Growth Differentiation Factor 15 (GDF-15), a New Biomarker in Heart Failure Management.

The emergence of biomarkers across medicine's subspecialties continues to evolve. In essence, a biomarker is a biological observation that clearly substitutes a clinical endpoint or intermediate outcome not only are more difficult to observe but also, biomarkers are easier, less expensive and could be measured over shorter periods. In general, biomarkers are versatile and not only used for disease screening and diagnosis but, most importantly, for disease characterization, monitoring, and determination of prognosis as well as individualized therapeutic responses. Obviously, heart failure (HF) is no exception to the use of biomarkers. Currently, natriuretic peptides are the most used biomarkers for both diagnosis and prognostication, while their role in the monitoring of treatment is still debatable. Although several other new biomarkers are currently under investigation regarding diagnosis and determination of prognosis, none of them are specific for HF, and none are recommended for routine clinical use at present. However, among these emerging biomarkers, we would like to highlight the potential for growth differentiation factor (GDF)-15 as a plausible new biomarker that could be helpful in providing prognostic information regarding HF morbidity and mortality.

Cardiogenic shock in autoimmune rheumatologic diseases: an insight on etiologies, management, and treatment outcomes.

Autoimmune rheumatological disorders are known to have an increased risk for cardiovascular diseases including coronary artery disease (CAD), myocarditis, pericarditis, valvulopathy, and in consequence cardiogenic shock. Data on cardiogenic shock in rheumatological diseases are scarce; however, several reports have highlighted this specific entity. We sought to review the available literature and highlight major outcomes and the management approaches in each disease. Systematic literature search, including PubMed, Ovid/Medline, Cochrane Library, and Web of Science, was conducted between January 2000 and December 2009. We reviewed all cases reporting cardiogenic shock with rheumatologic conditions, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Takayasu's arteritis (TA), granulomatosis with polyangiitis (GPA), giant cell arteritis (GCA), and antiphospholipid syndrome (APS). We selected 45 papers reporting a total of 48 cases. Mean age was 39 ± 7.3 years and 68.8% were females. Most common rheumatologic conditions associated with cardiogenic shock were SLE (31%), GPA (23%), TA (14.6%), APA (10.4%), and RA (8.3%). Cardiogenic shock was found to be caused by eosinophilic myocarditis in 58% of cases, CAD in 19% of cases, and valvulopathy in 6% of cases. Most patient required high-dose steroids and second immunosuppressant therapy. Mechanical circulatory supported was required in 23 cases, IABP in 16 cases, and ECMO in 12 cases. Complete recovery occurred in 37 patients while 9 patients died and 2 required heart transplant. Responsible for two-thirds of cases, eosinophilic myocarditis should be suspected in young cardiogenic shock patients with underlying rheumatologic conditions. Lupus and GPA are the two most common conditions.

Cardiovascular Predictors of Intracerebral Hematoma Expansion.

BACKGROUND: There is limited evidence on the effect and relevance of cardiovascular parameters on the cerebrovascular system when an intracerebral hemorrhage (ICH) occurs. While recent studies evaluating this relationship are conflicting, one evaluating the effect of systolic cardiac function on clinical outcomes in ICH patients, found low cardiac ejection fractions to be associated with poor clinical outcomes. Our primary objective was to study such correlations and identify various cardiovascular disease states that may be associated with hematoma expansion. METHODS: This is an IRB-approved single-center retrospective study utilizing our institutional "Get with the Guidelines"-Stroke registry between 2013 and 2017. Patients included were older than 18 years of age, admitted with an acute ICH, and had an echocardiogram during their hospitalization. Univariate and multivariate logistical regression analyses were used to identify cardiovascular predictors of hematoma expansion. RESULTS: Two-hundred forty-nine patients were identified from our GWTG-S registry that met initial inclusion criteria. Of these patients, a history of peripheral arterial disease (PAD) (p = 0.015), presence of aortic stenosis (AS) on the echocardiogram (p = 0.025), and a positive spot sign on the CT-angiogram (CTA) of the head (p < 0.001) were found to be independently associated with ICH expansion. Both a history of hypertension and elevated blood pressure on presentation were not significant predictors. Additionally, patients with a history of congestive heart failure had decreased odds of hematoma expansion (p = 0.027). CONCLUSION: This exploratory study highlights potential novel cardiac predictors of hematoma expansion, including PAD and AS, which warrant further study. Larger prospective studies are needed to further investigate such associations to ultimately optimize cardio-cerebral health.

