Association Between Psychosocial Risk Factors and Readmissions After Acute Myocardial Infarction: Role of COVID-19 Pandemic.

Psychosocial risk factors (PSRFs) are known to be associated with worse cardiovascular (CV) outcomes. However, there are limited data on the impact of PSRFs on readmissions after acute myocardial infarction (AMI) before and during the COVID-19 (Coronavirus Disease 2019) pandemic. Therefore, we aimed to examine this association and whether the effects of PSRFs were amplified during the COVID-19 pandemic. We queried the 2019 and 2020 Nationwide Readmissions Database for adult (age ≥18 years) index admissions with AMI as the primary diagnosis. They were then divided into 2 cohorts based on the presence or absence of ≥1 PSRF and compared across non-COVID-19 (2019) and COVID-19 (2020) time periods. The primary outcome was 30-day all-cause readmissions. Secondary outcomes included cause-specific readmissions (cardiac, noncardiac, AMI, heart failure). Multivariable hierarchical logistic regression was conducted to evaluate differences in outcomes. The study included 380,820 patients with index AMI, of which 214,384 (56%) had ≥1 PSRFs. Patients with PSRFs were younger, more likely to be female, and had a higher prevalence of CV risk factors. Of 30-day all-cause readmissions were higher in patients with PSRFs in both eras. Moreover, noncardiac and heart failure readmissions were also higher in patients with PSRFs admitted with AMI in 2019 and 2020. This study of a nationally representative population magnifies the association of PSRF with more unplanned readmissions after AMI in both pre-COVID-19 and COVID-19 times.

Association of Psychosocial Risk Factors and Outcomes in Heart Failure: Does COVID-19 Affect Outcomes?

Psychosocial risk factors (PSRFs) have emerged as crucial nontraditional risk factors affecting outcomes in patients with heart failure (HF). There is a paucity of data studying these risk factors in HF nationally. Additionally, whether the COVID-19 pandemic impacted outcomes remains unexplored, given the increased psychosocial risk during these times. Our objective is to assess the impact of PSRFs on the outcomes of HF and their comparison across non-COVID-19 and COVID-19 eras. Patients with a diagnosis of HF were selected using the 2019-2020 Nationwide Readmissions Database. Two cohorts were created based on the presence or absence of PSRFs and compared across non-COVID-19 and COVID-19 eras. We examined the association using hierarchical multivariable logistic regression models. A total of 305,955 patients were included, of which 175,348 (57%) had PSRFs. Patients with PSRFs were younger, less likely to be female, and had a higher prevalence of cardiovascular risk factors. All-cause readmissions were higher in patients with PSRFs in both the eras. All-cause mortality [odds ratio, OR 1.15 (1.04-1.27), P = 0.005] and composite of MACE [OR 1.11 (1.06-1.16), P < 0.001] were higher in patients in the non-COVID-19 era. Compared to 2019, patients with PSRFs and HF in 2020 had significantly higher all-cause mortality [OR 1.13 (1.03-1.24), P = 0.009]; however, the composite of MACE was comparable [OR 1.04 (1.00-1.09), P = 0.03]. In conclusion, the presence of PSRFs in patients with HF is associated with a significant increase in all-cause readmissions in COVID-19 and non-COVID-19 eras. The worse outcomes evident in the COVID-19 era highlights the importance of multidisciplinary care in this vulnerable population.

Utility of cardiac bioenzymes in predicting cardiovascular outcomes in SARS-CoV-2.

BACKGROUND: Cardiovascular complications have been increasingly recognized in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated coronavirus disease 2019 (COVID-19). Cardiac biomarkers are released because of this ongoing cardiovascular injury and can act as surrogate markers to assess the disease severity. AIM: To review the variation and utility of these biomarkers in COVID-19 to ascertain their role in diagnosis, prognosis and clinical outcomes of the disease. METHODS: We performed a literature search in PubMed, Medline and the Reference Citation Analysis (RCA), using the search terms "COVID-19" and "cardiac bioenzymes" or "cardiac biomarkers". Additionally, we also used the latest reference citation analysis tool to identify more articles. RESULTS: Cardiac troponin has been consistently elevated in patients with COVID-19 associated myocarditis, and strongly correlated with adverse prognosis. Natri-uretic peptides including brain natriuretic peptide (BNP) and pro-BNP is elevated in patients with COVID-19 associated cardiac injury, irrespective of their prior heart failure status, and independently correlated with worst outcomes. Alongside these traditional biomarkers, novel cardiac bioenzymes including presepsin, soluble ST2 and copeptin, are also increasingly recognized as markers of cardiovascular injury in COVID-19 and can be associated with poor outcomes. CONCLUSION: Assessment of cardiac bioenzymes at admission and their serial monitoring can help assess the severity of disease and predict mortality in patients with SARS-CoV-2 infection. Future studies are needed to elude the critical importance of novel biomarkers.

