Pathway for the Diagnosis and Management of Cardiac Amyloidosis.

The systemic amyloidoses are a broad spectrum of diseases that result from misfolding of proteins that aggregate into amyloid fibrils. In cardiac amyloidosis, amyloid fibrils accumulate in the interstitial space between cardiac myocytes causing cellular injury and impairing compliance. Current data suggest that cardiac amyloidosis is more common than previously thought. Advances in cardiac imaging, diagnostic strategies, and therapies have improved the recognition and treatment of cardiac amyloidosis. A position statement for the diagnosis and treatment of cardiac amyloidosis has been published in 2021 by the European Society of Cardiology and an expert consensus decision pathway was published in 2023 by the American College of Cardiology. These are excellent documents but quite lengthy and complex. For this reason, our team developed a novel and simple pathway to help health care providers diagnose and treat patients with cardiac amyloidosis. Our pathway starts with a section titled "suspicion" in which we provide simple clues or "red flags" that are associated with the cardiac amyloidosis phenotype. It is followed by a section titled "diagnosis," where we present in a simplified 2 × 2 format the laboratory and imaging tests that must be performed for an accurate diagnosis. In the section titled "treatment," we describe the 4 pillars in the management of patients with cardiac amyloidosis, which includes the following: heart failure treatments, management of arrhythmias, treatment of significant aortic stenosis, and appropriate selection of disease modifying therapies. Our algorithm ends with our simplified recommendation for follow-up.

Multi-Valvular Non-bacterial Thrombotic Endocarditis Causing Sequential Pulmonary Embolism, Myocardial Infarction, and Stroke: A Case Report and Literature Review.

Non-bacterial thrombotic endocarditis is an uncommon entity that tends to be related to malignancy or rheumatological disorders. The diagnosis is complex and requires a high index of suspicion. It commonly causes recurrent emboli; however, coronary embolism remains an infrequently reported entity. Herein we report a unique case of sequential pulmonary embolism, ST-elevation myocardial infarction (MI), and stroke associated with multi-valvular non-bacterial thrombotic endocarditis. The cornerstone of management is treating the underlying cause and anticoagulation therapy. Surgical treatment should be considered in patients with acute heart failure secondary to valvular dysfunction and recurrent thromboembolism despite proper anticoagulation. We have performed an extensive literature search and found nine cases of established antemortem diagnosis of myocardial infarction secondary to non-bacterial thrombotic endocarditis, and we reviewed them according to cause, treatment, and outcome.

Acute myocardial infarction in the young - National Trend Analysis with gender-based difference in outcomes.

INTRODUCTION: Although acute myocardial infarction (AMI) is a disease predominantly affecting adults >60 years of age, a significant proportion of the young population who have different risk profiles, are also affected. We undertook a retrospective analysis using National Inpatient Sample (NIS) 2010 to 2014 to evaluate gender differences in characteristics, treatments, and outcomes in the younger AMI population. METHODS: The NIS 2010-2014 was used to identify all patient hospitalizations with AMI between 18 to <45 years using ICD-9-CM codes. We demonstrated a gender-based difference of in-hospital all-cause mortality, other complications, and revascularization strategies in the overall AMI population and other subgroups of AMI [anterior wall ST-segment elevation MI (STEMI), and non-anterior wall STEMI and non-STEMI (NSTEMI)]. RESULTS: A total of 156,018 weighted records of AMI hospitalizations were identified, of which 111,894 were men and 44,124 were women. Young women had a higher prevalence of anemia, chronic lung disease, obesity, peripheral vascular disease, and diabetes. Conversely, young men had a higher prevalence of dyslipidemia, smoking, and alcohol. Among non-traditional risk factors, women had a higher prevalence of depression and rheumatologic/collagen vascular disease. There was no difference in all-cause in-hospital mortality in women compared to men [2.03% vs 1.48%; OR 1.04, CI (0.84-1.29); P = .68], including in subgroup analysis of NSTEMI, anterior wall STEMI, and non-anterior wall STEMI. Women with AMI were less likely to undergo percutaneous coronary intervention [47.13% vs 61.17%; OR 0.66, 95% CI (0.62-0.70; P < .001] and coronary artery bypass grafting [5.6% vs 6.0%; OR 0.73, 95% CI 0.64-0.83; P < .001] compared to men. Women were also less likely to undergo percutaneous coronary intervention within 24 h of presentation (38.47% vs 51.42%, P < .001). CONCLUSION: Despite higher baseline comorbidities in young women with AMI, there was no difference in in-hospital mortality in women compared to men. Additional studies are needed to evaluate the impact of gender on clinical presentation, treatment patterns, and outcomes of AMI in young patients.