Impact of chronic kidney disease on in-hospital outcomes and readmission rate after edge-to-edge transcatheter mitral valve repair.

BACKGROUND: Transcatheter mitral valve repair (TMVR) is a treatment option for patients with 3+ or greater mitral regurgitation who cannot undergo mitral valve surgery. Outcomes in patients with chronic kidney disease (CKD) and end stage renal disease (ESRD) are unclear. We sought to evaluate the TMVR in-hospital outcomes, readmission rates and its impact on kidney function. METHODS: Data from 2016 National Readmission Database was used to obtain all patients who underwent TMVR. Patients were classified by their CKD status: no CKD, CKD, or ESRD. The primary outcomes were: in-hospital mortality, 30- and 90-day readmission rate, and change in CKD status on readmission. Multivariable logistic regression analysis was used to assess in-hospital, readmission outcomes and kidney function stage. RESULTS: A total of 4,645 patients were assessed (mean age 78.5 ± 10.3 years). In-hospital mortality was higher in patients with CKD (4.0%, odds ratio [OR]:2.01 [95% CI, confidence interval: 1.27-3.18]) and ESRD (6.6%, OR: 6.38 [95% CI: 1.49-27.36]) compared with non-CKD (2.4%). 30-day readmission rate was higher in ESRD versus non-CKD patients (17.8% vs. 10.4%, OR: 2.24 [95% CI: 1.30-3.87]) as was 90-day readmission (41.2% vs. 21% OR: 2.51 [95% CI:1.70-3.72]). Kidney function improved in 25% of patients with CKD stage 3 and in 50% with CKD stage 4-5 at 30-and 90-day readmission. Incidence of AKI, major bleeding, and respiratory failure were higher in CKD group. CONCLUSIONS: Patients with CKD and ESRD have worse outcomes and higher readmission rate after TMVR. In patients who were readmitted after TMVR, renal function improved in some patients, suggesting that TMVR could potentially improve CKD stage.

Impact of cardiovascular comorbidities on inpatient mortality in patients hospitalized with neutropenic fever.

INTRODUCTION: Concomitant cardiovascular comorbidities in patients with cancer are not uncommon. There is limited data on the impact of cardiovascular comorbidities on in-hospital mortality in patients admitted with neutropenic fever. METHODS: This is a retrospective cohort study using the 2016 NIS database of adults (> 18 years old) hospitalized for neutropenic fever as the primary diagnosis. The primary outcome studied is all-cause mortality in patients with neutropenic fever. ICD-10-CM codes were used to identify cardiovascular risk factors including smoking; hyperlipidemia; peripheral vascular diseases; hypertension; history of cerebrovascular disease or transient ischemic attack; and cardiovascular morbidities including atrial fibrillation, coronary artery disease, and congestive heart failure. Multivariate linear regression analysis was used to adjust for cofounders. RESULTS: A total of 28,060 patients were admitted with neutropenic fever in 2016. Average age was 43.9 ± 1.7 years, and 49.3% were females. Among the cases identified, 205 patients died during hospitalization with an overall in-hospital mortality of 0.7%. Atrial fibrillation was independently associated with higher in-hospital mortality (odds ratio [OR] 3.01; CI 1.38 to 6.57; p = 0.005) as was congestive heart failure (OR 3.15; CI 1.08 to 10.14; p = 0.049). CONCLUSION: Atrial fibrillation and congestive heart failure were associated with higher inpatient mortality in patients with neutropenic fever. Identifying the risk factors for increased mortality in patients with neutropenic fever is important for risk stratification and guiding clinicians in taking therapeutic decisions in this set of patients.