Predictors and Rate of Progression of Aortic Root and Ascending Aorta Dilatation.

In the absence of risk factors like bicuspid aortic valve, connective tissue disorder, or family history of aortic dissections, degenerative thoracic aortic aneurysm appears to be an indolent disease. Most American and European societies recommend yearly or biannual imaging of the thoracic aorta with computed tomographic (CT) imaging, magnetic resonance (MRI) imaging, and transthoracic echocardiographic (TTE) examination. We aimed to identify the rate of progression and predictors of early degenerative aortic root dilatation (ARD) and ascending aortic dilatation (AAD) over a period of 10 years on the basis of echocardiographic measurements. A retrospective chart analysis was performed on 340 patients (mean age 67.4 ± 11.6 years; 85.6% men; 83.8% White) with known ARD and AAD. Aortic root and ascending aorta measurements were followed by serial echocardiograms from the time of the first diagnosis for a total of 10 years. During this time, the mean change in ARD was 0.28 ± 0.71 mm and AAD was 0.15 ± 0.18 mm. On multivariate regression after adjusting for baseline demographics, risk factors, and medication use, there was no statistically significant increase in their unit change in mean ARD or AAD. In conclusion, mild to moderate degenerative thoracic aortic aneurysm has a minimal change in dimensions over time, and current guidelines recommending yearly surveillance imaging of ARD and AAD need to be revisited to allow a more liberal follow-up interval.

Disparities in Cardio-oncology: Effects On Outcomes and Opportunities for Improvement.

PURPOSE OF REVIEW: The purpose of this article is to provide a comprehensive review of available data on health disparities and the interconnected social determinants of health (SDOH) in cardio-oncology. We identify the gaps in the literature and suggest areas for future research. In addition, we propose strategies to address these disparities at various levels. RECENT FINDINGS: There has been increasing recognition of health disparities and the role of SODH on an individual's access to health care, quality of care, and outcomes of the illness. There is growing evidence of sex and race-based differences in cancer therapy-related cardiotoxicity. Recent studies have shown how access and quality of health care are affected by financial stability and rurality. Our recent study utilizing the social vulnerability index (SVI) and county-level patient data found graded increase in county-level cardio-oncology mortality with greater social vulnerability. The incremental impact of social vulnerability was higher for cardio-oncology mortality than for mortality related to either cancer or CVD alone. The mortality rates in these patients were higher in rural areas compared to urban areas regardless of social vulnerability. Additionally, for those within the counties within highest social vulnerability, Black individuals had significantly higher cardio-oncology mortality compared with White individuals. Disparities in the cardio-oncology population are deep-rooted and widespread, leading to poor quality of life and increased mortality. It is crucial to integrate SDOH, not only in clinical care delivery but also in future research, and registry data to improve our understanding and the outcomes in our unique subset of cardio-oncology patients.

Mortality in Stable Coronary Disease in Patients With Intermediate- or High-Risk Myocardial Perfusion Imaging.

