Feasibility and Utility of a Cardiovascular Risk Screening Tool in Women Undergoing Routine Gynecology Evaluation.

Background: The goals of this multicenter survey were to examine the prevalence and patient awareness of cardiovascular risk factors, and the association between history of adverse pregnancy outcomes (APO­including gestational hypertension, gestational diabetes, and preeclampsia) and prevalence of cardiovascular risks among women presenting to outpatient obstetrics/gynecology (OB/GYN) clinics. Materials and Methods: We surveyed 2,946 female patients attending 16 outpatient OB/GYN clinics across the United States between January 2010 and January 2012. Main outcome measures were self-reported cardiovascular risk factors and symptoms such as angina and dyspnea. Results: Mean age of the patients was 51 ± 13.6 years. Cardiovascular risks and symptoms were highly prevalent (86.0% and 40.1%, respectively). Many patients did not know if they had common risk factors such as hypertension, hypercholesterolemia, or diabetes (18.4%, 32.0%, and 17.9%, respectively). Women with a history of APO were slightly more likely to be aware of common risk factors, including abnormal blood pressure (17% vs. 18.6%), high cholesterol (31.7% vs. 32%), and obesity/elevated body mass index (43.9% vs. 49.7%). Compared with patients with no history of APO, patients with APO (n = 380, 12.9%) were more likely to have risk factors (89.5% vs. 83.9%, p = 0.002) and symptoms (45.5% vs. 39.3%, p = 0.02). Conclusions: Awareness of cardiovascular risk factors and symptoms among all women surveyed in this study was poor, although awareness for some risk factors was relatively higher among patients with APO. This study demonstrates the feasibility of cardiovascular assessment in OB/GYN clinics using a simple questionnaire and its potential role for early recognition and timely intervention.

Transcatheter Aortic Valve Replacement Versus Surgery in Women at High Risk for Surgical Aortic Valve Replacement (from the CoreValve US High Risk Pivotal Trial).

The objective of this study was to compare outcomes in women after surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) using a self-expanding prosthesis in patients with severe aortic stenosis who were at high risk for SAVR. Although registries and meta-analyses have suggested that TAVR is of considerable benefit in women, perhaps even more so than in men, a rigorous evaluation of TAVR with a self-expanding valve versus SAVR in women from a randomized trial has not been performed. Patients with severe aortic stenosis were randomized 1:1 to either TAVR or SAVR. Outcomes at 1 year are reported. Treatment was attempted in a total of 353 women (183 TAVR and 170 SAVR). Baseline characteristics and predicted risk of the 2 groups were comparable, although the frequency of diabetes mellitus was lower in patients undergoing TAVR (33.3% vs 45.3%; p = 0.02). TAVR-treated patients experienced a statistically significant 1-year survival advantage compared with SAVR patients (12.7% vs 21.8%; p = 0.03). The composite all-cause mortality or major stroke rate also favored TAVR (14.9% vs 24.2%; p = 0.04). Quality of life, as measured by the Kansas City Cardiomyopathy Questionnaire summary score, for both the TAVR and SAVR groups increased significantly from baseline to 1 year. In conclusion, female TAVR patients had lower 1-year mortality and lower 1-year all-cause mortality or major stroke compared with women undergoing SAVR, with both cohorts experiencing improved quality of life. Further studies specifically in women are warranted to validate these findings.

Transcatheter Aortic Valve Replacement in Women Versus Men (from the US CoreValve Trials).

Treatment for severe symptomatic aortic stenosis has changed significantly in recent years due to advances in transcatheter aortic valve replacement (TAVR). Recent studies with the CoreValve prosthesis have demonstrated superior results compared with surgical aortic valve replacement in patients at increased risk for surgery, but there are limited data on gender-related differences in patient characteristics and outcomes with this device. We compared baseline characteristics and clinical outcomes in women and men undergoing TAVR with the CoreValve prosthesis. A total of 3,687 patients (1,708 women and 1,979 men) were included. At baseline, women tended to be slightly older and to have increased frailty, but they had fewer cardiac co-morbidities, higher left ventricular systolic function, less coronary artery disease, and fewer previous strokes. All-cause mortality was 5.9% for women and 5.8% for men at 30 days (p = 0.87) and 24.1% and 21.3%, respectively, at 1 year (p = 0.08). The incidence of stroke was 5.7% in women and 4.0% in men at 30 days (p = 0.02) and 9.3% and 7.7%, respectively, at 1 year (p = 0.05). Women had a higher incidence of bleeding, including more life-threatening bleeds, and a greater incidence of major vascular complications than men at 30 days. Device success was achieved in 86.9% of women and 86.1% of men (p = 0.50). In conclusion, although there were significant baseline differences and procedure-related complications between women and men undergoing TAVR with the CoreValve prosthesis, this analysis found no significant difference in 30-day or 1-year mortality.

