Mortality of patients with ST-segment-elevation myocardial infarction without standard modifiable risk factors among patients without known coronary artery disease: Age-stratified and sex-related analysis from nationwide readmissions database 2010-2014.

Objective: The proportion of ST-segment elevation myocardial infarction (STEMI) patients without standard modifiable risk factors (SMuRFs: hypertension, diabetes, hypercholesterolemia and smoking) has increased over time. The absence of SMuRFs is known to be associated with worse outcomes, but its association with age and sex is uncertain. We sought to evaluate the association between age and sex with the outcomes of post-STEMI patients without SMuRFs among patients without preexisting coronary artery disease. Methods: Patients who underwent primary PCI for STEMI were identified from the Nationwide Readmission Database of the United States. Clinical characteristics, in-hospital, and 30-day outcomes in patients with or without SMuRFs were compared in men versus women and stratified into five age groups. Results: Between January 2010 and November 2014, of 474,234 patients who underwent primary PCI for STEMI, 52,242 (11.0%) patients did not have SMuRFs. Patients without SMuRFs had higher in-hospital mortality rates than those with SMuRFs. Among those without SMuRFs, the in-hospital mortality rate was significantly higher in women than men (10.6% vs 7.3%, p<0.001), particularly in older age groups. The absence of SMuRFs was associated with higher 30-day readmission-related mortality rates (0.5% vs 0.3% with SMuRFs, p<0.001). Among patients without SMuRFs, women had a higher 30-day readmission-related mortality rates than men (0.6% vs 0.4%, p<0.001). After multivariable adjustment, the increased rates of in-hospital (odds ratio 1.89 (95% CI 1.72 to 2.07) and 30-day readmission-related mortality (hazard ratio 1.30 (95% CI 1.01 to 1.67)) in patients without SMuRFs remained significant. Conclusions: STEMI patients without SMuRFs have a significantly higher risk of in-hospital and 30-day mortality than those with SMuRFs. Women and older patients without SMuRFs experienced significantly higher in-hospital and 30-day readmission-related mortality.

Sex-Based Differences in 30-Day Readmissions After Cardiac Arrest: Analysis of the Nationwide Readmissions Database.

Background There are limited data on the sex-based differences in the outcome of readmission after cardiac arrest. Methods and Results Using the Nationwide Readmissions Database, we analyzed patients hospitalized with cardiac arrest between 2010 and 2015. Based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, we identified comorbidities, therapeutic interventions, and outcomes. Multivariable logistic regression was performed to assess the independent association between sex and outcomes. Of 835 894 patients, 44.4% (n=371 455) were women, of whom 80.7% presented with pulseless electrical activity (PEA)/asystole. Women primarily presented with PEA/asystole (80.7% versus 72.4%) and had a greater comorbidity burden than men, as assessed using the Elixhauser Comorbidity Score. Thirty-day readmission rates were higher in women than men in both PEA/asystole (20.8% versus 19.6%) and ventricular tachycardia/ventricular fibrillation arrests (19.4% versus 17.1%). Among ventricular tachycardia/ventricular fibrillation arrest survivors, women were more likely than men to be readmitted because of noncardiac causes, predominantly infectious, respiratory, and gastrointestinal illnesses. Among PEA/asystole survivors, women were at higher risk for all-cause (adjusted odds ratio [aOR], 1.07; [95% CI, 1.03-1.11]), cardiac-cause (aOR, 1.15; [95% CI, 1.06-1.25]), and noncardiac-cause (aOR, 1.13; [95% CI, 1.04-1.22]) readmission. During the index hospitalization, women were less likely than men to receive therapeutic procedures, including coronary angiography and targeted therapeutic management. While the crude case fatality rate was higher in women, in both ventricular tachycardia/ventricular fibrillation (51.8% versus 47.4%) and PEA/asystole (69.3% versus 68.5%) arrests, sex was not independently associated with increased crude case fatality after adjusting for differences in baseline characteristics. Conclusions Women are at increased risk of readmission following cardiac arrest, independent of comorbidities and therapeutic interventions.

Sex-Based Disparities in Outcomes With Abdominal Aortic Aneurysms.

