Ultrasound-Assisted Versus Standard Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: Insights From National Inpatient Sample.

Background: Pulmonary embolism is one of the leading causes of morbidity and mortality in the United States. Catheter-directed therapies have emerged as a promising treatment for managing intermediate- and high-risk patients; however, data comparing standard catheter-directed thrombolysis (SCDT) and ultrasound-assisted thrombolysis (USAT) are limited. This study aimed to investigate trends, outcomes, and predictors of mortality of both modalities from a nationally representative sample. Methods: This analysis used data from the National Inpatient Sample years 2016-2020. The primary outcome was in-hospital mortality. A multivariable regression model was used to compare the outcomes. Results: Among 39,430 patients who received catheter-directed thrombolysis, 26,710 (76.8%) received SCDT and 8060 (23.2%) received USAT. The utilization of SCDT and USAT increased during the study years except for 2020. In-hospital mortality was lower among patients who received USAT (2.7% vs 3.8%; P = .04) compared with patients who received SCDT in the unadjusted analysis. On multivariable regression analysis, there was no difference in the incidence of in-hospital mortality between USAT and SCDT (odds ratio, 0.75; 95% CI, 0.52-1.08; P = .13). There were no significant differences between SCDT and USAT groups in the rate of bleeding adverse events including intracranial hemorrhage (0.6% vs 0.4%; P = .47), and nonintracranial major bleeding (4.2% vs 4.1%; P = .72). Conclusions: Ultrasound-assisted thrombolysis was associated with similar in-hospital mortality and bleeding complications compared with SCDT for acute pulmonary embolism. Further studies are warranted to confirm evaluate the long-term outcomes with both modalities.

Disparities by sex, race, and region in acute myocardial infarction-related outcomes during the early COVID-19 pandemic: the national inpatient sample analysis.

BACKGROUND: Disparities in acute myocardial infarction (AMI)-related outcomes have been reported before the COVID-19 pandemic. We studied in-hospital outcomes of AMI across demographic groups in the United States during the early COVID-19 pandemic. METHODS: The National Inpatient Sample (NIS) database was queried for 2020 to identify AMI-related hospitalizations based on appropriate ICD-10-CM codes categorized by sex, race, and hospital region categories. The primary outcome was in-hospital mortality in females, racial and ethnic minority groups, and Northeast hospital region compared with males, White patients, and Midwest hospital region, respectively. Multivariable regression analysis was used to calculate the adjusted odds ratio and mean difference. RESULTS: A total of 820,893 AMI-related hospitalizations were identified during the study period. On adjusted analysis, during the early COVID-19 pandemic, females had lower odds of in-hospital mortality [aOR 0.89 (0.85-0.92); P < 0.01] and revascularization [aOR 0.68 (0.66-0.69); P < 0.01] than males. Racial and ethnic based analysis showed that Asian/Pacific Islander patients had higher odds of in-hospital mortality [aOR 1.13 (1.03-1.25); P < 0.01] than White patients. During the early COVID-19 pandemic, Northeast and Western region hospitals had higher odds of in-hospital mortality, lower odds of revascularization, longer length of stay, and higher total hospitalization costs than Midwest region hospitals. CONCLUSIONS: Our study disclosed disparities in AMI-related mortality and revascularization by sex, race and ethnic, and region during the early COVID-19 pandemic. Special attention should be given to at-risk populations. Whether these disparities continue in the post-vaccination era warrants further study.

Sex and Racial Disparities in Proportionate Mortality of Premature Myocardial Infarction in the United States: 1999 to 2020.