Comparison of In-Hospital Mortality and Length of Stay in Acute ST-Segment-Elevation Myocardial Infarction Among Urban Teaching Hospitals in China and the United States.

Background The aim of the study is to compare in-hospital outcomes of acute ST-segment-elevation myocardial infarction (STEMI) between China and the United States. Methods and Results Urban teaching hospitals were queried for adult patients with a primary diagnosis of acute STEMI during 2007-2010. The primary outcome was in-hospital mortality, and the secondary outcome was length of stay. Multivariable analyses adjusting for potential confounders were conducted for comparison between countries. Subgroup analysis was performed in acute STEMI patients receiving revascularization. In total, 32 228 patients in China and 76 117 patients in the United States were included. Overall in-hospital mortality was 8.23% in China and 7.96% in the United States (P<0.001). Multivariable analyses revealed that the 2 countries had similar overall in-hospital mortality (odds ratio, 0.97; 95% CI, 0.87-1.09; P=0.59), whereas China had lower 3-day mortality (odds ratio, 0.78; 95% CI, 0.70-0.89; P<0.001). In patients receiving primary percutaneous coronary interventions, Chinese hospitals had significant higher overall mortality (odds ratio, 2.39; 95% CI, 1.85-3.07; P<0.001) and 3-day mortality (odds ratio, 2.39; 95% CI, 1.78-3.20; P<0.001). For total acute STEMI patients, acute STEMI patients receiving percutaneous coronary intervention and coronary artery bypass grafting, median length of stay in China and the United States were 10 versus 3, 9 versus 3, and 25 versus 9 days, respectively (all P<0.001). Conclusions Overall in-hospital mortality in acute STEMI patients was comparable among urban teaching hospitals between China and the United States during 2007-2010. In addition, 3-day mortality was lower in China. However, worse outcomes in patients undergoing early revascularization and longer length of stay in China need to be given more attention.

Impact of prior bariatric surgery on outcomes of hospitalized patients with heart failure: a population-based study.

BACKGROUND: Studies have suggested that obesity could improve prognosis in patients with heart failure (HF), known as the "obesity paradox." However, the association between bariatric surgery (BS) and HF outcomes is not well established. OBJECTIVE: This study aimed to assess the effects of prior BS on outcomes of HF patients. SETTING: Inpatient hospital admissions from the Nationwide Inpatient Sample. METHODS: The Nationwide Inpatient Sample database for years 2006 to 2014 was queried for adults with a primary diagnosis of HF. We performed multivariable regression analyses to compare outcomes including in-hospital mortality, complications, cost, and length of stay between prior BS (body mass index <35 and ≥35 kg/m2) and morbid obesity. RESULTS: Of 164,220 patients with HF, 3617 were with prior BS and 160,603 were diagnosed with morbid obesity. Prior BS patients were younger, tended to be female, and had fewer co-morbidities and complications. Multivariate regression analyses adjusting for baseline patient and hospital characteristics revealed that compared with morbid obesity, prior BS with successful weight loss (body mass index <35 kg/m2) was associated with decreased mortality (odds ratio: .47; 95% confidence interval: .37-.74), urinary tract infection (odds ratio: .72; 95% confidence interval: .62-.84), 17% shorter hospitalization (median length of stay: 2.99 and 3.95 days), and 7% lower cost (median cost: $6984 and $7775). Propensity score-matching analysis validated main findings with permissible similarity regarding covariates between groups. CONCLUSION: Among HF hospitalized patients, prior BS is associated with better in-hospital outcomes, mainly in those who had successful weight loss. Our findings emphasize potential clinical and economic impact of BS on HF patients.

New oral anticoagulants in patients with cancer: current state of evidence.

