Trends and Outcomes of Type 2 Myocardial Infarction During the COVID-19 Pandemic in the United States.

BACKGROUND AND OBJECTIVES: There is limited data on the impact of type 2 myocardial infarction (T2MI) during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: The National Inpatient Sample (NIS) database from January 2019 to December 2020 was queried to identify T2MI hospitalizations based on the appropriate International Classification of Disease, Tenth Revision-Clinical Modification codes. Monthly trends of COVID-19 and T2MI hospitalizations were evaluated using Joinpoint regression analysis. In addition, the multivariate logistic and linear regression analysis was used to compare in-hospital mortality, coronary angiography use, and resource utilization between 2019 and 2020. RESULTS: A total of 743,535 patients hospitalized with a diagnosis of T2MI were identified in the years 2019 (n=331,180) and 2020 (n=412,355). There was an increasing trend in T2MI hospitalizations throughout the study period corresponding to the increase in COVID-19 hospitalizations in 2020. The adjusted odds of in-hospital mortality associated with T2MI hospitalizations were significantly higher in 2020 compared with 2019 (11.1% vs. 8.1%: adjusted odds ratio, 1.19 [1.13-1.26]; p<0.01). In addition, T2MI hospitalizations were associated with lower odds of coronary angiography and higher total hospitalization charges, with no difference in the length of stay in 2020 compared with 2019. CONCLUSIONS: We found a significant increase in T2MI hospitalizations with higher in-hospital mortality, total hospitalization costs, and lower coronary angiography use during the early COVID-19 pandemic corresponding to the trends in the rise of COVID-19 hospitalizations. Further research into the factors associated with increased mortality can increase our preparedness for future pandemics.

Cardiac POCUS: Another Tool in the Armory.

Introduction: This study assessed the educational impact of hybrid cardiac Point of Care Ultrasonography (POCUS) training in a community-based academic setting. Methods: Internal Medicine and Medicine/Pediatrics residents across all post-graduate years (PGY) at a midwestern medical school under-took a structured hybrid (online and hands-on teaching) model of POCUS training. Anonymous surveys with Likert-type scale responses were administered before and after the curriculum. Questions were categorized into domains to assess the residents' interest in learning POCUS, their understanding of fundamental cardiac ultrasound (US) concepts, and their confidence in its application. The authors used Fisher's Exact and t-test, and estimated odds ratios to gauge the impact of the training to achieve net scores above 0 on each domain. Results: A total of 27 and 26 residents completed the pre-and post-training surveys, respectively. Experience with previous cardiac US use showed a positive skew. The training resulted in a significant increase in both, the understanding of the principles, and the residents' confidence in its application. These findings were most significant amongst PGY 2 and 3 residents. Post-training mean scores were similar across all domains for subgroups of PGY level and previous ultrasound experience. Conclusions: Residents displayed greater understanding of the fundamental cardiac ultrasound concepts with improved confidence levels after implementing a structured hybrid teaching model for POCUS. Future studies with objective assessment tools are needed to gauge the clinical impact of POCUS and its adoption rate in clinical practice to guide a recommendation for its incorporation into the residency curriculum.

Hospital outcomes for patients with pulmonary arterial hypertension in sepsis and septic shock.

BACKGROUND: Pulmonary arterial hypertension (PAH) is associated with increased morbidity and mortality risk. The risk for adverse outcomes in patients with PAH in sepsis or septic shock (SSS) is uncertain. METHODS: Adult patients diagnosed with SSS were identified in the National Readmissions Database over the years 2016-2017. A 2:1 ratio nearest propensity matching method was employed for several demographic, social, and clinical variables. In-hospital outcomes were compared between patients with PAH and those without, using t-test and chi-squared test as appropriate. Patients with cardiogenic shock were excluded. Relevant ICD-10 codes were used, and statistical significance was set at 0.05. RESULTS: A total of 1,134 patients with PAH and sepsis/septic shock were identified, with a mean age of 65 years and 67% identifying as females. Patients with PAH had a higher prevalence of some chronic conditions, including chronic pulmonary disease, renal failure, congestive heart failure, coronary artery disease, obesity, coagulation disease. The prevalence of type 2 diabetes mellitus and alcohol use was lower in this cohort. After matching, patients with PAH and SSS, when compared to those with SSS and without PAH, had an increased occurrence of acute heart failure (24.1% vs. 19.6%, p = 0.003), amongst clinical outcomes. The differences in the occurrence of death, vasopressor use, paroxysmal atrial fibrillation, acute myocardial infarction, acute kidney injury, and stroke outcomes were not statistically different between the two groups. Patients with PAH, however, had a longer hospital stay (13.5 days vs. 10.9 days, p < 0.001) and hospital costs ($164,252 vs. $129,185, p < 0.001). CONCLUSION: Patients with PAH have worse outcomes for acute heart failure in sepsis or septic shock. Other mortality and morbidity outcomes are not statistically different. PAH is also associated with a longer hospital stay and increased hospital costs. These findings should be interpreted recognizing the inclusion of patients with re-admissions and the administrative nature of the database.

