Same day discharge following non-elective PCI for non-ST elevation acute coronary syndromes.

BACKGROUND AND AIM: Timing of discharge after percutaneous coronary intervention (PCI) is a crucial aspect of procedural safety and patient turnover. We examined predictors and outcomes of same-day discharge (SDD) after non-elective PCI for non-ST elevation acute coronary syndromes (NSTE-ACS) in comparison with next-day discharge (NDD). METHODS: Baseline demographic, clinical, and procedural data were collected as were in-hospital outcomes and post-PCI length of stay (LOS) for all patients undergoing non-elective PCI for NSTE-ACS between 2011 and 2014 at a central tertiary care center. Thirty day and 1-year mortality and bleeding as well as 30-day readmission rates were determined from social security record and medical chart review. Logistic regression was performed to identify predictors of SDD, and propensity-matched analysis was done to examine the differences in outcomes between NDD and SDD. RESULTS: Out of 2,529 patients who underwent non-elective PCI for NSTE-ACS from 2011 to 2014, 1,385 met the inclusion criteria (mean age = 63 years; 26% women) and were discharged either the same day of (N = 300) or the day after (N = 1,085) PCI. Thirty-day and one-year mortality and major bleeding rates were similar between the 2 groups. Logistic regression identified male sex, radial access, negative troponin biomarker status, and procedure start time as predictors of SDD. In propensity-matched analyses, there was no difference in 30-day mortality and readmission between SDD and NDD groups. CONCLUSIONS: SDD after non-elective PCI for NSTE-ACS may be a reasonable alternative to NDD for selected low-risk patients with comparable mortality, bleeding, and readmission rates.

Trends, Predictors, and Outcomes Associated With 30-Day Hospital Readmissions After Percutaneous Coronary Intervention in a High-Volume Center Predominantly Using Radial Vascular Access.

BACKGROUND AND AIM: Patients undergoing percutaneous coronary intervention (PCI) are at high-risk for hospital readmission. We examined the rate, factors associated with, and outcomes of 30-day readmissions for patients who underwent a PCI. METHODS: We reviewed medical records of all patients who underwent PCI between 2011 and 2014 at a central New England radial first, tertiary care center. Data was collected on occurrence and cause of readmission as well as patients' bleeding events and survival at one year. Logistic regression was used to examine factors associated with 30-day readmission as well as its association with bleeding and all-cause mortality. RESULTS: A total of 3858 patients were studied (mean age = 62.8 years with 26.1% women), among whom 348 (9.5%) patients were readmitted within 30-days. Cardiac causes of readmission represented 62% of all readmissions. In the multi-variable adjusted regression model, factors that were significantly associated with 30-day readmission included female gender, prior coronary bypass surgery, acute coronary syndrome, anemia, length of stay, and delay in initial presentation. Patients who were readmitted had more than twice the risk of bleeding and mortality at one year as compared to those who were not readmitted within 30 days. CONCLUSIONS: In conclusion, our results suggest that early hospital readmission after undergoing PCI is common and has not changed in recent years. Efforts should be made to identify and closely monitor patients who are at risk for readmission after PCI.

Recent Trends in Oral Anticoagulant Use and Post-Discharge Complications Among Atrial Fibrillation Patients with Acute Myocardial Infarction.

BACKGROUND: Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI).The CHA2DS2VAScand CHADS2risk scoresare used to identifypatients with AF at risk for strokeand to guide oral anticoagulants (OAC) use, including patients with AMI. However, the epidemiology of AF, further stratifiedaccording to patients' risk of stroke, has not been wellcharacterized among those hospitalized for AMI. METHODS: We examined trends in the frequency of AF, rates of discharge OAC use, and post-discharge outcomes among 6,627 residents of the Worcester, Massachusetts area who survived hospitalization for AMI at 11 medical centers between 1997 and 2011. RESULTS: A total of 1,050AMI patients had AF (16%) andthe majority (91%)had a CHA2DS2VAScscore >2.AF rates were highest among patients in the highest stroke risk group.In comparison to patients without AF, patients with AMI and AF in the highest stroke risk category had higher rates of post-discharge complications, including higher 30-day re-hospitalization [27 % vs. 17 %], 30-day post-discharge death [10 % vs. 5%], and 1-year post-discharge death [46 % vs. 18 %] (p < 0.001 for all). Notably, fewerthan half of guideline-eligible AF patientsreceived an OACprescription at discharge. Usage rates for other evidence-based therapiessuch as statins and beta-blockers,lagged in comparison to AMI patients free from AF. CONCLUSIONS: Our findings highlight the need to enhance efforts towards stroke prevention among AMI survivors with AF.

