The use of quality improvement interventions in reducing rarely appropriate echocardiograms: A systematic review and meta-analysis.

BACKGROUND: The volume of cardiac imaging continues to increase, with many tests performed for rarely appropriate indications. Appropriate use criteria (AUC) documents were published by the American Society of Echocardiography and American College of Cardiology, with quality improvement (QI) interventions developed in various institutions. However, the effectiveness of these interventions has not been assessed in a systematic fashion. METHODS: We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL for studies reporting association between cardiac imaging, AUC and QI. The search was not restricted to time or publication status. We selected studies assessing the effect of QI interventions on performance of rarely appropriate echocardiograms. The primary endpoint was reduction of rarely appropriate testing. RESULTS: Nine studies with 22,070 patients met inclusion criteria. Mean follow up was 15 months (1-60 months). QI interventions resulted in statistically significant reduction in rarely appropriate tests (OR 0.52, 95% CI: .41-.66; p < .01). The effects of QI interventions were analyzed over both the short (<3 months) and long-term (>3 months) post intervention (OR 0.62, 95% CI: .49-.79; p < .01 in the short term, and OR 0.47, 95% CI: .35-.62; p < .01 in the long term). Subgroup analysis of the type of intervention, classified as education tools or decision support tools showed both significantly reduced rarely appropriate testing (OR 0.54, 95% CI: .41-.73; p < .01; OR .47, 95% CI: .36-.61; p < .01). Adding a feedback tool did not change the effect compared to not using a feedback tool (OR 0.49 vs. 0.57, 95% CI: .36-.68 vs. 39-.84; p > .05). CONCLUSION: QI interventions are associated with a significant reduction in performance of rarely appropriate echocardiography testing, the effects of which persist over time. Both education and decision support tools were effective, while adding feedback tools did not result in further reduction of ordering rarely appropriate studies.

Safety and utility of mechanical circulatory support in patients with acute myocardial infarction complicated by cardiogenic shock: A systematic review and meta-analysis.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a major cause of morbidity and mortality. Although mechanical circulatory support (MCS) is an increasingly utilized therapeutic option in AMI-CS, studies evaluating the efficacy and safety of different forms of MCS have yielded conflicting results. This systematic review and meta-analysis aims to evaluate the safety and efficacy of different forms of MCS. METHODS: A database search was performed for studies reporting on the association of different forms of MCS with clinical outcomes in patients with AMI-CS. The primary efficacy endpoints were short term (≤30 days) and long term (>30 days) all-cause mortality. Secondary efficacy endpoints included recurrent AMI, cardiovascular (CV) mortality, device-related limb complications, moderate to severe bleeding events, and cerebrovascular accidents (CVA). RESULTS: 2752 patients with AMI-CS met inclusion criteria. Results were available comparing ECMO to other MCS or medical therapy alone, comparing IABP to medical therapy alone, and comparing pLVAD to IABP. Use of ECMO was not associated with lower risk of 30-day or long-term mortality compared to pVAD or standard medical therapy with or without IABP placement but was associated with higher risk of device-related limb complications and moderate to severe bleeding compared to pVAD. IABP use was not associated with a lower risk of 30 day or long-term mortality but was associated with higher risk of recurrent AMI and moderate to severe bleeding compared to medical therapy. Compared to IABP, pVAD use was associated with lower risk of CV mortality but not recurrent AMI. pVAD was associated with a higher risk of device-related limb complications and moderate to severe bleeding compared to IABP use. CONCLUSION: Use of ECMO or IABP in patients with AMI-CS is not associated with significant improvement in mortality. pVAD is associated with a lower risk of CV mortality. All MCS types are associated with increased risk of complications. Additional high-quality studies are needed to determine the optimal MCS therapy for patients with AMI-CS.

Utility of coronary revascularization in patients with ischemic left ventricular dysfunction.