Readmissions Rates After Myocardial Infarction for Gastrointestinal Bleeding: A National Perspective.

BACKGROUND AND AIMS: Gastrointestinal (GI) bleeding is one most common complications of acute myocardial infarction (AMI). We aimed to determine the incidence, in-hospital outcomes, associated healthcare burden and predictors of GI bleeding within 30 days after AMI. METHODS: Data were extracted from Nationwide Readmission Database 2010-2014. Patients were included if they had a primary diagnosis of ST or non-ST elevation myocardial infarction. Exclusion criteria were admissioned in December, aged less than 18 years and a diagnosis of type-2 MI. The primary outcome was 30-day readmission with upper or lower GI bleeding. Secondary outcomes were in-hospital mortality, etiology of bleeding, in-hospital complications, procedures, length of stay, and total hospitalization charges. Independent predictors of readmission were identified using multivariate logistic regression analysis. RESULTS: Out of the 3,520,241 patients discharged with ACS, 10,018 (0.3%) were readmitted with GI bleeding within 30 days of discharge. 60% had lower GI bleeding. Most common sources suspected were GI cancers in 17% and hemorrhoidal bleeding in 10%. In hospital mortality rate for readmission was 3.6%. Independent predictors of readmission were age, Charlson comorbidity score, history of chronic kidney disease, GI tumor, inflammatory bowel disease and artificial heart valve. Type of treatment for AMI had no impact on readmission. Patients readmitted had higher rates of shock (adjusted odds ratio, 1.48, 95% CI 1.01-3.72). CONCLUSIONS: In the first nationwide study, 30-day incidence of GI bleeding after AMI is 0.3%. GI bleeding complicating AMI carries a substantial in-hospital mortality and cost of care.

In-hospital outcomes of transcatheter versus surgical mitral valve repair in patients with chronic liver disease.

BACKGROUND: Mitral valve transcatheter edge-to-edge repair (TEER) using MitraClip is a treatment option for patients with moderate to severe mitral regurgitation who are not surgical candidate. Liver cirrhosis is associated with higher operative morbidity and mortality; however, it is not part of preoperative risk assessments calculators. We sought to evaluate the in-hospital outcomes in TEER and surgical mitral valve repair (SMVR) in liver cirrhosis. METHODS: National Inpatient Database from 2013 to 2017 was used to obtain all patients with cirrhosis who underwent TEER or SMVR using ICD-9-CM and ICD-10-CM codes. The primary outcome is to compare inpatient mortality between TEER and SMVR. Secondary outcomes were assessed including length of stay (LOS) and rate of complications including cardiogenic shock, blood transfusion and prolonged ventilation. RESULTS: A total of 875 patients with cirrhosis who underwent TEER (n = 123) or SMVR (n = 752) were identified in our analysis. Patients with TEER had significantly higher comorbidities such as congestive heart failure, coronary artery disease and chronic obstructive pulmonary disease. In-hospital mortality was lower in TEER group (8.2% vs 16%, P = .04). TEER was associated with lower rates of blood transfusion (30.3% vs 61.2%, P = .02) and reduced rates of prolonged mechanical ventilation (1.2% vs 17.2%, P = .042). In multivariate regression analysis, both blood transfusion and prolonged mechanical ventilation were significant predictors of mortality in liver cirrhosis. CONCLUSIONS: TEER was associated with lower rate of in-hospital mortality, LOS, blood transfusion and prolonged mechanical ventilation in cirrhosis patients. TEER can be considered as a viable option for cirrhosis patient with severe mitral regurgitation.

Role of Non-Perfusion Factors in Mildly Symptomatic Large Vessel Occlusion Stroke.

