Procedural and cardiovascular outcomes of geriatric vs non-geriatric patients undergoing permanent pacemaker implantation - a nationwide cohort analysis.

BACKGROUND: Permanent pacemaker implantation is increasing exponentially to treat atrio-ventricular block and symptomatic bradyarrhythmia. Despite being a minor surgery, immediate complications such as pocket infection, pocket hematoma, pneumothorax, hemopericardium, and lead displacement do occur. METHODS: The Nationwide Inpatient Sample was queried from 2016 to 2018 to identify patients with pacemakers using ICD-10 procedure code. The Chi-square test was used for statistical analysis. RESULTS: The sample size consisted of 443,460 patients with a pacemaker, 26% were <70 years (male 57%, mean age of (60.6±9.7) yr, Caucasian 70%) and 74% were ≥70 years (male 50%, mean age of (81.4±5.9) yr, Caucasian 79%). Upon comparison of rates in the young vs elderly: mortality (1.6% vs 1.5%; P<0.01), obesity (26% vs 13%; P<0.001), coronary artery disease (40% vs 49%; P<0.001), HTN (74% vs 87%; P<0.01), anemia (4% vs 5%; P<0.01), atrial fibrillation (34% vs 49%; P<0.01), peripheral artery disease (1.7% vs 3%; P<0.01), CHF (31% vs 39%; P<0.001), diabetes (31% vs 27.4%; P<0.01), vascular complications (1.1% vs 1.2%; P<0.01), pocket hematoma (0.5% vs 0.8%; P<0.01), AKI (16% vs 21%; P<0.01), hemopericardium (0.1% vs 0.1%; P = 0.1), hemothorax (0.3% vs 0.2%; P<0.01), cardiac tamponade (0.4% vs 0.5%; P<0.01), pericardiocentesis (0.4% vs 0.4%; P<0.01), cardiogenic shock (4% vs 2.3%; P<0.01), respiratory complications (1.9% vs 0.9%; P<0.01), mechanical ventilation (5.1% vs 2.9%; P<0.01); post-op bleed (0.5% vs 0.3%; P<0.01), need for transfusion (4.8% vs 3.8%; P<0.01), severe sepsis (0.6% vs 0.5%; P<0.01 ), septic shock (2% vs 1%; P<0.01), bacteraemia (0.8% vs 0.4%; P<0.01), lead dislodgement (1.4% vs 1.1%; P<0.01). CONCLUSIONS: Our study revealed that the overall complication rates were lower in the elderly despite higher co-morbidities. This aligns with previous studies which showed lower rates in the elderly. Hence providers should not hesitate to provide guideline driven pacemaker placement in the elderly especially in patients with good life expectancy.

Meta-Analysis of Efficacy and Safety of Intravenous Iron in Patients With Iron Deficiency and Heart Failure With Reduced Ejection Fraction.

Iron deficiency is an independent risk factor for heart failure (HF) exacerbation. We aim to study the safety and efficacy of intravenous (IV) iron therapy in patients with HF with reduced ejection fraction (HFrEF). A literature search was conducted on MEDLINE (Embase and PubMed) using a systematic search strategy by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) until October 2022. CRAN-R software (The R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis. The quality assessment was performed using the Cochrane Risk of Bias and Newcastle-Ottawa Scale. We included 12 studies with a total of 4,376 patients (IV iron n = 1,985 [45.3%]; standard of care [SOC] n = 2,391 [54.6%]). The mean age was 70.37 ± 8.14 years and 71.75 ± 7.01 years in the IV iron and SOC groups, respectively. There was no significant difference in all-cause mortality and cardiovascular mortality (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74 to 1.04, p <0.15). However, HF readmissions were significantly lower in the IV iron group (RR 0.73, 95% CI 0.56 to 0.96, p = 0.026). Non-HF cardiac readmissions were not significantly different between the IV iron and SOC groups (RR 0.92, 95% CI 0.82 to 1.02, p = 0.12). In terms of safety, there was a similar rate of infection-related adverse events in both arms (RR 0.86, 95% CI 0.74 to 1, p = 0.05). IV iron therapy in patients with HFrEF is safe and shows a significant reduction in HF hospitalizations compared with SOC. There was no difference in the rate of infection-related adverse events. The changing landscape of HFrEF pharmacotherapy in the last decade may warrant a re-demonstration of the benefit of IV iron with current SOC. The cost-effectiveness of IV iron use also needs further study.

