course of the IEA. © 2016 Wiley Periodicals, Inc.

PCI in failing saphenous vein grafts: DES trumps BMS for the older patient.

PCI to SVG is considered a higher risk intervention requiring clinical judgment, especially in the elderly who may have the oldest and most degenerated SVG conduits. In a cohort of patients with a median age of 75 years who received PCI to SVG with DES, all-cause mortality was lower compared to those receiving BMS, and no difference in MI or urgent revascularization was observed to 3 years. PCI to SVG using DES may be a viable and perhaps superior treatment option for elderly patients.

Doing a double take: when transthoracic echocardiography fails for mitral valve annuloplasty ring endocarditis with Streptococcus pyogenes: a case report.

BACKGROUND: This case highlights several complications of a late and rare presentation of culture-negative Streptococcus pyogenes endocarditis of a previously repaired mitral valve with an annuloplasty ring including recurrent cardioembolic strokes, which was initially missed on transthoracic echocardiography. CASE PRESENTATION: A 66-year-old Caucasian female with prior mitral valve prolapse status post mitral valve annuloplasty and left atrial appendage occlusion, followed by two strokes, presented with supraventricular tachycardia that resolved spontaneously. During an inpatient admission, she developed symptoms of another stroke, and imaging studies were suggestive of recurrent cardioembolic phenomenon. Additional workup revealed two small intra-atrial masses adherent to the mitral annuloplasty ring missed on prior evaluation for recurrent stroke. She underwent surgical repair in the setting of a chronic culture-negative infectious endocarditis with Streptococcus pyogenes and recovered well with no further cardioembolic phenomenon. CONCLUSION: This case serves to highlight the importance of having a higher index of suspicion in any cardiac prosthesis patient for endocarditis when presenting with symptoms such as recurrent stroke, arrhythmias, and abnormal cardiac lab work. It also demonstrates the need for appropriate imaging with transthoracic echocardiography followed by transesophageal echocardiography and reviews surgical indications to diagnose and treat culture-negative endocarditis.

Disparity between angiographic coronary lesion complexity and lipid core plaques assessed by near-infrared spectroscopy.

OBJECTIVE: The purpose of this study was to determine if there was a relationship between angiographic lesion complexity and the extent of lipid core plaque (LCP) identified by catheter-based near-infrared spectroscopy (NIRS). BACKGROUND: The angiographic complexity of coronary artery disease (CAD) is used to predict outcomes in patients undergoing percutaneous coronary intervention (PCI). The SYNTAX score, an angiographic tool quantifying the complexity of CAD, is associated with PCI outcomes. Recently, a novel catheter-based imaging technique using NIRS can identify LCP, which also is associated with PCI periprocedural myocardial infarction (MI). However, it is unknown whether these events are related to distinct adverse event prone pathobiology, such as a LCP within a complex angiographic lesion. Thus, we hypothesized that LCP identified by NIRS would be associated with high SYNTAX score. METHODS: Seventy-eight patients who underwent coronary angiography and target-vessel NIRS were selected from the Chemometric Observations of Lipid Core Containing Plaques of Interest in Native Coronary Arteries Registry, an industry sponsored registry to collate clinical findings in all patients undergoing NIRS evaluation. A lipid core burden index (LCBI) was obtained from the scan of the proximal 50 mm of the target vessel. Three vessel SYNTAX (total, tSYN) and target single vessel (only NIRS-interrogated vessel) SYNTAX (1vSYN) scores were calculated and compared to LCBI. High LCBI was defined as (>110) and was compared to tertile scores for 1vSYN score (low 0-5, intermediate 6-10, high ≥11) and previously established tertiles for tSYN score (low 0-22, intermediate 23-32, high ≥33). RESULTS: Patients had mean age of 63 years with prevalence of females (10%), diabetes mellitus (28%), hypertension (88%), and smoking history (72%); 1vSYN and tSYN scores correlated poorly with LCBI [(r(2) = 0.25; P = 0.02; n = 78) and (r(2) = 0.24; P = 0.04; n = 78), respectively]. Mean LCBI did not differ significantly across all tertiles of 1vSYN or tSYN scores. CONCLUSIONS: Angiographic SYNTAX score only weakly correlated with LCBI. It is of interest as well that high LCBI was also present in cases of low SYNTAX scores. The disparity between the degree of angiographic complexity and the amount of LCP supports postulated mechanisms of the adverse event propensity even in patients who demonstrate low angiographic complexity. Future studies are necessary to address the clinical significance of high LCBI in patients with low-to-intermediate angiographic complexity and their potential for PCI-related complications.

Shortened Duration of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: A Contemporary Clinical Review.