BACKGROUND: The incidence of premature myocardial infarction (PMI) in women (<65 years and men <55 years) is increasing. We investigated proportionate mortality trends in PMI stratified by sex, race, and ethnicity. METHODS AND RESULTS: CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths within the United States between 1999 and 2020, and trends in proportionate mortality of PMI were calculated using the Joinpoint regression analysis. We identified 3 017 826 acute myocardial infarction deaths, with 373 317 PMI deaths corresponding to proportionate mortality of 12.5% (men 12%, women 14%). On trend analysis, proportionate mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 (average annual percent change of 1.0 [0.8-1.2, P <0.01]) with a significant increase in women from 10% in 1999 to 17% in 2020 (average annual percent change of 2.4 [1.8-3.0, P <0.01]) and no significant change in men, 11% in 1999 to 10% in 2020 (average annual percent change of -0.2 [-0.7 to 0.3, P=0.4]). There was a significant increase in proportionate mortality in both Black and White populations, with no difference among American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic people. American Indian/Alaska Natives had the highest PMI mortality with no significant change over time. CONCLUSIONS: Over the last 2 decades, there has been a significant increase in the proportionate mortality of PMI in women and the Black population, with persistently high PMI in American Indian/Alaska Natives, despite an overall downtrend in acute myocardial infarction-related mortality. Further research to determine the underlying cause of these differences in PMI mortality is required to improve the outcomes after acute myocardial infarction in these populations.

Case report: unravelling the puzzle of unicuspid aortic valve with multimodality imaging.

Background: Unicuspid aortic valve (UAV) represents a rare congenital anomaly characterized by two subtypes: acommissural unicuspid aortic valve and unicommissural unicuspid aortic valve. Acommissural UAV is often diagnosed and corrected during the neonatal period due to haemodynamic instability. Unicommissural UAV leads to aortic stenosis (AS) in early adulthood. The diagnostic challenge associated with UAV primarily stems from its eccentric orifice opening and valvular calcification, resulting in difficult visualization of the commissures and localization of the orifice plane. This case report aims to demonstrate the unique morphological features of UAV through a comprehensive analysis using multimodality imaging. Case summary: A 61-year-old woman presented to the emergency department for recurrent episodes of dyspnoea. Severe AS was diagnosed on transthoracic echocardiography (TTE) by Doppler haemodynamic measurement. However, follow-up transesophageal echocardiography (TEE) and CT transcatheter aortic valve replacement showed moderate AS by planimetry. Following this, patient was monitored closely, but her dyspnoea kept worsening. Cardiovascular magnetic resonance (CMR) was performed due to persistent dyspnoea, identifying UAV with eccentric loophole orifice with unicommissural attachment and opposite free leaflet edge. The patient was managed medically. Discussion: TTE is the test of choice for AS that defines valvular morphology by direct visualization and grades the severity by haemodynamic measurement. However, the accuracy of TTE can be limited by poor acoustic windows and heavy valvular calcification. TEE measures aortic valve area (AVA) by planimetry that requires accurate localization of the AV orifice plane. Similarly, it applies to multi-detector computed tomography (MDCT). While CMR is expensive and mainly available in tertiary centres, it can provide additional information when there is discordance.

Clinical decision support systems to optimize adherence to anticoagulant guidelines in patients with atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Clinical decision support systems (CDSS) have been utilized as a low-cost intervention to improve healthcare process measures. Thus, we aim to estimate CDSS efficacy to optimize adherence to oral anticoagulant guidelines in eligible patients with atrial fibrillation (AF). METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through August 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) with a 95% confidence interval (CI). PROSPERO ID: CRD42023471806. RESULTS: We included nine RCTs with a total of 25,573 patients. There was no significant difference, with the use of CDSS compared to routine care, in the number of patients prescribed anticoagulants (RR: 1.06, 95% CI [0.98, 1.14], P = 0.16), the number of patients prescribed antiplatelets (RR: 1.01 with 95% CI [0.97, 1.06], P = 0.59), all-cause mortality (RR: 1.19, 95% CI [0.31, 4.50], P = 0.80), major bleeding (RR: 0.84, 95% CI [0.21, 3.45], P = 0.81), and clinically relevant non-major bleeding (RR: 1.05, 95% CI [0.52, 2.16], P = 0.88). However, CDSS was significantly associated with reduced incidence of myocardial infarction (RR: 0.18, 95% CI [0.06, 0.54], P = 0.002) and cerebral or systemic embolic event (RR: 0.11, 95% CI [0.01, 0.83], P = 0.03). CONCLUSION: We report no significant difference with the use of CDSS compared to routine care in anticoagulant or antiplatelet prescription in eligible patients with AF. CDSS was associated with a reduced incidence of myocardial infarction and cerebral or systemic embolic events.

