Clinical Outcomes of Percutaneous Coronary Intervention in Amyloidosis, Sarcoidosis, and Hemochromatosis.

Background: Infiltrative diseases (IDs), including amyloidosis, sarcoidosis, and hemochromatosis, are characterized by abnormal cellular infiltration in multiple organs, including the heart. The prognosis of percutaneous coronary intervention (PCI) patients with underlying IDs has not been well-studied. We evaluated the prevalence of IDs in patients undergoing PCI and their association with post-PCI outcomes. Methods: The National Inpatient Sample (NIS) 2016-2020 database was used to identify PCI patients with ICD-10 codes for a retrospective analysis. PCI patients were then divided into those with and without underlying IDs, which included amyloidosis, sarcoidosis, and hemochromatosis. Multivariable logistic regression was performed for composite post-PCI outcomes analyses. Results: Among 2,360,860 patients admitted to undergo PCI, 7855 patients had underlying IDs. The highest prevalence was observed for sarcoidosis (0.2%) followed by hemochromatosis (0.07%) and amyloidosis (0.04%). Underlying amyloidosis was associated with worse composite post-PCI outcomes (odds ratio [OR], 1.6; 95% CI, 1.1-2.44; P = .02), including higher in-hospital mortality (OR, 1.9; 95% CI, 1.1-3.4; P = .04), higher risk of intra/post-PCI stroke (OR, 4.0; 95% CI, 1.1-16.0; P = .04), but not major bleeding (OR, 2.2; 95% CI, 0.97-5.03; P = .058). In contrast, underlying sarcoidosis (OR, 1.1; 95% CI, 0.87-1.41; P = .4), and hemochromatosis (OR, 1.18; 95% CI, 0.77-1.8; P = .44) were not associated with composite post-PCI outcomes. Amyloidosis patients undergoing PCI also had higher hospitalization charges ($212,123 vs $141,137; P = .03) and longer length of stay (8.2 vs 3.9 days; P < .001). Conclusions: Underlying amyloidosis was associated with worse post-PCI outcomes including higher in-hospital mortality, intra/post-PCI stroke, and socioeconomic burden. A multidisciplinary approach and future studies are needed to investigate the screening and treatment strategies in these patients.

Thirty-day hospital readmission in females with acute heart failure and breast cancer: A retrospective cohort study from national readmission database.

BACKGROUND: Breast Cancer and cardiovascular diseases are amongst the two leading causes of mortality in the United States, and the two conditions are connected in part because of recognized cardiotoxicity of cancer treatments. The aim of this study is to investigate the predictors risk factors for thirty-day readmission in female breast cancer survivors presenting with acute heart failure. METHODS: This is a retrospective cohort study of acute heart failure (AHF) hospitalization in female patients with breast cancer in 2019 using the National Readmission Database (NRD), which is the largest publicly available all-payer inpatient readmission database in the United States. Our study sample included adult female patients aged 18 years and older. The primary outcome of interest was the rate of 30- day readmission. RESULTS: In 2019, there were 8332 total index admissions for AHF in females with breast cancer and 7776 patients were discharged alive. The mean age was 74.4 years (95% CI: 74, 74.7). The percentage of readmission at 30 days among those discharged alive was 21.8% (n = 1699). Hypertensive heart disease with chronic kidney disease accounted for the majority of readmission in AHF with breast cancer followed by sepsis, acute kidney injury, respiratory failure, pneumonia, and atrial fibrillation. Demographic factors including higher burden of comorbidities predict readmission. The total in-hospital mortality in index admission was 6.67% (n = 556) and for readmitted patients was 8.77% (n = 149). The mean length of stay for index admission was 7.5 days (95% CI: 7.25, 7.75). CONCLUSIONS: Readmission of female breast cancer survivors presenting with AHF is common and largely be attributed to high burden of comorbidities including hypertension, and chronic kidney disease. A focus on close outpatient follow-up will be beneficial in lowering readmissions.

Outcomes of Percutaneous Revascularization in Severe Ischemic Left Ventricular Dysfunction.