Although abdominal aortic aneurysms (AAA) are more common in men, women with AAA have increased morbidity and mortality. Additionally, there are discrepancies among professional society guidelines for AAA screening in women. In this retrospective study from the Nationwide Inpatient Sample (NIS) database from 2003 to 2014, we compared rates of AAA repair (rupture and elective) and AAA-related mortality in men vs. women to identify predictors of death among men and women with AAA. We divided the population into 1) AAA rupture 2) elective AAA repair. The main outcomes included temporal trends in AAA rupture, rupture-related death, AAA repair, in-hospital death, and predictors of AAA-related death. There were 570,253 discharge records for AAA admissions between 2003 and 2014, including 22.8% women and 77.2% men. Women had a higher proportion of rupture (18.4% vs 12.6%, p <0.01). A smaller proportion of women underwent endovascular aortic repair (EVAR) compared with men in the ruptured AAA (13.9% vs. 20.3%, p <0.01) and elective repair (55.7% vs. 67.4%, p <0.01) cohorts. Within the ruptured cohort, a higher proportion of women did not receive repair (46.4% vs. 26.1%, p <0.01). On multivariable analysis, female gender was a significant predictor of death with rupture (OR 1.39, 95% CI 1.16 to 1.66) and elective repair (OR 1.74, 95% CI 1.36 to 2.22), with both elective EVAR (OR 2.52, 95% CI 2.06 to 3.09) and elective open aortic repair (OAR; OR 1.50, 95% CI 1.33 to 1.68). Propensity score matching confirmed a higher risk of death in women in both the rupture (OR 1.19, 95% CI 1.09 to 1.30) and elective repair (OR 1.50, 95% CI 1.35 to 1.67) cohorts. In conclusion, AAA poses significant morbidity and mortality, especially in women. Women were more likely to die before repair with AAA rupture and female gender was an independent predictor of mortality in both the rupture and elective repair groups.

Sex-Based Differences in Revascularization and 30-Day Readmission After ST-Segment-Elevation Myocardial Infarction in the United States.

BACKGROUND: Cardiovascular disease is the leading cause of death for women in the United States. Revascularization is considered the standard of care for treatment of ST-segment elevation myocardial infarction (STEMI) and is known to reduce readmission. However there is a paucity of data that examines the sex-dependent impact of revascularization on readmission. We aimed to investigate sex differences in revascularization rates, 30-day readmission rates, and primary cause of readmissions following STEMIs. METHODS: STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. Revascularization rates, 30-day readmission rates, and primary cause of readmission were examined. Interaction between sex and revascularization was assessed. Multivariable regression analysis was performed to identify predictors of 30-day readmission and revascularization for both sexes. RESULTS: 219,944 women and 489,605 men were admitted with STEMIs. Women were more likely to be older, and have more comorbidities. Women were less likely to undergo revascularization by percutaneous coronary intervention (adjusted odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.66-0.70) or coronary artery bypass graft surgery (adjusted OR 0.40; CI 0.39-0.44). Women had higher 30-day readmission rates (15.7% vs. 10.8%, p < 0.001; OR 1.20, CI 1.17-1.23), and revascularization in women was not associated with a decreased likelihood of 30-day readmission. The primary cardiac cause of readmission in women was heart failure. CONCLUSION: Compared to men, women with STEMIs had lower rates of revascularization and higher rates of 30-day readmission. When revascularized, women were still more likely to be readmitted as compared to non-revascularized women.

Incidental Coronary Artery Calcium on Breast Radiation Therapy Planning Scans Identifies Patients for Cardiac Preventive Therapy.

PURPOSE/OBJECTIVE(S): The presence of coronary artery calcium (CAC>0) is associated with increased cardiac-related mortality and is a common indication to initiate statin therapy to prevent future long-term cardiac-related adverse events. CAC is also well visualized on noncontrast chest computed tomography simulation (CT sim) scans used for breast radiation planning. We hypothesize that by screening for incidental CAC on CT sims, radiation oncologists could help identify patients who may benefit from additional preventive medical interventions with their primary care physician or cardiologist. METHODS: A retrospective analysis of 126 consecutive patients with breast cancer treated with external beam radiation therapy at a single institution was performed. Noncontrast CT sim scans were reviewed for the presence of CAC and the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) was calculated to identify patients who may benefit from initiating statin therapy. Patients with CAC>0 and/or ASCVD risk >20% were identified as those who may benefit from statin therapy. RESULTS: Out of 72 patients with CAC>0, only 12(16%) had reported pre-existing coronary artery disease and 32(44%) were not already on recommended statin therapy. CAC>0 visualized on CT sim was able to identify 29 additional patients who would benefit from statin beyond what the ASCVD risk calculator could identify. CONCLUSION: Observation of incidental CAC on breast radiation-planning CT scans identified patients who could benefit from cardiac-related preventive strategies. By increasing attention, awareness, and reporting of incidental CAC visible on CT sims, radiation oncologists may fulfill a unique role to bridge a potential gap in cardiovascular preventive medicine.

