Venous Thromboembolism in Hospitalized COVID-19 Patients: Systematic Review.

BACKGROUND: Coagulopathy associated with COVID-19 infection and venous thromboembolism (VTE) have emerged as significant contributors to morbidity among patients infected with SARS-CoV-2. OBJECTIVE: We performed a systematic review to estimate VTE incidence in hospitalized patients and to analyze characteristic factors in the VTE cohort. METHODS: We searched PubMed and Google Scholar using specified title search terms "SARS-CoV-2" or "COVID-19" and "venous thromboembolism" and "anticoagulation" among others to identify peer-reviewed journal articles published between June 22, 2019, and June 22, 2020. Data were systematically extracted and synthesized using Microsoft Excel for analysis. The main outcome was VTE incidence, and measures included patient characteristics, anticoagulation, and clinical outcomes with assessment for associations. RESULTS: In total, 14 studies were included comprising 1677 patients. Most patients (n=1306, 82.4%) received anticoagulation (either VTE prophylaxis or treatment). VTE incidence was 26.9% (SE 3.1; 95% CI 20.8-33.1) and was correlated with systematic screening (r2=0.34, P=.03) and study duration (r2=-0.33, P=.03). D-dimer was higher for the VTE cohort (5.62 [SD 0.9] vs 1.43 [SD 0.6]; P<.001). Odds of VTE were higher at the intensive care unit (odds ratio [OR] 6.38, 95% CI 3.67-11.11; P<.001) but lower with anticoagulation (OR 0.58, 95% CI 0.36-0.92; P=.02). CONCLUSIONS: Despite the utilization of background anticoagulation, VTE incidence was historically high. Future studies are needed to provide additional data to guide optimal VTE prophylaxis and diagnostic strategies.

Wearable technology for cardiology: An update and framework for the future.

The field of cardiology has long used wearable medical devices to monitor heart rate and rhythm. The past decade has seen the emergence of many new wearable devices, including several that have been widely adopted by both physicians and consumers. In this review, we discuss existing and forthcoming devices designed to measure activity, heart rate, heart rhythm, and thoracic fluid. We also offer several frameworks to classify and better understand wearable devices, such that we may weigh their potential benefit in improving healthcare with the many challenges that must be addressed to reap these benefits.

Handheld Ultrasound as a Novel Predictive Tool in Atrial Fibrillation: Prediction of Outcomes Following Electrical Cardioversion.

BACKGROUND: Atrial fibrillation (AF) recurrence after successful direct current cardioversion (CV) is common, and clinical predictors may be useful. We evaluated the risk of early AF recurrence according to inferior vena cava (IVC) measurements by handheld ultrasound (HHU) at the time of CV. OBJECTIVE: Assess HHU and objectively obtained measurements acquired at the point of care as potential clinical predictors of future clinical outcomes in patients with AF undergoing CV. METHODS: Maximum IVC diameter (IVCd) and collapsibility with inspiration were measured by the Vscan HHU (General Electric Healthcare Division) in 128 patients immediately before and after successful CV for AF. Patients were followed by chart review for recurrence of AF. RESULTS: Mean IVCd was 2.16 cm in AF pre-CV and 2.01 cm in sinus rhythm post-CV (P<.001). AF recurred within 30 days of CV in 34 of 128 patients (26.6%). Among patients with IVCd <2.1 cm pre-CV and decrease in IVCd post-CV, AF recurrence was 12.1%, compared to 31.6% in patients not meeting these parameters (odds ratio [OR] 0.299, P=.04). This association persisted after adjustment for age, ejection fraction <50%, left atrial enlargement, and amiodarone use (adjusted OR 0.185, P=.01). Among patients with IVCd post-CV <1.7 cm, AF recurrence was 13.5%, compared to 31.9% in patients not meeting this parameter (OR 0.185, P=.01). IVC parameters did not predict AF recurrence at 180 or 365 days. CONCLUSIONS: The presence of a normal IVCd pre-CV that becomes smaller post-CV and the presence of a small IVCd post-CV were each independently associated with reduced likelihood of early, but not late, AF recurrence. HHU assessment of IVCd at the time of CV may be useful to identify patients at low risk of early recurrence of AF after CV.

Usefulness of Serial Measurements of Inferior Vena Cava Diameter by VscanTM to Identify Patients With Heart Failure at High Risk of Hospitalization.