PURPOSE OF REVIEW: This article presents a comprehensive review of coronary revascularization versus optimal medical therapy (OMT) in patients with severe ischemic left ventricular dysfunction. RECENT FINDINGS: The REVIVED-BCIS2 trial randomized 700 patients with extensive coronary artery disease and left ventricular (LV) ejection fraction (LVEF) ≤ 35% and viability in more than four dysfunctional myocardial segments to percutaneous coronary intervention (PCI) plus OMT versus OMT alone. Over a median duration of 41 months, there was no difference in the composite of all-cause mortality, heart failure hospitalization, or improvement in LVEF with PCI plus OMT versus OMT alone at 6 and 12 months, quality of life scores at 24 months, or fatal ventricular arrhythmia. The STICH randomized trial was conducted between 2002 and 2007, involving patients with LV dysfunction and coronary artery disease. The patients were assigned to either CABG plus medical therapy or medical therapy alone. At the 5-year follow-up, the trial showed that CABG plus medical therapy reduced cardiovascular disease-related deaths and hospitalizations but no reduction in all-cause mortality. However, a 10-year follow-up showed a significant decrease in all-cause mortality with CABG. The currently available evidence showed no apparent benefit of PCI in severe ischemic cardiomyopathy as compared to OMT, but that CABG improves outcomes in this patient population. The paucity of data on the advantages of PCI in this patient population underscores the critical need for optimization of medical therapy for better survival and quality of life until further evidence from RCTs is available.

Factors Associated With Myocardial Infarction in a Rural Population With Peripheral Arterial Diseases.

Peripheral arterial disease (PAD) studies in rural populations are limited. The incidence of myocardial infarction (MI) is higher in patients with PAD. This study examined the association between sociodemographic and clinical risk factors and MI in patients with PAD in Central Appalachia, comprising of 230 counties across six states in the United States. Data from electronic medical records of 13,455 patients with PAD were extracted from a large health system in Central Appalachia. Bivariate and logistic regression analyses were conducted. The final sample consisted of 5574 patients with PAD, of whom 24.85% were also diagnosed with MI. The mean age was 71 ± 11.23 years, and the majority were male (56.40%). After adjusting for confounders, patients with hypertension had three times higher odds of MI (adjusted Odds Ratio [aOR] = 3.21; 95% CI: 2.50-4.14) compared with those without hypertension. The likelihood of MI increased by 51% among patients with diabetes (aOR = 1.51; 95% CI: 1.33-1.71), 34% among ever-smokers (aOR = 1.34; 95% CI: 1.18-1.52), and 45% in males (aOR = 1.45; 95% CI: 1.27-1.65). Hypertension, diabetes, smoking, and male sex were identified as significant risk factors for MI. Screening and effective management of these risk factors in rural areas could potentially prevent MI incidence among patients with PAD.

Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis.

Limited data comparing prasugrel and ticagrelor in acute coronary syndrome are available. Online databases, including MEDLINE and Cochrane Central, were queried to compare these drugs. The primary outcomes of this meta-analysis are myocardial infarction (MI), all-cause mortality, cardiovascular mortality, noncardiovascular mortality, stent thrombosis, and stroke. The secondary outcome is major bleeding. A total of 9 studies, including 94,590 patients (prasugrel group = 32,759; ticagrelor group = 61,831), were included in this meta-analysis. The overall mean age was 62.73 years, whereas the mean age for the ticagrelor and prasugrel groups was 63.80 and 61.65 years, respectively. Prasugrel is equally effective as compared with ticagrelor in preventing MI. There was no difference between the 2 groups regarding all-cause mortality, stent thrombosis, stroke, or major bleeding. In patients with acute coronary syndrome, prasugrel is equally effective when compared with ticagrelor in preventing MI.

Predicting Risk of Cardiac Arrest in Young Asian Americans: Insights from an Artificial Neural Network Analysis of the Nationwide Cohort.

