Clinical Implications of the ISCHEMIA Trial: Invasive vs Conservative Approach in Stable Coronary Disease.

PURPOSE OF REVIEW: To identify key strengths and weaknesses of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and explore its clinical implications in patients with stable ischemic heart disease. RECENT FINDINGS: Previous studies have shown inconsistent benefit of early angiography and revascularization in patients with stable ischemic heart disease. The ISCHEMIA trial showed no significant reduction in mortality or cardiovascular outcomes in patients undergoing early angiography and revascularization with guideline-directed medical therapy compared to patients on medical therapy alone in specific patient population with stable coronary artery disease. The ISCHEMIA trial provides insights into invasive versus pharmacological treatment for patients with stable ischemic heart disease. Though it may have reduced applicability given its broad exclusion criteria, it offers useful information about the utility of non-invasive imaging modalities for selecting optimal revascularization candidates.

Racial and Ethnic Differences in Risk Factors and Outcomes in Adults With Acute Myocardial Infarction.

Introduction Understanding racial/ethnic differences in patients with acute myocardial infarction (AMI) lays the foundation for more equitable health care. This study evaluated racial/ethnic differences in risk factors, treatment, and outcomes in patients with AMI. Methods This retrospective study included patients aged 18-50 years hospitalized for AMI between 2006 and 2016. Cox regression models were used to evaluate the association of race/ethnicity with all-cause mortality. Results Among 1753 patients hospitalized for type 1 AMI (median age 44 years, 85% male), 35.8% self-identified as White, 9.4% non-Hispanic Black, 37.6% Hispanic, 14.5% Asian, and 2.6% as other. Compared to White patients, Black patients were more likely to have hypertension (53.1% vs 32.2%, p < 0.001) and Hispanic patients were more likely to have diabetes (28.2% vs 15.5%, p < 0.001) and obesity (23.9% vs 17.7%, p = 0.008). There were no substantial differences in revascularization rates or initial medical treatment. However, adherence to statin therapy was lower among Black and Hispanic patients (50.3% and 58.6% for Black and Hispanic vs 67.4% and 72.3% for White and Asian patients, respectively). Over a median follow-up of 7.5 years, Black patients had higher all-cause mortality (unadjusted hazard ratio = 1.88, 95% confidence interval = 1.09-3.24) compared to White patients, but this difference was no longer significant after adjustments (adjusted hazard ratio = 1.32, 95% confidence interval = 0.74-2.36). Discussion and Conclusion There are racial/ethnic differences in risk factors and medication adherence patterns in adults with AMI. To achieve equitable care, programs with tailored intervention addressing needs of different groups should be developed.

Cardiogenic Shock and Respiratory Failure Complicating Takotsubo Syndrome.

OBJECTIVES: This study's purpose is to evaluate the incidence, predictors, and outcomes of patients presenting to the cardiac catheterization laboratory with takotsubo syndrome complicated by respiratory failure or shock. BACKGROUND: The presentation of takotsubo syndrome mimics acute myocardial infarction. It is often diagnosed in the cardiac catheterization laboratory when no coronary obstruction is found. A subset of these patients develops shock or respiratory failure. METHODS: This is a retrospective study of patients who underwent cardiac catheterization at the Kaiser Permanente Southern California health system with takotsubo syndrome between 2006 to 2016. Medical records were manually reviewed to identify patient characteristics, treatment, and clinical outcomes. RESULTS: Among 530 patients with takotsubo syndrome, 56 (10.6%) developed shock or respiratory failure and required mechanical or inotropic support. A higher proportion of these patients were men (14.3% vs 5.7%) and Black (10.7% vs 7.0%). In multivariate logistic regression analyses, factors associated with respiratory failure or shock were age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.94-0.99; P=.02), chronic obstructive pulmonary disease (OR, 1.9; 95% CI, 1.1-3.5; P=.02), chronic kidney disease (OR, 2.6; 95% CI, 1.3-5.3; P=.01), physical trigger (OR, 5.7; 95% CI, 3.0-10.8; P<.01), and ST elevation on the presenting electrocardiogram (OR, 2.5; 95% CI, 1.4-4.8; P=.04). Patients who required mechanical ventilation or inotropic support had significantly higher mortality (hazard ratio, 3.9; 95% CI, 2.1-7.1; P<.001). CONCLUSION: Shock or respiratory failure occur in 10.6% of patients presenting with takotsubo syndrome. Men and patients with baseline respiratory or renal disease were disproportionally affected. These patients have significantly worse clinical outcomes.

Acute myocardial infarction in young adults with chronic kidney disease.