Contemporary trends of leadless pacemaker implantation in the United States.

INTRODUCTION: Leadless pacemakers (LPM) have established themselves as the important therapeutic modality in management of selected patients with symptomatic bradycardia. To determine real-world utilization and in-hospital outcomes of LPM implantation since its approval by the Food and Drug Administration in 2016. METHODS: For this retrospective cohort study, data were extracted from the National Inpatient Sample database from the years 2016-2020. The outcomes analyzed in our study included implantation trends of LPM over study years, mortality, major complications (defined as pericardial effusion requiring intervention, any vascular complication, or acute kidney injury), length of stay, and cost of hospitalization. Implantation trends of LPM were assessed using linear regression. Using years 2016-2017 as a reference, adjusted outcomes of mortality, major complications, prolonged length of stay (defined as >6 days), and increased hospitalization cost (defined as median cost >34 098$) were analyzed for subsequent years using a multivariable logistic regression model. RESULTS: There was a gradual increased trend of LPM implantation over our study years (3230 devices in years 2016-2017 to 11 815 devices in year 2020, p for trend <.01). The adjusted mortality improved significantly after LPM implantation in subsequent years compared to the reference years 2016-2017 (aOR for the year 2018: 0.61, 95% CI: 0.51-0.73; aOR for the year 2019: 0.49, 95% CI: 0.41-0.59; and aOR for the year 2020: 0.52, 95% CI: 0.44-0.62). No differences in adjusted rates of major complications were demonstrated over the subsequent years. The adjusted cost of hospitalization was higher for the years 2019 (aOR: 1.33, 95% CI: 1.22-1.46) and 2020 (aOR: 1.69, 95% CI: 1.55-1.84). CONCLUSION: The contemporary US practice has shown significantly increased implantation rates of LPM since its approval with reduced rates of inpatient mortality.

Pericardial effusion requiring intervention in patients undergoing leadless pacemaker implantation: A real-world analysis from the National Inpatient Sample database.

Background: Pericardial effusion requiring percutaneous or surgical-based intervention remains an important complication of a leadless pacemaker implantation. Objective: The study sought to determine real-world prevalence, risk factors, and associated outcomes of pericardial effusion requiring intervention in leadless pacemaker implantations. Methods: The National Inpatient Sample and International Classification of Diseases-Tenth Revision codes were used to identify patients who underwent leadless pacemaker implantations during the years 2016 to 2020. The outcomes assessed in our study included prevalence of pericardial effusion requiring intervention, other procedural complications, and in-hospital outcomes. Predictors of pericardial effusion were also analyzed. Results: Pericardial effusion requiring intervention occurred in a total of 325 (1.1%) leadless pacemaker implantations. Patient-level characteristics that predicted development of a serious pericardial effusion included >75 years of age (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75), female sex (OR 2.03, 95% CI 1.62-2.55), coagulopathy (OR 1.50, 95% CI 1.12-1.99), chronic pulmonary disease (OR 1.36, 95% CI 1.07-1.74), chronic kidney disease (OR 1.53, 95% CI 1.22-1.94), and connective tissue disorders (OR 2.98, 95% CI 2.02-4.39). Pericardial effusion requiring intervention was independently associated with mortality (OR 5.66, 95% CI 4.24-7.56), prolonged length of stay (OR 1.36, 95% CI 1.07-1.73), and increased cost of hospitalization (OR 2.49, 95% CI 1.92-3.21) after leadless pacemaker implantation. Conclusion: In a large, contemporary, real-world cohort of leadless pacemaker implantations in the United States, the prevalence of pericardial effusion requiring intervention was 1.1%. Certain important patient-level characteristics predicted development of a significant pericardial effusion, and such effusions were associated with adverse outcomes after leadless pacemaker implantations.