Effectiveness of new oral anticoagulants (NOAC) in patients with cancer is not clearly defined. There remain concerns of doubtful benefit and chances of potential harm with newer agents. In this meta-analysis, we evaluated the efficacy and safety of NOAC in patients with cancer. PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched from January 01, 2001 through February 28, 2013. Randomized controlled trials reporting efficacy and safety data of NOACs (rivaroxaban, dabigatran, and apixaban) with control (low-molecular-weight heparin/vitamin K antagonists/placebo) for patients with cancer were included. Primary efficacy outcome was venous thromboembolism (VTE) or VTE-related death, and primary safety outcome was clinically relevant bleeding. We used random-effects models. Six trials randomized 19,832 patients, and 1197 patients had cancer. Risk of VTE or VTE-related death was not significantly different with NOAC versus control [odds ratio (OR), 0.80; 95% confidence interval (CI), 0.39-1.65] in patients with cancer. Separate analysis for individual effects showed similar results for rivaroxaban (OR, 1.08; 95% CI, 0.60-1.94) and dabigatran (OR, 0.91; 95% CI, 0.21-3.91). Clinically relevant bleeding was not higher with NOAC compared with control (OR, 1.49; 95% CI, 0.82-2.71); individual effect of rivaroxaban showed similar results. No statistically significant difference of efficacy and safety with NOAC was found between patients with and without cancer. Rivaroxaban might be equally effective and safe as vitamin K antagonist in patients with cancer. Dabigatran is as effective as comparator; however, safety profile of dabigatran is unknown. Randomized trials of new anticoagulants specific to the cancer population are necessary, and NOAC also need to be evaluated against low-molecular-weight heparin.

A structured, parsimonious approach to establish the cause of moderate-to-large pericardial effusion.

The workup of moderate-to-large pericardial effusion should focus on its hemodynamic impact and potential cause. A structured approach to diagnostic evaluation of pericardial effusion is needed. We retrospectively studied a contemporary cohort of 103 patients with moderate-to-large pericardial effusion hospitalized at St. Luke's Roosevelt Hospital Center from July 2009 till August 2013. Diagnosis of pericardial effusion was independently ascertained by chart review. We applied a stepwise parsimonious approach to establish the cause of pericardial effusion. In the studied cohort, the mean age was 61 years, 50% were men, and 65 patients (63%) underwent pericardial effusion drainage. Using the structured approach, the cause of the effusion was ascertained in 70 patients (68%) by noninvasive targeted testing. Malignant effusion was confirmed in 19 patients (19%). All patients with malignant effusion had either history of malignancy or suggestive noninvasive findings. In conclusion, a structured approach can help to ascertain the diagnosis in patients with moderate-to-large pericardial effusion and guide the need for pericardial drainage or sampling.

Paradoxical hypertension with cardiac tamponade.

Subacute (medical) tamponade develops over a period of days or even weeks. Previous studies have shown that subacute tamponade is uncommonly associated with hypotension. On the contrary, many of those patients are indeed hypertensive at initial presentation. We sought to determine the prevalence and predictors of hypertensive cardiac tamponade and hemodynamic response to pericardial effusion drainage. We conducted a retrospective study of patients who underwent pericardial effusion drainage for subacute pericardial tamponade. Diagnosis of pericardial tamponade was established by the treating physician based on clinical data and supportive echocardiographic findings. Patients were defined as hypertensive if initial systolic blood pressure (BP) was ≥140 mm Hg. Thirty patients with subacute tamponade who underwent pericardial effusion drainage were included in the analysis. Eight patients (27%) were hypertensive with a mean systolic BP of 167 compared to 116 mm Hg in 22 nonhypertensive patients. Hypertensive patients with tamponade were more likely to have advanced renal disease (63% vs 14%, p <0.05) and pre-existing hypertension (88% vs 46, p <0.05) and less likely to have systemic malignancy (0 vs 41%, p <0.05). Systolic BP decreased significantly in patients with hypertensive tamponade after pericardial effusion drainage. Those results are consistent with previous studies with an estimated prevalence of hypertensive tamponade from 27% to 43%. In conclusion, a hypertensive response was observed in approximately 1/3 of patients with subacute pericardial tamponade. Relief of cardiac tamponade commonly resulted in a decrease in BP.

Implementing a pathway for the management of acute coronary syndrome leads to improved compliance with guidelines and a decrease in angina symptoms.