Comparison of trends and outcomes of infective endocarditis in patients with versus without leukemia, 2002 to 2017, from a nationwide inpatient sample.

Patients with leukemia are at an increased risk for infective endocarditis secondary to their immunocompromised state, chemotherapy, and specific risk factors such as the presence of indwelling central venous catheters. There is a paucity of data regarding temporal trends and clinical outcomes of infective endocarditis in leukemia patients. Previous studies have shown a high rate of complications related to surgical valve procedures for treatment of infective endocarditis in patients with hematological malignancies. In this study, we aimed to analyze the contemporary trends and clinical outcomes of treatment in infective endocarditis patients with and without leukemia based on data available from the Nationwide Inpatient Sample, which is a publicly accessible, large sample-sized national dataset of hospitalized patients across the US. We present key findings on baseline characteristics, microbiological profile, outcomes, rates of valve surgical procedures, and mortality in infective endocarditis patients with and without leukemia between 2002 and 2017 in the US.

Differential Effects of Cardiac Rehabilitation in Obese and Non-Obese Population.

Background Cardiac rehabilitation (CR) improves outcomes in patients with heart disease. We investigated the differences in outcomes of comprehensive phase II CR in obese and non-obese patients. Methods We performed a retrospective analysis of functional outcomes including metabolic equivalents (METS), heart rate (chronotropic competence - CC), and blood pressure response (BPR) in 178 patients undergoing CR based on underlying body mass index (BMI). Demographic and clinical variables were assessed for age, gender, race, smoking, hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, stroke, heart failure, medication use, and several sessions attended. Results Initial CC and METS were impaired in majority of patients attending CR, whereas BPR to exercise was mostly preserved. Significant improvement occurred in CC (non-obese: 0.71 ± 0.11 vs 0.76 ± 0.11, p < 0.001; obese: 0.72 ± 0.10 vs 0.75 ± 0.12, p = 0.0010) and METS (non-obese: 4.96 ± 1.98 vs 7.33 ± 2.94, p < 0.001; obese: 4.39 ± 1.81 vs 6.79 ± 3.34, p < 0.001). Post-CR obese patients were able to reach similar level of physical activity as non-obese patients (6.79 ± 3.34 vs 7.33 ± 2.94; p = 0.2). Improvement in BPR was only seen in non-obese patients (24.02 ± 20.07 vs 30.18 ± 21.93; p = 0.019). Improvement in functional variables occurred despite increase in BMI in non-obese (25.91 ± 2.85 vs 26.21 ± 2.96; p = 0.031), and there was no significant change in BMI in obese (35.30 ± 5.60 vs 34.93 ± 5.42; p > 0.05). Conclusion CR concurrently improves functional outcomes in both obese and non-obese patients despite no associated weight loss. The difference in BPR, however, is seen in only non-obese individuals. Future studies are needed to validate the role of weight-optimized CR protocols as a potential target for improving cardiac outcomes.

Comparison of the prognostic value of non-ischaemic fractional flow reserve using intracoronary versus intravenous adenosine.

