Assessing and Addressing Social Determinants of Cardiovascular Health: JACC State-of-the-Art Review.

Social determinants of health (SDOH) are the social conditions in which people are born, live, and work. SDOH offers a more inclusive view of how environment, geographic location, neighborhoods, access to health care, nutrition, socioeconomics, and so on are critical in cardiovascular morbidity and mortality. SDOH will continue to increase in relevance and integration of patient management, thus, applying the information herein to clinical and health systems will become increasingly commonplace. This state-of-the-art review covers the 5 domains of SDOH, including economic stability, education, health care access and quality, social and community context, and neighborhood and built environment. Recognizing and addressing SDOH is an important step toward achieving equity in cardiovascular care. We discuss each SDOH within the context of cardiovascular disease, how they can be assessed by clinicians and within health care systems, and key strategies for clinicians and health care systems to address these SDOH. Summaries of these tools and key strategies are provided.

Rotational Atherectomy in Acute Coronary Syndrome: A Meta-Analysis.

BACKGROUND: The use of rotational atherectomy (RA) in percutaneous coronary intervention (PCI) of acute coronary syndrome (ACS) is considered relatively contraindicated. There have been several observational studies showing RA use in ACS, however, no systemic studies have been undertaken. We sought to evaluate the feasibility and outcomes of RA PCI in ACS by performing a meta-analysis. METHODS: We searched PUBMED, EMBASE, CINAHL, and Cochrane Central Register of Clinical Trials for any studies that evaluated the role of RA PCI in ACS. The outcomes analyzed were all-cause mortality, cardiac mortality, short and long-term major adverse cardiac events (MACE), procedural complications and cardiac perforations. RESULTS: There was a total of 8 retrospective studies with a total population of 1237 with a median follow up of 23 months. The median age of the included patient was 73. Angiographic success rate was 97.4%. The rate of all-cause mortality and cardiac mortality were 5% (range 1-12%, p < 0.001, I2 = 92%) and 2% (range 0-5%, P = 0.03, I2 = 58%) respectively. In-hospital MACE and long-term MACE were 7% (range 3-13%, p < 0.001, I2 = 87%) and 29% (range 21-37%, p = 0.21, I2 = 34%) respectively. The incidence of total procedural complications was noted to be 7% (range 2-14%, p < 0.001, I2 = 90%). Rate of perforation was 1% (range 0-1%, p = 0.9, I2 = 0%). CONCLUSION: Our results show that RA PCI is feasible in ACS with comparable procedural complications and short-term MACE, but with a higher long-term MACE rate compared to RA PCI in routine cases.

Association Between Pulmonary Hypertension and Transcatheter Aortic Valve Replacement: Analysis of a Nationwide Inpatient Sample Database.

INTRODUCTION: This study was done to review the association of pulmonary hypertension (PH) with Transcatheter Aortic Valve Replacement (TAVR) procedures done in the US for years 2010 to 2012. METHODS: We used Nationwide Inpatient Sample (NIS) data to extract data for patients who were hospitalized with a primary/secondary diagnosis of TAVR as specified by International Classification of Disease (ICD-9) codes 35.05 and 35.06. PH was identified with ICD-9 codes 416.0 and 416.8. Logistic regression models were used to analyze the association between PH and clinical outcomes of TAVR. RESULTS: A total of 8,824 weighted discharges were identified with a primary/secondary diagnosis of TAVR, of which 1,976 (22.4%) also had PH. Mean age of patients undergoing TAVR with and without PH was 81.4 and 81.1 years, respectively. More females had a diagnosis of PH with TAVR when compared to males, (56.9% vs. 43.1). When controlling for demographics, diabetes and hypertension; the association between PH and TAVR was statistically significant (p<.0001). Estimated odds of TAVR with PH was 5.46 (95% CI: 4.63, 6.41) times greater than for TAVR without PH. Similarly, the estimated odds for a length of stay greater than 1 week for TAVR with PH was 1.43 (95% CI: 1.12, 1.82; p=.0034) times greater than odds for TAVR without PH. PH was not statistically significant for in-hospital mortality in patients receiving TAVR (p=0.7067). CONCLUSION: This study suggests that underlying PH does not influence the immediate mortality of patients underlying TAVR. Further studies are needed to delve into the bearing of PH on TAVR.

Association Between Hypothyroidism and Takotsubo Cardiomyopathy: Analysis of Nationwide Inpatient Sample Database.