The management of patients with stable coronary disease and intermediate- or high-risk features on single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) continues to be controversial as to whether they should be treated with an initial invasive strategy (catheterization and revascularization when feasible) or medical therapy alone to improve mortality. We performed a retrospective observational study of 1,946 patients with intermediate- or high-risk SPECT MPI scans performed over a 6-year period (from 2014 to 2019). Each patient was followed from the time of SPECT MPI to 16 months after the last patient was enrolled. The primary end point was all-cause mortality and the secondary end point cardiovascular mortality. Of the eligible 1,697 patients, 1,144 had an intermediate-risk scan, 553 a high-risk scan, 915 had medical therapy alone, and 782 went on an initial invasive strategy. All patients were divided into the following three groups: combined SPECT MPI (both intermediate- and high-risk), high-risk SPECT MPI, and intermediate-risk SPECT MPI groups. After propensity score matching, there was a statistically significant difference in cardiovascular death (5.9% vs 2.7%; p = 0.038) in the medical therapy cohort compared with initial invasive cohort in the combined SPECT MPI group, but no difference in all-cause death (15.7% vs 13%; p = 0.318). On subgroup analysis, in intermediate-risk SPECT MPI group, there was no significant difference in either all-cause death (13.8 vs 11.7%; p = 0.583) or cardiac death (5.4% vs 2.5%; p = 0.16) in conservative cohort compared with invasive strategy cohort. In high-risk SPECT MPI group, conservative therapy cohort had higher cardiac death (11.7% vs 2.5%; p = 0.002) compared with initial invasive strategy cohort, but there was no significant difference in all-cause death (24.5% vs 15.3%; p = 0.052). In conclusion, this study supports that patients with intermediate- or high-risk SPECT MPI scans when considered together or only with high-risk features, derive a cardiovascular mortality benefit with an initial invasive strategy. Patients who had undergone intermediate-risk SPECT MPI had similar outcomes with either medical therapy alone or initial invasive evaluation.

Abdomino-anal Dyscoordination in Defecatory Disorders.

BACKGROUND & AIMS: The contribution of the abdominal muscles to normal defecation and disturbances thereof in defecatory disorders (DDs) are unknown. METHODS: In 30 healthy and 60 constipated women with normal rectal balloon expulsion time (BET) (n = 26) or prolonged BET (ie, DD; n = 34), seated anorectal pressures (manometry) and thickness (ultrasound) of the external and internal oblique and transversus abdominis muscles were measured simultaneously at rest, during hollowing, squeeze, evacuation, and a Valsalva maneuver. RESULTS: Compared with healthy women with a normal BET, DD women had a lower rectal and greater anal pressure increase during evacuation (P ≤ .05), and more activation of the internal oblique and the transversus abdominis muscles during squeeze (P < .05). The change in transversus abdominis thickness during a Valsalva maneuver vs hollowing (rho = 0.5; P = .002) and separately vs evacuation (rho = 0.7; P < .0001) were correlated in DD but not in healthy women with a normal BET. A principal component (PC) analysis of anorectal pressures and muscle thicknesses during evacuation uncovered a PC (PC3) that was associated with a prolonged BET. Higher PC3 scores were associated with low rectal and high anal pressures at rest and during evacuation, thinner external oblique muscle, and thicker internal oblique muscle during evacuation. A greater PC3 score was associated with increased odds for DD vs health (odds ratio, 1.84; 95% CI, 1.05-3.23), and separately vs constipation with a normal BET (odds ratio, 3.64; 95% CI, 1.73-7.69). CONCLUSIONS: Taken together, these findings show 3, possibly inter-related, disturbances suggestive of dyscoordination in DD: aberrant activation of abdominal muscles during squeeze in DD, dyscoordination of the abdominal muscles during various tasks in constipated women, and abdomino-anal dyscoordination.

Improving the utility of high-resolution manometry for the diagnosis of defecatory disorders in women with chronic constipation.

BACKGROUND: We compared the utility of existing and modified versions of high-resolution manometry for diagnosing defecatory disorders (DD). METHODS: In 64 healthy and 136 constipated women, we compared left lateral (LL) and seated manometry, and analyzed with existing (ManoView™) and new methods, for discriminating between constipated patients with normal and prolonged rectal balloon expulsion time (BET). In both positions, the rectoanal gradient (RAG) and, for the new analysis, the pressure topography pattern during evacuation were used to discriminate between constipated patients without and with DD. KEY RESULTS: The BET was prolonged, suggestive of a DD, in 52 patients (38%). During evacuation, rectoanal pressures and the RAG were greater in the seated than the LL position (P≤.001). The new analysis identified 4 rectoanal pressure patterns. In the seated position, the BET was associated with the pattern (P=.0001), being prolonged in, respectively, 45%, 15%, 53%, and 0% of patients with minimal change, anal relaxation, paradoxical contraction, and transmission. Within each pattern, the RAG was greater (ie, less negative, P<.0001) in patients with a normal than a prolonged BET. Compared to the ManoView™ RAG in the LL position, the integrated analysis (ie, pattern and new RAG) in the LL position (P<.01) and the seated ManoView™ gradient (P=.02) were more effective for discriminating between constipated patients without and with DD. CONCLUSIONS & INFERENCES: Anorectal HRM ideally should be performed in the more physiological seated position and analyzed by a two-tier approach, which incorporates the overall pattern followed by the rectoanal gradient. These findings reinforce the utility of manometry for diagnosing DD.