AIMS: Intracoronary adenosine (ICA) yields similar fractional flow reserve (FFR) results to the "gold standard" of intravenous adenosine (IVA). Whether they have similar prognostic significance is unknown. We therefore sought to study the prognostic value of the route of adenosine administration for the measurement of FFR in deferred coronary lesions in a large, real-world cohort. METHODS AND RESULTS: Five hundred and seventy-six patients with 787 lesions in whom PCI was deferred based on FFR >0.75 were studied. The primary outcome was the first major adverse cardiovascular event (MACE; defined as death, myocardial infarction [MI], or target vessel revascularisation [TVR]), and the secondary outcome was a composite of MI and target vessel failure (TVF). FFR was measured with ICA in 426 lesions and IVA in 361 lesions. Median follow-up duration was 3.2 years (interquartile range: 1.7- 4.6). Propensity-matched cohorts of ICA and IVA were well matched for baseline clinical, angiographic and haemodynamic characteristics. In the propensity-matched cohort, MACE occurred in 23.5% of the ICA group and in 22.3% of the IVA group (p=0.29). On multivariate analysis, acute coronary syndrome, FFR and prior MI/revascularisation were independent predictors of MACE and MI/TVF. The route of adenosine administration was not predictive of MACE or MI/TVF. CONCLUSIONS: ICA and IVA yield similar FFR values and show comparable long-term prognostic utility in a deferred population. These findings provide confirmation that non-ischaemic FFR using a simpler ICA protocol provides prognostic data similar to the gold standard IVA.

Clinical Decision-Making for the Hemodynamic "Gray Zone" (FFR 0.75-0.80) and Long-Term Outcomes.

BACKGROUND: Fractional flow reserve (FFR) value between 0.75 and 0.80 is considered the "gray zone" and outcomes data relative to treatment strategy (revascularization vs medical therapy alone [deferral]) are limited for this group. METHODS AND RESULTS: A total of 238 patients (64.3 ± 8.6 years; 97% male; 45% diabetic) with gray-zone FFR were followed for the primary endpoint of major adverse cardiovascular event (MACE), defined as a composite of death, myocardial infarction (MI), and target-vessel revascularization. Mean follow-up duration was 30 ± 17 months. Deferred patients (n = 48 [20%]) had a higher prevalence of smoking and chronic kidney disease compared with the percutaneous coronary intervention (PCI) group (n = 190 [80%]; P<.05). Patients who underwent PCI had significantly lower MACE compared with the deferred patients (16% vs 40%; log rank P<.01). While there was a trend toward a decrease in all-cause mortality (8% vs 19%; log rank P=.06), the composite of death or MI was significantly lower in the PCI group (9% vs 27%; P<.01). On multivariate Cox proportional hazards regression analysis, PCI was associated with lower MACE (hazard ratio, 0.5; 95% confidence interval, 0.27-0.95; P=.03). CONCLUSION: Revascularization for patients with gray-zone FFR was associated with a significantly reduced risk of MACE compared with medical therapy alone.

Prognostic Value of Late Gadolinium Enhancement CMR in Systemic Amyloidosis.

OBJECTIVES: The aim of this study was to access the prognostic implication of late gadolinium enhancement (LGE) in patients with systemic amyloidosis undergoing cardiac magnetic resonance (CMR). BACKGROUND: Cardiac amyloidosis confers significantly worse prognosis in patients with systemic amyloidosis. CMR imaging has emerged as an attractive noninvasive modality to diagnose cardiac involvement in patients with systemic amyloidosis. We performed a systemic review and meta-analysis to evaluate the prognostic role of LGE-CMR imaging in patients with systemic amyloidosis. METHODS: Electronic databases MEDLINE, PubMed, Embase, and Cochrane were systematically searched to identify studies evaluating the association between LGE-CMR and prognosis in systemic amyloidosis with cardiac involvement. The present study was designed to systematically review and assess the association between LGE and the primary endpoint of all-cause mortality. A random effects model was used to calculate a pooled odds ratio using inverse-variance weighting. RESULTS: Data were included from 7 studies with a total of 425 patients and a mean follow-up of 25 months. Patients had a weighted average age of 64 years and left ventricular ejection fraction of 59.2%; 67% were male. Endomyocardial biopsy was positive for amyloidosis in 20%, whereas LGE was present in 73% of patients. LGE-positive patients had increased overall mortality compared with those without LGE (pooled odds ratio: 4.96; 95% confidence interval [CI]: 1.90 to 12.93; p = 0.001). For the LGE group, the pooled death rate was 0.07 (95% CI: 0.03 to 0.19) events per year and for the LGE+ group, the rate was 0.25 (95% CI: 0.16 to 0.39 per year; p = 0.001). The proportion of patients with cardiac biopsy within each study ranged from 3% to 68%, and the relationship between LGE status and death did not vary according to cardiac biopsy proportion across studies. CONCLUSIONS: LGE on CMR in patients with systemic amyloidosis with known or suspected cardiac amyloidosis is associated with increased risk of all-cause mortality.