Association of chronic kidney disease and end-stage renal disease with procedural complications and inpatient outcomes of leadless pacemaker implantations across the United States.

BACKGROUND: Leadless pacemakers have emerged as a promising alternative to transvenous pacemakers in patients with kidney disease. However, studies investigating leadless pacemaker outcomes and complications based on kidney dysfunction are limited. OBJECTIVE: The objective of this study was to evaluate the association of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with inpatient complications and outcomes of leadless pacemaker implantations. METHODS: National Inpatient Sample and International Classification of Diseases, Tenth Revision codes were used to identify patients with CKD and ESRD who underwent leadless pacemaker implantations in the United States from 2016 to 2020. Study end points assessed included inpatient complications, outcomes, and resource utilization of leadless pacemaker implantations. RESULTS: A total of 29,005 leadless pacemaker placements were identified. Patients with CKD (n = 5245 [18.1%]) and ESRD (n = 3790 [13.1%]) were younger than patients without CKD and had higher prevalence of important comorbidities. In crude analysis, ESRD was associated with higher prevalence of major complications, peripheral vascular complications, and inpatient mortality. After multivariable adjustment, CKD and ESRD were associated with inpatient mortality (CKD: adjusted odds ratio [aOR], 1.62 [95% CI, 1.40-1.86]; ESRD: aOR, 1.38 [95% CI, 1.18-1.63]) and prolonged length of stay (CKD: aOR, 1.55 [95% CI, 1.46-1.66]; ESRD: aOR, 1.81 [95% CI 1.67-1.96]). ESRD was also associated with higher hospitalization costs (aOR, 1.63; 95% CI, 1.50-1.77) and major complications (aOR, 1.33; 95% CI, 1.13-1.57) after leadless pacemaker implantation. CONCLUSION: Approximately one-third of patients undergoing leadless pacemaker implantation had CKD or ESRD. CKD and ESRD were associated with greater length and cost of stay and inpatient mortality.

Impact of Social Vulnerability on Cardiac Arrest Mortality in the United States, 2016 to 2020.

BACKGROUND: Cardiac arrest is 1 of the leading causes of morbidity and mortality, with an estimated 340 000 out-of-hospital and 292 000 in-hospital cardiac arrest events per year in the United States. Survival rates are lower in certain racial and socioeconomic groups. METHODS AND RESULTS: We performed a county-level cross-sectional longitudinal study using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research multiple causes of death data set between 2016 and 2020 among individuals of all ages whose death was attributed to cardiac arrest. The Social Vulnerability Index is a composite measure that includes socioeconomic vulnerability, household composition, disability, individuals from racial and ethnic minority groups status and language, and housing and transportation domains. We examined the impact of social determinants on cardiac arrest mortality stratified by age, race, ethnicity, and sex in the United States. All age-adjusted mortality rate (cardiac arrest AAMRs) are reported as per 100 000. Overall cardiac arrest AAMR during the study period was 95.6. The cardiac arrest AAMR was higher for men compared with women (119.6 versus 89.9) and for the Black population compared with the White population (150.4 versus 92.3). The cardiac arrest AAMR increased from 64.8 in counties in quintile 1 of Social Vulnerability Index to 141 in quintile 5, with an average increase of 13% (95% CI, 9.8%-16.9%) in AAMR per quintile increase. CONCLUSIONS: Mortality from cardiac arrest varies widely, with a >2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the United States based on social determinants of health.

Non-calcified plaque in asymptomatic patients with zero coronary artery calcium score: A systematic review and meta-analysis.