BACKGROUND: Takotsubo Cardiomyopathy (TC), also called transient left ventricular (LV) ballooning syndrome, resembles myocardial infarction and is characterized by LV dysfunction in the absence of coronary artery disease. Hypothesis described for TC has been an intense social stressor, pheochromocytoma, thyrotoxicosis among others. We performed this study to analyze the association of hypothyroidism with TC. METHODS: We queried the Nationwide Inpatient Sample which represents 20% of all the United States hospital data for our study. We identified TC and hypothyroidism through their respective ICD9. Codes for years 2006-2012. SAS 9.4 was used to perform a chi-square analysis to find any statistical significance and p < 0.05 used to determine statistical significance. Significant differences were identified using odds ratio (OR) estimates. RESULTS: A total of 19,713 cases with TC were identified of which 17,340 (87.96%) were females and 2,373 (12.04%) were males. 3,272 patients with TC had diagnosis of hypothyroidism. There is statistically significant evidence of an association between TC and hypothyroidism (OR 2.21 (95% CI: 2.11- 2.31); p<0.0001). There is evidence of increased statistical significance of females having TC 5.24 (95% CI: 4.96-5.53; (p<0.0001)) compared to males, with an increased statistically significance of females with hypothyroidism having TC, OR 6.65 (95% CI: 5.57-7.93; p< 0.001) compared to males. CONCLUSION: There is an increased association of hypothyroidism, especially hypothyroidism for females with TC.

Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative.

OBJECTIVE: The 'Detroit Cardiogenic Shock Initiative' is a single-arm, multicenter study to assess the feasibility of early mechanical circulatory support (MCS) in patients who present with acute myocardial infarction complicated by cardiogenic shock (AMICS) who undergo percutaneous coronary intervention. METHODS: Between July 2016 and February 2017, 4 metro Detroit sites participated in the study. The centers agreed to treat patients with AMICS using a mutually agreed-upon protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those from the 'SHOCK' trial with an additional exclusion criteria being use of intra-aortic balloon pump counter pulsation prior to MCS. RESULTS: A total of 41 consecutive patients were included. Patients had an average age of 65 ± 14 years, 71% were male and 59% of patients were admitted to the hospital in cardiogenic shock. Prior to receiving MCS, 93% of patients were on vasopressors or inotropes, 15% of patients had a witnessed out of hospital cardiac arrest, 27% of patients had an in-hospital cardiac arrest, and 17% were under active cardiopulmonary resuscitation while MCS was being implanted. In accordance to the protocol recommendation, 66% of patients had a MCS device inserted prior to PCI. Right heart catheterization and hemodynamic monitoring was performed in 83% of patients. Door to support times averaged 83 ± 58 minutes and 71% of patients were able to reduce the levels of inotropes and vasopressors within the first 24-hours of their index procedure. Pre-procedure cardiac power output (CPO) was 0.57 W and post-procedure CPO was 0.95 W, a 67% increase (p < 0.001). Survival to explant for the entire cohort was 85% a significant improvement from institutional historical controls (85% vs 51% p < 0.001) and survival to discharge was 76%. CONCLUSION: Centers who adopted a regional shock protocol emphasizing the delivery of early MCS with invasive hemodynamic monitoring can achieve rapid door to support times and can improve survival in patients who present with AMICS. Larger national studies will be needed to further validate this pilot feasibility study.

Mid-term outcomes of consecutive 998 cases of coronary atherectomy in contemporary clinical practice.

OBJECTIVES: To compare clinical and safety endpoints with use of rotational (RA) and orbital (OA) atherectomy in a large patient population with moderate to severely calcified lesions undergoing percutaneous coronary intervention (PCI). BACKGROUND: Coronary artery calcification (CAC) has been recognized as a risk factor for adverse outcomes with coronary artery disease (CAD). Though atheroablative techniques, RA and OA have been used extensively, comparison of their clinical and safety endpoints is lacking. Comparison of these two modalities formed the basis of our study. METHODS AND RESULTS: Of 12 001 patients who underwent PCI at our institution between January 2013-December 2015, we studied 998 consecutive patients with severe calcification treated with atheroablation. We assessed clinical outcomes including death, myocardial infarction (MI) and target lesion revascularization (TLR) at 30 days and 6 months in addition to post-procedural complications. Device perforation occurred more frequently with use of OA at high burr speed versus RA (1.9%, n = 3 vs. 0.2%, n = 2, P = 0.03). Rates of composite adverse events were similar between groups at 6 months (18.55 vs. 11.46%; P = 0.11) CONCLUSION: In this retrospective, single center study, we observed no significant differences in 6-month rates of adverse events associated with use of OA vs. RA in patients with moderate to severe calcification undergoing PCI. Larger, prospective studies are needed to confirm our findings.

Clinical and angiographic predictors of haemodynamically significant angiographic lesions: development and validation of a risk score to predict positive fractional flow reserve.