OBJECTIVE: The goal of this study was to evaluate the prevalence of chronic kidney disease (CKD) in young patients with acute myocardial infarction (AMI) and to report their characteristics and clinical outcomes. BACKGROUND: Underlying renal dysfunction is a risk factor for poor cardiovascular outcomes in older patients. The implication of CKD in young patients with AMI is not well studied. METHODS: This is a retrospective population-based cohort study of patients aged 18-50 who presented with AMI between 2006 and 2016. Medical records were reviewed to confirm diagnosis and to identify treatment and long-term outcomes. Cox regression models were used to evaluate the association of CKD with mortality. RESULTS: Among 1753 young patients with type 1 AMI (median age 45 years, 85.3% male), CKD was present in 112 (6.8%) patients. A higher proportion of CKD patients had concomitant hypertension, hyperlipidemia, diabetes, and obesity. Use of statin and P2Y12 inhibitors post-AMI was lower in CKD patients. Over a median follow-up of 7.2 years, CKD was associated with higher all-cause mortality [hazard ratio (HR), 9.3; 95% CI, 6.3-13.8]. This association persisted after adjusting for demographics, comorbidities, and treatment (adjusted HR, 3.6; 95% CI, 2.2-6.0). CONCLUSION: Presence of CKD was associated with 3.6-fold higher mortality over a median follow-up of 7.2 years. A lower proportion of CKD patients were treated with statin therapy and P2Y12 inhibitors. These findings highlight the need for intensive risk factor modification and optimal use of guideline-directed medical therapies in this high-risk population.

Overall Effects and Moderators of Rehabilitation in Patients With Wrist Fracture: A Systematic Review.

OBJECTIVE: Wrist fractures constitute the most frequently occurring upper limb fracture. Many individuals report persistent pain and functional limitations up to 18 months following wrist fracture. Identifying which individuals are likely to gain the greatest benefit from rehabilitative treatment is an important research priority. This systematic review aimed to summarize effectiveness of rehabilitation after wrist fracture for pain and functional outcomes and identify potential effect moderators of rehabilitation. METHODS: A comprehensive search of 7 databases (including MEDLINE, EMBASE, and the Physiotherapy Evidence Database) was performed for randomized controlled trials involving adults >50 years of age who sustained wrist fracture and had received 1 or more conservative treatments (eg, exercise/manual therapy, lifestyle, diet, or other advice). Study selection, data extraction, and risk-of-bias assessment were conducted independently by 2 reviewers. Results of included trials were summarized in a narrative synthesis. RESULTS: A total of 3225 titles were screened, and 21 studies satisfying all eligibility criteria were reviewed. Over one-half of the included studies (n = 12) comprised physical therapist and/or occupational therapist interventions. Rehabilitative exercise/manual therapy was generally found to improve function and reduce pain up to 1 year after wrist fracture. However, effects were small, and home exercises were found to be comparable with physical therapist-led exercise therapy. Evidence for the effects of other nonexercised therapy (including electrotherapy, whirlpool) was equivocal and limited to the short term (<3 months). Only 2 studies explored potential moderators, and they did not show evidence of moderation by age, sex, or patient attitude of the effects of rehabilitation. CONCLUSION: Effectiveness of current rehabilitation protocols after wrist fracture is limited, and evidence for effect moderators is lacking. Currently available trials are not large enough to produce data on subgroup effects with sufficient precision. To aid clinical practice and optimize effects of rehabilitation after wrist fracture, potential moderators need to be investigated in large trials or meta-analyses using individual participant data. IMPACT: Many patients report persistent pain and functional limitations up to 18 months following wrist fracture. Effectiveness of current rehabilitation protocols after wrist fracture is limited and may be due to insufficient targeting of specific rehabilitation to individuals who are likely to benefit most. However, evidence for effect moderators is lacking within the currently available literature. To aid clinical practice and optimize effects of rehabilitation, investigating potential moderators of rehabilitation in individuals with wrist fracture via large trials or meta-analysis of individual participant data is research and policy imperative.

Survival and risk of recurrence of takotsubo syndrome.

OBJECTIVE: The goal of this study is to evaluate the long-term outcomes of patients with takotsubo syndrome and assess factors associated with death or recurrence. METHODS: This is a retrospective population-based cohort study of consecutive patients who presented to an integrated health system in Southern California with takotsubo syndrome between 2006 and 2016. Medical records were manually reviewed to confirm diagnosis and to identify predisposing factors, medication treatment and long-term outcomes. Factors associated with death or recurrent takotsubo syndrome were tested using Cox regression models. RESULTS: Between 2006 and 2016, there were 519 patients with a confirmed diagnosis of takotsubo syndrome. Patients were followed for 5.2 years (IQR 3.0-7.2). During the follow-up period, 39 (7.5%) had recurrent takotsubo syndrome and 84 (16.2%) died. In multivariate modelling, factors associated with higher risk of recurrence or death were age (HR 1.56 per 10-year increase, 95% CI 1.29 to 1.87), male sex (HR 2.52, 95% CI 1.38 to 4.60), diabetes (HR 1.6, 95% CI 1.06 to 2.43), pulmonary disease (HR 2.0, 95% CI 1.37 to 2.91) and chronic kidney disease (HR 1.58, 95% CI 1.01 to 2.47). Treatment with beta-blockers were associated with lower risk of recurrence or death (HR 0.46, 95% CI 0.29 to 0.72). No association was observed between treatment with ACE inhibitors or angiotensin-receptor blockers and recurrence or death (HR 0.92, 95% CI 0.59 to 1.42). CONCLUSIONS: Recurrent takotsubo syndrome occurred in a minor subset of patients. Treatment with beta-blocker was associated with higher event-free survival.