BACKGROUND: There is growing interest in understanding the coronary atherosclerotic burden in asymptomatic patients with zero coronary artery calcium score (CACS). In this population, we aimed to investigate the prevalence and severity of non-calcified coronary plaques (NCP) as detected by coronary CT angiography (CCTA), and to analyze the associated clinical predictors. METHODS: This was a systematic review with meta-analysis of studies indexed in PubMed/Medline and Web of Science from inception of the database to March 31st, 2023. Using the random-effects model, separate Forest and Galbraith plots were generated for each effect size assessed. Heterogeneity was assessed using the I2 statistics whilst Funnel plots and Egger's test were used to assess for publication bias. RESULTS: From a total of 14 studies comprising 37808 patients, we approximated the pooled summary estimates for the overall prevalence of NCP to be 10% (95%CI: 6%-13%). Similarly, the pooled prevalence of obstructive NCP was estimated at 1.1% (95%CI: 0.7%-1.5%) from a total of 10 studies involving 21531 patients. Hypertension [OR: 1.46 (95%CI:1.31-1.62)] and diabetes mellitus [OR: 1.69 (95%CI: 1.41-1.97)] were significantly associated with developing any NCP, with male gender being the strongest predictor [OR: 3.22 (95%CI: 2.17-4.27)]. CONCLUSION: There is a low burden of NCP among asymptomatic subjects with zero CACS. In a subset of this population who have clinical predictors of NCP, the addition of CCTA has a potential to provide a better insight about occult coronary atherosclerosis, however, a risk-benefit approach must be factored in prior to CCTA use given the low prevalence of NCP.

Development and Validation of a Machine Learning Risk-Prediction Model for 30-Day Readmission for Heart Failure Following Transcatheter Aortic Valve Replacement (TAVR-HF Score).

Transcatheter aortic valve replacement (TAVR) is the treatment of choice for patients with severe aortic stenosis across the spectrum of surgical risk. About one-third of 30-day readmissions following TAVR are related to heart failure (HF). Hence, we aim to develop an easy-to-use clinical predictive model to identify patients at risk for HF readmission. We used data from the National Readmission Database (2015-2018) utilizing ICD-10 codes to identify TAVR procedures. Readmission was defined as the first unplanned HF readmission within 30-day of discharge. A machine learning framework was used to develop a 30-day TAVR-HF readmission score. The receiver operator characteristic curve was used to evaluate the predictive power of the model. A total of 92,363 cases of TAVR were included in the analysis. Of the included patients, 3299 (3.6%) were readmitted within 30 days of discharge with HF. Individuals who got readmitted, vs those without readmission, had more emergent admissions during index procedure (33.4% vs 19.8%), electrolyte abnormalities (38% vs 16.7%), chronic kidney disease (34.8% vs 21.2%), and atrial fibrillation (60.1% vs 40.7%). Candidate variables were ranked by importance using a parsimony plot. A total of 7 variables were selected based on predictive ability as well as clinical relevance: HF with reduced ejection fraction (25 points), HF preserved EF (20 points), electrolyte abnormalities (17 points), atrial fibrillation (12 points), Charlson comorbidity index (<6 = 0, 6-8 = 9, 9-10 = 13, >10 = 14 points), chronic kidney disease (7 points), and emergent index admission (5 points). On performance evaluation using the testing dataset, an area under the curve of 0.761 (95% CI 0.744-0.778) was achieved. Thirty-day TAVR-HF readmission score is an easy-to-use risk prediction tool. The score can be incorporated into electronic health record systems to identify at-risk individuals for readmissions with HF following TAVR. However, further external validation studies are needed.

Intensive Care Admissions and Outcome of Cardiac Arrests; A National Cohort Study From the United States.