Antiplatelet Therapy Changes for Patients With Myocardial Infarction With Recurrent Ischemic Events: Insights Into Contemporary Practice From the TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) Study.

BACKGROUND: Guidelines recommend P2Y12 inhibitor therapy for 1 year after myocardial infarction (MI), yet little guidance is provided on antiplatelet management for patients with recurrent ischemic events during that year. We describe changes in P2Y12 inhibitor type among patients with recurrent ischemic events in the first year after MI. METHODS AND RESULTS: The TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study enrolled 12 365 patients with MI treated with percutaneous coronary intervention. We examined whether P2Y12 inhibitor choice changed among patients with recurrent MI, stent thrombosis, and/or unplanned revascularization during the first year after MI, and modeled factors associated with P2Y12 inhibitor intensification (changing clopidogrel to prasugrel or ticagrelor). In the first year after MI, 1414 patients (11%) had a total of 1740 recurrent ischemic events (771 recurrent MIs, 969 unplanned revascularizations, and 165 stent thromboses). Median time to the first recurrent ischemic event was 154 days (25th-75th percentiles, 55-287 days). Of those with recurrent ischemic events, 101 of 1092 (9.3%) occurring in clopidogrel-treated patients led to P2Y12 inhibitor intensification. Recurrent events involving stent thrombosis or MI were the strongest factors associated with P2Y12 inhibitor intensification, yet only 40% of patients with stent thrombosis and 14% of patients with recurrent MI had P2Y12 inhibitor intensification. Increasing age and longer time from the index MI were associated with lower likelihood for intensification. CONCLUSIONS: Few patients after MI with a recurrent ischemic event who were taking clopidogrel switched to a more potent P2Y12 inhibitor, even after stent thrombosis events. Specific guidance is needed for patients who have recurrent ischemic events, particularly when closely spaced. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01088503.

Relation of Atrial Fibrillation in Acute Myocardial Infarction to In-Hospital Complications and Early Hospital Readmission.

Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) and contributes to high rates of in-hospital adverse events. However, there are few contemporary studies examining rates of AF in the contemporary era of AMI or the impact of new-onset AF on key in-hospital and postdischarge outcomes. We examined trends in AF in 6,384 residents of Worcester, Massachusetts, who were hospitalized with confirmed AMI during 7 biennial periods between 1999 and 2011. Multivariate logistic regression analysis was used to examine associations between occurrence of AF and various in-hospital and postdischarge complications. The overall incidence of AF complicating AMI was 10.8%. Rates of new-onset AF increased from 1999 to 2003 (9.8% to 13.2%), and decreased thereafter. In multivariable adjusted models, patients developing new-onset AF after AMI were at a higher risk for in-hospital stroke (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.6 to 4.1), heart failure (OR 2.0, 95% CI 1.7 to 2.4), cardiogenic shock (OR 3.7, 95% CI 2.8 to 4.9), and death (OR 2.3, 95% CI 1.9 to 3.0) than patients without AF. Development of AF during hospitalization for AMI was associated with higher rates of readmission within 30 days after discharge (21.7% vs 16.0%), but no significant difference was noted in early postdischarge 30-day all-cause mortality rates (8.3% vs 5.1%). In conclusion, new-onset AF after AMI is strongly related to in-hospital complications of AMI and higher short-term readmission rates.

Variable response of conductance and resistance coronary arteries to endothelial stimulation in patients with heart failure due to nonischemic dilated cardiomyopathy.