Estimation of volume status is integral to heart failure (HF) management. Measurement of inferior vena cava (IVC) diameter (IVCd) by ultrasound provides a noninvasive estimate of right atrial pressures. The GE Vscan is a handheld ultrasound (HHU) device that allows for point-of-care measurements to assess volume status. We hypothesize that IVCd measurements using HHU can predict the risk of HF admission. We retrospectively analyzed a cohort of patients with HF treated in an ambulatory care setting over 17 months. Serial measurements of IVCd were obtained using HHU in the supine position from the subcostal window. Log-binomial regression models were used to compare IVCd measurements between patients with and without HF admissions and to estimate the association between IVCd and risk of HF admission. Of the 355 patients with systolic (38%) and diastolic HF (62%) who were analyzed, 45% were women with a mean age of 73 years at the time of the first IVCd measurement. Overall, 3,488 measurements were obtained, and 32.4% of patients were hospitalized during follow-up. Patients with at least 1 hospital admission had a greater mean IVCd than those who were not admitted (2.0 vs 1.8 cm, p <0.01). In our analysis, every 0.5-cm increase in the mean IVCd was associated with a 38% increase in risk of HF admission (risk ratio [RR] 1.38, 95% CI 1.16 to 1.62, p <0.01). The risk of HF admission was also significantly increased in patients with IVCd 2.0 to 2.49 cm (RR 1.79, 95% CI 1.27 to 2.52, p <0.01) and ≥2.5 cm (RR 2.39, 95% CI 1.55 to 3.67, p <0.01), compared with patients with an IVCd < 2.0 cm. Increasing IVCd as measured by HHU at the point-of-care is associated with an increased risk of HF admission and may provide clinically useful information at the point-of-care to guide HF management.

Implementation of a Home Monitoring System for Heart Failure Patients: A Feasibility Study.

BACKGROUND: Improving the management of patients with complex chronic disease is a substantial undertaking with the simultaneous goals of improving patient outcomes and controlling costs. Reducing avoidable hospitalization for such patients is a step toward both objectives. Some of the deterioration experienced in chronic disease patients occurs outside the view of their clinicians, and before the patient becomes overtly symptomatic. Home monitoring has been used for more than 20 years to detect deterioration earlier so that the patients could be treated before they became ill enough to require hospitalization. Patient participation is an important requirement for successful home monitoring. There has been some concern that patients would be unwilling or unable to engage in a program that collected multiple measurements. The Cedars-Sinai Cardiology Center provides a high-touch, intense management program for patients with congestive heart failure (CHF). A group of their patients were chosen to join a complex, multidevice home monitoring system to see whether such patients would find value in the additional effort. OBJECTIVE: The objective of our study was to determine whether patients already actively engaged in a high-touch intensive management program for CHF would take on the additional burden of a complex home monitoring effort. METHODS: A total of 20 patients from the Cedars-Sinai group were enrolled in a monitoring program utilizing 5 different devices. Anonymous surveys were collected from the patients to assess their satisfaction with the program. RESULTS: In total, 90% (18/20) completed the program, and 61% (11/20) submitted the survey. Among the 18 patients, overall compliance with the requested measurements was 70%. It was found that 73% (8/11) felt better about their health as a result of the program, whereas another 73% (8/11) believed that the care team now had a better picture of their health. CONCLUSIONS: Substantial patient compliance and satisfaction can be achieved in a sophisticated home monitoring program.

The efficacy of sonographic measurement of inferior vena cava diameter as an estimate of central venous pressure.

BACKGROUND: Central venous pressure (CVP) and right atrial pressure (RAP) are important parameters in the complete hemodynamic assessment of a patient. Sonographic measurement of the inferior vena cava (IVC) diameter is a non-invasive method of estimating these parameters, but there are limited data summarizing its diagnostic accuracy across multiple studies. We performed a comprehensive review of the existing literature to examine the diagnostic accuracy and clinical utility of sonographic measurement of IVC diameter as a method for assessing CVP and RAP. METHODS: We performed a systematic search using PubMed of clinical studies comparing sonographic evaluation of IVC diameter and collapsibility against gold standard measurements of CVP and RAP. We included clinical studies that were performed in adults, used current imaging techniques, and were published in English. RESULTS: Twenty one clinical studies were identified that compared sonographic assessment of IVC diameter with CVP and RAP and met all inclusion criteria. Despite substantial heterogeneity in measurement techniques and patient populations, most studies demonstrated moderate strength correlations between measurements of IVC diameter and collapsibility and CVP or RAP, but more favorable diagnostic accuracy using pre-specified cut points. Findings were inconsistent among mechanically ventilated patients, except in the absence of positive end-expiratory pressure. CONCLUSION: Sonographic measurement of IVC diameter and collapsibility is a valid method of estimating CVP and RAP. Given the ease, safety, and availability of this non-invasive technique, broader adoption and application of this method in clinical settings is warranted.