We used the Artificial Neural Network (ANN) model to identify predictors of Sudden Cardiac Arrest (SCA) in a national cohort of young Asian patients in the United States. The National Inpatient Sample (2019) was used to identify young Asians (18-44-year-old) who were hospitalized with SCA. The neural network's predicted criteria for SCA were selected. After eliminating missing data, young Asians (n = 65,413) were randomly divided into training (n = 45,094) and testing (n = 19347) groups. Training data (70%) was used to calibrate ANN while testing data (30%) was utilized to assess the algorithm's accuracy. To determine ANN's performance in predicting SCA, we compared the frequency of incorrect prediction between training and testing data and measured the area under the Receiver Operating Curve (AUC). The 2019 young Asian cohort had 327,065 admissions (median age 32 years; 84.2% female), with SCA accounting for 0.21%. The exact rate of error in predictions vs. tests was shown by training data (0.2% vs 0.2%). In descending order, the normalized importance of predictors to accurately predict SCA in young adults included prior history of cardiac arrest, sex, age, diabetes, anxiety disorders, prior coronary artery bypass grafting, hypertension, congenital heart disease, income, peripheral vascular disease, and cancer. The AUC was 0.821, indicating an excellent ANN model for SCA prediction. Our ANN models performed excellently in revealing the order of important predictors of SCA in young Asian American patients. These findings could have a considerable impact on clinical practice to develop risk prediction models to improve the survival outcome in high-risk patients.

Examining Disparities in Current E-Cigarette Use among U.S. Adults before and after the WHO Declaration of the COVID-19 Pandemic in March 2020.

This paper aims to estimate the prevalence of e-cigarette use before and after the COVID-19 pandemic declaration and to delineate disparities in use across subpopulations. Data were derived from the 2020 Health Information National Trends Survey (N = 3865) to conduct weighted multivariable logistic regression and marginal analyses. The overall prevalence of current e-cigarette use increased from 4.79% to 8.63% after the COVID-19 pandemic declaration. Furthermore, non-Hispanic Black people and Hispanic people had lower odds of current e-cigarette use than non-Hispanic White people, but no significant differences were observed between groups before the pandemic. Compared to heterosexual participants, sexual minority (SM) participants had higher odds of current e-cigarette use after the declaration, with insignificant differences before. People who had cardiovascular disease conditions, relative to those without, had higher odds of current e-cigarette use after the declaration, but no group differences were found before the declaration. The marginal analyses showed that before and after the pandemic declaration, SM individuals had a significantly higher probability of using e-cigarettes compared to heterosexual individuals. These findings suggest the importance of adopting a subpopulation approach to understand and develop initiatives to address substance use, such as e-cigarettes, during pandemics and other public health emergencies.

Prevalence, characteristics and mortality of cancer patients undergoing pericardiocentesis in the United States between 2004 and 2017.

BACKGROUND: Pericardiocentesis is undertaken in patients with cancer for diagnostic and therapeutic purposes. However, there are limited data on the frequency, characteristics and mortality of patients with different cancers undergoing pericardiocentesis. METHODS: All hospitalisations of adult cancer patients (≥18 years) in the US National Inpatient Sample between January 2004 and December 2017 were included. The cohort was stratified by discharge code of pericardiocentesis and cancer, using the International Classification of Diseases. The prevalence of pericardiocentesis, patient characteristics, cancer types and in-hospital all-cause mortality were analysed between cancer patients undergoing pericardiocentesis versus not. RESULTS: A total of 19,773,597 weighted cancer discharges were analysed, out of which 18,847 (0.1%) underwent pericardiocentesis. The most common cancer types amongst the patients receiving pericardiocentesis were lung (51.3%), haematological (15.9%), breast (5.4%), mediastinum/heart (3.2%), gastroesophageal (2.2%) and female genital cancer (1.8%), whilst 'other' cancer types were present in 20.2% patients. Patients undergoing pericardiocentesis had significantly higher mortality (15.6% vs. 4.2%, p < 0.001) compared to their counterparts. The presence of metastatic disease (aOR 2.67 95% CI 1.79-3.97), weight loss (aOR 1.48 95% CI 1.33-1.65) and coagulopathy (aOR 3.22 95% CI 1.63-6.37) were each independently associated with higher mortality in patients who underwent pericardiocentesis. CONCLUSION: Pericardiocentesis is an infrequent procedure in cancer patients and is most commonly performed in patients with lung, haematological and breast cancer. Cancer patients undergoing pericardiocentesis have increased mortality, irrespective of the underlying cancer type.

Management and outcomes of patients admitted with type 2 myocardial infarction with and without standard modifiable risk factors.