Obstetrical Complications and Long-Term Cardiovascular Outcomes.

PURPOSE OF REVIEW: Obstetrical complications including indicated preterm birth (PTB), hypertension (HTN), IUGR, and GDM are risk factors for future cardiovascular disease. To identify patients at risk, the American Heart Association recommends obtaining a detailed obstetric history. Our objective was to determine if non-OB-GYN physicians-in-training obtain an obstetric history when assessing a risk profile for cardiovascular disease and to identify differences based on level of training. In 2019, an anonymous survey was distributed to trainees in internal medicine, cardiology, endocrinology, nephrology, and neurology. Subjects were queried about frequency of asking a history of PTB, IUGR, GDM, and HTN in pregnancy. Survey options were always/frequently/sometimes/rarely/never and were categorized into two groups: "ask" (always/frequently/sometimes) vs. "do not ask" (rarely/never). Comparisons between specialties and levels of training were made using chi-square and Fisher's exact test. Comparisons within subjects were made using McNemar's test. RECENT FINDINGS: The response rate was 64% (210 total possible participants), including 98 internal medicine residents and 37 fellows in cardiology (21), endocrinology (3), nephrology (8), and neurology (5). Asking about medical complications (HTN + GDM) was significantly more common than asking about OB complications (PTB + IUGR) (p < 0.001). Internal medicine residents were less likely than subspecialty fellows to ask about HTN (31% vs. 70%; p < 0.001). There were no differences in likelihood of eliciting OB history based on PGY level. An OB history can identify risk factors for cardiovascular morbidity. Our data demonstrates that physicians caring for women lack awareness on the association between complications in pregnancy and cardiovascular health.

Impact Of Cirrhosis On 90-Day Outcomes After Percutaneous Coronary Intervention (from A Nationwide Database).

Patients with cirrhosis often have concomitant coronary artery disease and require percutaneous coronary intervention (PCI). PCI in cirrhotics can be associated with significant risks due to thrombocytopenia, possible coagulopathies, bleeding, and renal failure. Longer term risks of PCI in cirrhotics have not been well studied. Our study seeks to evaluate the 90-day outcomes of PCI in patients with cirrhosis. Patients receiving PCI were identified from the Nationwide Readmissions Database from 2010 to 2014 and stratified by the presence of co-morbid cirrhosis. The total mortality during index admission and 90-day readmissions as well as the readmissions rate were examined. Adverse events including bleeding, stroke, kidney injury, and vascular complications were also compared. Patients with cirrhosis had a significantly higher number of co-morbidities. The cirrhosis group had a higher overall 90-day mortality (10.3% vs 2.5%, p < 0.01), including during the index hospitalization (7.0% vs 1.8%, p < 0.01), as well as a higher 90-day readmission rate (38.2% vs 20.2%, p < 0.01). Patients with cirrhosis also had higher frequencies of overall 90-day adverse events (44.7% vs 17.7%, p < 0.01), including gastrointestinal bleeding (15.3% vs 2.7%, p < 0.01) and acute kidney injury (28.4% vs 10.1%, p < 0.01). In conclusion, patients with cirrhosis face a significantly higher risk of adverse outcomes including mortality, readmissions, and adverse events in the 90 days after hospitalization for PCI compared with the general population.

Cardiac Monitoring for Thoracic Radiation Therapy: Survey of Practice Patterns in the United States.

OBJECTIVE: The American Society of Clinical Oncology (ASCO) 2017 guidelines on cardiac monitoring during cancer treatments identified patients receiving thoracic radiation (TRT) ≥30 Gy (heart in field) at increased risk for developing radiation-induced heart disease (RIHD). ASCO encouraged clinicians to actively screen and monitor for baseline modifiable cardiac risk factors and therapy-induced cardiotoxicity in this high-risk population. Coronary artery calcium (CAC) is an independent risk factor for adverse cardiac events that can be mitigated with preventative medical therapy. It is unclear whether radiation oncologists (ROs) are aware of ASCO guidelines or the implications of CAC observed on computed tomographic scans. We report on practice patterns, perceptions, and experiences of cardiac monitoring for patients receiving definitive TRT, excluding breast patients. MATERIALS AND METHODS: A 28-question survey was emailed to United States ROs 3 times from September 2018 to January 2019. RESULTS: There were 162 respondents from 42 states, 51% in academic practice. Most ROs (81%) were not aware of the ASCO guidelines. Only 24% agreed with the guidelines, only 27% believed symptomatic RIHD could manifest within 2 years of TRT, and 69% thought there was a lack of strong evidence for type and timing of cardiac monitoring tests. If CAC was evident on computed tomographic scans, 40% took no further action to inform the patient or referring doctor. CONCLUSIONS: This survey highlights a critical gap in knowledge about cardiac monitoring and potentially life-saving opportunities for preventive cardiac medical management. Future studies focusing on timing and detection of RIHD may elucidate the utility of cardiac monitoring for TRT patients.