Clinical features and disturbances of gastrointestinal transit in patients with rapid gastric emptying.

AIMS: Some patients with upper gastrointestinal symptoms have rapid gastric emptying (GE). We aimed to compare patients with normal and rapid GE and to identify phenotypes among patients with rapid GE. METHODS: Among 2798 patients who underwent GE scintigraphy, we compared patients with normal and rapid GE and separately, patients with rapid GE at 1 hour (GE1), 2 hours (GE2), or both (GE12). RESULTS: In 2798 patients, GE was normal (74%), delayed (18%), or rapid (8%). Among 211 patients with rapid GE, patterns were rapid GE1 (48%), 2 hours (17%), or 1 and 2 hours (35%); 42 (20%) had diseases that explain rapid GE. A combination of upper and lower gastrointestinal symptoms (54%) was more common that isolated upper (17%) or lower (28%) gastrointestinal symptoms (P < .001). Constipation was more prevalent in patients with rapid GE 2 (72%) than rapid GE 1 (47%) or rapid GE12 hours (67%) (P < .05). Among 179 diabetes mellitus (DM) patients, 15% had rapid GE, which was not associated with the DM phenotype. By multivariable analysis, insulin therapy (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.15-0.88), and weight loss (OR, 0.10; 95% CI, 0.01-0.78) were associated with a lower risk of rapid than normal GE in DM. CONCLUSIONS: Eight percent of patients undergoing scintigraphy had rapid GE, which is most frequently associated with upper and lower gastrointestinal symptoms; constipation is common. Insulin therapy and weight loss were associated with a lower risk of rapid than normal GE in DM patients.

Anorectal pressures measured with high-resolution manometry in healthy people-Normal values and asymptomatic pelvic floor dysfunction.

BACKGROUND: High-resolution manometry (HRM) is used to measure rectoanal pressures in defecatory disorders and fecal incontinence. This study sought to define normal values for rectoanal HRM, ascertain the effects of age and BMI on rectoanal pressures, and compare pressures in asymptomatic women with normal and prolonged balloon expulsion time (BET). METHODS: High-resolution manometry pressures and BET were measured in 163 asymptomatic healthy participants. Women (96) and men (47) with normal BET were used to estimate normal values and the effects of age/BMI on pressures using a Medtronic 4.2-mm-diameter rectoanal catheter. KEY RESULTS: Age is associated with lower resting pressure, higher rectal pressure during evacuation, and a higher rectoanal gradient during evacuation in women and men. In women, the BET is also inversely correlated with age while the BMI is correlated with a higher threshold volume for discomfort and a longer BET. The anal squeeze pressure increment, squeeze duration, and HPZ length are higher in men than women. The rectoanal gradient during evacuation is also lower (ie, more negative) in asymptomatic women with an abnormal than a normal BET. CONCLUSIONS & INFERENCES: These findings provide an expanded database of normal values for anorectal HRM in men and women. Age and sex affect anal resting and squeeze pressures, respectively; rectal pressure during evacuation is also higher in older people. Less than 15% of asymptomatic people have BET >60 seconds, which is associated with manometry features of impaired evacuation.

Effects of psychosensory stimulation on anal pressures: Effects of alfuzosin.

BACKGROUND: Our aim is to explain the lack of clarity in the ways in which anxiety and depression, which are common in defecatory disorders (DD), may contribute to the disorder. In this study, we evaluate the effects of mental stress and relaxation on anal pressures and the mechanisms thereof. METHODS: In 38 healthy women and 36 DD patients, rectoanal pressures were assessed at rest and during mental stressors (ie, word-color conflict [Stroop] and mental arithmetic tests) and mental relaxation, before and after randomization to placebo or the adrenergic α1 -antagonist alfuzosin. KEY RESULTS: During the baseline Stroop test, the anal pressure increased by 6 ± 13 mm Hg (mean ± SD, P = 0.004) in healthy women and 9 ± 10 mm Hg (P = 0.0001) in constipated women. During mental arithmetic, the anal pressure increased in healthy (4 ± 8 mm Hg, P = 0.002) and constipated women (5 ± 9 mm Hg, P = 0.004). After relaxation, anal pressure declined (P = 0.0004) by 3 ± 4 mm Hg in DD patients but not in controls. Alfuzosin reduced (P = 0.0001) anal resting pressure (by 31 ± 19 mm Hg) vs placebo (16 ± 18 mm Hg). However, during the postdrug Stroop test, anal pressure increased (P = 0.0001) in participants who received alfuzosin but not placebo. CONCLUSIONS & INFERENCES: In healthy controls and DD patients, mental stressors likely increased anal pressure by contracting the internal anal sphincter; relaxation reduced anal pressure in DD patients. Alfuzosin reduced anal resting pressure but did not block the Stroop-mediated contractile response, which suggests that this response is not entirely mediated by adrenergic α1 receptors.