Clinical Characteristics and Outcomes of Patients With Takotsubo Syndrome.

BACKGROUND: Characteristics and outcomes of patients with takotsubo syndrome remain to be defined. The goal of this study was to report the characteristics and long-term outcomes of patients presenting with takotsubo syndrome compared with other patients presenting with acute myocardial infarction (AMI) in a community-based population. METHODS: This retrospective population-based study included patients hospitalised for AMI from 2006 to 2016. Those patients with takotsubo syndrome were compared with the patients with AMI. The primary outcome was all-cause mortality. Matching was performed to assemble a cohort of patients with similar baseline characteristics. RESULTS: Among 26,015 patients hospitalised with an initial diagnosis of AMI, 530 (2.0%) were diagnosed with takotsubo syndrome. Patients with takotsubo syndrome were older (68.3 ± 11.3 vs 65.6 ± 12.2 years) and more likely to be women (93.4% vs 30.7%). Concomitant hypothyroidism, rheumatologic disorders, and lung disease were more prevalent in the takotsubo syndrome group, whereas diabetes and hyperlipidemia were less prevalent. Mortality was lower in the takotsubo syndrome group (1-year mortality 4.0% vs 8.9%; P < 0.001). The 530 patients with takotsubo syndrome were matched with 1,315 AMI patients with similar baseline characteristics. At a follow-up of 5.4 ± 3.3 years, patients with takotsubo syndrome had a lower risk for all-cause death than other patients who presented with AMI (hazard ratio 0.59, 95% CI 0.47-0.76). CONCLUSIONS: Among patients presenting with AMI, patients with takotsubo syndrome were older and more likely to be women. Patients with takotsubo syndrome had better long-term outcomes compared with matched AMI patients.

Quantitative and qualitative results from implementation of a two-item food insecurity screening tool in healthcare settings in Connecticut.

Millions of Americans face food insecurity, yet a universal screening tool is not in place. Food insecurity is known to be associated with poor health outcomes such as heart disease, diabetes mellitus, and hypertension in adults, and low school performance and mental illness in children. From January 2017 through February 2017, we utilized a validated two-item screening tool to assess the prevalence of households at risk for food insecurity and conducted a focus group of pediatricians. Patients at a Federally Qualified Health Center in New Haven, Connecticut were screened. Pediatricians of the American Academy of Pediatricians comprised the focus group. 534 of 1272 screening tool respondents were at risk for food insecurity (41.4%). Male respondents had higher prevalence than females (46.3% vs 38.9%, p = 0.009), and Hispanics (34.4%) less than Whites (54.4%) and Blacks (53.8%) (p < 0.001). Moreover, we executed a qualitative study of pediatricians' perception of food insecurity screening via a focus group. Themes that emerged from the focus group were agreement on the high importance of food insecurity screening, concern from caregivers about child neglect, and the difficulty of implementing the screening tool due to time constraints. We achieved successful implementation of the screening tool into the electronic medical record with a high completion rate of 97.9%. Identified barriers to universal screening for food insecurity include lack of efficient methods to direct food-insecure patients to resources and continued stigma regarding food insecurity.

Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors and Ezetimibe on Risk of New-Onset Diabetes: A Systematic Review and Meta-Analysis of Large, Double-Blinded Randomized Controlled Trials.

BACKGROUND: Previous meta-analyses have shown that statins may cause incident diabetes. This article reviews randomized controlled trials using proprotein convertase subtilisin/kexin 9 inhibitors (PCSK9i) or ezetimibe on the risk of new-onset diabetes. METHODS: Eight trials involving PCSK9i and 3 trials of ezetimibe were selected for review. PubMed, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov were thoroughly searched for relevant trials. Inclusion criteria included at least 100 patients per treatment arm, follow-up of at least 52 weeks, and at least double-blinded study design. Exclusion criteria included patients with previously diagnosed diabetes, nonrandomized, placebo-controlled, open-label, and crossover trials. The primary outcome was the number of incident diabetes cases. A random effects model was used. Heterogeneity in effect sizes was measured with I2 parameter and the Q statistic was used to test for excessive between-study heterogeneity. RESULTS: A total of 52 214 participants for the PCSK9i and a total of 20 084 for the ezetimibe meta-analyses were included. Participants randomized to PCSK9i did not differ from the control patients in diabetes incidence (risk ratio [RR] = 0.99, P = .87, 95% CI = 0.92-1.07). Participants randomized to ezetimibe did not differ from the control patients in diabetes incidence (RR = 1.05, P = .37, 95% CI = 0.95-1.15). DISCUSSION: The use of PCSK9i and ezetimibe does not appear to impact the risk of incident diabetes mellitus when added to guideline-directed medical therapy.