OBJECTIVE: Outcomes of cardiac arrest among patients who had cardiopulmonary resuscitation (CPR) in intensive care units (ICU) has limited data on the national level basis in the United States. We aimed to study the outcomes of ICU CPRs. METHODS: Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the United States were analyzed for ICU-related hospitalizations for the years 2016 to 2019. ICU CPR was defined by procedure codes. RESULTS: A total of 4,610,154 ICU encounters were reported for the years 2016 to 2019 in the NRD. Of these patients, 426,729 (9.26%) had CPR procedure recorded during the hospital encounter (mean age 65 ± 17.81; female 42.4%). And 167,597 (39.29%) patients had CPR on the day of admission, of which 63.16% died; while 64,752 (15.18%) patients had CPR on the day of ICU admission, of which 72.85% died. And 36,002 (8.44%) had CPR among patients with length of stay 2 days, of which 73.34% died. A total of 1,222,799 (26.5%) admitted to ICU died, and patients who had ICU CPR had higher mortality, 291,391(68.3%). Higher complication rates were observed among ICU CPR patients, especially who died. Over the years from 2016 to 2019, ICU CPR rates increased from 8.18% (2016) to 8.66% (2019); p-trend = 0.001. The mortality rates among patients admitted to ICU increased from 22.1% (2016) to 24.1% (2019); p-trend = 0.005. CONCLUSION: The majority of ICU CPRs were done on the first day of ICU admission. The trend for ICU CPR was increasing. The mortality trend for overall ICU admissions has increased, which is concerning and would suggest further research to improve the high mortality rates in the CPR group.

Trends and cardiovascular outcomes of Takotsubo syndrome with cardiogenic shock vs. mixed cardiogenic and septic shock: a nationwide propensity matched analysis.

INTRODUCTION: Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, can be complicated by shock. The outcomes of patients with TTS complicated with cardiogenic shock (CS) versus mixed cardiogenic and septic shock (MS) is not known. METHODS: We queried Nationwide Inpatient Sample (NIS) from 2009-2020 to compare TTS patients with CS and MS using International Classification of Disease, Ninth & Tenth Edition, Clinical Modification (ICD- 9 & 10-CM) coding. In-hospital outcomes were compared using one: one propensity score matched (PSM) analysis. The primary outcome was in-hospital mortality. RESULTS: Of 23,126 patients with TTS 17,132 (74%) had CS, and 6,269 (26%) had MS. The mean age was 67 years in CS and 66 years in MS, and majority of patients were female (n = 17,775, 77%). On adjusted multivariate analysis, MS patients had higher odds of in-hospital mortality (aOR 1.44, 95% CI 1.36-1.52), AKI (aOR 1.53, 95% CI 1.48-1.58), pressor requirement (aOR 1.37, 95% CI 1.25-1.50). However, had lower odds of MCS use (aOR 0.44, 95% CI 0.40-0.48) and cardiac arrest (aOR: 0.81, 95% CI 0.73-0.90) (p-value <0.0001). Mean LOS and inflation-adjusted hospital charges were higher in MS. CONCLUSION: MS in the setting of TTS have higher rates of in-hospital mortality, AKI, and pressor requirements.

Trends in Premature Mortality from Acute Myocardial Infarction in American Indians/Alaska Natives in the United States from 1999 to 2020.

Cardiovascular disease is the leading cause of mortality in American Indian and Alaska Native (AI/AN) groups. They are disproportionately found to have a higher rate of premature myocardial infarction (MI). The Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research were queried to identify premature MI deaths (female <65 years and male <55 years) occurring within the United States between 1999 and 2020. We investigated proportionate mortality trends related to premature MI in AI/ANs stratified by gender. Deaths attributed to acute MI (AMI) were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes I21 to I22. We compared the proportional mortality rate because of premature MI with that of a non-AI/AN racial group, which comprised all other races (Blacks, Whites, and Asian/Pacific Islander populations). In AI/ANs, we analyzed a total of 14,055 AMI deaths, of which 3,211 were premature MI deaths corresponding to a proportionate mortality rate of 22.8% (male 20.8%, female 26.2%). The non-AI/AN population had a lower proportionate mortality of 14.8% (male 13.7%, female 16%), p <0.01). On trend analysis, there was no significant improvement over time in the proportionate mortality of AI/ANs (19.8% in 1999 to 21.7% in 2020, p = 0.09). Upon comparison of gender, proportionate mortality of premature MI in women showed a statistically nonsignificant increase from 21.6% in 1999 to 27.3% in 2020 [average annual percent change of 0.7, p = 0.06)]. However, men had a statistically significant decrease in proportionate mortality of premature MI from 18.5% in 1999 to 18.2% in 2020 [average annual percent change of -0.8, p = 0.01)]. AI/ANs have an alarmingly higher rate of proportionate mortality of premature MI than that of other races, with no improvement in the proportionate mortality rates over 20 years, despite an overall downtrend in AMI mortality. Further research to address the reasons for the lack of improvement in premature MI is needed to improve outcomes in this patient population.