We describe our experience with the Advanced Cardiac Admission Program (ACAP) at our institution. The ACAP program is a hospital-wide implementation of critical pathways-based management of all cardiac patients. Data review of patients admitted for acute coronary syndromes from the ACAP-PAIN database and a comparative study of outcomes before and after implementation of the pathways-based assessment and treatment protocols. In the pre-ACAP and post-ACAP patient groups, antiplatelet use at admission improved from 50% to 75% (p<.01), ACE-I use improved from 32% to 54% (p<.0001), statins use increased from 35% to 62% (p<.0001), and smoking cessation awareness increased from 15% to 86% (p<.0001). At 1-year follow-up, 84% of patients with CAD were treated with statins, and 47% had LDL cholesterol <100 mg/dL, compared with 20% and 9%, respectively, with conventional treatment before ACAP implementation (p<.0001). Recurrent angina symptoms and nonfatal myocardial infarction rates decreased from 28.5% to 13% (p = .02), and 15% to 5% (p = 0.03), respectively. Pathway-based programs like ACAP significantly enhance administration of guidelines-based cardioprotective medications both during hospital stay and at 1-year follow-up.

Malnutrition as assessed by nutritional risk index is associated with worse outcome in patients admitted with acute decompensated heart failure: an ACAP-HF data analysis.

Malnutrition is common at hospital admission and tends to worsen during hospitalization. This controlled population study aimed to determine if serum albumin or moderate and severe nutritional depletion by Nutritional Risk Index (NRI) at hospital admission are associated with increased length of hospital stay (LOS) in patients admitted with acute decompensated heart failure (ADHF). Serum albumin levels and lymphocyte counts were retrospectively determined at hospital admission in 1740 consecutive patients admitted with primary and secondary diagnosis of ADHF. The Nutrition Risk Score (NRI) developed originally in AIDS and cancer populations was derived from the serum albumin concentration and the ratio of actual to usual weight, as follows: NRI = (1.519 × serum albumin, g/dL) + {41.7 × present weight (kg)/ideal body weight(kg)}. Patients were classified into four groups as no, mild, moderate or severe risk by NRI. Multiple logistic regressions were used to determine the association between nutritional risk category and LOS.Three hundred and eighty-one patients (34%) were at moderate or severe nutritional risk by NRI score. This cohort had lower BMI (24 ± 5.6 kg/m(2)), albumin (2.8±0.5 g/dL), mean NRI (73.5±9) and lower eGFR (50±33 mL/min per 1.73 m(2)). NRI for this cohort, adjusted for age, was associated with LOS of 10.1 days. Using the Multiple Logistic regression module, NRI was the strongest predictor for LOS (OR 1.7, 95% CI: 1.58-1.9; P=0.005), followed by TIMI Risk Score [TRS] (OR 1.33, 95% CI: 1.03-1.71; P=0.02) and the presence of coronary artery disease (OR 2.29, 95%CI: 1.03-5.1; P=0.04). Moderate and severe NRI score was associated with higher readmission and death rates as compared to the other two groups.Nutritional depletion as assessed by Nutritional Risk Index is associated with worse outcome in patients admitted with ADHF. Therefore; we recommend adding NRI to further risk stratify these patients.

Strategies for the prevention and treatment of sudden cardiac death.

Cardiovascular diseases account for 40% of all deaths in the West. Sudden cardiac death (SCD) is a major health problem affecting over 300,000 patients annually in the United States alone. Presence of coronary artery disease (CAD), usually in the setting of diminished left ventricular ejection fraction, is still the single major risk factor for SCD. Additionally, acute myocardial ischemia, structural cardiac defects, anomalous coronary arteries, cardiomyopathies, genetic mutations, and ventricular arrhythmias are all attributed to SCD, demonstrating the perplexity of this condition. With the recent advancements in cardiovascular medicine, the incidence of SCD is expected to increase steeply as the prevalence of CAD and heart failure is uprising in general population. Considering SCD, the major challenge confronting contemporary cardiology, multiple strategies for prevention against SCD have been developed. ß-blockers have been shown to reduce the risk of SCD, whereas implantable cardioverter-defibrillator devices are found to be effective at terminating the malignant arrhythmias. In recent years, multiple clinical trials were carried out to identify patients who may benefit from preventive intervention, including medical therapy and automatic cardioverter-defibrillator implantations. This review article provides insight into the advanced strategies for the prevention and treatment of SCD based on the data available in medical literature to date.