INTRODUCTION: Uncertainty regarding reperfusion of mildly-symptomatic (minor) large vessel occlusion (LVO)-strokes exists. Recently, benefits from reperfusion were suggested. However, there is still no strong data to support this. Furthermore, a proportion of those patients don't improve even after non-hemorrhagic reperfusion. Our study evaluated whether or not non-perfusion factors account for such persistent deconditioning. METHODS: Patients with identified minor LVO-strokes (NIHSS ≤ 8) from our stroke alert registry between January-2016 and May-2018 were included. Variables/ predictors of outcome were tested using univariate/multivariate logistic and linear regression analyses. Three month-modified ranking scale (mRS) was used to differentiate between favorable (mRS = 0-2) and unfavorable outcomes (mRS = 3-6). RESULTS: Eighty-one patients were included. Significant differences between the two outcome groups regarding admission-NIHSS and discharge-NIHSS existed (OR = 0.47, 0.49 / p = 0.0005, <0.0001 respectively).The two groups had matching perfusion measures. In the poor outcome group, discharge-NIHSS was unchanged from the admission-NIHSS while in the good outcome group, discharge-NIHSS significantly improved. CONCLUSION: Admission and discharge NIHSS are independent predictors of outcome in patients with minor-LVO strokes. Unchanged discharge-NIHSS predicts worse outcomes while improved discharge-NIHSS predicts good outcomes. Unchanged NIHSS in the poor outcome group was independent of the perfusion parameters. In literature, complement activation and pro-inflammatory responses to ischemia might account for the progression of stroke symptoms in major-strokes. Our study concludes similar phenomena might be present in minor-strokes. Therefore, discharge-NIHSS may be useful as a clinical marker for future therapies.

The Significance of Contrast Density of the Computed Tomography-Angiographic Spot Sign and its Correlation with Hematoma Expansion.

BACKGROUND AND PURPOSE: The computed tomography angiographic (CTA) spot sign has been shown to predict hematoma expansion in patients with intracranial hemorrhage (ICH), but the significance of the spot sign density (SSD) and the spot sign ratio (SSR) has not yet been explored. METHODS: Using the institutional Neurocritical care and Stroke registry, we retrospectively reviewed patients with ICH from January-2013 to June-2017. We selected patients who had baseline CT-head (CTH), CTA with positive-spot sign within 6 hours of last known well and at least one follow-up CTH within 24 hours. Baseline demographics and variables known to affect hematoma-volume were collected. Hematoma-volumes and SSR were calculated using computer-assisted 3D-volumetric measurement and the average of the surrounding hematoma density divided by the SSD, respectively. The 2-sample t test and the area-under-the-curve (receiver operating characteristic) were used to detect the association between hematoma expansion and outcome at discharge. RESULTS: A total of 320 patients were reviewed; 22 met the inclusion criteria. Significant hematoma expansion (volume expansion ≥12.5 cc or ≥33% compared to baseline) was noted in 14 (64%) subjects. SSD was significantly higher in subjects with hematoma expansion (216 ± 66) than those without (155 ± 52, P = .036). With a cut-off SSD of ≥150 HU, we had sensitivity of 86% and specificity of 75%. For SSR, lower ratios suggested a trend toward hematoma expansion, although it was not statistically significant (P = .12). There was no significant correlation between SSD or SSR and modified ranking scale at discharge and after 3-6 months. CONCLUSION: SSD might be a good predictor of hematoma growth. Although SSR showed a trend toward expansion, results were not statistically significant.

Nonobstructive epicardial coronary artery disease: an evolving concept in need of diagnostic and therapeutic guidance.

