Percutaneous coronary intervention involving coronary bifurcation is associated with higher mortality and complications.

BACKGROUND: Percutaneous coronary intervention (PCI) in patients with bifurcation lesions is associated with higher complexity and adverse outcomes. The goal of this study was to evaluate the inpatient outcomes of patients with PCI of bifurcation lesions. METHODS: The National Inpatient Sample (NIS) database, years 2016-2020, was studied using ICD 10 codes. Patients undergoing PCI for bifurcation lesions were compared to those undergoing PCI for non-bifurcation lesions, excluding chronic total occlusion lesions. We evaluated post-procedural inpatient mortality and complications. RESULTS: PCI in patients with bifurcation lesions was associated with higher mortality and post-procedural complications. A weighted total of 9,795,154 patients underwent PCI; of those, 43,480 had a bifurcation lesion. The bifurcation cohort had a 3.79% mortality rate, and the rate in those with non-bifurcation lesions was 2.56% (OR, 1.50; CI: 1.34-1.68; P<0.001). Upon conducting multivariate analysis, which adjusted for age, sex, race, and significant comorbidities, PCI for bifurcation lesions remained significantly associated with a higher mortality rate compared to non-bifurcation lesion PCI (OR, 1.68; 95% CI, 1.49-1.88; P<0.001). Furthermore, PCI for bifurcation lesions was associated with higher rates of myocardial infarction (OR, 2.26; 95% CI, 1.68-3.06; P<0.001), coronary perforation (OR, 7.97; 95% CI, 6.25-10.17; P<0.001), tamponade (OR, 3.46; 95% CI, 2.49-4.82; P<0.001), and procedural bleeding (OR, 5.71; 95% CI, 4.85-6.71; P<0.001). Overall, post-procedural complications were 4 times more in patients with bifurcation lesions than in those without (OR, 4.33; 95% CI, 3.83-4.88; P<0.001). CONCLUSION: Using a large, national inpatient database, we demonstrate that both mortality rates and post-procedural complication rates were significantly higher in patients undergoing PCI for bifurcation lesions than in those undergoing PCI for non-bifurcation lesions.

The occurrence of ST elevation myocardial infarction (STEMI) and non-STEMI in patients with post traumatic stress disorder (PTSD) using the large nationwide inpatient sample (NIS).

BACKGROUND: PTSD leads to increased levels of stress hormones and dysregulation of the autonomic nervous system which may trigger cardiac events. The goal of this study is to evaluate any association between PTSD and the occurrence of STEMI and NSTEMI using a large database. METHOD: Using the Nationwide Inpatient Sample (NIS) and ICD-9 codes from 2005 to 2014 (n=1,621,382), we performed a univariate chi-square analysis of in-hospital occurrence of STEMI and NSTEMI in patients greater than 40 years of age with and without PTSD. We also performed a multivariate analysis adjusting for baseline characteristics including age, gender, diabetes, race, hyperlipidemia, hypertension, and tobacco use. RESULTS: The 2005-2014 dataset contained 401,485 STEMI patients (745, or 0.19%, with PTSD) and 1,219,897 NSTEMI patients (2,441, or 0.15%, with PTSD). In the 2005 dataset, 0.5% of PTSD patients had STEMI compared to 1.0% of non-PTSD patients (OR=0.46, 95% C.I., 0.36-0.59). Similarly, 0.6% of patients with PTSD and 2.2% of patients without PTSD had NSTEMI (OR=0.28, 95% C.I., 0.23-0.35). In the 2014 dataset, 0.3% of PTSD patients had STEMI compared to 0.7% of non-PTSD patients (OR=0.43, 95% C.I., 0.35-0.51). Similarly, 1.4% of patients with PTSD versus 2.9% of patients without PTSD had NSTEMI (OR=0.48, 95% C.I., 0.44-0.52). Similar trends were seen throughout the ten-year period. After adjusting for age, gender, diabetes, race, hyperlipidemia, hypertension, and tobacco use, PTSD was associated with a lower occurrence of STEMI (2005: OR=0.50, 95% C.I., 0.37-0.66; 2014: OR=0.35, 95% C.I., 0.29-0.43) and NSTEMI (2005: OR=0.44, 95% C.I., 0.34-0.57; 2014: OR=0.63, 95% C.I., 0.58-0.69). CONCLUSION: Using a large inpatient database, we did not find an increased occurrence of STEMI or NSTEMI in patients diagnosed with PTSD, suggesting that PTSD is not an independent risk factor for myocardial infarction.