BACKGROUND: Whilst it is known patients without standard modifiable cardiovascular risk factors (SMuRF; hypertension, diabetes, hypercholesterolaemia, smoking) have worse outcomes in Type 1 acute myocardial infarction (AMI), the relationship between type 2 AMI (T2AMI) and outcomes in patients with and without SMuRF is unknown. This study aimed to determine the prevalence, characteristics and clinical outcomes of patients hospitalised with T2AMI based on the presence of SMuRF. METHODS: Using the National Inpatient Sample, all hospitalizations with a primary discharge diagnosis of T2AMI were stratified according to SMuRF status (SMuRF and SMURF-less). Primary outcome was all-cause mortality while secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and ischemic stroke. Multivariable logistic regression was used to determine adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS: Among 17,595 included hospitalizations, 1345 (7.6%) were SMuRF-less and 16,250 (92.4%) were SMuRF. On adjusted analysis, SMuRF-less patients had increased odds of all-cause mortality (aOR 2.43, 95% CI 1.83 to 3.23), MACCE (aOR 2.32, 95% CI 1.79 to 2.90) and ischaemic stroke (aOR 2.57, 95% CI 1.56 to 4.24) compared to their SMuRF counterparts. Secondary diagnoses among both cohorts were similar, with respiratory disorders most prevalent followed by cardiovascular and renal disorders. CONCLUSIONS: T2AMI in the absence of SMuRF was associated with worse in-hospital outcomes compared to SMuRF-less patients. There was no SMuRF-based difference in the secondary diagnoses with the most common being respiratory, cardiovascular, and renal disorders. Further studies are warranted to improve overall care and outcomes of SMuRF-less patients.

P2Y12 Inhibitors versus Aspirin Monotherapy for Long-term Secondary Prevention of Atherosclerotic Cardiovascular Disease Events: A Systematic Review and Meta-analysis.

Patients with established atherosclerotic cardiovascular disease (ASCVD) need long-term antiplatelet therapy to decrease the risk of future ASCVD events. We searched PubMed, Cochrane Library, and ClinicalTrials.gov (inception through September 2021) for randomized controlled trials (RCTs) evaluating P2Y12 inhibitors vs aspirin for secondary prevention of ASCVD events. Seven RCTs including a total of 56,982 patients were included in this analysis. The median follow-up duration was 22.8 (IQR 12) months. When P2Y12 inhibitors were compared with aspirin as long-term antiplatelet therapy for secondary prevention of ASCVD events, there was a significant decrease in the risk of myocardial infarction [RR: 0.83; 95% CI: 0.72-0.94], and stroke [RR: 0.90; 95% CI: 0.83-0.99]. However, there was no significant difference in all-cause mortality [RR: 1.02; 95% CI: 0.92-1.12], or cardiovascular mortality [RR: 0.95; 95% CI: 0.83-1.08] between P2Y12 inhibitors and aspirin users. Additionally, there was no significant difference in major bleeding events [RR: 0.88; 95% CI: 0.74-1.04], or all bleeding events [RR: 1.09; 95% CI: 0.90-1.33] between P2Y12 inhibitors and aspirin groups. Use of P2Y12 inhibitor monotherapy is associated with lower rates of myocardial infarction and stroke in ASCVD patients without any significant difference in mortality, or bleeding compared to aspirin monotherapy.

Between and Within Sexual Identity-Group Differences in Asthma Prevalence in the United States.

BACKGROUND: Although prior studies have established the association of asthma with smoking and obesity, literature on difference-in-differences analyses involving sexual identity is sparse. Therefore, this study aimed to examine the between and within sexual identity-group differences in asthma prevalence among individuals who smoke and are obese. METHODS: We aggregated the 2017-2019 National Survey on Drug Use and Health data on adults (N = 128,319) to perform weighted multivariable logistic regression analysis and marginal estimates and marginsplot to determine asthma prevalence by sexual identity and the status of smoking and obesity. RESULTS: About 66% of the study population reported having asthma. Among the individuals with asthma, 42% were obese, 10% were daily cigarette smokers, and 6% identified as bisexual persons. Lesbian/gay daily smokers (86%) or former smokers (75%) had a higher probability of having asthma than bisexual (daily smokers = 78% vs former smokers = 72%) and heterosexual (daily smokers = 68% vs former smokers = 65%) persons. Within each sexual identity subgroup, daily smokers (68-86%) had the highest probability of asthma. Obese bisexual (73%) or lesbian/gay (72%) persons had higher probabilities of having asthma than heterosexual persons (69%). Obese (73%) or overweight (72%) bisexual (compared to normal weight = 70% or underweight = 51%) and obese (69%) or overweight (65%) heterosexual (compared to normal weight = 62% or underweight = 57%) persons had the highest probabilities of having asthma within their groups, whereas overweight persons (overweight = 81% vs underweight = 79%, normal weight = 78%, and obese = 72%) had the highest probabilities within lesbian/gay persons. CONCLUSIONS: Smoking and obesity show heightened odds for asthma, with significant odds for sexual minorities in asthma diagnosis relative to heterosexuals. These findings provide formative information for future longitudinal and experimental studies to explore these mechanisms of asthma risks among sexual and gender minorities.