Does Preoperative Platelet Function Predict Bleeding in Patients Undergoing Off Pump Coronary Artery Bypass Surgery?

OBJECTIVE: We sought to examine the relationship between preoperative platelet function and perioperative bleeding in patients undergoing CABG. BACKGROUND: There are many ways to measure platelet aggregability. Little is known about their correlations with one another, or with bleeding. METHODS: We prospectively studied 50 patients undergoing a first isolated off-pump CABG. Thirty-four were exposed to a thienopyridine prior to surgery; 16 were not. Preoperative platelet function was measured by VerifyNow®, TEG®, AggreGuide™, Plateletworks®, vasodilator-stimulated phosphoprotein (VASP) phosphorylation, and light transmission aggregometry. Bleeding was assessed 2 ways: drop from pre- to nadir postoperative hematocrit, and chest tube drainage. Correlation coefficients were calculated using Spearman's rank-order correlation. RESULTS: Mean age was 62 years. Patient characteristics and surgical details were similar between the thienopyridine-exposed and non-exposed patients. The correlation coefficients between the 4 point-of-care platelet function measurements and hematocrit change ranged from -0.2274 to 0.2882. Only Plateletworks® correlated with drop in hematocrit (r = 0.2882, P = 0.0470). The correlation coefficients between each of the 4 point-of-care platelet function tests and the chest tube drainage were also poor, ranging from -0.3073 to 0.2272. Both AggreGuide™ (r = -0.3073, P = 0.0317) and VASP (r = -0.3187, P = 0.0272) were weakly but significantly correlated with chest tube drainage. The correlation among the 4 point-of-care platelet function measurements was poor, with coefficients ranging from -0.2504 to 0.1968. CONCLUSIONS: We observed little correlation among 4 platelet function tests, and between those assays and perioperative bleeding defined 2 different ways. Whether any of these assays should be used to guide decision making in individual patients is unclear.

Intravascular cell delivery device for therapeutic VEGF-induced angiogenesis in chronic vascular occlusion.

Site specific targeting remains elusive for gene and stem cell therapies in the cardiovascular field. One promising option involves use of devices that deliver larger and more sustained cell/gene payloads to specific disease sites using the versatility of percutaneous vascular access technology. Smooth muscle cells (SMCs) engineered to deliver high local concentrations of an angiogenic molecule (VEGF) were placed in an intravascular cell delivery device (ICDD) in a porcine model of chronic total occlusion (CTO) involving ameroid placement on the proximal left circumflex (LCx) artery. Implanted SMC were retained within the ICDD and were competent for VEGF production in vitro and in vivo. Following implantation, micro-CT analyses revealed that ICDD-VEGF significantly enhanced vasa vasora microvessel density with a concomitant increase in tissue VEGF protein levels and formation of endothelial cell colonies suggesting increased angiogenic potential. ICDD-VEGF markedly enhanced regional blood flow determined by microsphere and contrast CT analysis translating to a functional improvement in regional wall motion and global left ventricular (LV) systolic and diastolic function. Our data indicate robust, clinically relevant angiogenesis can be achieved in a human scale porcine chronic vascular occlusion model following ICDD-VEGF-based delivery of angiogenic cells. This may have implications for percutaneous delivery of numerous therapeutic factors promoting creation of microvascular bypass networks in chronic vaso-occlusive diseases.

Evaluation of XIENCE V everolimus-eluting and Taxus Express2 paclitaxel-eluting coronary stents in patients with jailed side branches from the SPIRIT IV trial at 2 years.