Coronary perforation occurring during percutaneous coronary intervention is associated with persistently high mortality and complication.

INTRODUCTION: Coronary perforation is one of the major complications of percutaneous coronary intervention (PCI). The goal of this study was to evaluate adverse outcomes and mortality in patients suffering from coronary perforation during PCI above the age of 30. METHODS: The National Inpatient Sample (NIS) database, years 2016-2020, was studied using ICD 10 codes. Patients suffering from perforation were compared to patients without perforation during PCI. RESULTS: PCI was performed in a weighted total of 10,059,269 patients. Coronary perforation occurred in 11,725 (0.12 %) of all PCI performed. The mortality rate of patients with perforations was very high in comparison to patients without perforations. (12.9% vs 2.5%, OR: 5.6, CI:5-6.3 p<0.001). Furthermore, patients with coronary perforations had much higher rates of urgent coronary bypass surgery, tamponade, cardiac arrest, and major cardiovascular outcomes. Mortality remained high and over 10% in the 5-year study period. CONCLUSION: Using a large national inpatient database, all-cause inpatient mortality in patients with coronary perforation is very high (over 10%) with persistently high mortality rates over the years study suggesting that treatment of perforations needs further improvement.

Higher inpatient mortality following percutaneous coronary intervention in patients with advanced chronic kidney disease.

BACKGROUND: Advanced chronic kidney disease (ACKD) is common in patients undergoing percutaneous coronary intervention (PCI) and is associated with adverse outcomes. These patients are often excluded from revascularization studies. The goal of this study was to evaluate the impact of ACKD in patients undergoing PCI. METHODS: We analyzed the national inpatient sample database to compare the inpatient mortality rate for ACKD patients [chronic kidney disease (CKD) stage 3 and above] who underwent PCI between 2006 and 2011 to patients without ACKD. Specific ICD-9 CM codes were used to identify these patients. RESULTS: A total of 1 826 536 PCIs were performed during the study period, of which 113 018 (6.2%) were patients with advanced CKD. The age-adjusted inpatient mortality rates were significantly higher in the ACKD group in all years studied compared to the no CKD group. For the first year studied in 2006, the age-adjusted mortality rate for patients undergoing PCI was 149 per 100 000 vs. 48 per 100 000 in patients without ACKD (P < 0001). In the last year studied in 2011, age-adjusted mortality was 124.1 per 100 000 vs. 40.4 per 100 000 in patients with no ACKD, (P < 0.0001). The presence of ACKD remained independently associated with higher mortality despite multivariate adjustment (odds ratio: 1.32, confidence interval: 1.27-1.36, P < 0.001). CONCLUSION: ACKD is independently associated with higher mortality in patients undergoing PCI. Therefore, PCI in these patients should be performed with more caution.

Do breast implants not cause an increased rate of abnormal electrocardiograms (ECG)?

BACKGROUND: Breast implants interfere may interfere with surface ECG recording. The goal of this study was to evaluate if the presence of breast implants can lead to abnormal electrocardiogram (ECG) using a large database in adults. METHODS: Using ICD 10 codes for breast implants and abnormal ECG, we evaluated any association between abnormal ECG coding in adult women with breast implants compared to women without breast implants utilizing the National Inpatient Sample (NIS) database. Using different age cutoffs showed similar results. RESULTS: A total of 252,200 women in the NIS database had coding for abnormal EKG over age 18. There were no differences in the presence of abnormal EKG in women with or without breast implants (0.28% vs 0.3%, P = 0.64, OR: 1.02, CI: 0.72-1.32, p = 0.89). After multivariate adjustment for age, baseline characteristics, and comorbid conditions, women with or without breast implants had similar rates of abnormal ECG. CONCLUSION: Using a large database, we could not find any effect of breast implants on ECG recording suggesting that breast implant has no significant interference with ECG.

In Patients with Cardiogenic Shock, Extracorporeal Membrane Oxygenation Is Associated with Very High All-Cause Inpatient Mortality Rate.