BACKGROUND: Revascularization in patients with left ventricular (LV) dysfunction has been a subject of ongoing uncertainty and conflicting results. This is further complicated by factors including viability, severity of LV dysfunction, and method of revascularization using percutaneous coronary intervention (PCI) versus coronary-artery bypass grafting (CABG). OBJECTIVES: The purpose of this meta-analysis is to evaluate the association of coronary revascularization with outcomes in patients with ischemic LV dysfunction. METHODS: A literature search was conducted for studies reporting on cardiovascular outcomes after revascularization compared to optimal medical therapy (OMT) in patients with ischemic LV dysfunction. RESULTS: A total of 23 studies with 10,110 participants met inclusion criteria. Revascularization was significantly associated with lower all-cause mortality and CV mortality compared to OMT. The association was statistically significant regardless of severity of LV dysfunction or method of revascularization. Subgroup analysis demonstrated that revascularization was significantly associated with lower all-cause and CV mortality compared to OMT for patients with viable myocardium and mixed cohorts with variable viability, but not patients without viable myocardium. Revascularization was not associated with a significant difference in risk of heart failure (HF) hospitalization or acute myocardial infarction (AMI) compared to OMT. CONCLUSIONS: Revascularization in patients with ischemic LV dysfunction is associated with lower risk of all-cause and CV mortality independent of severity of LV dysfunction or method of revascularization. Revascularization is not associated with lower risk of mortality in patients without evidence of viable myocardium and is not associated with lower risk of AMI or HF hospitalization.

Utility of native T1 mapping and myocardial extracellular volume fraction in patients with nonischemic dilated cardiomyopathy: A systematic review and meta-analysis.

Background: Cardiac magnetic resonance imaging (CMR) based T1 mapping and extracellular volume fraction (ECV) are powerful tools for identifying myocardial fibrosis. This systematic review and meta-analysis aims to characterize the utility of native T1 mapping and ECV in patients with non-ischemic cardiomyopathy (NICM) and to clarify the prognostic significance of elevated values. Methods: A literature search was conducted for studies reporting on use of CMR-based native T1 mapping and ECV measurement in NICM patients and their association with major adverse cardiac events (MACE), ventricular arrhythmias (VAs), and left ventricular reverse remodeling (LVRR). Databases searched included: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results: Native T1 and ECV were significantly higher in NICM patients compared to controls (MD 78.80, 95 % CI 50.00, 107.59; p < 0.01; MD 5.86, 95 % CI 4.55, 7.16; p < 0.01). NICM patients who experienced MACE had higher native T1 and ECV (MD 52.87, 95 % CI 26.59, 79.15; p < 0.01; MD 6.03, 95 % CI 3.79, 8.26; p < 0.01). There was a non-statistically significant trend toward higher native T1 time in NICM patients who experienced VAs. NICM patients who were poor treatment responders had higher baseline native T1 and ECV (MD 40.58, 95 % CI 12.90, 68.25; p < 0.01; MD 3.29, 95 % CI 2.25, 4.33; p < 0.01). Conclusions: CMR-based native T1 and ECV quantification may be useful tools for risk stratification of patients with NICM. They may provide additional diagnostic utility in combination with LGE, which poorly characterizes fibrosis in patients with diffuse myocardial involvement.

The Use of Quality Improvement Interventions in Reducing Rarely Appropriate Cardiac Imaging.

The use of cardiac imaging has become increasingly prevalent over the last decade. Approximately 10% to 15% of noninvasive cardiac imaging is ordered for rarely appropriate indications. The appropriate use criteria (AUC) for cardiac imaging were issued to decrease unnecessary testing and reduce health care costs. However, it remains unclear whether these efforts have been successful. This meta-analysis evaluates whether AUC quality improvement (QI) interventions effectively reduce inappropriate cardiac imaging. Databases were searched for studies reporting QI intervention effect aiming to reduce rarely appropriate noninvasive cardiac imaging based on AUC. Imaging modalities assessed include transthoracic echocardiography, stress echocardiography, and myocardial perfusion imaging. We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL. The primary end point was a decrease of rarely appropriate testing. The search was not restricted to time or publication status. The literature search identified 2,391 possible studies, 13 studies and 26,557 patients were included. Mean follow-up was 12 months (1 to 60 months). QI interventions were statistically significant in reducing rarely appropriate tests after the intervention compared with the control group (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.41 to 0.64, p <0.01). The QI interventions were also assessed for persistence based on short-term (<3 months) and long-term (>3 months) efficacy. Both the short-term effect and long-term effect were persistent (OR 0.6, 95% CI 0.47 to 0.77, p <0.01 and OR 0.47, 95% CI 0.37 to 0.61, p <0.01, respectively). AUC QI interventions are associated with the successful decrease of inappropriate noninvasive cardiac testing with these effects persisting over time.