For decades, we have been treating patients presenting with angina and concerning electrocardiographic changes indicative of ischemia or injury, in whom no culprit epicardial coronary stenosis was found during diagnostic coronary angiography. Unfortunately, the clinical outcomes of these patients were not better than those with recognized obstructive coronary disease. Improvements in technology have allowed us to better characterize these patients. Consequently, an increasing number of patients with ischemia and no obstructive coronary artery disease (INOCA) or myocardial infarction in the absence of coronary artery disease (MINOCA) have now gained formal recognition and are more commonly encountered in clinical practice. Although both entities might share functional similarities at their core, they pose significant diagnostic and therapeutic challenges. Unless we become more proficient in identifying these patients, particularly those at higher risk, morbidity and mortality outcomes will not improve. Though this field remains in constant flux, data continue to become available. Therefore, we thought it would be useful to highlight important milestones that have been recognized so we can all learn about these clinical entities. Despite all the progress made regarding INOCA and MINOCA, many important knowledge gaps continue to exist. For the time being, prompt identification and early diagnosis remain crucial in managing these patients. Even though we are still not clear whether intensive medical therapy alters clinical outcomes, we remain vigilant and wait for more data.

Emerging Trends in Atherosclerosis: Time to Address Atherosclerosis From a Younger Age.

Over the past two decades, research efforts into cardiovascular disease (CVD) have uncovered findings that fundamentally challenge our understanding of CVD, particularly atherosclerosis. Atherosclerosis was primarily attributed to the well-described abnormal lipid accumulation theory, involving plaque growth with subsequent plaque hemorrhage resulting in acute vessel thrombosis that may or may not rupture. This perspective has now evolved to encompass more complex pathways, wherein the accumulation of abnormal products of oxidation and inflammation is the most likely factor mediating atherosclerotic plaque growth. Furthermore, atherosclerosis was traditionally thought of as a disease in patients aged 40 and older. However, mounting evidence has demonstrated that significant atherosclerosis and CVD events are more prevalent in younger patients than previously realized and accelerating in incidence. With this alarming trend among younger individuals, our review sought to explore why this trend may be happening and what can be done about this developing problem.

Improving diagnostic assessments in the ever-changing landscape of atherosclerosis.

As our understanding of atherosclerotic vascular injury continues to evolve, so should our diagnostic approaches. Emerging data have recently challenged our basic understanding in linking ischemia to its adverse outcomes as well as the need for invasive testing for both diagnosis and treatment. The advent of coronary computed tomography in providing improved visualization of coronary arteries has led to the identification of both subclinical atherosclerosis and high-risk coronary lesions. Recognition of asymptomatic coronary artery disease (CAD) with objective localization of subclinical coronary atherosclerosis improves atherosclerotic cardiovascular risk assessment and allows healthcare providers to take effective primary prevention measures. Therefore, reshaping the diagnostic landscape in proposing new testing modalities would be highly dependent on local resource availability and the reading expertise of each clinical practice and medical institution. The main objective of this Review is to propose a potentially new diagnostic approach of simply using noninvasive stress testing or coronary angiography in the routine assessment of CAD.

Role of Cardiac Biomarkers in Monitoring Cardiotoxicity in Chemotherapy Patients.

PURPOSE: This review aims to highlight the different types of chemotherapy-induced cardiotoxicity and will discuss the evidence base behind the use of different cardiac biomarkers to predict cardiovascular complications. Additionally, we will review the use of cardiac biomarkers to monitor cardiac outcomes and the role of cardioprotective medications in reducing cardiovascular side effects. RECENT FINDINGS: Chemotherapy has been linked to an increased risk of cardiotoxicity and heart failure. Currently, patients receiving chemotherapy undergo echocardiogram before starting chemotherapy and every 6 months to monitor for any decline in cardiac function. We reviewed the current evidence and practice guidelines of monitoring chemotherapy cardiotoxicity. SUMMARY: Cardio-oncology is a rapidly evolving subspecialty in cardiology, especially with the advent of new chemotherapeutic agents, which have cardiovascular side effects. Early detection of these effects is crucial to prevent life-threatening and irreversible cardiovascular outcomes. Monitoring troponin, pro-brain natriuretic peptide, and other cardiac biomarkers during chemotherapy will help to early detect cardiotoxicity.

Vasospastic Angina With ST-Segment Elevation Seen During Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring.