Trends in Infective Endocarditis Mortality in the United States: 1999 to 2020: A Cause for Alarm.

BACKGROUND: Data on national trends in mortality due to infective endocarditis (IE) in the United States are limited. METHODS AND RESULTS: Utilizing the multiple causes of death data from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2020, IE and substance use were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Between 1999 and 2020, the IE-related age-adjusted mortality rates declined. IE-related crude mortality accelerated significantly in the age groups 25-34 years (average annual percentage change, 5.4 [95% CI, 3.1-7.7]; P<0.001) and 35-44 years (average annual percentage change, 2.3 [95% CI, 1.3-3.3]; P<0.001), but remained stagnant in those aged 45-54 years (average annual percentage change, 0.5 [95% CI, -1.9 to 3]; P=0.684), and showed a significant decline in those aged ≥55 years. A concomitant substance use disorder as multiple causes of death in those with IE increased drastically in the 25-44 years age group (P<0.001). The states of Kentucky, Tennessee, and West Virginia showed an acceleration in age-adjusted mortality rates in contrast to other states, where there was predominantly a decline or static trend for IE. CONCLUSIONS: Age-adjusted mortality rates due to IE in the overall population have declined. The marked acceleration in mortality in the 25- to 44-year age group is a cause for alarm. Regional differences with acceleration in IE mortality rates were noted in Kentucky, Tennessee, and West Virginia. We speculate that this acceleration was likely due mainly to the opioid crisis that has engulfed several states and involved principally younger adults.

A systematic review and meta-analysis of the prevalence, incidence, and predictors of atrial fibrillation in cardiac sarcoidosis.

BACKGROUND: The occurrence of atrial arrhythmias, in particular, atrial fibrillation (AF) in patients with cardiac sarcoidosis (CS) are of growing interest in the field of infiltrative cardiomyopathies. Via a systematic review with meta-analysis, we sought to synthesize data on the prevalence, incidence, and predictors of atrial arrhythmias as well as outcomes in patients with CS. METHODS: PubMed/Medline, Web of Science, and Scopus were systematically queried from inception until April 26th, 2023. Using the random-effects model, separate plots were generated for each effect size assessed. RESULTS: From a total of 8 studies comprising 978 patients with CS, the pooled summary estimates for the prevalence of AF was 23% (95% CI: 13%-34%). Paroxysmal AF was the most common subtype of AF (83%; 95% CI: 77%-90%), followed by persistent AF (17%; 95% CI: 10%-23%). In 9 studies involving 545 patients with CS, the pooled incidence of AF was estimated at 5%, 13.1%, and 8.9% at <2 years, 2-4 years, and > 4 years of follow-up respectively, with an overall cumulative incidence of 10.6% (95% CI: 4.9%-17.8%) over a 6-year follow-up period. Increased left atrial size and atrial 18F-fluorodeoxyglucose uptake were identified as strong independent predictors for the development of atrial arrhythmias on qualitative synthesis. CONCLUSION: The burden of AF and related arrhythmias in CS patients is considerable. This necessitates close follow-up and predictive risk-stratification tools to guide the initiation of appropriate strategies, including therapeutic interventions for prevention of AF-related embolic phenomenon, especially in those with known clinical predictors.

Impact of social vulnerability on cardiac arrest mortality in the United States, 2016-2020.