Diastolic function grading by American Society of Echocardiography guidelines and prediction of heart failure readmission and all-cause mortality in a community-based cohort.

BACKGROUND: Diastolic function (DF) guidelines have been simplified but lack extensive outcome data. Using a rural university heart failure (HF) database, we assessed whether DF grading could predict HF, HF readmission, and all-cause mortality (ACM). METHODS: In this single-center retrospective study that included 613 patients in sinus rhythm hospitalized for HF (HF with preserved-254 patients, with mid-range-216 patients, and reduced ejection fraction-143 patients), we recorded demographics, Doppler-echo, Framingham HF score, laboratories, HF readmission, and ACM with follow-up to 2167 days. RESULTS: Diastolic dysfunction (Ddys) parameters (left atrial volume index [LAVI] > 34 ml/m2 , tricuspid regurgitation [TR] velocity > 2.8 m/sec, and E/e' > 14) had moderate sensitivity (46.2%-65.0%) for predicting HF among all phenotypes combined with DF grading having moderate predictability and additive to a clinical composite for HF prediction (AUC = .677, P < 0.0001; difference = .043, P < 0.001) for combined phenotypes. Ddys parameters and Ddys severity (2016 ASE criteria: grade II and III) were significantly associated with HF readmission for decompensated HF within 60-2167 days of follow-up (LAVI > 34 ml/m2 : HR 1.56 [1.26-2.19]; E/e' > 14: HR 1.44 [1.21-1.99]; TR > 2.8 m/sec: H1.43 [1.19-1.88]; LV Dys grade II: HR 2.12 [1.42-2.96]; LV Ddys grade III: HR 2.39 [1.57-4.82]). CONCLUSION: The findings of this study highlight the clinical and prognostic relevance of determining the severity of LV Ddys in patients with HF with regard to HF verification and HF readmission.

Medical Therapy Versus Revascularization in Patients with Stable Ischemic Heart Disease and Advanced Chronic Kidney Disease.

PURPOSE OF REVIEW: This article reviews the evidence on optimal medical therapy (OMT) versus coronary revascularization in patients with stable ischemic heart disease (SIHD) and advanced chronic kidney disease (CKD). RECENT FINDINGS: A post hoc analysis of the COURAGE trial in patients with SIHD and CKD showed no difference in freedom from angina, death, and nonfatal myocardial infarction (MI) between OMT and percutaneous intervention plus OMT compared with patients without CKD. The ISCHEMIA-CKD trial of 777 patients with advanced CKD revealed no difference in cumulative incidence of death or nonfatal MI at 3 years between OMT and revascularization but the composite of death or new dialysis was higher in the invasive arm. Additionally, there were no significant or sustained benefits in related to angina-related health status in invasive versus conservative strategy. An initial revascularization strategy does not reduce mortality or MI or relieve angina symptoms in patients with SIHD and advanced CKD.

The Cardiovascular Effects of Electronic Cigarettes.

