Impact of same-admission percutaneous coronary intervention on periprocedural outcomes of transcatheter aortic valve implantation.

Background: Current guidelines recommend percutaneous coronary intervention (PCI) prior to transcatheter aortic valve implantation (TAVI) if significant coronary artery disease is present, but whether PCI should be done in the same admission as TAVI is not determined. Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2019 to compare TAVI with and without same-admission PCI and compare in-hospital outcomes after propensity score matching. Results: Among 170,030 hospitalizations for TAVI, 4425 (2.6%) had same-admission PCI performed. After propensity score matching, 4425 hospitalizations were allocated to those with and without same-admission PCI. No difference in in-hospital mortality (odds ratio [OR] 1.59, 95% confidence interval [CI] 0.81-3.12) was observed between the two groups. However, TAVI with same-admission PCI was associated with higher odds of cardiac arrest (OR 2.25, 95% CI 1.02-4.98), cardiogenic shock (OR 2.21, 95% CI 1.29-3.79), and acute myocardial infarction (OR 3.23, 95% CI 2.11-4.93). It was also associated with longer length of stay and more expensive hospital cost. Conclusion: TAVI with same-admission PCI was associated with higher odds of periprocedural complications and higher immediate cost. Our findings should be interpreted in the context of the same-admission PCI and TAVI cohort potentially being sicker and the isolated TAVI control group may or may not having obstructive coronary artery disease.

Human Immunodeficiency Virus and Cardiac End-Organ Damage in Women: Findings From an Echocardiographic Study Across the United States.

BACKGROUND: People with human immunodeficiency virus (HIV) have been reported to have increased risk of clinical and subclinical cardiovascular disease. Existing studies have focused on men and often have been uncontrolled or lacked adequate HIV-negative comparators. METHODS: We performed echocardiography in the Women's Interagency HIV Study to investigate associations of HIV and HIV-specific factors with cardiac phenotypes, including left ventricular systolic dysfunction (LVSD), isolated LV diastolic dysfunction (LVDD), left atrial enlargement (LAE), LV hypertrophy (LVH), and increased tricuspid regurgitation velocity (TRV). RESULTS: Of 1654 participants (age 51 ± 9 years), 70% had HIV. Sixty-three (5.4%) women with HIV (WWH) had LVSD; 71 (6.5%) had isolated LVDD. Compared with women without HIV (WWOH), WWH had a near-significantly increased risk of LVSD (adjusted relative risk = 1.69; 95% confidence interval = 1.00 to 2.86; P = .051). No significant association was noted for HIV seropositivity with other phenotypes, but there was a risk gradient for decreasing CD4+ count among WWH that approached or reached significance for isolated LVDD, LAE, and LVH. WWH with CD4+ count <200 cells/mm3 had significantly higher prevalence of LAE, LVH, and high TRV than WWOH. There were no consistent associations for viral suppression or antiretroviral drug exposure. CONCLUSIONS: This study suggests that WWH have a higher risk of LVSD compared with sociodemographically similar WWOH, but their risk for isolated LVDD, LAE, LVH, and high TRV is increased only with reduced CD4+ count. Although these findings warrant replication, they support the importance of cardiovascular risk-factor and HIV-disease control for heart disease prevention in this population.

Trends and Predictors of Palliative Care Consultation Among Patients Admitted for LVAD: A Retrospective Analysis From the Nationwide Inpatient Sample Database From 2006-2014.

BACKGROUND: Left ventricular assist devices (LVADs) are an essential part of advanced heart failure (HF) management, either as a bridge to transplantation or destination therapy. Patients with advanced HF have a poor prognosis and may benefit from palliative care consultation (PCC). However, there is scarce data regarding the trends and predictors of PCC among patients undergoing LVAD implantation. AIM: This study aims to assess the incidence, trends, and predictors of PCC in LVAD recipients using the United States Nationwide Inpatient Sample (NIS) database from 2006 until 2014. METHODS: We conducted a weighted analysis on LVAD recipients during their index hospitalization. We compared those who had PCC with those who did not. We examined the trend in palliative care utilization and calculated adjusted odds ratios (aOR) to identify demographic, social, and hospital characteristics associated with PCC using multivariable logistic regression analysis. RESULTS: We identified 20,675 admissions who had LVAD implantation, and of them 4% had PCC. PCC yearly rate increased from 0.6% to 7.2% (P < 0.001). DNR status (aOR 28.30), female sex (aOR 1.41), metastatic cancer (aOR: 3.53), Midwest location (aOR 1.33), and small-sized hospitals (aOR 2.52) were positive predictors for PCC along with in-hospital complications. Differently, Black (aOR 0.43) and Hispanic patients (aOR 0.25) were less likely to receive PCC. CONCLUSION: There was an increasing trend for in-hospital PCC referral in LVAD admissions while the overall rate remained low. These findings suggest that integrative models to involve PCC early in advanced HF patients are needed to increase its generalized utilization.