A 54-year-old man presented with significant ST-segment elevations noted on both channels displayed on the mobile cardiac outpatient telemetry (MCOT). Pertinent cardiac history was remarkable for syncope and episodes of atypical chest pain. The latter were described as infrequent and not associated with exercise intolerance. His syncopal episodes were described as occurring mostly in the mornings after the use of the restroom. Episodes happen 1 or 2 times a year since 2015. Patient had undergone thorough investigation with no significant findings. An MCOT was prescribed since frequency of symptoms has recently increased. Significant ST-segment elevations were noted. The patient described atypical chest pain and a sensation of presyncope during these recordings. He was urgently admitted, and a coronary angiogram revealed no epicardial luminal stenosis. However, the presence of sluggish coronary flow was suggestive of possible vasospastic angina. No ST-segment changes were noted during his coronary angiogram. The remarkable element portrayed by this case hinges in showing the unique utility of MCOT, as the most uncharacteristic diagnostic tool, in identifying transient ST-segment elevations that finally led to the diagnosis.

Early repolarization: Electrocardiographic cues to distinguish benign from malignant variants.

Historically, early repolarization (ER) has been considered a marker of good health as it is more prevalent in athletes, younger persons, and at slower heart rates. However, contemporary reports, largely based on data from resuscitated sudden cardiac arrest patients, suggest an association between ER and an increased risk for sudden cardiac death and the development of malignant ventricular arrhythmias. Therefore, after we present a brief-case presentation, we intend to review a challenging topic in recognition of malignant variants and propose a four-step comprehensive approach to simplify ECG discrimination when assessing ER changes.

Epigenetic Regulation and its Effects on Aging and Cardiovascular Disease.

Cardiovascular disease (CVD), specifically coronary atherosclerosis, is regulated by an interplay between genetic and lifestyle factors. Most recently, a factor getting much attention is the role epigenetics play in atherosclerosis; particularly the development of coronary artery disease. Furthermore, it is important to understand the intricate interaction between the environment and each individual genetic material and how this interaction affects gene expression and consequently influences the development of atherosclerosis. Our main goal is to discuss epigenetic regulations; particularly, the factors contributing to coronary atherosclerosis and their role in aging and longevity. We reviewed the current literature and provided a simplified yet structured and reasonable appraisal of this topic. This role has also been recently linked to longevity and aging. Epigenetic regulations (modifications) whether through histone modifications or DNA or RNA methylation have been shown to be regulated by environmental factors such as social stress, smoking, chemical contaminants, and diet. These sensitive interactions are further aggravated by racial health disparities that ultimately impact cardiovascular disease outcomes through epigenetic interactions. Certainly, limiting our exposure to such causative events at younger ages seems our "golden opportunity" to tackle the incidence of coronary atherosclerosis and probably the answer to longevity.

Profiling Cardiometabolic Health in Jordan: A Call to Action to Improve Cardiovascular Health.

Over the past decades, Jordan has witnessed unprecedented growth in the prevalence of cardiometabolic diseases, with a crude prevalence of 48.2% in 2020, up from 38% in 2009. This is slightly higher than the reported prevalence of 40% in the US population. According to the latest World Health Organization report published in 2020, Jordan's leading cause of mortality is cardiovascular diseases with a cause-specific mortality rate of 18.6%. Since the advancement of the healthcare system in Jordan took place in the early 2000s, Jordan has witnessed a major epidemiologic transition where the burden of infectious disease has decreased, but on the other hand, the burden of cardiometabolic disease has increased as well. For such a country with limited resources and healthcare infrastructure where two-thirds of its population is below the age of 30, this is alarming. This growth can be attributed to a complex interplay between genetic and lifestyle factors. Smoking, physical inactivity, obesity, and unhealthy diet are considered major public health problems in Jordan, as reported in 2007 by the Jordanian Behavioral Risk Factor Surveillance. We attempt to raise awareness through this review article, so healthcare providers in Jordan understand the magnitude of the issue, and appropriate steps are taken to reestablish screening and management guidelines pertaining to cardiometabolic diseases in Jordan.