PURPOSE OF REVIEW: Electronic cigarettes (e-cigarettes) are gaining rapid popularity among all age groups, especially among youth. They have evolved into technologically advanced devices capable of delivering nicotine concentration and other substances. In addition to nicotine, e-cigarettes' constituents possess variety of toxic chemicals that have adverse effects on human body. RECENT FINDINGS: In recent years, steady downward trend in tobacco usage has been observed; however, e-cigarette use is on upward trend. E-cigarettes are advertised as "safer" alternatives to conventional smoking and as an aid to smoking cessation. Emerging studies have, however, shown that e-cigarettes have harmful effects on the cardiovascular system and that most of the e-cigarette users are dual users, concurrently using e-cigarettes and smoking conventional cigarettes. Despite a gap in clinical studies and randomized trials analyzing adverse cardiovascular effects of e-cigarette use, the existing literature supports that different constituents of e-cigarettes such as nicotine, carbonyls, and particulate matters carry potential risk for cardiovascular diseases (CVD) on its users.

Association Between Cardiovascular Risk Factors and the Diameter of the Thoracic Aorta in an Asymptomatic Population in the Central Appalachian Region.

BACKGROUND: Effects of cardiovascular (CV) risk factors on the diameter of the thoracic aorta have not been fully studied. This study examined the associations between CV risk factors and diameter of thoracic aorta. MATERIALS AND METHODS: Study population comprised of 1273 asymptomatic adults aged ≥18 years from Central Appalachia region of the United States who participated in a coronary artery screening between January 2014 and December 2016. Descriptive statistics and multiple linear regression analyses were performed to examine associations between multiple CV risk factors and diameters of the thoracic aorta. RESULTS: Mean (±SD) age of participants was 57.9±9.7 years; that of body mass index (BMI) was 29.4±5.9. The mean aortic sinus, ascending aorta, and descending aorta diameter were 34.1±4.4 mm, 33.8±4.4 mm, and 26.0±3.6 mm, respectively. Increasing age, being male, and having a higher BMI were associated with wider aortic sinus, ascending aorta, and descending aorta diameters. Hypertension (p < 0.05) and obesity (p < 0.0001) were significantly associated with wider diameter for all measured aortic diameters. Participants with diabetes had wider descending aorta compared to those without (26.6±3.9 mm vs. 25.9±3.5 mm, P = 0.012). Participants who had ever smoked a cigarette had significantly wider descending aorta diameter compared to never smokers (26.3±3.6 mm vs. 25.9±3.5 mm, p = 0.031). CONCLUSIONS: The study results suggest that decreasing BMI and management of CV risk factors such as hypertension and modifying behavioral risk factors such as smoking are likely to be emphasized in order to decrease the rate of aortic dilatation and subsequent aortic dissection, if aortic dilatation is detected during a CT scan.

Characteristics and Long-Term Outcomes of Patients With Prior Coronary Artery Bypass Grafting Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

Limited data are available on characteristics and long-term outcomes of patients with coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). Between January 2000 to December 2014, we identified STEMI patients with prior CABG undergoing primary percutaneous coronary intervention from 3 sites. Kaplan-Meier methods to estimate survival and major adverse cardiac events (MACE) were employed and compared to a propensity matched cohort of non-CABG STEMI patients. Independent predictors of outcomes were analyzed with Cox modeling. Of the 3,212 STEMI patients identified, there were 296 (9.2%) CABG STEMI patients, having nearly similar frequencies of culprit graft (47.6%) versus culprit native (52.4%) as the infarct-related artery (IRA). At 10 years, the adjusted survival was 44% in CABG STEMI versus 55% in non-CABG STEMI (HR 1.26; 95%CI 0.86 to 1.87; p = 0.72). Survival free of MACE was lower for CABG STEMI (graft IRA, 37%; native IRA, 46%) as compared to non-CABG STEMI controls (63%) (p = 0.02). Neither CABG history nor IRA (native vs graft) was independently associated with death or MACE in multivariable analysis. Temporal trends showed no significant change in death or MACE rates of CABG STEMI patients over time. In conclusion, long term survival of CABG STEMI patients is not significantly different than matched STEMI patients without prior CABG; however, CABG STEMI patients were at significantly higher risk for MACE events.

Current Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Intervention.