Prevalence of cardiovascular diseases in COVID-19 related mortality in the United States.

BACKGROUND: Several cardiovascular disease (CVD) risk factors and sequelae have been associated with COVID-19. Little is known about the distribution of CVD conditions in COVID-19 related deaths in the US population. METHODS: The public-use dataset by CDC, "Conditions Contributing to COVID-19 Deaths, by State and Age, Provisional 2020-2021", was abstracted as of August 1, 2021. A descriptive analysis was conducted to explore the overall and age-specific prevalence of various CVD and risk factors grouped by pre-specified ICD-10 codes amongst COVID-19 patient deaths. Respective trends over the duration of the pandemic were analyzed using the Mann-Kendall method, including time-periods before and after the introduction of vaccines in January 2021. All time-related analysis was conducted between March 2020 and June 2021. RESULTS: A total of 600,241 COVID-19 related deaths were reported between March 2020 and June 2021. Hypertensive diseases were the most prevalent (19.6%), followed by diabetes (15.9%), ischemic heart disease (IHD;10.9%), heart failure (7.7%), cardiac arrhythmias (7.5%), other diseases of the circulatory system (6.6%), cerebrovascular diseases (5%), and obesity (4.1%). While a significant downward trend was noted for hypertensive diseases over the course of the pandemic, cardiac arrhythmias, heart failure (HF), obesity, and other circulatory system diseases demonstrated a significant upward trend. Since the introduction of vaccines, the trends for heart failure and cardiac arrhythmias remained steady while having demonstrated a significant rise in the pre-vaccination time-period. While obesity and other diseases of the circulatory system predominated (>50%) amongst the CVD burden in the younger population (0-24 years and 25-34 years), the percentage occurrence of cardiac arrhythmias, hypertensive diseases, HF, and IHD increased with age. CONCLUSION: Hypertensive diseases, diabetes, and IHD were the most prevalent cardiovascular conditions amongst COVID-19 related deaths. These patterns varied by age. While the trend for hypertensive diseases declined over the course of the pandemic, cardiac arrhythmias, HF, obesity, and other diseases of the circulatory system demonstrated an upward trend. An important limitation is the source of the data being limited to death certificates.

CT assessment of the left atrial appendage post-transcatheter occlusion - A systematic review and meta analysis.

BACKGROUND: Transesophageal echocardiography (TEE) is the standard imaging modality used to assess the left atrial appendage (LAA) after transcatheter device occlusion. Cardiac computed tomography angiography (CCTA) offers an alternative non-invasive modality in these patients. We aimed to conduct a comparison of the two modalities. METHODS: We performed a comprehensive systematic review of the current literature pertaining to CCTA to establish its usefulness during follow-up for patients undergoing LAA device closure. Studies that reported the prevalence of inadequate LAA closure on both CCTA and TEE were further evaluated in a meta-analysis. 19 studies were used in the systematic review, and six studies were used in the meta-analysis. RESULTS: The use of CCTA was associated with a higher likelihood of detecting LAA patency than the use of TEE (OR, 2.79, 95% CI 1.34-5.80, p â€‹= â€‹0.006, I2 â€‹= â€‹70.4%). There was no significant difference in the prevalence of peridevice gap ≥5 â€‹mm (OR, 3.04, 95% CI 0.70-13.17, p â€‹= â€‹0.13, I2 â€‹= â€‹0%) between the two modalities. Studies that reported LAA assessment in early and delayed phase techniques detected a 25%-50% higher prevalence of LAA patency on the delayed imaging. CONCLUSION: CCTA can be used as an alternative to TEE for LAA assessment post occlusion. Standardized CCTA acquisition and interpretation protocols should be developed for clinical practice.