Transplant coronary artery disease.

Transplant coronary artery disease (TCAD) remains the most significant cause of morbidity and mortality after orthotopic heart transplantation. Transplant coronary artery disease is largely an immunologic phenomenon, driven by an inflammatory milieu consisting of multiple cell types that contribute to fibromuscular and smooth muscle cell proliferation with subsequent coronary obstruction. Multiple clinical factors contribute to the development of TCAD. Coronary angiography is the gold standard for the diagnosis of TCAD. Current treatments for TCAD include pharmacotherapy, percutaneous coronary intervention, and repeat transplantation, although other novel therapies are emerging. Although percutaneous coronary intervention has generally demonstrated high procedural success rates, it has been plagued by a high incidence of in-stent restenosis. Drug-eluting stents reduce in-stent restenosis compared with bare metal stents. Repeat transplantation is the only definitive treatment. Prospective randomized trials comparing different pharmacotherapies as well as revascularization strategies are needed to identify the optimal therapy for patients who develop TCAD.

Preprocedural white blood cell count as a predictor of death and major adverse cardiac events in patients undergoing percutaneous coronary intervention with drug-eluting stents.

BACKGROUND: Patients with elevated white blood cell (WBC) counts who undergo percutaneous coronary intervention (PCI) are at increased risk for short- and long-term mortality as well as major adverse cardiac events (MACE). We assessed the relationship between elevated WBC counts and clinical events in patients who underwent PCI with drug-eluting stents (DES). METHODS: Our retrospective study includes 878 consecutive patients who underwent both elective and emergent PCI with DES at the UCLA Medical Center. The cohort was divided into tertiles based upon the presenting WBC count: 2.8-6.3 x 109 cells/L (tertile 1 [T1]), 6.4-8.7 x 109 cells/L (tertile 2 [T2]), > or = 8.8 x 109 cells/L (tertile 3 [T3]). RESULTS: Survival at 1 year was significantly different between all three tertiles, and was poorest in patients with WBC counts in T3 (93.9%-T1, 98.4%-T2, 87.3%-T3; p < 0.0001), while T2 had the highest survival rate at 1 year. Age, chronic renal insufficiency, chronic obstructive pulmonary disease, low WBC count in T1, elevated WBC count in T3 and presentation with myocardial infarction were identified as multivariable predictors for survival at 1 year. CONCLUSION: Both elevated and low WBC counts are associated with increased mortality and MACE at 1 year following PCI with DES. WBC count is an independent predictor of survival in patients who undergo PCI with DES implantation.

Impact of diabetes and acute coronary syndrome on survival in patients treated with drug-eluting stents.

BACKGROUND: Diabetics who undergo percutaneous coronary intervention (PCI) are at increased risk for death, myocardial infarction, repeat revascularization, and stent thrombosis. METHODS: Our retrospective study includes 887 consecutive patients who underwent PCI with drug-eluting stents (DES) at UCLA Medical Center. The cohort was divided into four groups: group 1, no diabetes and no acute coronary syndrome (ACS); group 2, no diabetes and ACS; group 3, diabetes and no ACS; group 4, diabetes and ACS. RESULTS: Survival at 1 year was the lowest in diabetics who presented with ACS (90% in diabetics with ACS, 95% in diabetics without ACS, 95% in non-diabetics with ACS, and 96% in the non-diabetics without ACS, P = 0.03). At 1 year, age, diabetes, chronic renal insufficiency, ejection fraction, and myocardial infarction were identified as independent predictors for mortality. CONCLUSION: In the DES era, diabetics who undergo PCI for ACS continue to have an excess risk of death and major adverse cardiac events at 1 year.

Clinical presentation of patients with in-stent restenosis in the drug-eluting stent era.