Importance: Cardiac arrest is one of the leading causes of morbidity and mortality, with an estimated 340,000 out-of-hospital and 292,000 in-hospital cardiac arrest events per year in the U.S. Survival rates are lower in certain racial and socioeconomic groups. Objective: To examine the impact of social determinants on cardiac arrest mortality among adults stratified by age, race, and sex in the U.S. Design: A county-level cross-sectional longitudinal study using death data between 2016 and 2020 from the Centers for Disease Control and Prevention's (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) database. Setting: Using the multiple causes of death dataset from the CDC's WONDER database, cardiac arrests were identified using the International Classification of Diseases (ICD), tenth revision, clinical modification codes. Participants: Individuals aged 15 years or more whose death was attributed to cardiac arrest. Exposures: Social vulnerability index (SVI), reported by the CDC, is a composite measure that includes socioeconomic vulnerability, household composition, disability, minority status and language, and housing and transportation domains. Main outcomes and measures: Cardiac arrest mortality per 100,000 adults. Results: Overall age-adjusted cardiac arrest mortality (AAMR) during the study period was 95.6 per 100,000 persons. The AAMR was higher for men as compared with women (119.6 vs. 89.9 per 100,000) and for Black, as compared with White, adults (150.4 vs. 92.3 per 100,000). The AAMR increased from 64.8 per 100,000 persons in counties in Quintile 1 (Q1) of SVI to 141 per 100,000 persons in Quintile 5, with an average increase of 13% (95% CI: 9.8-16.9) in AAMR per quintile increase. Conclusion and relevance: Mortality from cardiac arrest varies widely, with a more than 2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the U.S. based on social determinants of health.

Predictors of non-calcified plaque presence and future adverse cardiovascular events in symptomatic rural Appalachian patients with a zero coronary artery calcium score.

BACKGROUND: Coronary artery calcium (CAC) scoring is a proven predictor for future adverse cardiovascular events (CVE) in asymptomatic individuals. Data is emerging regarding the usefulness of non-calcified plaque (NCP) assessment on cardiac computed tomography (CCT) angiography in symptomatic patients with a zero CAC score for further risk assessment. METHODS: A retrospective review from January 2019 to January 2022 of 696 symptomatic patients with no known CAD and a zero CAC score identified 181 patients with NCP and 515 patients without NCP by a visual assessment on CCT angiography. The primary endpoint was to identify predictors for NCP presence and adverse CVEs (death, myocardial infarction, or cerebrovascular accident) within two years. RESULTS: Based on logistic regression, age (OR 1.039, 95% CI [1.020-1.058], p â€‹< â€‹0.001), diabetes mellitus (OR 2.192, 95% CI [1.307-3.676], p â€‹< â€‹0.003), tobacco use (OR 1.748, 95% CI [1.157-2.643], p â€‹< â€‹0.008), low-density lipoprotein cholesterol level (OR 1.009, 95% CI [1.003-1.015], p â€‹< â€‹0.002), and hypertension (OR 1.613, 95% CI [1.024-2.540], p â€‹< â€‹0.039) were found to be predictors of NCP presence. NCP patients had a higher pretest probability for CAD using the Morise risk score (p â€‹< â€‹0.001∗), with NCP detection increasing as pretest probability increased from low to high (OR 55.79, 95% CI [24.26-128.26], p â€‹< â€‹0.001∗). 457 patients (66%) reached a full two-year period after CCT angiography completion, with NCP patients noted to have shorter follow-up times and higher rates of elective coronary angiography, intervention, and CVEs. The presence of NCP (aOR 2.178, 95% CI [1.025-4.627], p â€‹< â€‹0.043) was identified as an independent predictor for future adverse CVEs when adjusted for diabetes mellitus, age, and hypertension. CONCLUSION: NCP was identified at high rates (26%) in our symptomatic Appalachian population with no known CAD and a zero CAC score. NCP was identified as an independent predictor of future adverse CVEs within two years.