Factors associated with bleeding events in patients on rivaroxaban for non-valvular atrial fibrillation: A real-world experience.

BACKGROUND: Rivaroxaban is a direct oral anticoagulant (DOAC) approved for the treatment of non-valvular atrial fibrillation (NVAF). Data related to the risk factors associated with rivaroxaban-induced bleeding in patients with NVAF remain scarce in the community setting. We sought to investigate these bleeding risk factors in a racially diverse patient population. METHODS: We conducted a single-center, retrospective study based on a chart review of patients who received rivaroxaban from our outpatient pharmacy from January 2015 to April 2018 for NVAF. Any reported bleeding event (BE) was recorded as either major or minor bleeding event. Demographic and clinical data were collected and analyzed. RESULTS: Of the 327 patients included in our analysis, 105 (32%) were female, and the mean age was 62 ± 12 years. Among the included patients, 176 (54%) patients were black, 71 (22%) were white, 51 (15.6%) were Hispanic, 13 (4%) were Asian, and 15 (4.6%) belonged to other races. 89 (27.2%) of the patients had co-prescription of aspirin. A total of 24 (7.3%) patients developed BE, out of which 9 (2.7%) patients had a major BE, and 15 (4.5%) patients had minor BE. Non-fatal gastrointestinal bleeding and epistaxis were the most common type of BE. On multivariable analysis, concurrent aspirin use (81 to 325 mg) (P = 0.03; odds ratio (OR) 2.60 [1.08-6.28]) and increasing age (P = 0.00; OR 1.06 [1.01-1.11]) were independent predictors of BE. CONCLUSION: In community practice, aspirin co-prescription is common among NVAF patients prescribed rivaroxaban. Increasing age and concurrent aspirin use are independent predictors of BE.

Bibliometric Analysis of the Top 100 Most Cited Articles in the First 50 Years of Heart Transplantation.

The world celebrates over 50 years since the first human-to-human heart transplant. Bibliometric analysis is a statistical concept that has recently evolved, enabling scientists to study citation patterns and identify characteristics of highly cited scholarly work in different fields. Although it has been widely utilized, such analyses have not been conducted to date on heart transplant literature. We sought to assess the characteristics of the top 100 most referenced citations in the field of heart transplantation. We searched the Scopus database (www.scopus.com) to identify all articles relating to heart transplantation. The articles were arranged in descending order from most cited to least cited and selected articles were scrutinized for data extraction. One hundred articles were included in the final list. Of the total 40,660 citations identified, 3,210 (8.0%) were self-citations, which impacted the final rank order. The articles were published in 25 different journals between 1960 and 2013. The most productive 5-year time period was between 2000 and 2005, when 24 of the 100 most cited publications were produced. There was no correlation between the journals' impact factors and the number of articles produced per journal. The presence and type of funding were not associated with the number of citations. Over 85% of first and senior investigators were men. In conclusion, our study highlights key features of the most highly cited scientific literature on heart transplantation and provides insights into trends of published work in this field. Additionally, this work may serve as a useful guide to researchers and funding bodies by highlighting the most prolific areas of cardiac transplant research to date.

Usefulness of Oximetry Paradoxus to Diagnose Cardiac Tamponade.