The aim of this study was to determine whether patients from the Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System in the Treatment of Patients With de Novo Native Coronary Artery Lesions (SPIRIT) IV trial who underwent percutaneous coronary intervention, who had target lesions with jailed side branches, had improved clinical outcomes when treated with the XIENCE V versus Taxus Express(2) drug-eluting stent. In the SPIRIT III randomized trial, patients with target lesions with jailed side branches after XIENCE V compared with Taxus Express(2) implantation had lower 2-year rates of major adverse cardiac events. The SPIRIT IV trial represents a larger more diverse patient population compared with SPIRIT III. In the large-scale, prospective, multicenter, randomized SPIRIT IV trial, 3,687 patients who underwent coronary stenting with up to 3 de novo native coronary artery lesions were randomized 2:1 to receive XIENCE V versus Taxus Express(2) stents. Two-year clinical outcomes of patients with or without jailed side branches after stenting were compared. A jailed side branch was defined as any side branch >1.0 mm in diameter within the target segment being stented, excluding bifurcations deemed to require treatment. Of the 3,687 patients in SPIRIT IV, a total of 1,426 had side branches that were jailed during angioplasty of the target lesion. Patients with jailed side branches after XIENCE V compared with Taxus Express(2) implantation had significantly lower 2-year rates of target lesion failure (6.5% vs 11.9%, p = 0.001), major adverse cardiac events (6.6% vs 12.2%, p = 0.0008), ischemia-driven target vessel revascularization (4.1% vs 7.9%, p = 0.004), and stent thrombosis (0.6% vs 2.8%, p = 0.001). In conclusion, patients with jailed side branches after stenting with XIENCE V compared to Taxus Express(2) devices had superior clinical outcomes at 2 years in the large-scale randomized SPIRIT IV trial.

Readmission in the 30 days after percutaneous coronary intervention.

OBJECTIVES: This study sought to identify the frequency and etiology of readmission within 30 days of percutaneous coronary intervention (PCI) in a large integrated healthcare system. BACKGROUND: One-fifth of Medicare patients are readmitted within 30 days of hospitalization. Identifying the causes of readmission may help identify strategies to prevent readmission. METHODS: All patients undergoing PCI (elective, urgent, and emergent) at our center between January 1, 2007, and April 12, 2010, were prospectively entered into the American College of Cardiology National Cardiovascular Data Registry. Patients readmitted to any hospital within 30 days of the index procedure were identified using an administrative database and telephone follow-up. Individual charts were reviewed independently by 2 investigators; disagreements regarding the cause for readmission were resolved by a third investigator. RESULTS: During the study period, 3,255 PCI were performed, and 262 patients (8.0%) were readmitted within 30 days. Of these, 261 (99.6%) had medical records available for review. Reasons for readmission included: complications related to the PCI (n = 31, 11.9%); non-PCI cardiac causes related to index admission (n = 93, 35.6%); noncardiac causes related to index admission (n = 34, 13%); causes unrelated to the index admission (n = 103, 39.5%). Multivariable logistic regression modeling revealed that female sex, advanced age, peripheral arterial disease, prior valvular surgery, and PCI complications during the index procedure were associated with 30-day readmission. CONCLUSIONS: Readmissions within 30 days due to complications related to PCI performed on index admission are rare (0.9% of all PCI) and are an infrequent cause of readmission (<12% of readmissions). Thirty-day readmission after PCI should not be used as a quality metric of PCI performance.

Frequency of coronary angiography and revascularization among men and women with myocardial infarction and their relationship to mortality at one year: an analysis of the Geisinger myocardial infarction cohort.

OBJECTIVES: To determine sex bias in the selection of strategies to evaluate patients with acute myocardial infarction (AMI), and determine if the choice of strategy influences survival. BACKGROUND: Controversy exists regarding the role of female sex in the use of invasive evaluation for AMI and its possible effect on adverse outcomes. METHODS: Electronic health record data from the Geisinger Acute Myocardial Infarction Cohort (GAMIC) was analyzed which included 1,968 men and 1,047 women admitted to the Geisinger Medical Center between January 2001 and December 2006 with acute myocardial infarction (AMI).Multivariate logistic regression analyses were used to determine independent correlates of an invasive evaluation. Multivariate logistic regression modeling stratified on sex was used to determine when invasive evaluation was done and whether there was a correlation with mortality. RESULTS: In unadjusted analyses, male sex was a significant predictor for the use of invasive evaluation (odds ratio = 1.71, 95% CI = [1.46, 2.00]). Adjusted for baseline differences (like age, renal function, co-morbid conditions) multivariate analyses found no significant relationship between male sex and invasive evaluation (OR = 1.02, 95% CI = [0.82, 1.23]). Females in the STEMI group were found to be less revascularized. No difference was observed in the one-year mortality between women and men regardless of invasive evaluation or revascularization. CONCLUSIONS: Sex was not independently associated with the occurrence of an invasive evaluation of a MI. Females in the STEMI group were less revascularized. There was no strong gender effect on survival irrespective of the performance on an invasive evaluation or revascularization.

The occupational effects of interventional cardiology: results from the WIN for Safety survey.