Outcomes and Medical Therapy in Myocardial Infarction With Nonobstructive Coronary Arteries: A Systematic Review and Meta-Analysis.

Myocardial infarction with nonobstructive coronary arteries (MINOCAs) is a disease that has been poorly characterized with unclear clinical and therapeutic outcomes. The association of medical therapy with cardiovascular outcomes in patients with MINOCA has been inadequately assessed. The purpose of this meta-analysis is to evaluate the association of MINOCA at risk of adverse cardiovascular outcomes as compared with myocardial infarction with coronary artery disease (MICAD) and the efficacy of medical therapy in reducing the risk of adverse outcomes. A literature search was conducted for studies reporting on the association of MINOCA at risk of adverse outcomes as compared with MICAD. A literature search was also conducted for studies reporting on the association of medical therapy at risk of adverse outcomes in patients with MINOCA. A total of 29 studies with 893,134 participants met inclusion criteria comparing MINOCA to MICAD. Patients with MINOCA had a significantly lower risk of adverse outcomes as compared with MICAD. Nine studies with 27,731 MINOCA patients met inclusion criteria for evaluating the utility of medical therapy. Medical therapy did not significantly reduce risk of MACE; however, there was a trend toward lower risk in patients treated with ß blockers. In conclusion, our results suggest that MINOCA is associated with a lower risk of in-hospital and long-term adverse outcomes compared with MICAD. Standard medical therapy is not associated with a lower risk of adverse cardiovascular outcomes in patients with MINOCA. Additional high-quality studies are required to evaluate the utility of specific medication classes for the treatment of specific etiologies of MINOCA.

Utility of Fractional Flow Reserve Computed Tomography Angiography in Patients With Stable Coronary Artery Disease.

Coronary computed tomography angiography is a modality with high negative predictive value for evaluation of coronary artery disease (CAD). However, its diagnostic accuracy for obstructive CAD is limited by multiple factors. Fractional flow reserve (FFR) computed tomography (FFRCT) is an emerging analysis tool for identifying flow-limiting disease; nonetheless, the prognostic value of FFRCT is not well established. This meta-analysis aims to evaluate the association of FFRCT with clinical outcomes in patients with stable CAD. A literature search was conducted for studies reporting the association between FFRCT measurements and all-cause mortality, major adverse cardiovascular events (MACEs), acute myocardial infarction (AMI), and any need for coronary revascularization. Obstructive disease was defined as a FFR value ≤0.80; nonobstructive disease was defined as an FFR value >0.80. Ten studies were identified to meet the inclusion criteria; mean follow-up was 17 months (range, 3 to 56 months). There was no difference in risk of all-cause mortality between patients with obstructive and those with nonobstructive CAD on FFRCT. However, obstructive lesions were associated with increased risk of MACE, AMI, and any need for revascularization. FFRCT is a useful adjunctive modality for further risk stratification of patients with stable CAD. Obstructive lesions identified by FFRCT are associated with increased risk of MACE, AMI, and any need for revascularization.

Prevalence and Predictors of Cardiovascular Disease and Risk Factors in Transgender Persons in the United States.

BACKGROUND: The cardiovascular health of transgender and gender diverse (TGD) persons, a growing population in the United States, has become a subject of heightened interest. We sought to assess the prevalence and predictors of cardiovascular disease (CVD) in transgender men, transgender women, and gender nonconforming persons in the United States. METHODS: A cohort of individuals self-identified as TGD (ie, transgender or gender nonconforming) in the United States was identified using the 2018 Centers for Disease Control's Behavioral Risk Factor Surveillance Survey. RESULTS: Among the 1019 TGD individuals studied, 378 (37.1%) identified their transition status as male-to-female, 394 (38.7%) as female-to-male, and the remaining 247 (24.2%) as gender nonconforming. A total of 138 (13.5%) had reported CVD, while 881 (86.5%) did not. The prevalence of CVD in TGD individuals identified as male-to-female, female-to-male, and gender nonconforming were noted to be similar (14.6% vs. 13.5% vs. 12.1%; P = 0.69). TGD persons with CVD were older with lower annual income. They also had higher rates of smoking, lower rates of regular exercise, and higher rates of smoking and chronic medical comorbidities. Independent predictors of CVD in TGD persons included older age, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, and depressive disorder. CONCLUSIONS: In this contemporary cross-sectional nationally representative survey, CVD was prevalent in nearly 14% of TGD persons. Further studies examining interventions to reduce CV risk and enhance access to medical care in the TGD population are warranted.