Background: The goal of this study was to evaluate the effect of extracorporeal membrane oxygenation (ECMO) on mortality in patients with cardiogenic shock excluding Impella and IABP use. Method: The large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of ECMO in adults over the age of 18 and mortality and complications with a diagnosis of cardiogenic shocks. Results: ICD-10 codes for ECMO and cardiogenic shock for the available years 2016-2020 were utilized. A total of 796,585 (age 66.5 ± 14.4) patients had a diagnosis of cardiogenic shock excluding Impella. Of these patients, 13,160 (age 53.7 ± 15.4) were treated with ECMO without IABP use. Total inpatient mortality without any device was 32.7%. It was 47.9% with ECMO. In a multivariate analysis adjusting for 47 variables such as age, gender, race, lactic acidosis, three-vessel intervention, left main myocardial infarction, cardiomyopathy, systolic heart failure, acute ST-elevation myocardial infarction, peripheral vascular disease, chronic renal disease, etc., ECMO utilization remained highly associated with mortality (OR: 1.78, CI: 1.6-1.9, p < 0.001). Evaluating teaching hospitals only revealed similar findings. Major complications were also high in the ECMO cohort. Conclusions: In patients with cardiogenic shock, the use of ECMO was associated with the high in-hospital mortality regardless of comorbid condition, high-risk futures, or type of hospital.

Suspected colchicine-induced late myocardial rupture occurring after the late presentation of acute inferior ST-elevation myocardial infarction.

Colchicine is one of the established drugs of choice for post-myocardial infarction (MI) induced pericarditis, given its anti-inflammatory properties. Recently, colchicine received FDA approval for secondary prevention of atherosclerotic cardiovascular disease, which leads to concerns regarding its anti-healing effects on myocardial tissue post-infarction. We present a case of a suspected colchicine-induced myocardial rupture in an elderly male, who presented with a syncopal episode while on colchicine three weeks after the late presentation of infero-posterior ST-elevation myocardial infarction.

Reported physical symptoms during screening echocardiography are not associated with presence of suspected hypertrophic cardiomyopathy.

BACKGROUND: The prevalence of hypertrophic cardiomyopathy (HCM) can be silent and can present with sudden death as the first manifestation of this disease. The goal of this study was to evaluate any association between reported physical symptoms with the presence of suspected HCM. METHOD: The Anthony Bates Foundation has been performing screening echocardiography across the United States for the prevention of sudden death since 2001. A total of 4,120 subjects between the ages of 6 and 79 underwent echocardiographic screening. We evaluated any association between any symptoms and suspected HCM defined as any left ventricular wall thickness ³ 15 mm. RESULTS: The total prevalence of suspected HCM in the entire study population was 1.1%. The presence of physical symptoms was not associated with HCM (chest pain in 4.3% of participants with HCM vs. 9.9% of the control, p=0.19, palpitation in 4.3% of participants with HCM vs. 7.3% of the control., p=0.41, shortness of breath in 6.4% of participant with HCM vs. 11.7% of the control., p=0.26, lightheadedness in 4.3% of participant with HCM vs. 13.1% of the control., p=0.07, ankle swelling in 2.1% of participant with HCM vs. 4.0% of the control., p=0.52, dizziness in 8.5% of participant with HCM vs. 12.2% of the control., p=0.44). CONCLUSION: Echocardiographic presence of suspected HCM is not associated with a higher prevalence of physical symptoms in the participants undergoing screening echocardiography.

Intra-aortic balloon pump is associated with the lowest whereas Impella with the highest inpatient mortality and complications regardless of severity or hospital types.

Impella and intra-aortic balloon pumps (IABP) are commonly utilized in patients with cardiogenic shock. However, the effect on mortality remains controversial. The goal of this study was to evaluate the effect of Impella and IABP on mortality in patients with cardiogenic shock the large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of IABP or Impella on outcome. ICD-10 codes for Impella, IABP, and cardiogenic shock for available years 2016-2020 were utilized. A total of 844,020 patients had a diagnosis of cardiogenic shock. A total of 101,870 patients were treated with IABP and 39645 with an Impella. Total inpatient mortality without any device was 34.2% vs only 25.1% with IABP use (OR = 0.65, CI 0.62-0.67) but was highest at 40.7% with Impella utilization (OR = 1.32, CI 1.26-1.39). After adjusting for 47 variables, Impella utilization remained associated with the highest mortality (OR: 1.33, CI 1.25-1.41, p < 0.001), whereas IABP remained associated with the lowest mortality (OR: 0.69, CI 0.66-0.72, p < 0.001). Separating rural vs teaching hospitals revealed similar findings. In patients with cardiogenic shock, the use of Impella was associated with the highest whereas IABP was associated with the lowest in-hospital mortality regardless of comorbid condition.

