Impella in Acute Myocardial Infarction Complicated by Cardiogenic Shock: History and Current Controversies.

In this review, the authors discuss a brief history of the Impella mechanical circulatory support device, a mechanistic role for the device in the context of the underlying pathophysiology of acute myocardial infarction cardiogenic shock (AMI-CS), the current body of literature evaluating its role in AMI-CS, and upcoming efforts to identify a role more clearly for the device in AMI-CS.

Prevalence of Obstructive Sleep Apnea Is Increased in Patients With Inflammatory Bowel Disease: A Large, Multi-Network Study.

Background: Crohn's disease (CD) and ulcerative colitis (UC) involve an inflammatory state where sleep dysregulation is common. Little is known about implications, if any, of inflammatory bowel disease (IBD) on the development of obstructive sleep apnea (OSA). This study aims to investigate if IBD patients are at higher risk for OSA. Methods: This retrospective multivariate analysis utilized a commercial database named Explorys (IBM Watson). We identified patients from 1/2015 to 1/2020 with UC and CD. Cohorts of these patients with and without OSA were then created and prevalence values were obtained. A multivariate analysis was used to correct for several potential confounding variables. Results: The overall prevalence of OSA was 7.8% in UC and 7.2% in CD, as compared with a prevalence of 4.3% in non-IBD patients (odds ratio [OR] for UC: 1.9 [95% CI 1.86-1.94, P < .0001], OR for CD: 1.72 [95% CI 1.69-1.76, P < .0001]). In multivariate analysis, age above 65, Caucasian race, male sex, obesity, smoking, hypertension, and diabetes were all independent risk factors for the development of OSA, with obesity being the most significant. After controlling for the listed variables in the multivariate analysis, IBD was an independent risk factor associated with OSA (OR 1.46, 95% CI 1.43-1.48). Conclusions: In this large population-based study, IBD was independently associated with increased prevalence of OSA. This has implications for screening for OSA in IBD, as well as management of other risk factors for OSA in IBD.

Outcomes of transcatheter aortic valve replacement in patients with cognitive dysfunction.

IMPORTANCE: The impact of pre-existing cognitive dysfunction on outcomes after transcatheter aortic valve replacement (TAVR) remains unclear. OBJECTIVE: To study the association between dementia and post-TAVR outcomes. DESIGN: Cohort study with propensity-score matching was conducted using the Nationwide Inpatient Sample. EXPOSURES: History of dementia at the time of undergoing TAVR. MAIN OUTCOMES: All-cause in-hospital mortality, stroke, bleeding requiring transfusion, acute kidney injury, post-procedural vascular complications, post-procedural pacemaker implantation, length of stay, in-hospital delirium, and discharge disposition in patients with and without dementia undergoing TAVR. RESULTS: Of 57,805 patients undergoing TAVR, 2910 (5.0%) had a diagnosis of dementia. Propensity-score matching yielded 2895 matched pairs of patients. TAVR was associated with an increased risk of bleeding requiring transfusion (14.7% vs 8.6%, odd ratio (OR) 1.82 [95% confidence interval (CI) 1.26-2.63]; p < 0.01), discharge to a rehabilitation facility (45.8% vs 31.6%, OR 2.27 [95% CI 1.67-3.08]; p < 0.001), in-hospital delirium (7.4% vs 3.6%, OR 2.13 [95% CI 1.26-3.61]; p < 0.01), increased length of stay (6.75 ± 0.07 days vs 6.11 ± 0.06 days, slope = 1.11 [95% CI 1.03-1.19]; p < 0.01), but comparable in-hospital mortality (2.1% vs 2.6%, OR 1.26 [95% CI 0.57-2.79]; p = 0.57] in patients with dementia compared with patients without dementia. CONCLUSIONS AND RELEVANCE: This study found that patients with dementia undergoing TAVR had a longer hospital stay as well as higher rates of discharge to a rehabilitation facility and in-hospital delirium, which may indicate debility and functional decline during hospitalization; however, in-hospital mortality and other outcomes were comparable between the two groups. TAVR candidates should be subjected to a comprehensive geriatric and cognitive assessment to help risk-stratify them for potential post-procedural functional decline. Prospective studies aimed at standardizing cognitive scoring and evaluating the post-procedural quality of life are needed.

Toward Brief Dual Antiplatelet Therapy and P2Y12 Inhibitors for Monotherapy After PCI.