AIMS: Interventional cardiologists are amongst the most intensive radiation users within medicine. To assess the implications of this usage, the "Women In Innovation" Group (WIN) created a web-based survey called "WIN for Safety" distributed through the European Association of Percutaneous Coronary Intervention (EAPCI) to all catheterisation laboratory healthcare professionals, enquiring about radiation protection measures, compliance with monitoring, health (orthopaedic issues), radiation-associated problems (cataracts and cancer) and restrictions imposed upon the pregnant female. METHODS AND RESULTS: In total, there were 615 participants: 72.8% were interventional cardiologists. Most (73.5%) of them were male and 63.3% were aged 31-50 years. A radiation collar badge was used by the majority (64.4%) and the most frequently utilised protective measure was the thyroid shield (87.2%). Potential illnesses related to radiation exposure included 19.5% orthopaedic problems (back/neck/hip pain), 5.5% varicose veins, 2.4% blood count problems and 2.0% cataracts. Notably, an association between orthopaedic problems and years of exposure was found (p=0.001). Overall, only 2.2% had ever been diagnosed with a cancer, with a trend for more females to be affected (4.4% vs. 1.8%; p=0.067). Finally, 62.1% have restrictions imposed upon the pregnant female in the working environment. CONCLUSIONS: Awareness of radiation in the field of interventional cardiology is essential. The main risk is orthopaedic problems and measures should be taken for prevention. Cancer has not been demonstrated to be a direct consequence; however, we should remain vigilant and monitor individuals.

SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel.

Concerns regarding radiation exposure and its effects during pregnancy are often quoted as an important barrier preventing many women from pursuing a career in Interventional Cardiology. Finding the true risk of radiation exposure from performing cardiac catheterisation procedures can be challenging and guidelines for pregnancy exposure have been inadequate. The Women in Innovations group of Cardiologists with endorsement of the Society for Cardiovascular Angiography and Interventions aim to provide guidance in this publication by describing the risk of radiation exposure to pregnant physicians and cardiac catheterisation personnel, to educate on appropriate radiation monitoring and to encourage mechanisms to reduce radiation exposure. Current data do not suggest a significant increased risk to the foetus of pregnant women in the cardiac catheterisation laboratory and thus do not justify precluding pregnant physicians from performing procedures in the cardiac catheterisation laboratory. However, radiation exposure amongst pregnant physicians should be properly monitored and adequate radiation safety measures are still warranted.

SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel.

Concerns regarding radiation exposure and its effects during pregnancy are often quoted as an important barrier preventing many women from pursuing a career in Interventional Cardiology. Finding the true risk of radiation exposure from performing cardiac catheterisation procedures can be challenging and guidelines for pregnancy exposure have been inadequate. The Women in Innovations group of Cardiologists with endorsement of the Society for Cardiovascular Angiography and Interventions aim to provide guidance in this publication by describing the risk of radiation exposure to pregnant physicians and cardiac catheterisation personnel, to educate on appropriate radiation monitoring and to encourage mechanisms to reduce radiation exposure. Current data do not suggest a significant increased risk to the fetus of pregnant women in the cardiac catheterisation laboratory and thus do not justify precluding pregnant physicians from performing procedures in the cardiac catheterisation laboratory. However, radiation exposure among pregnant physicians should be properly monitored and adequate radiation safety measures are still warranted.

SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel.

Concerns regarding radiation exposure and its effects during pregnancy are often quoted as an important barrier preventing many women from pursuing a career in Interventional Cardiology. Finding the true risk of radiation exposure from performing cardiac catheterization procedures can be challenging and guidelines for pregnancy exposure have been inadequate. The Women in Innovations group of Cardiologists with endorsement of the Society for Cardiovascular Angiography and Interventions aim to provide guidance in this publication by describing the risk of radiation exposure to pregnant physicians and cardiac catheterization personnel, to educate on appropriate radiation monitoring and to encourage mechanisms to reduce radiation exposure. Current data do not suggest a significant increased risk to the fetus of pregnant women in the cardiac catheterization laboratory and thus do not justify precluding pregnant physicians from performing procedures in the cardiac catheterization laboratory. However, radiation exposure among pregnant physicians should be properly monitored and adequate radiation safety measures are still warranted.

Gender-based issues in interventional cardiology: a consensus statement from the Women in Innovations (WIN) initiative.

Cardiovascular disease (CVD) is the leading cause of mortality in women, yet studies have suggested that it is often under-recognized. Of particular concern is the apparent suboptimal treatment of women in comparison to men, with less revascularisation and use of evidence-based medications. The Women in Innovations group of cardiologists aims to highlight these issues and change perceptions to optimize the treatment of female patients with CVD, to support future research, and to encourage and guide training of female interventional cardiologists.

Gender-based issues in interventional cardiology: a consensus statement from the Women in Innovations (WIN) initiative.