PURPOSE OF REVIEW: To review the clinical evidence on the use of percutaneous coronary intervention (PCI) revascularization options in left main (LM) disease in comparison with coronary artery bypass graft (CABG). Coronary artery disease (CAD) involving the LM is associated with high morbidity and mortality. Though CABG remains the gold standard for complex CAD involving the LM artery, recent trials have shown a trend towards non-inferiority of the LM PCI when compared with CABG in certain subset of patients. RECENT FINDINGS: Two recent major randomized trials compared the outcomes of PCI versus CABG in the LM and multi-vessel disease with LM involvement. The NOBLE trial included patients with all range of Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) scores and utilized biolimus drug-eluting stent (DES). The trial concluded that MACCE (major adverse cardiac and cerebrovascular event) was significantly higher with PCI (28%) when compared with CABG (18%) but overall stroke and motility were not different. EXCEL trial evaluated the same treatment option in low to intermediate SYNTAX score population with third-generation everolimus DES platform as PCI option. Results showed no significant differences in the composite primary endpoints of death, stroke, and myocardial infarction (MI) at the end of 30 days (22% versus 19.2%, p = 0.13), although repeat revascularization was higher in PCI group (16.9% versus 10%). Recent evidence suggests that PCI is an acceptable alternative to treat symptomatic LM stenosis in select group of patients. In low to medium SYNTAX score, particularly in patients without diabetes mellitus, PCI remains a viable option. Future trials focusing on evaluating subset of patients who would benefit from one particular revascularization option in comparison with other is warranted.

Association between smoking status and homocysteine levels and possible effect modification by cholesterol and oestradiol.

Introduction: This study aimed to examine the association of smoking status with homocysteine levels and to determine whether the association is modified by oestradiol or cholesterol.Methods: Data (N = 4580) were obtained from National Health and Nutrition Examination Survey 2003-2004 with analysis done in 2018 on adults aged ≥20 years. The outcome was homocysteine; smoking status was the exposure variable and categorized as current, former or never smoker. Generalized linear models were used to examine the associations between smoking status and homocysteine levels, while assessing the impact of oestradiol and cholesterol.Results: After adjusting for age, sex, ethnicity, education and income level, homocysteine levels did differ by smoking status ((current smokers versus never smokers: ß: 0.18 CI: 0.00, 0.36), (former smokers: ß: 0.10 CI: -0.09, 0.28)). The addition of oestradiol as an interaction term in adjusted models was associated with a 16.6% increase in homocysteine levels when compared to models without the interaction term. Oestradiol but not cholesterol did moderate the association between smoking status and homocysteine levels.Discussion and conclusions: Homocysteine levels did differ across smoking status after adjusting for confounders. Oestradiol did moderate the relationship between homocysteine and smoking status.

Sildenafil for Pulmonary Arterial Hypertension.

Pulmonary hypertension is a life-threatening illness with debilitating physical and emotional consequences. The progression of this devastating disease is characterized by a continuous increase in pulmonary vascular resistance, which results in elevated pulmonary artery pressure and leads to right heart failure. Treatment is focused on targeting the underlying complex etiology via the endothelin, prostacyclin, and nitric oxide (NO) pathways. Emergence of new treatments over the past 2 decades has led to improvement in the functional status and time to clinical worsening. Even with recent advances, outcomes remain suboptimal. Phosphodiesterase-5 (PDE-5) inhibitors, such as sildenafil, were approved for treatment of pulmonary arterial hypertension (PAH) by the Food and Drug Administration (FDA) in 2005, which holds promise in improving quality of life and therefore making this class of medications effective palliative therapy agents. In this review, we summarize the emergence of sildenafil as a treatment for PAH and its role as palliative therapy.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis.

PURPOSE OF REVIEW: This article reviews the latest data on unprotected left main (ULM) percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery, with a focus on the NOBLE and EXCEL trials. RECENT FINDINGS: In EXCEL trial, the primary endpoint at 3 years was 15.4% in the PCI group and 14.7% in the CABG group (p = 0.02 for non-inferiority of PCI versus CABG). In NOBLE, the primary endpoint at 5 years was 28% and 18% for PCI and CABG, respectively (HR 1.51, CI 1.13-2.0, which did not meet the criteria for non-inferiority of PCI to CABG; p for superiority of CABG was 0.0044). Higher repeat revascularization and non-procedural myocardial infarction were noted in PCI group but there was no difference in all-cause or cardiac mortality between the two groups. A heart team approach with appropriate patient selection, careful assessment of LM lesions, and meticulous procedural technique makes PCI a valid alternative to CABG for ULM stenosis.