Percutaneous coronary intervention with stent implantation is an integral aspect of minimally interventional cardiac procedures. The technology and techniques behind stent design and implantation have evolved rapidly over several decades. However, continued discourse remains around optimal peri- and post-interventional management with dual antiplatelet therapy to minimise both major cardiovascular or cerebrovascular events and iatrogenic bleeding risk. Standard guidelines around dual antiplatelet therapy historically recommended long-term dual antiplatelet therapy for 12 months (with consideration for >12 months in certain patients); however, emerging data and generational improvements in the safety of drug-eluting stents have ushered in a new era of short-term therapy to reduce the incidence of major bleeding events. This case review will provide an overview of the current state of guidelines around duration of dual antiplatelet therapy and examine recent updates and continued gaps in existing research.

Asymmetric focal pericardial thickening causing physiologically significant constrictive pericarditis.

A 34-year-old woman presented with refractory ascites and edema. Echocardiography revealed normal left ventricular function with a restrictive diastolic filling pattern. Tissue Doppler velocities of the mitral annulus were normal. Cardiac magnetic resonance imaging (MRI) revealed a focal region of pericardial thickening anterior to the right ventricle and normal thickness pericardium in the other segments. However, abnormal delayed enhancement MRI (consistent with inflammation) was present in both the thickened and the normal pericardial segments. Invasive hemodynamics confirmed constrictive physiology and the patient underwent successful pericardiectomy. This case highlights the utility of multimodality imaging in the diagnosis of constrictive pericarditis and the underappreciated fact that the pericardium need not be globally thickened to cause hemodynamically significant constrictive physiology.

Unique morphological variations of transient midventricular syndrome: a case series-review.

Older individuals (especially women) enduring an inciting emotional or physical event are prone to developing left ventricular ballooning syndrome. Ballooning of apical distribution is the most common type. However, a midventricular variant is increasingly reported. As this variant becomes further delineated, we describe a case series in which various morphological patterns of midleft ventricular segments are seen. Each case involves a female patient with a presumptive diagnosis of acute coronary syndrome, who upon further cardiac workup demonstrated normal epicardial coronary blood flow. Subsequent cardiac imaging, including transthoracic echocardiography, revealed unique midventricular dilation and akinesis, with preserved or hypercontractility of the basal and apical segments. However, more unique to this, was the fact that the left ventricular regional wall motion abnormalities were of either "symmetric" ballooning morphology, involving all mid segments of the left ventricle; or more dramatically, "asymmetric" ballooning morphology, which involves abnormal regional motion of only a focal left ventricular wall. Furthermore, we review current literature on midventricular ballooning and propose likely mechanisms and optimal treatment strategies in the face of potential complications of midventricular ballooning syndrome.

Right heart failure in the setting of thyrotoxic valvulopathy: the pathophysiology of an often neglected diagnosis: a case report.

Background: Hyperthyroidism has a significant, well-established impact on the cardiovascular system on both a molecular and circulatory level. The cardiac consequences of thyrotoxicosis are not uncommon, indicated by a 1.2% prevalence of this disorder in the United States. However, our case describes the less widely observed association between thyrotoxicosis and valvulopathy. Case summary: A 69-year-old Hispanic male presented with a 3-week history of shortness of breath, intermittent chest pain, and lower extremity swelling. Transthoracic echocardiogram revealed a dilated left and right atrium with severe tricuspid regurgitation, moderate mitral regurgitation, malcoaptation of the tricuspid valve leaflets, and a myxomatous mitral valve. In addition, right ventricular systolic function was moderately reduced. A right and left heart catheterization was performed with findings of normal right heart pressures and normal coronary arteries, respectively. To further evaluate the aetiology of the patient's heart failure, thyroid studies were sent, revealing a thyroid-stimulating hormone value of <0.010 uIU/mL and a free T4 of 1.96 ng/dL. A 4.9 cm lesion was seen on thyroid ultrasound. We concluded that the patient's heart failure and notable valvular abnormalities were likely as a result of thyrotoxic heart disease. Furosemide and methimazole were initiated while inpatient, and the patient was discharged with close follow-up. Discussion: We demonstrate a unique case of the possible hemodynamic and cellular effects of thyroid hormone on the development of primary and secondary valve dysfunction. This association is important for clinicians to be aware of, as treatment of its underlying aetiology can lead to improvement in a patient's cardiac outcomes.

Transcatheter closure of a mechanical perivalvular leak using real-time three-dimensional transesophageal echocardiography guidance.