Cardiovascular disease is the leading cause of mortality in women yet studies have suggested it is often under-recognized. Of particular concern is the apparent suboptimal treatment of women in comparison to men, with less revascularization and use of evidence-based medications. The Women in Innovations group of cardiologists, aims to highlight these issues and change perceptions to optimize the treatment of female patients with cardiovascular disease, support future research, and encourage and guide the training of female interventional cardiologists.

Feasibility and safety of ad hoc percutaneous coronary intervention in the modern era.

BACKGROUND: The frequency of ad hoc percutaneous coronary intervention (PCI) varies among institutions and regions of the country. It is unclear what factors limit use of the ad hoc strategy. OBJECTIVE: To define factors which limit the use of the ad hoc strategy. METHODS: All patients who underwent PCI at our center in 2004 were reviewed. Patients who had emergent PCI for ST-elevation myocardial infarction (n = 188), those who had undergone diagnostic coronary angiography at a referring facility (n = 54), and those who had a repeat PCI after a previous ad hoc PCI (n = 19) were excluded. PCIs performed the same day as diagnostic angiography were considered "ad hoc"; all others were designated "staged". Demographic and procedural factors through hospital discharge were prospectively recorded. Logistic regression analysis was performed to identify correlates of ad hoc PCI, PCI success, and PCI complications. RESULTS: Of the 580 PCI procedures eligible for analysis, 557 (96%) were ad hoc and 23 (4%) were staged. Patients undergoing staged PCI had more lesions treated, a higher rate of no-reflow and periprocedural myocardial infarction, and higher contrast volumes and fluoroscopic times. Logistic regression analysis revealed that patients with history of heart failure, renal insufficiency and a recent myocardial infarction were more likely to undergo a staged PCI. Patients undergoing a staged PCI and those who had previous bypass surgery were more likely to have an unsuccessful PCI procedure. CONCLUSION: Most PCI procedures can be performed safely and effectively on the same day as diagnostic coronary angiography.

Spontaneous coronary artery dissection related to menstruation.

We present the case of a young woman who developed an acute onset of classic cardiac symptoms, but because of her age and lack of risk factors, had a significant delay in transfer for cardiac catheterization. She was found to have spontaneous dissection of the left coronary system, eventually requiring emergent bypass surgery. The patient had recently began her menstrual period, and we speculate that hormonal fluctuations contributed to this process. The role of hormonal influences on the coronary vasculature is not entirely understood, but the incidence of spontaneous coronary dissection is higher in women, and is usually related to changes in hormones such as pregnancy and oral contraceptive use. We review the literature on spontaneous coronary dissection, the influence of hormones on the vasculature, as well as diagnosis and treatment options.

Bone marrow-derived cardiomyocytes are present in adult human heart: A study of gender-mismatched bone marrow transplantation patients.

BACKGROUND: Recent studies have identified cardiomyocytes of extracardiac origin in transplanted human hearts, but the exact origin of these myocyte progenitors is currently unknown. METHODS AND RESULTS: Hearts of female subjects (n=4) who had undergone sex-mismatched bone marrow transplantation (BMT) were recovered at autopsy and analyzed for the presence of Y chromosome-positive cardiomyocytes. Four female gender-matched BMT subjects served as controls. Fluorescence in situ hybridization (FISH) for the Y chromosome was performed on paraffin-embedded sections to identify cells of bone marrow origin with concomitant immunofluorescent labeling for alpha-sarcomeric actin to identify cardiomyocytes. A total of 160 000 cardiomyocyte nuclei were analyzed approximating 20 000 nuclei per patient. The mean percentage of Y chromosome-positive cardiomyocytes in patients with sex-mismatched BMT was 0.23+/-0.06%. Not a single Y chromosome-positive cardiomyocyte was identified in any of the control patients. Immunofluorescent costaining for laminin and chromosomal ploidy analysis with FISH showed no evidence of either pseudonuclei or cell fusion in any of the chimeric cardiac myocytes identified. CONCLUSIONS: These data establish for the first time human bone marrow as a source of extracardiac progenitor cells capable of de novo cardiomyocyte formation.

Occlusion of a saphenous vein graft aneurysm with a vein-covered stent.

A 67-year-old man was admitted with unstable angina, 15 years after saphenous vein graft bypass surgery. Cardiac catheterization demonstrated a large saccular aneurysm arising from the proximal segment of the vein graft to the obtuse marginal artery. Intravascular ultrasound revealed the opening of the aneurysm that measured 15 mm in length. The aneurysm was successfully occluded by deployment of a vein-covered stent.