Impact of Chronic Kidney Disease on Revascularization and Outcomes in Patients with ST-Elevation Myocardial Infarction.

Chronic kidney disease (CKD) in patients with ST-elevation myocardial infarction (STEMI) is associated with worse outcomes. We assessed the impact of CKD on guideline directed coronary revascularization and outcomes among STEMI patients. The Nationwide Inpatient Sample dataset from 2012-2014 was used to identify patients with STEMI using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were categorized as non-CKD, CKD without dialysis, and CKD with dialysis (CKD-HD). Outcomes were revascularization, death and acute renal failure requiring dialysis (ARFD). A total of 534,845 were included (88.9% non-CKD; 9.6% CKD without dialysis, and 1.5% CKD-HD). PCI was performed in 77.4% non-CKD, 56.2% CKD without dialysis, and 48% CKD-HD patients (p < 0.0001). In-hospital mortality and ARFD were significantly higher in CKD patients (16.5% and 40.6%) compared with non-CKD patients (7.12% and 7.17%) (p < 0.0001). In-hospital mortality was significantly lower in patients treated revascularization compared with patients treated medically (non-CKD: adjusted odds ratio (aOR) 0.280, p < 0.0001; CKD without dialysis: aOR 0.39, p < 0.0001; CKD-HD: aOR 0.48, p < 0.0001). CKD was associated with higher length of hospital stay and cost (5.86 ± 13.97, 7.57 ± 26.06 and 3.99 ± 11.09 days; p < 0.0001; $25,696 ± $63,024, $35,666 ± $104,940 and $23,264 ± $49,712; p < 0.0001 in non-CKD, CKD without dialysis and CKD-HD patients respectively). In conclusion, CKD patients with STEMI receive significantly less PCI compared with patients without CKD. Coronary revascularization for STEMI in CKD patients was associated with lower mortality compared to medical management. The presence of CKD in patients with STEMI is associated with higher mortality and ARFD, prolonged hospital stay and higher hospital cost.

Comprehensive Geriatric Assessment in the Management of Older Patients With Cardiovascular Disease.

Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.

Measurement of Ejection Fraction by Cardiac Magnetic Resonance Imaging and Echocardiography to Monitor Doxorubicin-Induced Cardiotoxicity.

Doxorubicin is a standard treatment option for breast cancer, lymphoma, and leukemia, but its benefits are limited by its potential for cardiotoxicity. The primary objective of this study was to compare cardiac magnetic resonance imaging (CMRI) versus echocardiography (ECHO) to detect a reduction in left ventricular ejection function, suggestive of doxorubicin cardiotoxicity. We studied eligible patients who were 18 years or older, who had breast cancer or lymphoma, and who were offered treatment with doxorubicin with curative intent dosing of 240 to 300 mg/m 2 body surface area between March 1, 2009 and October 31, 2013. Patients underwent baseline CMRI and ECHO. Both imaging studies were repeated after four cycles of treatment. Ejection fraction (EF) calculated by both methods was compared and analyzed with the inferential statistical Student's t test. Twenty-eight eligible patients were enrolled. Two patients stopped participating in the study before undergoing baseline CMRI; 26 patients underwent baseline ECHO and CMRI. Eight of those 26 patients declined posttreatment studies, so the final study population was 18 patients. There was a significant difference in EF pre- and posttreatment in the CMRI group ( p = 0.009) versus the ECHO group that showed no significant differences in EF ( p = NS). It appears that CMRI is superior to ECHO for detecting doxorubicin-induced reductions in cardiac systolic function. However, ECHO is less expensive and more convenient for patients because of its noninvasive character and bedside practicality. A larger study is needed to confirm these findings.

An Updated Review on Myocardial Bridging.

Myocardial bridging is a congenital coronary anomaly with normal epicardial coronary artery taking an intra-myocardial course also described as tunneled artery. The majority of patients with this coronary anomaly are asymptomatic and generally it is a benign condition. However, it is an important cause of myocardial ischemia, which may lead to anginal symptoms, acute coronary syndrome, cardiac arrhythmias and rarely sudden cardiac death. There are numerous studies published in the recent past on understanding the pathophysiology, diagnostic and management strategies of myocardial bridging. This review highlights some of the recent updates in the diagnosis and management of patients with myocardial bridging. We discuss the role of various non-invasive and invasive diagnostic methods to evaluate functional significance of bridging. In addition, role of medical therapy such as beta-blockers, percutaneous coronary intervention with stents/bioresorbable scaffolds and surgical unroofing in patients unresponsive to medical therapy is highlighted as well.

Outcomes of Nonagenarians Admitted to the Cardiac Intensive Care Unit by the Elders Risk Assessment Score for Long-Term Mortality Risk Stratification.

There are limited data on outcomes of older adults admitted to cardiac intensive care units (CICU), and there are no data on outcomes after admission to the CICU in nonagenarians. Our purpose was to identify whether the Elders Risk Assessment (ERA) index could risk stratify older adults after CICU admission. We retrospectively identified 453 nonagenarians admitted to the CICU between 2004 and 2013. End points included mortality, length of stay, incidence of delirium, and discharge disposition. Average age of the cohort was 92 ± 2 years, and the average ERA score was 13 ± 6. A total of 258 patients were female (57%). Most common admission indication was acute decompensated heart failure (57%) followed by acute myocardial infarction (49%). Loss of independence was observed after CICU admission, with 66% of patients living independently before admission, decreasing to 47% at discharge. Overall length of stay was 6 ± 5 days and CICU stay was 2 ± 2 days. Fifteen percent of patients died before hospital discharge. Median survival was 452 (interquartile range 40 to 1,371) days. ERA score effectively predicted survival (log-rank test, p = 0.002). ERA score of 16 or greater and ERA score of 9 to 15 were both associated with increased risk of mortality compared with the reference (score 4 to 8): hazard ratio 2.00, 95% confidence interval 1.37 to 2.90, p = 0.003, and hazard ratio 1.48, 95% confidence interval 1.06 to 2.08, p = 0.02, respectively. In conclusion, nonagenarians admitted to CICU experience reasonable outcomes. The ERA score effectively risk stratifies nonagenarians admitted to the CICU and may help with identification of vulnerable patients at risk of adverse outcomes.