Although echocardiography is usually diagnostic of cardiac tamponade, it may not be readily available at the point-of-care. We sought to develop and validate a measurement of respirophasic variation in the amplitude of pulse oximetry plethysmographic waveforms as a diagnostic tool for cardiac tamponade. Pulse oximetry plethysmographic waveforms were recorded, and the ratio of maximum-to-minimum measured amplitude of these waveforms from one respiratory cycle was calculated by blinded observers. Ratios from 3 consecutive respiratory cycles were then averaged to derive an "oximetry paradoxus" ratio. Cardiac tamponade was independently confirmed or excluded according to a "blinded" objective interpretation of echocardiography or right heart catheterization. Seventy four subjects were enrolled (51% men; mean age 54 ± 15 years); 19 of whom had cardiac tamponade. Oximetry paradoxus area under the curve for diagnosis of cardiac tamponade was 0.90 (95% confidence interval, 0.84 to 0.97); its diagnostic performance was superior to sphygmomanometer-measured pulsus paradoxus (area under the curve difference = 0.16, p = 0.022). In a derivation cohort (n = 37; tamponade, 9 cases), 3 diagnostic oximetry paradoxus thresholds were identified and validated in an independent validation cohort (n = 37; tamponade, 10 cases): 1.2 (100% sensitivity, 44% specificity), 1.5 (80% sensitivity, 81% specificity), and 1.7 (80% sensitivity, 89% specificity). Furthermore, oximetry paradoxus was significantly reduced after draining pericardial fluid. In conclusion, we defined and validated oximetry paradoxus as a simple and ubiquitous point-of-care test to diagnose cardiac tamponade using respirophasic changes in pulse plethysmography waveforms. This test can aid in identifying patients with cardiac tamponade, thus expediting confirmatory testing and life-saving treatment.

Rare Cause of Late Recurrent Angina following Coronary Artery Bypass Grafting: Iatrogenic Aortocoronary Arteriovenous Fistula Causing Coronary Steal.

Iatrogenic aortocoronary arteriovenous fistula is a very rare complication of coronary artery bypass grafting in which one of the arterial grafts inadvertently forms a fistulous tract with a cardiac vein, shunting blood from the anastomosed coronary artery. We report a patient with an iatrogenic left internal mammary artery graft to cardiac vein fistula presenting with recurrent angina three years after a three-vessel coronary artery bypass grafting.

Sodium-glucose co-transporter 2 inhibitors and cardiovascular outcomes: A systematic review and meta-analysis.

Background The risks and benefits of sodium-glucose co-transporter 2 (SGLT2) inhibitors on cardiovascular outcomes have not been well established. We pooled evidence from all available clinical trials to assess the cardiovascular effects of this drug. Design A systematic review and meta-analysis of randomised controlled trials. Methods We queried electronic databases (MEDLINE, Scopus, CENTRAL and clinicaltrials.gov) from their inception to July 2017 for published and unpublished placebo controlled trials of SGLT2 inhibitors. Only studies with a follow-up period of at least 24 weeks and reporting at least one cardiovascular outcome were included. Results from trials were presented as odds ratios (ORs) with 95% confidence intervals (CIs) and were pooled using a random-effects model. Results Thirty-five eligible studies (canagliflozin, nine; empagliflozin, eight; dapagliflozin, 18), consisting of 34,987 patients with type 2 diabetes mellitus were included. Pooled results show that SGLT2 inhibitors, when compared to placebo, significantly reduce all-cause mortality (OR 0.79, 95% CI 0.70-0.89; P < 0.001), major adverse cardiac events (OR 0.8, 95% CI 0.76-0.92; P < 0.001), non-fatal myocardial infarction (OR 0.85, 95% CI 0.73-0.98; P = 0.03) and heart failure/hospitalisation for heart failure (OR 0.67, 95% CI 0.59-0.76; P < 0.001) in patients with type 2 diabetes mellitus. No significant difference was noted in the occurrence of stroke (OR 1.02, 95% CI 0.85-1.21; P = 0.87), atrial fibrillation (OR 0.61, 95% CI 0.31-1.19; P = 0.15) or unstable angina (OR 0.95, 95% CI 0.73-1.25; P = 0.73). In addition, there was no heterogeneity between different drugs in the SGLT2 inhibitor class for all of the clinical outcomes studied ( I2 = 0). Conclusions SGLT2 inhibitors significantly reduce the incidence of mortality, major adverse cardiac events, non-fatal myocardial infarction and heart failure in patients with type 2 diabetes mellitus. Subtypes of SGLT2 inhibitors appear to have similar cardiovascular effects.