Angina pectoris worsened by mouthwash.

We report a case of variant (Prinzmetal's) angina pectoris in a 51-year-old man in whom coronary angiography revealed sluggish flow of contrast material. His chest pain was not controlled with standard antianginal therapy, but it resolved after discontinuation of mouthwash. This is the first case of angina pectoris reported that vastly improved after discontinuation of mouthwash.

Breast Arterial Calcium: A Game Changer in Women's Cardiovascular Health?

In 2018, cardiovascular disease (CVD) was the leading cause of death among women, and current CVD prevention paradigms may not be sufficient in this group. In that context, it has recently been proposed that detection of calcification in breast arteries may help improve CVD risk screening and assessment in apparently healthy women. This review provides an overview of breast arterial anatomy; and the epidemiology, pathophysiology, and measurement of breast artery calcium (BAC); and discusses the features of the BAC-CVD link. The potential clinical applications that BAC may offer for CVD prevention in the context of current clinical practice guidelines and recommendations are also discussed. Finally, current gaps in evidence gaps are outlined, and future directions in the field are explored with a focus on the implementation of BAC mammography as a CVD risk-screening tool in routine clinical practice.

Headed in the right direction but at risk for miscalculation: a critical appraisal of the 2013 ACC/AHA risk assessment guidelines.

The newly released 2013 ACC/AHA Guidelines for Assessing Cardiovascular Risk makes progress compared with previous cardiovascular risk assessment algorithms. For example, the new focus on total atherosclerotic cardiovascular diseases (ASCVD) is now inclusive of stroke in addition to hard coronary events, and there are now separate equations to facilitate estimation of risk in non-Hispanic white and black individuals and separate equations for women. Physicians may now estimate lifetime risk in addition to 10-year risk. Despite this progress, the new risk equations do not appear to lead to significantly better discrimination than older models. Because the exact same risk factors are incorporated, using the new risk estimators may lead to inaccurate assessment of atherosclerotic cardiovascular risk in special groups such as younger individuals with unique ASCVD risk factors. In general, there appears to be an overestimation of risk when applied to modern populations with greater use of preventive therapy, although the magnitude of overestimation remains unclear. Because absolute risk estimates are directly used for treatment decisions in the new cholesterol guidelines, these issues could result in overuse of pharmacologic management. The guidelines could provide clearer direction on which individuals would benefit from additional testing, such as coronary calcium scores, for more personalized preventive therapies. We applaud the advances of these new guidelines, and we aim to critically appraise the applicability of the risk assessment tools so that future iterations of the estimators can be improved to more accurately assess risk in individual patients.

The prevalence of anxiety and depression in adults with implantable cardioverter defibrillators: a systematic review.

OBJECTIVE: The implantable cardioverter defibrillator (ICD) is used to treat life-threatening ventricular arrhythmias and in the prevention of sudden cardiac death. A significant proportion of ICD patients experience psychological symptoms including anxiety, depression or both, which in turn can impact adjustment to the device. The objective of this systematic review was to assess the prevalence of anxiety and depression or symptoms of anxiety and depression among adults with ICDs. METHODS: Search of MEDLINE®, CINAHL®, PsycINFO®, EMBASE® and Cochrane® for English-language articles published through 2009 that used validated diagnostic interviews to diagnose anxiety or depression or self-report questionnaires to assess symptoms of anxiety or depression in adults with an ICD. RESULTS: Forty-five studies that assessed over 5000 patients were included. Between 11% and 28% of patients had a depressive disorder and 11-26% had an anxiety disorder in 3 small studies (Ns=35-90) that used validated diagnostic interviews. Rates of elevated symptoms of anxiety (8-63%) and depression (5-41%) based on self-report questionnaires ranged widely across studies and times of assessment. Evidence was inconsistent on rates pre- versus post-implantation, rates over time, rates for primary versus secondary prevention, and for shocked versus non-shocked patients. CONCLUSION: Larger studies utilizing structured interviews are needed to determine the prevalence of anxiety and depression among ICD patients and factors that may influence rates of anxiety and depressive disorders. Based on existing data, it may be appropriate to assume a 20% prevalence rate for both depressive and anxiety disorders post-ICD implant, a rate similar to that in other cardiac populations.