Effects of Alfuzosin, an α1-Adrenergic Antagonist, on Anal Pressures and Bowel Habits in Women With and Without Defecatory Disorders.

BACKGROUND & AIMS: Some patients with defecatory disorders (DD) have high anal pressures that may impede rectal evacuation. Alpha-1 adrenoreceptors mediate as much as 50% of anal resting pressure in humans. We performed a randomized, placebo-controlled study of the effects of alfuzosin, an alpha1-adrenergic receptor antagonist, on anal pressures alone in healthy women and also on bowel symptoms in women with DD. METHODS: In a double-blind study performed from March 2013 through March 2017, anal pressures were evaluated before and after 36 women with DD (constipation for at least 1 year) and 36 healthy women (controls) were randomly assigned (1:1) to groups given oral alfuzosin (2.5 mg immediate release) or placebo. Thereafter, patients were randomly assigned (1:1) to groups given oral alfuzosin (10 mg extended release) or placebo each day for 2 weeks. Participants kept daily diaries of bowel symptoms for 2 weeks before (baseline) and during administration of the test articles (treatment). Weekly questionnaires recorded the overall severity of constipation symptoms, bloating, abdominal pain, nausea, and vomiting; overall satisfaction with treatment of constipation was evaluated at weeks 2 and 4. The primary endpoint was the change in the number of spontaneous (SBMs) and complete SBMs (CSBMs) between the treatment and baseline periods. We evaluated relationships between stool form, passage, and complete evacuation. RESULTS: Alfuzosin reduced anal resting pressure by 32 ± 3 mm Hg versus 16 ± 3 mm Hg for placebo (P = .0001) and anal pressure during evacuation by 26 ± 3 mm Hg versus 16 ± 3 mm Hg for placebo, (P = .03). However, alfuzosin did not significantly increase the rectoanal gradient, SBMs or CSBMs compared with placebo. Both formulations of alfuzosin were well tolerated. Hard stools and the ease of passage during defecation accounted for 72% and 76% of the variance in the satisfaction after defecation, respectively, during baseline and treatment periods. CONCLUSIONS: In a randomized trial, alfuzosin reduced anal pressure at rest and during simulated evacuation in healthy and constipated women, compared with placebo, but did not improve bowel symptoms in constipated women. This could be because the drug does not improve stool form or dyssynergia, which also contribute to DD. ClinicalTrials.gov number, NCT 01834729.

Intrinsic Mode Function Complexity Index Using Empirical Mode Decomposition discriminates Normal Sinus Rhythm and Atrial Fibrillation on a Single Lead ECG.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia affecting approximately 3 million Americans, and is a prognostic marker for stroke, heart failure and even death. Current techniques to discriminate normal sinus rhythm (NSR) and AF from single lead ECG suffer several limitations in terms of sensitivity and specificity using short time ECG data which distorts ECG and many are not suitable for real-time implementation. The purpose of this research was to test the feasibility of discriminating single lead ECG's with normal sinus rhythm (NSR) and AF using intrinsic mode function (IMF) complexity index. 15 sets of ECG's with NSR and AF were obtained from Physionet database. Custom MATLAB® software was written to compute IMF index for each of the data set and compared for statistical significance. The mean IMF index for NSR across 15 data sets was 0.37 ± 0.08, and the mean IMF index for ECG with AF was 0.21 ± 0.07 showing robust discrimination with statistical significance (p<0.01). IMF complexity robustly discriminates single lead ECG with normal sinus rhythm and AF. Further validation of this result is required on a larger dataset. The results also motivate the use of this technique for analysis of other complex cardiac arrhythmias such as ventricular tachycardia (VT) or ventricular fibrillation (VF).