Sex differences in acute cardiovascular care: a review and needs assessment.

Despite significant progress in the care of patients suffering from cardiovascular disease, there remains a persistent sex disparity in the diagnosis, management, and outcomes of these patients. These sex disparities are seen across the spectrum of cardiovascular care, but, are especially pronounced in acute cardiovascular care. The spectrum of acute cardiovascular care encompasses critically ill or tenuous patients with cardiovascular conditions that require urgent or emergent decision-making and interventions. In this narrative review, the disparities in the clinical course, management, and outcomes of six commonly encountered acute cardiovascular conditions, some with a known sex-predilection will be discussed within the basis of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where improvement in clinical approaches are needed.

Influence of primary payer status on non-ST-segment elevation myocardial infarction: 18-year retrospective cohort national temporal trends, management and outcomes.

BACKGROUND: The role of insurance on outcomes in non-ST-segment-elevation myocardial infarction (NSTEMI) patients is limited in the contemporary era. METHODS: From the National Inpatient Sample, adult NSTEMI admissions were identified [2000-2017]. Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes included in-hospital mortality, overall and early coronary angiography, percutaneous coronary intervention (PCI), resource utilization and discharge disposition. RESULTS: Of the 7,290,565 NSTEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 62.9%, 6.1%, 24.1%, 4.6% and 2.3%, respectively. Compared to others, those with Medicare insurance older (76 vs. 53-60 years), more likely to be female (48% vs. 25-44%), of white race, and with higher comorbidity (all P<0.001). Population from the Medicare cohort had higher in-hospital mortality (5.6%) compared to the others (1.9-3.4%), P<0.001. With Medicare as referent, in-hospital mortality was higher in other {adjusted odds ratio (aOR) 1.15 [95% confidence interval (CI), 1.11-1.19]; P<0.001}, and lower in Medicaid [aOR 0.95 (95% CI, 0.92-0.97); P<0.001], private [aOR 0.77 (95% CI, 0.75-0.78); P<0.001] and uninsured cohorts [aOR 0.97 (95% CI, 0.94-1.00); P=0.06] in a multivariable analysis. Coronary angiography (overall 52% vs. 65-74%; early 15% vs. 22-27%) and PCI (27% vs. 35-44%) were used lesser in the Medicare population. The Medicare population had longer lengths of stay, lowest hospitalization costs and fewer home discharges. CONCLUSIONS: Compared to other types of primary payers, NSTEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.

Coronary allograft vasculopathy managed by Flash ostial balloon in a pediatric patient.

Coronary allograft vasculopathy (CAV) is the most significant cause of morbidity and mortality in heart transplant recipients. Inflammation and endothelial dysfunction caused by graft rejection and viral infections leads to a combination of circumferential intimal fibromuscular hyperplasia, atherosclerosis, and inflammation affecting all layers of the vessel wall. Though obstructive CAV is often asymptomatic, posing a diagnostic challenge in post-transplant patients, early diagnosis and treatment aid faster recovery and improved outcomes. The role of percutaneous coronary intervention in the treatment of CAV is unknown and not well studied in the pediatric population. We present a first-in-human case of ostial left main coronary artery disease managed with flaring of the ostial coronary stent using a Flash ostial balloon in a pediatric patient with history of an orthotopic heart transplant.

Contemporary National Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Patients with Prior Chronic Kidney Disease and End-Stage Renal Disease.

BACKGROUND: There are limited data on acute myocardial infarction with cardiogenic shock (AMI-CS) stratified by chronic kidney disease (CKD) stages. OBJECTIVE: To assess clinical outcomes in AMI-CS stratified by CKD stages. METHODS: A retrospective cohort of AMI-CS during 2005-2016 from the National Inpatient Sample was categorized as no CKD, CKD stage-III (CKD-III), CKD stage-IV (CKD-IV) and end-stage renal disease (ESRD). CKD-I/II were excluded. Outcomes included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS). We also evaluated acute kidney injury (AKI) and acute hemodialysis in non-ESRD admissions. RESULTS: Of 372,412 AMI-CS admissions, CKD-III, CKD-IV and ESRD comprised 20,380 (5.5%), 7367 (2.0%) and 18,109 (4.9%), respectively. Admissions with CKD were, on average, older, of the White race, bearing Medicare insurance, of a lower socioeconomic stratum, with higher comorbidities, and higher rates of acute organ failure. Compared to the cohort without CKD, CKD-III, CKD-IV and ESRD had lower use of coronary angiography (72.7%, 67.1%, 56.9%, 61.1%), PCI (53.7%, 43.8%, 38.4%, 37.6%) and MCS (47.9%, 38.3%, 33.3%, 34.2%), respectively (all p < 0.001). AKI and acute hemodialysis use increased with increase in CKD stage (no CKD-38.5%, 2.6%; CKD-III-79.1%, 6.5%; CKD-IV-84.3%, 12.3%; p < 0.001). ESRD (adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.21-1.31]; p < 0.001), but not CKD-III (OR 0.72 [95% CI 0.69-0.75); p < 0.001) or CKD-IV (OR 0.82 [95 CI 0.77-0.87] was predictive of in-hospital mortality. CONCLUSIONS: CKD/ESRD is associated with lower use of evidence-based therapies. ESRD was an independent predictor of higher in-hospital mortality in AMI-CS.