The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention remains a controversial topic. The European Society of Cardiology and the American College of Cardiology/American Heart Association recommend at least 6 and 12 months of DAPT after PCI in patients with stable coronary artery disease or acute coronary syndrome, respectively. Although prolonging DAPT duration reduces ischemic events, it is associated with higher rates of bleeding and possible fatal outcomes. The DAPT score can be an important tool to identify patients who may still benefit from prolonged therapy. Nevertheless, several recent randomized controlled trials showed that shortening DAPT duration from 12 to 1-3 months reduces bleeding rates without significantly increasing ischemic event rates. These trials also suggested replacing acetylsalicylic acid (aspirin) with P2Y12 inhibitors after short-term DAPT. We review and compare past and present studies regarding DAPT and analyze the evidence favoring a short DAPT duration and the long-term single antiplatelet agent of choice.

Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Large Database Study.

OBJECTIVES: Studies on the incidence of venous thromboembolism (VTE) in acute pancreatitis (AP) are scarce. We conducted a large database study to evaluate this relationship. METHODS: Data were extracted from a large electronic health record (Explorys; IBM Watson Health, Armonk, NY). We identified patients with AP in 2018 and 2019, analyzing VTE incidence at 30 days after diagnosis of AP. Univariate and multivariate analyses were performed to identify risk factors associated with VTE. RESULTS: A total of 25,620 cases of acute necrotizing pancreatitis (ANP) and 155,800 cases of acute nonnecrotizing pancreatitis (ANNP) were identified. The incidence of VTE was 7.1% for ANP, compared with 2.8% in ANNP (P < 0.001). On multivariate analysis, ANP conferred significantly greater odds of VTE (adjusted odds ratio, 2.78; 95% confidence interval, 2.73-2.84; P < 0.001), independent of other variables. In those with ANP, the presence of VTE was associated with a significantly higher mortality (23.5% vs 15.9%, P < 0.001). CONCLUSIONS: Acute necrotizing pancreatitis carries near 2.5-fold risk of VTE, and a 3-fold risk of PE, compared with those with ANNP. Venous thromboembolism development in ANP is associated with higher mortality.

Weekend Operation and Outcomes of Patients Admitted for Nonelective Coronary Artery Bypass Surgery.

BACKGROUND: The "weekend effect" is a purported phenomenon whereby patients admitted for time-sensitive medical and surgical conditions on a weekend suffer worse outcomes than those admitted on a weekday. There are limited data on the weekend effect for nonelective coronary artery bypass grafting (CABG). METHODS: We studied outcomes for weekend vs weekday operations for all adult patients in the 2013 to 2014 National Inpatient Sample (NIS) undergoing nonelective CABG. RESULTS: Of 101,510 patients undergoing nonelective CABG, 12,795 patients (12.6%) underwent CABG on the day of admission (n = 1230 for weekend and 11,565 for weekday admission, respectively). Patients undergoing surgical procedures on a weekend were more likely to have a diagnosis of ST-elevation acute coronary syndrome (47.2% vs 20.2%, P < .001), require intraaortic balloon pump support (46.3% vs 23.1%, P < .001), and undergo same-day coronary angiography (66.7% vs 41.8%; P < .001) or same-day percutaneous coronary intervention (11.8% vs 7.1%; P = .01). Weekend admission was associated with increased mortality in unadjusted analysis (6.1% vs 3.2%; odds ratio, 1.99; 95% confidence interval, 1.13-3.52; P = .02), but this effect was attenuated in the adjusted model (adjusted odds ratio, 1.22; 95% confidence interval, 0.63-2.33; P = .47). CONCLUSIONS: Patients undergoing CABG on a weekend had higher crude mortality but similar risk-adjusted mortality compared with their weekday counterparts. Some of the excess mortality observed for weekend operations is likely attributable to a sicker cohort of patients undergoing CABG on the weekend.

Relation of Concomitant Heart Failure to Outcomes in Patients Hospitalized With Influenza.

Influenza is a major public health challenge. Patients hospitalized with influenza who also have heart failure (HF) may be at risk for worse outcomes compared with patients without HF. There is a lack of large studies examining this issue. We queried the 2013 to 2014 National Inpatient Sample for all adult patients (aged ≥ 18 years) admitted with influenza with and without concomitant HF. Using propensity score matching, patients were matched across demographics, discharge weights, and comorbidities. Outcomes included in-hospital mortality, complications, length of stay, and average hospital costs. Of 218,540 influenza hospitalizations, 45,460 (20.8%) had concomitant HF. Patients with HF had higher in-hospital mortality (6.1% vs 3.8%, adjusted odds ratio [aOR] 1.66 [95% confidence interval [CI] 1.44 to 1.91]; p <0.001), acute kidney injury (29.5% vs 22.2%, aOR 1.47 [95% CI 1.37 to 1.57]; p <0.001), acute kidney injury requiring dialysis (2.0% vs 1.0%, aOR 2.08 [1.62 to 2.67], acute respiratory failure (36.2% vs 23.5%, aOR 1.85 [1.73 to 1.97]; p <0.001), and acute respiratory failure requiring mechanical ventilation (17.1% vs 9.3%, OR 2.01 [1.84 to 2.21]; p <0.001), longer length of stay (5.70 ± 0.02 days vs 4.60 ± 0.01 days, p <0.001) and higher average hospital costs ($11,609 ± $52 vs $9,003 ± $38, p <0.001). In conclusion, in patients hospitalized with influenza, HF is associated with increased risk of in-hospital mortality and complications. Our results highlight a need for early recognition and aggressive treatment of HF in these patients to try to improve outcomes.