UNLABELLED: Attenuation of endothelial-dependent coronary vasodilation has been reported in idiopathic dilated cardiomyopathy and anatomically normal coronaries; however, data are insufficient for understanding the incidence and extent of this finding. The response of conductance and resistance coronary arteries to endothelial stimulation with acetylcholine was examined in 25 patients. Coronary blood flow had a variable response to acetylcholine and suggested coronary endothelial dysfunction in approximately half of the patients. Abnormal endothelial dysfunction involved the large conductance epicardial coronary arteries and the small resistance vessels. Abnormal endothelial response of coronary blood flow to acetylcholine could not be predicted by demographic and hemodynamic data. CONCLUSIONS: Coronary artery endothelial function is heterogeneous in patients with idiopathic dilated cardiomyopathy. Endothelial dysfunction is present in approximately half of the cases and involves both resistance as well as conductance coronary blood vessels. Furthermore, coronary endothelial function cannot be predicted by demographic and hemo-dynamic parameters or left ventricular ejection fraction.

Left atrial thrombosis in pregnant women with mitral stenosis and sinus rhythm.

OBJECTIVE: The purpose of this study was to describe pregnant patients with mitral stenosis who had intracardiac thrombosis in the absence of atrial fibrillation. STUDY DESIGN: We reviewed the clinical course of 3 pregnant women with severe mitral stenosis and normal sinus rhythm who had clinically significant intracardiac thrombosis. RESULTS: The first patient was examined at 21 weeks of gestation with embolic stroke that was the result of left atrial thrombus. A second patient was found to have a large left atrial thrombus that prevented the performance of balloon valvuloplasty. The third patient had left atrial clot that partially occluded the mitral valve orifice and led to the development of pulmonary edema that resulted in an emergent cesarean delivery and anoxic brain injury in the newborn infant. CONCLUSION: Pregnant patients with mitral stenosis in normal sinus rhythm can experience thromboembolic events that can be detrimental to both the mother and the fetus. Anticoagulation therefore should be strongly considered in this group.

Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation.

BACKGROUND: Cardiomyopathy associated with pregnancy was first described more than half a century ago. However, because of its rare occurrence and geographical differences, the clinical profile of this condition has remained incompletely defined. METHODS AND RESULTS: Data obtained from 123 women with a history of cardiomyopathy diagnosed during pregnancy or the postpartum period were reviewed. One hundred women met traditional criteria of peripartum cardiomyopathy; 23 were diagnosed with pregnancy-associated cardiomyopathy earlier than the last gestational month. Peripartum cardiomyopathy patients had a mean age of 31+/-6 years and were mostly white (67%). Common associated conditions were gestational hypertension (43%), tocolytic therapy (19%), and twin pregnancy (13%). Left ventricular ejection fraction at the time of diagnosis was 29+/-11% and improved to 46+/-14% (P< or =0.0001) at follow-up. Normalization of left ventricular ejection fraction occurred in 54% and was more likely in patients with left ventricular ejection fraction >30% at diagnosis. Maternal mortality was 9%. A comparison between the peripartum cardiomyopathy and early pregnancy-associated cardiomyopathy groups revealed no differences in age, race, associated conditions, left ventricular ejection fraction at diagnosis, its rate and time of recovery, and maternal outcome. CONCLUSIONS: This study helps to define the clinical profile of patients with pregnancy-associated cardiomyopathy diagnosed in the United States. Clinical presentation and outcome of patients with pregnancy-associated cardiomyopathy diagnosed early in pregnancy are similar to those of patients with traditional peripartum cardiomyopathy. These 2 conditions may represent a continuum of a spectrum of the same disease.

Survey of the use of organic nitrates for the treatment of chronic congestive heart failure in the United States.

A survey of members of the Heart Failure Society of America revealed that despite their lack of approval by the United States Food and Drug Administration, nitrates are widely used in patients with chronic congestive heart failure (CHF). Most members reported using nitrates in patients with ischemic (90%) and nonischemic (81%) causes of chronic CHF, especially those with symptomatic CHF (43% reported using nitrates in >50% of their patients with ischemic and 25% with nonischemic causes). Ninety-six percent reported using nitrates to reduce symptoms, 74% for hemodynamic improvement, 65% for better exercise tolerance, and only 14% for left ventricular reversed remodeling. Nitrates were always combined with hydralazine in 25% of patients and occasionally combined with hydralazine in 67%.