Atrial Septal Defect Closure Device-Related Infective Endocarditis in a 20-Week Pregnant Woman.

With increasing atrial septal defect (ASD) repairs, more women of childbearing age will have ASD closure devices. Current ASD closure trials have excluded women planning pregnancy, making their management challenging. We present a pregnant woman, with a repaired ASD, who presented with device-related infective endocarditis. (Level of Difficulty: Beginner.).

Clinical Characteristics and Angiographic Findings of Acute Myocardial Infarction Associated With Marijuana Use: Consecutive Case Series.

BACKGROUND: Marijuana use has been increasingly legalized in the United States resulting in substantial rise in the number of users especially in the younger populations. While our group and others had described various metabolic effects of this drug, little is known about its association with acute myocardial infarction. OBJECTIVE: To present a series of 8 patients with 10 events of ST-elevation MI (STEMI) associated with marijuana use; highlighting their demographic, clinical presentation, laboratory results and angiographic characteristics. METHODS: Retrospective chart review of patients with STEMI presenting to our inner city hospital Coronary Care Unit over a period of 4 years (December 2013-April 2017). RESULTS: Of the 10 case subjects studied who presented with chest pain, EKG evidence of STEMI with cannabis use, mean age at presentation was 40.1 ± 9.7 (years) SD, ranging from 26 to 59 years old. There were 9 males and one female, of them, 8 were Black, 2 Hispanic and 1 White. Of the 10 cases, 3 (30%) had no known cardiovascular disease (CVD) risk factors (RF) on admission, 1 patient had 3 RF, 4 patients had 2 RF and 2 had 1 CVD RF, which included age, diabetes mellitus type 2 (DM2), hypertension, dyslipidemia, smoking, and family history of premature coronary heart disease. Troponin I (cTnI) peak mean level was 93.5 ± 34.35 ng/ml, range 7.86 - 358.0 ng/ml. All patients had angiographic evidence of obstructive coronary angiography. CONCLUSION: In our study, marijuana use is associated with ST-elevation MI in largely minority population, occurring at a relatively younger age with half of the cases either low risk or CVD risk free. Additional studies are needed to further characterize this population given the increase in marijuana use.

Clinical Characteristics and Angiographic Findings of Myocardial Infarction among Marijuana Users and Non-Users.

BACKGROUND: Marijuana use has been increasingly legalized in the United States resulting in substantial rise in the number of users especially in the younger populations. While our group and others had described various metabolic effects of this drug, little is known about its association with acute myocardial infarction (AMI). OBJECTIVE: This follow up study presents contemporaneous cohort of non-THC user patients at a single, urban center hospital diagnosed with ST-elevation AMI; highlighting and comparing demographic, clinical, laboratory and angiographic characteristics based on exposure to THC at time of presentation. METHODS: Retrospective chart review of patients with ST-elevation AMI presenting to our inner city hospital Coronary Care Unit over a period of 4 years (December 2013-April 2017). RESULTS: Of the 10 case subjects studied whom presented with chest pain, EKG evidence of ST-elevation MI (STEMI) with cannabis use, mean age at presentation was 40 years old, which was 10 years younger than our control group with no marijuana use (n = 11, p = 0.107). Of the patients who had marijuana exposure upon admission, 3 (30%) had no known cardiovascular disease (CVD) risk factors (RF) on admission, 1 patient had 3 RF, 4 patients had 2 RF and 2 had 1 CVD risk factor, which included age, diabetes mellitus type 2 (DM2), hypertension, dyslipidemia, smoking status, and family history at time of triage. Patients who were negative for marijuana use had higher number of CVD risk factors present upon admission. ASCVD risk scores were 10% vs. 16% (p = 0.312). In angiographic findings, 100% of the marijuana users had 1 vessel disease compared with 55% in the non-users (p = 0.0351). Severity of stenosis for both groups was averaged at 93% for non-users vs 95% in THC users (p = 0.62414). Collateral vessels were visible during coronary arteriogram in 91% of non-THC users and in only 20% of THC users (p = 0.0019). Furthermore, non-users had 35% higher rate of Rentrop grade 1 collaterals (55% vs. 20%, p = 0.4872). Similar difference was shown in grade 2 collaterals between the two groups with non-users having 36% higher rate (36% vs. 0%, p = 0.0902). Amongst the patients who had collateral circulation present at the time of angiography (Rentrop grade >0), good collaterals (Rentrop grade 2 or 3) were present in 40% of non-THC users, while there was 0% presence of grade 2+ collaterals in THC users (p = 0.5152). CONCLUSION: In our study, marijuana use is associated with ST-elevation MI in largely minority population, occurring at a relatively younger age with half of the cases CVD risk free. Additional studies are needed to further characterize this population given the increase in marijuana use.