Heart Failure with Preserved Left Ventricular Ejection Fraction: A Complex Conundrum Simply Not Limited to Diastolic Dysfunction.

Over the last two decades, the changing paradigm of heart failure with preserved ejection fraction (HFpEF) has transformed our understanding not only of the pathophysiology of this clinical entity but also the diagnostic and therapeutic approaches aimed at treating this complex patient population. No longer HFpEF should be seen as simply left ventricular diastolic dysfunction but as a group of that in addition of having small and thick left ventricles with abnormal diastolic filling patterns as their main pathophysiologic abnormality; they also have whole host of different abnormalities. In fact, this heterogeneous clinical entity embodies numerous mechanisms and is linked to multiorgan dysfunction, with hypertension and obesity playing a major role. Although we have gained an enormous amount of understanding not only on the causes but also the downstream effects of HFpEF, there is still much to be learned before we can fully comprehend this complex clinical entity. It is the main intention of this review to synthesize the most recent attributes, mechanism, diagnostic tools, and most useful therapeutic alternatives to be considered when evaluating patients either complaining of dyspnea on exertion as well as exercise intolerance or those recently admitted with HF symptoms but with normal LVEF in the absence of any other valvular abnormalities.

Our Hidden Enemy: Ultra-Processed Foods, Inflammation, and the Battle for Heart Health.

Over the past few decades, we have witnessed unprecedented growth in new data that has fundamentally changed our traditional understanding of the progression of atherosclerotic plaques, as well as our strategies for preventing cardiovascular diseases, especially atherosclerosis. It was once believed that atherosclerosis was primarily caused by abnormal lipid buildup in the vessel intima, leading to plaque growth and luminal stenosis, with or without rupture. This perspective has now evolved to encompass more complex pathways, wherein the accumulation of abnormal products of oxidation and inflammation are the most likely factors mediating the growth of atherosclerotic plaques. The review aims to provide a comprehensive and detailed exploration of the relationship between ultra-processed foods, chronic inflammation, cardiovascular diseases, obesity, insulin resistance, and the role of the gut microbiota. It touches on several important aspects of modern diet and health.

National Trends of Percutaneous Mechanical Support Utilization During Percutaneous Coronary Interventions in Chronic Total Occlusion.

Coronary chronic total occlusion (CTO) is common in patients with multivessel coronary artery disease. Percutaneous coronary artery (PCI) interventions have shown favorable outcomes in patients with CTO. Nevertheless, the data regarding the utilization of mechanical circulatory support in CTO PCIs is not well established. We sought to investigate the trends in utilization and periprocedural complications in this population. Using the National Inpatient Sample database from 2011 to 2019, we identified patients diagnosed with CTO who underwent PCI. We investigated the presence of a linear trend in the utilization of mechanical circulatory support (MCS) during those procedures and the associated periprocedural complications using the Cochran-Armitage method. A total of 208,123 patients who were diagnosed with CTO and underwent PCI from 2011 to 2019, of which in 6,319 patients MCS was used during the procedure. Patients in the MCS group were older (67.4 vs 66.4 years), less likely to be women (24.0% vs 26.4%), and equally likely to be African-American (9.4% vs 8.8%) with a higher burden of co-morbidities in terms of coronary artery disease, congestive heart failure, and atrial fibrillation (p <0.001 for all). Using the Cochrane-Armitage method, we found a statistically significant linear uptrend in the utilization of MCS from 269 (1.4%) to 990 cases (7.0%) from 2011 to 2019. Using multivariable logistic regression, female gender, renal failure, alcohol abuse, coagulopathy, and fluid and electrolyte disorders were identified as independent predictors of mortality in CTO PCI procedures assisted with MCS (p ≤0.007). In conclusion, the utilization of MCS in CTO PCI procedures has been increasing over the years. Female gender and renal failure are independently associated with a higher mortality risk.