The significance of post-stress decrease in left ventricular ejection fraction in patients undergoing regadenoson stress gated SPECT myocardial perfusion imaging.

BACKGROUND: The significance of post-stress decrease in left ventricular ejection fraction (LVEF) with regadenoson stress gated SPECT (GSPECT) myocardial perfusion imaging (MPI) has not been studied. METHODS AND RESULTS: Consecutive patients who underwent rest/regadenoson stress GSPECT-MPI followed by coronary angiography within 6 months were analyzed. Change in LVEF by GSPECT-MPI was calculated as stress LVEF minus rest LVEF; a significant decrease was tested at 5% and 10% thresholds. In a diagnostic cohort of 793 subjects, LVEF change was not predictive of severe/extensive coronary artery disease (area under the curve, 0.50; 95% confidence interval, 0.44-0.57; P = 0.946). There was no significant difference in the rates of severe/extensive coronary artery disease in patients with or without a decrease in LVEF, irrespective of MPI findings. In an outcome cohort of the 929 subjects followed for 30 ± 16 months, post-regadenoson stress decrease in LVEF was not associated with increased risk of the composite endpoint of cardiac death or myocardial infarction or in the risk of coronary revascularization. CONCLUSIONS: In patients selected to undergo coronary angiography following regadenoson stress GSPECT-MPI, a decrease in LVEF after regadenoson stress is not predictive of severe/extensive CAD or adverse clinical outcomes, irrespective of MPI findings.

Regadenoson use in chronic kidney disease and end-stage renal disease: A focused review.

Regadenoson is a selective A2A adenosine receptor agonist that has been approved as a vasodilator stress agent with single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI). Since its approval by the Food and Drug Administration (FDA) in 2008, it has become the most commonly used pharmacologic stress agent with SPECT-MPI. Given that it is predominantly renally excreted, its use in patients with chronic kidney disease has been the subject of active post-marketing clinical research. Until recently, prescribing information regarding the use of regadenoson in patients with end-stage renal disease (ESRD) was not defined in the package insert. Based on accumulating data since its initial approval, the FDA has recently outlined the use of regadenoson in patients with ESRD in a label update on January 17, 2017. In this review, we discuss the evidence leading to the recent label update, focusing on the pharmacokinetics of regadenoson in patients with impaired kidney function, the safety and tolerability of regadenoson in patients with chronic kidney disease and ESRD, and the prognostic value of regadenoson stress MPI in this patient population.

Stress SPECT Myocardial Perfusion Imaging in End-Stage Renal Disease.

PURPOSE OF REVIEW: Patients with end-stage renal disease (ESRD) have an increased risk of cardiovascular morbidity and mortality. Cardiac risk assessment, though challenging, is critical in these high-risk patients, particularly in the pre-transplant population. In this review, we discuss the burden of coronary artery disease in the ESRD population and review the literature on the diagnostic and prognostic performance, clinical value, and future directions of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in ESRD patients. RECENT FINDINGS: Stress myocardial perfusion imaging provides incremental prognostic value to clinical data. The AHA/ACCF consensus statement on the cardiac assessment of kidney transplant candidates provides some guidance on the selection of asymptomatic patients for further non-invasive risk stratification. Additionally, the novel selective A2A receptor agonist vasodilator stress agent, regadenoson, is safe and effective in ESRD and has recently been approved by the Food and Drug Administration for use in this population. Ancillary stress MPI findings, namely heart rate response to vasodilator stress, can provide incremental risk stratification. SUMMARY: While myocardial perfusion imaging is widely used as a risk assessment tool, its utilization and clinical implications in the ESRD population are controversial. Though stress SPECT-MPI has imperfect diagnostic accuracy in this specific patient population, it is still a valuable non-invasive modality in cardiovascular risk assessment.

The significance of automatically measured transient ischemic dilation in identifying severe and extensive coronary artery disease in regadenoson, single-isotope technetium-99m myocardial perfusion SPECT.