Aortic regurgitation is associated with African American and Asian race, smoking, renal disease, and numerous autoimmune diseases in addition to traditional cardiovascular risk factors but has lower risk with alcohol intake.

BACKGROUND: Aortic regurgitation (AR) is associated with increasing age, rheumatic heart disease, and a bicuspid aortic valve, but its association with other comorbidities and race is less known. The purpose of this study was to investigate any association between AR and comorbid conditions in older adults above 40. METHOD: The large Nationwide Inpatient Sample database was utilized for our study using uni- and multivariate analysis. Data were extracted from available ICD-10 codes for the years of 2016-2020. RESULTS: The NIS data included 112,982,565 patients. A total of 660,730 were found to have AR. AR was found to be associated with male gender (OR 1.15, CI 1.14-1.16, P < 0.001), smoking (OR 1.04, CI 1.02-1.05, P < 0.001), hypertension (OR 1.65, CI 1.62-1.68, P < 0.001), hyperlipidemia (OR 1.36, CI 1.34-1.37, P < 0.001), chronic kidney disease (OR 1.22, CI 1.21-1.24, P < 0.001), antiphospholipid antibody syndrome (OR 1.56, CI 1.33-1.83, P < 0.001), rheumatoid arthritis (OR 1.1, CI 1.06-1.14, P < 0.001), scleroderma (OR 1.49, CI 1.31-1.7, P < 0.001), systemic connective tissue disorders (OR 1.32, CI 1.25-1.4, P < 0.001), Raynaud's syndrome (OR 1.62, CI 1.47-1.77, P < 0.001), and systemic lupus erythematosus (OR 1.44, CI 1.34-1.54, P < 0.001) in add to known bicuspid aortic valve. CONCLUSION: Using a very large database, we found new associations between AR and many comorbid conditions, including many inflammatory and chronic degenerative diseases in addition to the known risk factors.

The Majority of Participants With Suspected Hypertrophic Cardiomyopathy Documented During Screening Echocardiography Have a Normal Electrocardiogram.

BACKGROUND: Patients with hypertrophic cardiomyopathy (HCM) usually have abnormal electrocardiograms consistent with left ventricular hypertrophy (LVH). The goal of this study was to evaluate the prevalence of abnormal ECG findings (LVH, T wave inversion, left bundle branch block, and left atrial enlargement) in participants with suspected HCM detected during screening echocardiography. METHOD: The Anthony Bates Foundation has been performing screening echocardiography across the United States for the prevention of sudden death since 2001. A total of 682 subjects between the ages of 8 and 71 underwent echocardiographic screening together with ECG documentation. We evaluated the prevalence of abnormal ECG in participants with suspected HCM defined as any left ventricular wall thickness ≥15 mm. RESULTS: The prevalence of LVH and T wave inversion were higher in HCM subjects as expected [HCM occurred in 23.5% (4/17) vs. 5.6% (37/665), P = 0.002, T wave inversion occurred in 17.6% (3/17) vs. 4.1% (27/664), P = 0.007]. However, despite adding these 2 common ECG abnormalities in this population, the presence of detected abnormal ECG remained less than 25% (23.5% of HCM subjects had LVH or T wave inversion on ECG vs. 8.7% of control, P = 0.036). Left bundle branch block or abnormal left atrium on ECG were not found in any participants with suspected HCM. CONCLUSIONS: The prevalence of abnormal ECG in the participants with suspected HCM detected during screening echocardiography is less than 25%. This suggests that ECG alone is not a sensitive marker for the detection of HCM.

Berberine: A Multi-Target Natural PCSK9 Inhibitor with the Potential to Treat Diabetes, Alzheimer's, Cancer and Cardiovascular Disease.