A 47-year-old female with symptomatic mitral stenosis from a prior undersized mitral annuloplasty ring underwent mitral valve replacement with a mechanical valve. Later, she developed heart failure from a severe paravalvular leak (PVL). Because of the excessive mortality risks from a possible third open heart procedure, the patient was instead referred for transcatheter PVL closure. Standard fluoroscopy, invasive hemodynamics, and two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) imaging were performed during device placement with excellent image quality. The case highlights the unique benefit of 3D TEE imaging for preprocedure sizing, guidance of device deployment intraprocedure, and confirmation of PVL closure.

Association of social risks with avoiding or delaying health care and with emergency department visits: evidence from 2017 Ohio Medicaid Assessment Survey.

OBJECTIVES: The primary aim was to examine the association of social risks with avoiding/delaying health care after controlling for sociodemographic covariates, and the secondary aim was to examine the association of social risks with emergency department (ED) visits after controlling for avoiding/delaying health care and sociodemographic covariates. STUDY DESIGN: 2017 Ohio Medicaid Assessment Survey data were analyzed. METHODS: Descriptive, bivariate analysis and multiple weighted logistic regressions were conducted. First, weighted logistic regression assessed the association of aggregated social risk (food insecurity, housing instability, financial strain) and health insurance type with avoiding/delaying health care after controlling for sociodemographic covariates. Next, weighted logistic regression assessed the association of social risks with ED visits after controlling for avoiding/delaying health care and sociodemographic covariates. RESULTS: Among 39,711 respondents, 21.7% reported avoiding/delaying health care and 27.2% reported having at least 1 ED visit in the past year. Individuals with higher vs lower aggregated social risk had higher odds of avoiding/delaying health care (odds ratio [OR], 1.30; 95% CI, 1.26-1.34) and were more likely to have any ED visits (OR, 1.10; 95% CI, 1.07-1.13). Uninsured individuals compared with those with private insurance were more likely to avoid/delay health care (OR, 1.98; 95% CI, 1.73-2.26) and have higher likelihood of any ED visits (OR, 1.23; 95% CI, 1.06-1.42). Finally, individuals who reported avoiding/delaying getting health care were more likely to have higher odds of any ED visits (OR, 1.33; 95% CI, 1.23-1.45). CONCLUSIONS: Social risks are important factors in patients' decisions to avoid/delay health care and are associated with increased odds of any ED visits. To reduce ED visits, policy-level efforts need to be made to address these social challenges.

A rare case of a right atrial lipoma originating from the superior vena cava: review, diagnosis and management.

Primary cardiac tumors are usually found incidentally on imaging and are much less common than tumors that metastasize to the heart. Cardiac lipomas are benign cardiac tumors that are usually found in the right atrium or left ventricle. Primary intravascular venous lipomas of the great cardiac vessels are extremely rare and there are few reported cases of a lipoma originating from the superior vena cava causing direct compressive intracardiac effects. Here we describe a case of a symptomatic right atrial lipoma originating from the superior vena cava.

Early recognition of catheter-induced left main coronary artery vasospasm: implications for revascularization.

Catheter-induced left main coronary artery (LMCA) vasospasm is a rare complication of coronary angiography that confounds the decision for coronary artery bypass graft (CABG) surgery. We report two cases of catheter-induced LMCA vasospasm. The first case was a 68-year-old woman who presented 6 years after CABG for presumed severe LMCA atherosclerotic disease. Coronary angiography demonstrated totally occluded CABGs and normal native coronary arteries, including a normal LMCA. The second case was a 56-year-old man with severe LMCA stenosis, who was scheduled for unprotected LM percutaneous coronary intervention (PCI). Repeat angiography 2 days later showed no stenosis. These cases emphasize the need for meticulous technique and a high index of suspicion of LMCA vasospasm. Intravascular ultrasound (IVUS) at the time of angiography may help to identify minimal atherosclerotic disease suggesting vasospasm. Alternatively, noninvasive testing, such as computed tomography (CT) angiography, may diagnose LM spasm in these patients prior to CABG surgery.

Influence of obstructive sleep apnea and treatment with continuous positive airway pressure on fractional flow reserve measurements for coronary lesion assessment.

Obstructive sleep apnea (OSA) and sleep-disordered breathing have been implicated in the progression of cardiovascular disease and with increased risk of coronary artery disease, congestive heart failure, and stroke. Fractional flow reserve (FFR) is used to evaluate the physiological significance of coronary artery stenosis, and this technique is largely thought to be independent of systemic hemodynamic changes. Herein, we describe a case of OSA and sleep-disordered breathing cyclically altering FFR measurements from normal to abnormal in a patient with coronary artery disease. More specifically, we show that the abnormal FFR across a coronary lesion in a patient with sleep disordered apnea improves (to a normal threshold) with the initiation of continuous positive airway pressure (CPAP). This finding may have implications for the mechanisms of cardiac dysfunction in patients with OSA.