BACKGROUND: The critical threshold and clinical significance of transient ischemic dilation (TID) for regadenoson, single-isotope (99m)Tc SPECT myocardial perfusion imaging (MPI) are not defined. METHODS: From 100 patients with low likelihood of CAD, we derived the abnormal TID threshold (mean + 2 SD). We validated the threshold in a cohort of 547 patients who received one-day, rest/regadenoson-stress, (99m)Tc-tetrofosmin SPECT-MPI followed by coronary angiography within 6 months. Patients were classified into three CAD severity strata: no significant CAD, mild to moderate CAD, and severe and extensive CAD. RESULTS: The abnormal TID threshold was determined to be 1.31. Though mean TID ratios were different between the three CAD severity groups and the derivation cohort (P < .001), there was no difference in the mean TID ratios between the categories of CAD severity or in the prevalence of severe CAD between TID+ and TID- groups (P = .74). By ROC analysis, TID had a poor discriminatory capacity in identifying severe and extensive CAD [AUC of 0.55 (95% CI 0.47-0.62, P = .25)]. Stepwise multivariate logistic analysis demonstrated that adding TID to clinical and perfusion data did not provide incremental diagnostic value (P = .87). CONCLUSIONS: The clinical utility of TID with regadenoson-stress MPI in this era of declining CAD burden is questionable.

Regadenoson use in patients with chronic obstructive pulmonary disease: the state of current knowledge.

Stress testing is challenging in patients with chronic obstructive pulmonary disease (COPD). Functional capacity is generally decreased in this patient population, limiting patients' ability to achieve physiologic stress through exercise. Additionally, due to emphysematous changes, COPD patients tend to have poor acoustic windows that impair the quality and therefore diagnostic accuracy of stress echocardiography techniques. Pharmacologic stress myocardial perfusion imaging (MPI) testing is also problematic, particularly due to the concern for adenosine-induced bronchoconstriction with conventional vasodilator stress agents. Regadenoson, a selective A2A adenosine receptor agonist, has gained popularity due to its ease of administration and improved patient experience in the general population. The literature describing the experience with regadenoson in COPD patients, though limited, is rapidly growing and reassuring. This review summarizes the pharmacology and clinical application of this novel stress agent and presents the available data on the safety and tolerability of its use in COPD patients.

Impact of appropriate use on the prognostic value of single-photon emission computed tomography myocardial perfusion imaging.

BACKGROUND: Appropriate use criteria (AUC) have been developed to aid in the optimal use of single-photon emission computed tomography (SPECT)-myocardial perfusion imaging (MPI), a technique that is a mainstay of risk assessment for ischemic heart disease. The impact of appropriate use on the prognostic value of SPECT-MPI is unknown. METHODS AND RESULTS: A prospective cohort study of 1511 consecutive patients undergoing outpatient, community-based SPECT-MPI was conducted. Subjects were stratified on the basis of the 2009 AUC for SPECT-MPI into an appropriate or uncertain appropriateness group and an inappropriate group. Patients were prospectively followed up for 27±10 months for major adverse cardiac events of death, death or myocardial infarction, and cardiac death or myocardial infarction. In the entire cohort, the 167 subjects (11%) with an abnormal scan experienced significantly higher rates of major adverse cardiac events and coronary revascularization than those with normal MPI. Among the 823 subjects (54.5%) whose MPIs were classified as appropriate (779, 51.6%) or uncertain (44, 2.9%), an abnormal scan predicted a multifold increase in the rates of death (9.2% versus 2.6%; hazard ratio, 3.1; P=0.004), death or myocardial infarction (11.8% versus 3.3%; hazard ratio, 3.3; P=0.001), cardiac death or myocardial infarction (6.7% versus 1.7%; hazard ratio, 3.7; P=0.006), and revascularization (24.7% versus 2.7%; hazard ratio, 11.4; P<0.001). Among the 688 subjects (45.5%) with MPI classified as inappropriate, an abnormal MPI failed to predict major adverse cardiac events, although it was associated with a high revascularization rate. Furthermore, appropriate MPI use provided incremental prognostic value beyond myocardial perfusion and ejection fraction data. CONCLUSIONS: When performed for appropriate indications, SPECT-MPI continues to demonstrate high prognostic value. However, inappropriate use lacks effectiveness for risk stratification, further emphasizing the need for optimal patient selection for cardiac testing.