Berberine is a natural product with a wide range of pharmacological effects. It has antimicrobial, anti-cancer, anti-inflammatory, anti-hyperlipidemic, neuroprotective, and cholesterollowering properties, among others. It has been used in traditional Chinese and Ayurvedic medicine for 3000 years and is generally well-tolerated with few side effects. Its main drawback is low oral bioavailability, which has hindered widespread clinical use. However, recent interest has surged with the emergence of evidence that berberine is effective in treating cancer, diabetes, Alzheimer's disease, and cardiovascular disease via multiple mechanisms. It enhances insulin sensitivity and secretion by pancreatic ß-cells in Type 2 Diabetes Mellitus in addition to reducing pro-inflammatory cytokines such as IL-6, IL-1ß, TLR4 and TNF-α. These cytokines are elevated in Alzheimer's disease, cardiovascular disease, and diabetes. Reductions in pro-inflammatory cytokine levels are associated with positive outcomes such as improved cognition, reduced cardiovascular events, and improved glucose metabolism and insulin sensitivity. Berberine is a natural PCSK9 inhibitor, which contributes to its hypolipidemic effects. It also increases low-density lipoprotein receptor expression, reduces intestinal cholesterol absorption, and promotes cholesterol excretion from the liver to the bile. This translates into a notable decrease in LDL cholesterol levels. High LDL cholesterol levels are associated with increased cardiovascular disease risk. Novel synthetic berberine derivatives are currently being developed that optimize LDL reduction, bioavailability, and other pharmacokinetic properties.

Various techniques for transcatheter retrieval of the atrial septal defect or patent foramen ovale closure devices: a systematic review.

Atrial septal abnormalities are common congenital lesions that remain asymptomatic in many patients until adulthood. Adults with atrial septal defects (ASD) most commonly have ostium secundum ASD. Transcatheter closure has become increasingly popular in recent years as a successful alternative method to surgery for treating ASD and patent foramen ovale (PFO). The overall rate of ASD transcatheter closure device embolization has been reported to be less than 1%; however, retrieving the device via surgery or by trans-catheter route can be necessary. The current manuscript describes a systematic review of the techniques used to retrieve ASD closure devices, as well as their success rates, complications, and limitations. A comprehensive search was performed covering various databases including PubMed, MEDLINE, SCOPUS, Google Scholar, and Cochrane Library from inception until April 2022 for English-published case reports, case series, and experimental studies investigating the indications, safety, and limitations of ASD closure and ASD device retrieval by trans-catheter approaches. Finally, 20 studies were included in our review. Our findings showed that most of the studies used a single snare technique; of these, all but one reported 100% success. Double tool retrieval methods (snare plus snare, snare plus bioptome, or snare plus forceps) and the gooseneck snare technique yielded 100% success. One study that used the lasso technique reported unsuccessful retrieval and the need for surgical intervention. More recently, the novel "coronary wire trap technique" was introduced, which provides a simpler method for embolized device removal by trapping the device for retrieval using coronary wire.

Association Between Idiopathic Thrombocytopenic Purpura and Hemorrhagic and Nonhemorrhagic Stroke.

BACKGROUND: Idiopathic thrombocytopenic purpura (ITP) is characterized by a low platelet count. This may lead to an increased risk of hemorrhagic stroke but a lower rate of nonhemorrhagic stroke. The goal of this study was to evaluate the association between ITP and both hemorrhagic and nonhemorrhagic strokes using a large database. METHODS: We used the Nationwide Inpatient Sample (NIS) database to analyze the occurrence of hemorrhagic and nonhemorrhagic stroke in patients with and without a diagnosis of ITP from 2005 to 2014. RESULTS: Univariate analysis revealed a higher incidence of hemorrhagic stroke in patients with ITP in the year studied. (for example, in 2005: OR, 1.75; 95% CI, 1.57-1.94; P < 0.001; 2014: OR, 2.19; 95% CI, 2.03-2.36; P < 0.001). After adjusting for age, gender, race, and hypertension, hemorrhagic stroke remained significantly associated with ITP (in 2005: OR, 1.85; 95% CI, 1.49-1.89; P < 0.001; 2014: OR, 2.01; 95% CI, 1.86-2.18; P < 0.001) for all the years studied. Nonhemorrhagic stroke occurred at a lower rate in patients with ITP in most years (2006: OR, 0.91; 95% CI, 0.85-0.97; P = 0.004; 2014: OR, 0.88; 95% CI, 0.83-0.93; P < 0.001). Multivariate analysis confirmed a higher rate of nonhemorrhagic stroke in ITP patients. CONCLUSION: Our analysis showed that there was a higher rate of hemorrhagic stroke but a lower rate of ischemic stroke in ITP patients, suggesting an important role of platelets in the occurrence of stroke.