Chylous ascites following retroperitoneal lymphadenectomy for testes cancer.

BACKGROUND: A 31-year-old man underwent a radical orchiectomy for a stage I mixed germ-cell tumor with angiolymphatic invasion. A subsequent laparoscopic retroperitoneal lymphadenectomy was complicated by a laceration to the aorta at the ostia of the more inferior of two right renal arteries. This was repaired following conversion to an open laparotomy. The patient presented 14 days later with genital swelling and increasing abdominal girth. INVESTIGATIONS: Physical examination, abdominal and pelvic CT, laboratory albumin testing, lymphoscintogram and lymphangiogram. DIAGNOSIS: Chylous ascites with tracking of lymphatic fluid into the left groin through a defect in the internal inguinal ring. MANAGEMENT: Conservative management with salt restriction, a medium-chain fatty-acid diet and diuretics; exploratory laparoscopy, during which a small left inguinal hernia was repaired and chylous fluid was drained. Following further leakage, the patient was placed on total parenteral nutrition, followed by image-guided sclerotherapy with doxycycline.

Evolutionary changes in the cochlea and labyrinth: Solving the problem of sound transmission to the balance organs of the inner ear.

This review article examines the evolutionary adaptations in the vertebrate inner ear that allow selective activation of auditory or vestibular hair cells, although both are housed in the same bony capsule. The problem of separating acoustic stimuli from the vestibular end organs in the inner ear has recently reemerged with the recognition of clinical conditions such as superior canal dehiscence syndrome and enlarged vestibular aqueduct syndrome. In these syndromes, anatomical defects in the otic capsule alter the functional separation of auditory and vestibular stimuli and lead to pathological activation of vestibular reflexes in response to sound. This review demonstrates that while the pars superior of the labyrinth (utricle and semicircular canals) has remained fairly constant throughout evolution, the pars inferior (saccule and other otolith, macular, and auditory end organs) has seen considerable change as many adaptations were made for the development of auditory function. Among these were a relatively rigid membranous labyrinth wall, a variably rigid otic capsule, immersion of the membranous labyrinth in perilymph, a perilymphatic duct to channel acoustic pressure changes away from the vestibular organs, and different operating frequencies for vestibular versus auditory epithelia. Even in normal human ears, acoustic sensitivity of the labyrinth to loud clicks or tones is retained enough to be measured in a standard clinical test, the vestibular-evoked myogenic potential test.

Phosphorylation Activity in the Alzheimer's Disease and Normal Brain is Modulated by Microtubule-Associated Protein, Tau in Vitro.

One of the hallmarks of Alzheimer's Disease is the presence of abundant neurofibrillary tangles (NFTs) in the brains of affected individuals. Hyperphosphorylated tau is a major component of paired helical filaments (PHFs) in NFTs. Tau is a neuronal microtubule associated protein found primarily in axons. Normal tau promotes tubulin polymerization and stabilizes microtubule (MT) structures, whereas hyperphosphorylated tau reduces its affinity for MTs and destabilizes MT-structures. This results in the disruption of vital cellular processes (e.g. axonal transport) and leads to the degeneration of affected neurons. Processes leading to the hyperphosphorylation of tau and formation of neurofibrillary lesions in Alzheimer's Disease (AD) brains are not understood. Phosphorylation of a substrate molecule like tau depends upon the equilibrium between kinase and phosphatase activities and the availability of their substrate molecules in a given system. Therefore, to understand the relative roles of kinase and phosphatase activities, we studied the long-term kinetics of phosphorylation in AD and control brain extracts in the presence and absence of the phosphatase inhibitor okadaic acid (OA) using histone, casein and bacterially expressed tau as exogenous substrates. It was found that both kinase and phosphatase activities were higher in AD compared to control brains. Surprisingly, between 18 and 24 hours, there was a robust increase in phosphorylation of endogenous proteins in the brain extracts only when bacterially expressed tau was present in the phosphorylation reaction mixture. This pattern of phosphorylation activity was unaffected by OA. Significant difference in the phosphorylation of tau isoforms was also seen during this period. These data suggest that the expression and differential phosphorylation of certain tau isoforms may be responsible for the robust increase in phosphorylation and may play an important role in Alzheimer's pathology.