BACKGROUND: Drug-eluting stents (DES) represent a significant improvement in the treatment of coronary artery disease as they decrease restenosis rates by approximately 50% compared with bare-metal stents. In-stent restenosis (ISR) is perceived to be a benign phenomenon because it is a gradual process and may lead to angina pectoris. With bare-metal stents, ISR has been associated with myocardial infarction in approximately 10% to 15% of cases. Comparable data with DES are lacking. METHODS: From April 2003 to December 2005, 42 out of 889 patients (4.7%) with DES ISR were identified at our institution. We excluded 3 orthotopic heart transplant patients who had ISR. Therefore, the final analysis included 39 patients. RESULTS: The mean age was 66 +/- 10 years, 77% were male, and 33% were diabetic. A mean of 1.8 +/- 0.9 stents were implanted with a total stent length of 39 +/- 24 mm. The mean time from percutaneous coronary intervention to detection of ISR was 396 +/- 290 days. At a mean from follow up of 35 +/- 10 months, 8% were asymptomatic, 77% presented with angina pectoris, 5% with unstable angina, and 10% with non-ST-segment elevation myocardial infarction. CONCLUSIONS: In the DES era, although most patients with ISR have stable symptoms, myocardial infarction occurred in 10%, suggesting that ISR is not a benign clinical entity. DES with improved designs or drug elution systems that further decrease the incidence of ISR are needed.

Outcomes of nonagenarians who undergo percutaneous coronary intervention with drug-eluting stents.

BACKGROUND: Age is an important predictor of mortality after percutaneous coronary intervention (PCI). The safety and efficacy of PCI with drug-eluting stents (DES) in nonagenarians have not been extensively studied. METHODS: A retrospective analysis of 889 consecutive patients identified 28 (3.1%) nonagenarians who underwent PCI with DES from May 2003 to December 2005 at our institution. RESULTS: The mean age was 92 +/- 2 years, 39% were male, and 4% were diabetic. Sirolimus-eluting stents were used in 79%. A mean of 1.5 +/- 0.9 stents/patient were implanted with a total stent length of 31 +/- 20 mm. Twenty-nine percent presented with unstable angina and 39% with myocardial infarction. The angiographic success rate obtained was 100%. The 30-day mortality rate was 21%. The 6 patients who died within 30 days included 3 patients who had cardiogenic shock and one patient with critical aortic stenosis who died due to complications during percutaneous aortic valvuloplasty. The cumulative survival rate for all nonagenarians at 1 year and 3 years was (68 +/- 9)% and (61 +/- 9)%. When the four patients who were in extremis on presentation were excluded, there were no in-hospital deaths, the 30-day mortality was 8%, and the 1 year and 3 year survival rate was (79 +/- 8)% and (71 +/- 9)% for the nonagenarians. No patient had definite stent thrombosis. CONCLUSIONS: The majority of the nonagenarians who underwent PCI with DES presented with acute coronary syndrome. Percutaneous coronary intervention with DES was safe in nonagenarians as there were no in-hospital deaths and acceptable 3-year survival rates when patients who were in extremis on presentation were excluded. The high-risk profile of these patients and the expected attrition of nonagenarians may contribute to their mortality rates.

Comparison of bypass surgery with drug-eluting stents for diabetic patients with multivessel disease.

BACKGROUND: This retrospective study of prospectively collected data compared coronary artery bypass graft (CABG) surgery to drug-eluting stenting (DES) in diabetic patients with multivessel coronary artery disease (CAD). Prior randomized trials and clinical studies have suggested that CABG may be the preferred revascularization strategy in diabetic patients with multivessel CAD. Data are limited regarding the impact of DES vs. CABG on clinical outcomes. METHODS: We included 205 consecutive diabetic patients who underwent either CABG (n=103) or DES (n=102). The primary clinical end points were freedom from major adverse cardiac events (MACE) at 30 days and 1 year. RESULTS: Baseline characteristics were similar between both groups. At 1 year, the mortality rate was similar in the CABG and DES group (8% vs. 10%, p=0.6) but the MACE rate was lower in the CABG group (12% vs. 27%, p=0.006) due to less repeat revascularization with CABG (3% vs. 20%, p<0.001). Stroke occurred only in the CABG group (4% vs. 0%, p=0.04). Angiographically-documented stent thrombosis after DES occurred in 3%. Presentation with acute myocardial infarction (hazard ratio [HR], 2.26, 95% CI, 1.13 to 4.55) and DES (HR, 2.4, 95% CI, 1.23 to 4.77) were positive independent predictors, whereas therapy with a statin was a negative independent predictor of MACE (HR, 0.40, 95% CI, 0.21 to 0.76). CONCLUSIONS: Bypass surgery was associated with less MACE primarily due to the higher repeat revascularization rate with DES and is therefore superior to DES despite more extensive CAD in CABG patients.