Regulation of MSR-1 and CD36 in macrophages by LOX-1 mediated through PPAR-γ.

We observed uniform sustained Dil-ox-LDL uptake in macrophages in the presence or absence of ox-LDL receptor-1 (LOX-1). We wondered if the deficiency of LOX-1 modulates the expression of two other scavenger receptors, macrophage scavenger receptor-1 (MSR1) and CD36, on macrophages to account for the unaltered ox-LDL uptake. Macrophages were isolated from wild-type (WT) and LOX-1 knockout (KO) mice and stimulated with ox-LDL. Dil-ox-LDL uptake and expression of MSR1 and CD36 examined. Abrogation of LOX-1 did not significantly change Dil-ox-LDL uptake by macrophages. LOX-1 KO macrophages showed a significant decrease in CD36 at baseline as well as after ox-LDL stimulation and a marked almost 100% increase in the expression of MSR1, both at mRNA and protein levels (all p<0.05 vs. WT macrophages). Further, we observed a reduction in the expression of PPAR-γ in LOX-1 KO macrophages. To ascertain the role of PPAR-γ in the altered expression of MSR1 and CD36, LOX-1 KO macrophages were treated with troglitazone, a PPAR-γ agonist. Activation of PPAR-γ by troglitazone reversed the increased expression of MSR1 as well as the decreased expression of CD36 in LOX-1 KO macrophages. LOX-1 abrogation induces MSR1 and inhibits CD36 expression. The increase in MSR1 most likely accounts for sustained Dil-ox-LDL uptake despite LOX-1 abrogation. The alterations in CD36 and MSR1 occur through a decrease in PPAR-γ.

Coronary artery calcium and plaque association with left ventricular mass, assessed by multi-row detector computed tomography.

INTRODUCTION: Few studies have been published describing the association of coronary plaques and coronary artery calcium (CAC) to left ventricular (LV) mass and LV function using multi-detector computed tomography (MDCT). Coronary plaques can potentially influence the LV function. We sought to evaluate LV mass and function on MDCT and its correlation with CAC and plaque burden in the coronary arteries. METHODS: We included 197 symptomatic patients from the multicenter ACCURACY Study. The LV mass was measured manually using Advantage 4.4 workstation. Interobserver variability of LV mass was assessed using 34 randomly selected studies. LV mass was indexed to the body surface area. The coronary plaque severity was assessed in each segment using MDCT, following the 15 segment American Heart Association model. Plaque and segment scores were calculated accordingly. Statistical analysis using multiple logistic regression analysis was performed. RESULTS: We divided the cohort into those with CAC=0 [n=67 (34%)] and those with CAC greater than 0 [n=130 (66%)]. A significant correlation was found between indexed LV mass and CAC, plaque, and segment scores in both adjusted and unadjusted models. A significant association was observed between nonindexed LV mass with CAC, MDCT plaque score and segment score upon adjusting for various cardiovascular risk factors. A significant correlation was found between hyperlipidemia, hypertension, family history of CAD, and greater than 50% and greater than 70% stenosis on invasive cardiac catheterization with LV mass (all P<0.05). CONCLUSION: To our knowledge, this is the first study evaluating coronary plaque on computed tomographic angiography with LV mass. We were able to show a significant correlation of LV mass with CAC score, and with total plaque and total segment scores. The poor prognosis associated with increased CAC scores may be partially explained by this association with increased LV mass.