AIMS: Coronary revascularisation based upon physiological evaluation of lesions improves clinical outcomes. Angiographic or visual stenosis assessment alone is insufficient in predicting haemodynamic stenosis severity by fractional flow reserve (FFR) and therefore cannot be used to guide revascularisation, particularly in the lesion subset <70%. Accordingly, we sought to identify independent determinants of angiographic intermediate lesions with haemodynamic significance. METHODS AND RESULTS: We assessed consecutive intermediate lesions for patients from January 2014 to April 2015 at our institution. Independent predictors of FFR positivity (FFR ≤0.8) were identified and a scoring system formulated. Of 1,023 consecutive lesions (883 patients), 314 (31%) were haemodynamically significant. Characteristics associated with FFR ≤0.8 include male gender, higher SYNTAX score, lesions ≥20 mm, stenosis >50%, bifurcation, calcification, absence of tortuosity and smaller reference diameter. A user-friendly integer score was developed with the five variables demonstrating the strongest association. On prospective validation (in 279 distinct lesions), the increasing value of the score correlated well with increasing haemodynamic significance (C-statistic 0.85). CONCLUSIONS: We identified several clinical and angiographic characteristics and formulated a scoring system to guide the approach to intermediate lesions. This may translate into cost savings. Larger studies with prospective validation are required to confirm our results.

Left main coronary artery disease: A review of the spectrum of noninvasive diagnostic modalities.

Medically managed significant left main (LM) stem disease has been considered a determinant of increased cardiac mortality approaching 50% at 3-year follow-up. Despite the clinical significance of LM disease, studies comparing the various diagnostic modalities, especially noninvasive, are sparse. Clinicians, particularly imagers, should be aware of the strengths and weaknesses of existing modalities to diagnose LM disease as integrating many clues (history, symptoms, electrocardiogram, and stress hemodynamics are essential to suspect this diagnosis and proceed to the next step). Here we review the existing data on the current role of electrocardiography, nuclear myocardial perfusion imaging (single photon emission computed tomography and positron emission tomography), stress echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging in diagnostic evaluation of LM disease. Wherever applicable we have extended our discussion to multivessel coronary artery disease encompassing scenarios where LMS can present as LM equivalent with or without extensive multivessel coronary artery disease.

Strain Imaging: From Physiology to Practical Applications in Daily Practice.

Non-Doppler, 2-dimensional strain imaging is a new echocardiographic technique for obtaining strain and strain rate measurements, which serves as a major advancement in understanding myocardial deformation. It analyzes motion in ultrasound imaging by tracking speckles in 2 dimensions. There are a lot of data emerging with multiple applications of strain imaging in the clinical practice of echocardiography. As incorporation of strain imaging in daily practice has been challenging, we intend to systematically highlight the top 10 applications of speckle-tracking echocardiography, which every cardiologist should be aware of: chemotherapy cardiotoxicity, left ventricular assessment, cardiac amyloidosis, hypertrophic obstructive cardiomyopathy, right ventricular dysfunction, valvular heart diseases (aortic stenosis and mitral regurgitation), cardiac sarcoidosis, athlete heart, left atrial assessment, and cardiac dyssynchrony.

Safety of echocardiographic contrast in hospitalized patients with pulmonary hypertension: a multi-center study.

AIMS: Echocardiographic contrast (EC) improves the diagnostic accuracy of suboptimal echocardiograms. In October 2007, the Food and Drug Administration (FDA) placed a black box warning on the label of the perflutren-based agents Definity and Optison, contraindicating their use in patients with pulmonary hypertension (PHT) and unstable cardiopulmonary status, after serious cardiopulmonary reactions occurred in temporal relation to EC administration. In 2008 and 2011, the FDA revised the black box warning allowing their use in this same population. However, limited data exist regarding the safety profile of these agents in patients with PHT. METHODS AND RESULTS: Consecutive hospitalized patients with PHT who were referred for echocardiographic evaluation, but required the use of EC, were included. All our patients received the EC agent Definity. We evaluated these patients for serious adverse events (respiratory decompensation, hypotension, syncope, convulsions, arrhythmias, anaphylactic reactions, or death) occurring within 24 h of EC administration. The study group included 1513 patients (age 69 ± 14 years, 55% males, BMI 33 ± 9 kg/m(2)), of which 911 (60%) had mild PHT, 515 (34%) had moderate PHT, and 87 (6%) had severe PHT. The mean pulmonary artery systolic pressures (PASP) in the groups with mild, moderate, and severe PHT were 41 ± 4 (range 35-49) mmHg, 55 ± 5 (range 50-69) mmHg, and 78 ± 9 (range 70-122) mmHg, respectively. The incidence of adverse events in all subgroups was rare (0.002%) and they were not attributed to EC because of temporal and clinical considerations. CONCLUSION: The use of the EC agent Definity is safe in hospitalized patients with PHT.