Evaluation of myocardial ischemia and viability by noninvasive cardiac imaging.

Noninvasive cardiac imaging plays a central role in the diagnosis of coronary artery disease and cardiomyopathy, as well as in the decision making for therapeutic interventions. Proper assessment of the degree of myocardial ischemia and viability is essential to aid in therapies that may improve patient outcomes. In addition, a wealth of evidence exists on the prognostic value of the information obtained from noninvasive imaging. One must utilize an imaging study or studies in an organized fashion, incorporating the latest scientific evidence, guidelines and appropriateness criteria. This review summarizes the advantages, disadvantages and relevant literature on various imaging modalities currently available for the evaluation of myocardial ischemia and viability.

Patterns of upstream antiplatelet therapy use before primary percutaneous coronary intervention for acute ST-elevation myocardial infarction (from the CRUSADE National Quality Improvement Initiative).

We sought to determine the usage patterns and impact of upstream glycoprotein IIb/IIIa inhibitor and clopidogrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). We studied trends in the use of upstream glycoprotein IIb/IIIa inhibitors and clopidogrel in 3,895 patients with STEMI undergoing primary PCI at 124 hospitals in the United States participating in the CRUSADE initiative from March 2005 to December 2006. Administration of these agents >15 minutes before PCI was considered pre-PCI use, and administration < or =15 minutes before, during, and after PCI was considered peri-PCI use. A total of 3,566 patients (91.6%) received glycoprotein IIb/IIIa inhibitors within 24 hours of presentation, of whom 1,225 (34.4%) received this medication before PCI. Similarly, 3,785 patients (97.2%) received clopidogrel within 24 hours of presentation, of whom 1,029 (27.2%) received this medication before PCI. From 2005 to 2006, pre-PCI glycoprotein IIb/IIIa inhibitor use decreased from 43.4% to 33.5%, whereas pre-PCI clopidogrel use increased from 21.2% to 31.5%. Clinical characteristics, risk of adverse outcomes, and bleeding events were similar in the pre- versus peri-PCI glycoprotein IIb/IIIa inhibitor and clopidogrel cohorts, respectively. In conclusion, most patients with STEMI undergoing primary PCI receive glycoprotein IIb/IIIa inhibitors and clopidogrel, but only (1/3) are treated upstream with these agents and this upstream use does not have a significant impact on outcomes. These results indicate that further studies are needed to determine the optimal dosing and timing of antiplatelet therapies for patients undergoing primary PCI.

Womens heart health series: a mini-symposium.

Coronary artery disease is the leading cause of death for both men and women in the United States. While its incidence in men has been long appreciated, the impact on women has been underestimated for many years. This is in part because coronary artery disease generally appears later in women, the incidence increasing after the onset of the female menopause. There are approximately 8 million women living with heart disease in this country; almost 400.000 died from it in 1999 compared to almost 42.000 from breast cancer. Yet many women feel that cancer is more likely to be a cause of mortality. This review examines the common misperception of the prevalence of coronary artery disease in women and examines contributing risk factors such as hypertension, elevated serum cholesterol, diabetes mellitus and cigarette smoking. It considers access to care and diagnosis, both non-invasive and invasive, of coronary artery disease specifically as it pertains to women. Treatment options, ranging from medical management, through cardiac catheterization and percutaneous catheter based intervention, to coronary artery bypass surgery are discussed. In addition is included a section addressing the controversial issue of estrogen and its role in the incidence and treatment of heart disease in women.