Effect of elevated admission serum creatinine and its worsening on outcome in hospitalized patients with decompensated heart failure.

Renal insufficiency (RI), as represented by elevated serum creatinine (>1.5 mg/dl) on admission, is common and found in almost half of patients hospitalized with decompensated heart failure. This finding is associated with prolongation of length of stay and rate of rehospitalizations after discharge and also has an independent unfavorable effect on 6-month mortality. Similarly, an increase in serum creatinine (>0.5 mg/dl) in the hospital results in a significantly longer length of stay and has an independent effect on long-term mortality.

Anticoagulation in pregnant women with prosthetic heart valves.

BACKGROUND: Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. Effective anticoagulation is therefore critical in such patients but remains problematic, since oral anticoagulation and both unfractionated and low-molecular-weight heparin may be associated with important fetal and maternal side effects. PURPOSE: To review information related to the use of anticoagulation with both warfarin and heparin and reassess the safety and efficacy of these therapies in pregnant women with mechanical prosthetic heart valves. DATA SOURCE AND SELECTION: A MEDLINE search from 1966 to October 2003 for English and non-English language articles that reported the use of anticoagulation in pregnancy was conducted. Articles were included if they reported use of anticoagulation in pregnancy with emphasis on those that included women with mechanical prosthetic heart valves. CONCLUSIONS: Anticoagulation prophylaxis with both warfarin and heparin (unfractionated heparin and low-molecular-weight heparin) may be associated with important fetal and maternal side effects. Optional regimens for the treatment of low-risk and high-risk patients are proposed to minimize potential complications.

Comparison of effects on left ventricular filling pressure of intravenous nesiritide and high-dose nitroglycerin in patients with decompensated heart failure.

The results of this study showed an advantage of nesiritide compared with high-dose nitroglycerin in the treatment of patients with decompensated heart failure. Nesiritide resulted in an early decrease in pulmonary capillary wedge pressure (< or =15 minutes), which was sustained throughout the study period (24 hours) without the need for up-titration. In contrast, the onset of the nitroglycerin-mediated hemodynamic effect was delayed, and despite aggressive up-titration, the decrease in pulmonary capillary wedge pressure was gradually attenuated because of the early development of tolerance.

Intravenous nitroglycerin in the treatment of decompensated heart failure: potential benefits and limitations.

Acute decompensated heart failure (ADHF) is a common cause of hospitalizations. Intravenous nitroglycerin is widely used in the treatment of this condition. The use of this drug is based on its nitric oxide-mediated vasodilatory effect, which can lead to beneficial hemodynamic effects as well as improvement of myocardial ischemia and reduction of mitral regurgitation. However, information regarding the use of nitroglycerin for ADHF is limited to mostly hemodynamic evaluations in small groups of patients without cardiovascular outcome data. A single randomized, placebo controlled study that evaluated commonly used doses of nitroglycerin in patients with ADHF was disappointing and failed to show a significant hemodynamic effect or improvement of symptoms compared with placebo. The potential benefit of nitroglycerin seems to be limited by a decreased vasodilatory response in patients with heart failure, which requires an active titration of the drug and the use of high doses (>120 microg/min). In addition, the initial beneficial hemodynamic effect achieved with the appropriate dose of nitroglycerin is associated with neurohumoral activation and limited by an early development of nitrate tolerance that leads to a marked attenuation of the initial effect. More information obtained in large-scale studies that are appropriately designed to evaluate the effect of variable doses of nitroglycerin on short- and long-term cardiovascular outcome, with and without interventions shown to prevent nitrate tolerance, is needed before intravenous nitroglycerin can be recommended as a standard therapy for ADHF.

Evaluation of myocardial blood flow reserve in patients with chronic congestive heart failure due to idiopathic dilated cardiomyopathy.

This study demonstrates a significant impairment in coronary blood flow reserve in most patients with idiopathic dilated cardiomyopathy despite normal epicardial coronary arteries. This change may prevent appropriate increases in coronary blood flow and thus lead to myocardial ischemia and progression of disease. An association between decreased response to adenosine and acetylcholine supports previous observations indicating that adenosine-induced vasodilation of coronary microcirculation is dependent on endothelial nitric oxide production.