Stroke Incidence and Outcome Disparity in Rural Regions of Southern West Virginia.

INTRODUCTION: West Virginia has the highest incidence of obesity, smoking, and diabetes within the United States, placing its population at higher risk of stroke. In addition to these endemic risk factors, Appalachia faces various socioeconomic and health care access challenges that could negatively impact stroke incidence and outcomes. At present, there are limited data regarding geographic variables on stroke outcomes in rural Appalachia. We set out to quantify Appalachian geographic patterns of stroke incidence and outcomes. METHODS: This is a retrospective analysis of all patients hospitalized with a diagnosis of stroke in West Virginia's largest tertiary hospital. During the study (2000-2018), 14,488 patients were analyzed, with an emphasis on those who died from stroke (n = 1022). We first used institutional ICD-9/10 data alongside demographics information and chart reviews to evaluate disease patterns while also exploring emerging hot spot pattern changes over time; we then exploited an emerging time series analysis using temporal trends to assess differing instances of stroke occurrence regionally with hot spots defined as higher than expected incidences of stroke and stroke death. RESULTS: Data analysis revealed several hot spots of increasing stroke and mortality rates, many of which achieved statistically significant variance compared to expected norms (P = 0.001). Moreover, this study revealed high-risk zones in rural West Virginia wherein the incidence and mortality rates of stroke are suggestively higher and less resistance to economic change than urban centers. CONCLUSIONS: Stroke incidence and mortality were found to be higher than expected in many areas of rural West Virginia. The higher stroke risk populations correlate with area that may be impacted by socioeconomic factors and limited access to primary care. These high-risk areas may therefore benefit from investments in infrastructure, patient education, and unrestricted primary care.

A low-cost texture-based pipeline for predicting myocardial tissue remodeling and fibrosis using cardiac ultrasound.

BACKGROUND: Maturation of ultrasound myocardial tissue characterization may have far-reaching implications as a widely available alternative to cardiac magnetic resonance (CMR) for risk stratification in left ventricular (LV) remodeling. METHODS: We extracted 328 texture-based features of myocardium from still ultrasound images. After we explored the phenotypes of myocardial textures using unsupervised similarity networks, global LV remodeling parameters were predicted using supervised machine learning models. Separately, we also developed supervised models for predicting the presence of myocardial fibrosis using another cohort who underwent cardiac magnetic resonance (CMR). For the prediction, patients were divided into a training and test set (80:20). FINDINGS: Texture-based tissue feature extraction was feasible in 97% of total 534 patients. Interpatient similarity analysis delineated two patient groups based on the texture features: one group had more advanced LV remodeling parameters compared to the other group. Furthermore, this group was associated with a higher incidence of cardiac deaths (p = 0.001) and major adverse cardiac events (p < 0.001). The supervised models predicted reduced LV ejection fraction (<50%) and global longitudinal strain (<16%) with area under the receiver-operator-characteristics curves (ROC AUC) of 0.83 and 0.87 in the hold-out test set, respectively. Furthermore, the presence of myocardial fibrosis was predicted from only ultrasound myocardial texture with an ROC AUC of 0.84 (sensitivity 86.4% and specificity 83.3%) in the test set. INTERPRETATION: Ultrasound texture-based myocardial tissue characterization identified phenotypic features of LV remodeling from still ultrasound images. Further clinical validation may address critical barriers in the adoption of ultrasound techniques for myocardial tissue characterization. FUNDING: None.

The Patient Selection Criteria for Veno-arterial Extracorporeal Mechanical Oxygenation.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) plays a crucial role in the management of patients with refractory cardiac and pulmonary dysfunction by providing temporary mechanical hemodynamic and respiratory support. However, the paucity of guidelines on indications for administering it and the failure to timely initiate VA-ECMO often result in a high in-hospital mortality rate and poor six-month outcomes after VA-ECMO deployment. Due to ethical issues, randomized controlled studies with VA-ECMO have not been conducted so that no recommended evidence-based guidelines exist for VA-ECMO patient-selection criteria. Therefore, the indication for administering the device depends solely on expert opinion after reviewing the literature. We conducted a review of the current literature to better understand and classify the need for proper patient selection, including proven indications for VA-ECMO.