Risk of Myocardial Infarction in Inflammatory Bowel Disease: A Population-based National Study.

BACKGROUND & OBJECTIVE: Chronic inflammation is linked to increased cardiovascular risk. Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract and elevated pro-inflammatory markers. The association between IBD and myocardial infarction (MI) is not well understood. We sought to elucidate this risk using a large database. METHODS: We reviewed data from a large commercial database (Explorys, IBM Watson) that aggregates electronic medical records from 26 nationwide health care systems. Using systemized nomenclature of medicine-clinical terms, we identified adult patients (20 to 65 years) with a diagnosis of IBD-ulcerative colitis (UC) or Crohn's disease (CD)-who had active records between August 2013 and August 2018. We then examined the risk of MI in patients with or without IBD. RESULTS: Out of 29,090,220 patients, 131,680 (0.45%) had UC, and 158,750 (0.55%) had CD. Prevalence of MI was higher in patients with UC and CD versus non-IBD patients (UC 6.7% vs CD 8.8% vs non-IBD 3.3%, odds ratio [OR] for UC 2.09 [2.04 -2.13], and CD 2.79 [2.74-2.85]. The odds of MI in IBD patients overall were highest in younger patients and decreased with age (age 30-34 years: OR 12.05 [11.16-13.01], age 65+ years: OR 2.08 [2.04-2.11]). After adjusting for age, race, sex, and traditional cardiovascular risk factor, IBD conferred greater odds of MI (adjusted odds ratio [aOR] 1.25 [1.24-1.27]). CONCLUSION: In this large cohort, IBD is associated with significantly increased MI compared with non-IBD patients. The relative risk of MI was highest in younger patients and decreased with age. These findings emphasize the need for aggressive risk factor reduction in IBD.

Tolosa-Hunt syndrome: an arcane pathology of cavernous venous sinus.

Tolosa-Hunt syndrome, an idiopathic granulomatous inflammation of the cavernous sinus, is primarily a diagnosis of exclusion. The majority of patients present with unilateral orbital pain and features suggestive of paralysis of one or more of the cranial nerves passing through the cavernous sinus and/or superior orbital fissure. MRI of the head may show unilateral enhancement of the cavernous sinus and orbital apex. Treatment is with high-dose intravenous steroids followed by tapering oral steroids. Rapid amelioration of pain within 24-48 h supports this rare diagnosis. Resolution of neuropathies may take longer. We describe a case of a young man who presented with left periorbital pain, complete ophthalmoplaegia and ptosis of the left eye. MRI showed enhancement of the left cavernous sinus and orbital apex. High dose steroids led to complete resolution of pain, while ptosis and ophthalmoplaegia improved gradually.

A naturally occurring GIP receptor variant undergoes enhanced agonist-induced desensitization, which impairs GIP control of adipose insulin sensitivity.

Glucose-dependent insulinotropic polypeptide (GIP), an incretin hormone secreted from gastrointestinal K cells in response to food intake, has an important role in the control of whole-body metabolism. GIP signals through activation of the GIP receptor (GIPR), a G-protein-coupled receptor (GPCR). Dysregulation of this pathway has been implicated in the development of metabolic disease. Here we demonstrate that GIPR is constitutively trafficked between the plasma membrane and intracellular compartments of both GIP-stimulated and unstimulated adipocytes. GIP induces a downregulation of plasma membrane GIPR by slowing GIPR recycling without affecting internalization kinetics. This transient reduction in the expression of GIPR in the plasma membrane correlates with desensitization to the effects of GIP. A naturally occurring variant of GIPR (E354Q) associated with an increased incidence of insulin resistance, type 2 diabetes, and cardiovascular disease in humans responds to GIP stimulation with an exaggerated downregulation from the plasma membrane and a delayed recovery of GIP sensitivity following cessation of GIP stimulation. This perturbation in the desensitization-resensitization cycle of the GIPR variant, revealed in studies of cultured adipocytes, may contribute to the link of the E354Q variant to metabolic disease.