Sex Differences in Quality of Life in Patients with Ischemia with No Obstructive Coronary Artery Disease (INOCA): A Patient Self-Report Retrospective Survey from INOCA International.

Women with obstructive coronary artery disease (CAD) have a relatively lower quality of life (QoL) compared to men, but our understanding of sex differences in QoL in ischemia with no obstructive coronary artery disease (INOCA) is limited. We conducted a survey of patient members of INOCA International with an assessment of self-reported health measures. Functional capacity was retrospectively estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed before and after INOCA symptom onset. Of the 1579 patient members, the overall survey completion rate was 21%. Women represented 91% of the respondents. Estimated functional capacity, expressed as metabolic equivalents (METs), was higher before compared to after INOCA diagnosis comparably for both women and men. For every one MET decline in functional capacity, there was a significantly greater decline in QoL for men compared with women in physical health (4.0 ± 1.1 vs. 2.9 ± 0.3 days/month, p < 0.001), mental health (2.4 ± 1.2 vs. 1.8 ± 0.3 days/month, p = 0.001), and social health/recreational activities (4.1 ± 1.0 vs. 2.9 ± 0.3 days/month, p = 0.0001), respectively. In an international survey of patients living with INOCA, despite similar diagnoses, clinical comorbidities, and symptoms, INOCA-related functional capacity declines are associated with a greater adverse impact on QoL in men compared to women.

Low educational attainment is associated with higher all-cause and cardiovascular mortality in the United States adult population.

INTRODUCTION: Educational attainment is an important social determinant of health (SDOH) for cardiovascular disease (CVD). However, the association between educational attainment and all-cause and CVD mortality has not been longitudinally evaluated on a population-level in the US, especially in individuals with atherosclerotic cardiovascular disease (ASCVD). In this nationally representative study, we assessed the association between educational attainment and the risk of all-cause and cardiovascular (CVD) mortality in the general adult population and in adults with ASCVD in the US. METHODS: We used data from the 2006-2014 National Death Index-linked National Health Interview Survey for adults ≥ 18 years. We generated age-adjusted mortality rates (AAMR) by levels of educational attainment (< high school (HS), HS/General Education Development (GED), some college, and ≥ College) in the overall population and in adults with ASCVD. Cox proportional hazards models were used to examine the multivariable-adjusted associations between educational attainment and all-cause and CVD mortality. RESULTS: The sample comprised 210,853 participants (mean age 46.3), representing ~ 189 million adults annually, of which 8% had ASCVD. Overall, 14.7%, 27%, 20.3%, and 38% of the population had educational attainment < HS, HS/GED, Some College, and ≥ College, respectively. During a median follow-up of 4.5 years, all-cause age-adjusted mortality rates were 400.6 vs. 208.6 and 1446.7 vs. 984.0 for the total and ASCVD populations for < HS vs ≥ College education, respectively. CVD age adjusted mortality rates were 82.1 vs. 38.7 and 456.4 vs 279.5 for the total and ASCVD populations for < HS vs ≥ College education, respectively. In models adjusting for demographics and SDOH, < HS (reference = ≥ College) was associated with 40-50% increased risk of mortality in the total population and 20-40% increased risk of mortality in the ASCVD population, for both all-cause and CVD mortality. Further adjustment for traditional risk factors attenuated the associations but remained statistically significant for < HS in the overall population. Similar trends were seen across sociodemographic subgroups including age, sex, race/ethnicity, income, and insurance status. CONCLUSIONS: Lower educational attainment is independently associated with increased risk of all-cause and CVD mortality in both the total and ASCVD populations, with the highest risk observed for individuals with < HS education. Future efforts to understand persistent disparities in CVD and all-cause mortality should pay close attention to the role of education, and include educational attainment as an independent predictor in mortality risk prediction algorithms.

Ischemia with No Obstructive Arteries (INOCA): A Review of the Prevalence, Diagnosis and Management.

Ischemia with no obstructive arteries (INOCA) is defined as patients with angiographic evidence of ischemia but no obstructive coronary artery disease (CAD) at coronary angiography. INOCA is estimated to be prevalent is 3-4 million individuals with a female predominance. INOCA is composed of different endotypes including: microvascular dysfunction, vasospasm and a combination of the 2. Diagnosis of INOCA requires either non-invasive or invasive techniques aimed at assessing coronary flow reserve (CFR), Index of Microcirculatory Resistance (IMR) and spasm secondary to acetylcholine injection. Although INOCA is associated with an increased risk of MACE and a decrease in quality of life, less than half of patients are appropriately treated. Treatment of INOCA remains elusive with current therapeutics tailored towards the specific endotype and ongoing clinical trials looking to assess the efficacy of traditional CAD medications.

Ischemia with no obstructive coronary artery disease (INOCA): A patient self-report quality of life survey from INOCA international.

BACKGROUND: There is limited information available regarding evidence of ischemia with no obstructive coronary arteries (INOCA) and quality of life. PURPOSE: To determine associations between INOCA and self-reported physical, social, and mental health. METHODS: We conducted a survey of all members (n = 1579) of the INOCA International patient support group. Current self-reported diagnosis and health measures were collected. Functional capacity was retrospectively estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior and after symptom onset. RESULTS: A total of 297 (20.8% response rate, 91% women) reported symptoms of chest pain, pressure, or discomfort in 92.9%. Overall, 34.4% were living with symptoms for ≥3 years before an INOCA diagnosis, and 77.8% were told their symptoms were not cardiac. Estimated functional capacity was higher prior to compared to after symptom onset (8.6 ± 1.8 METs vs 5.6 ± 1.8 METs; P < 0.0001). Most respondents reported an adverse impact of symptoms on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%), while approximately three-quarters reduced their work hours or stopped work completely, 47.5% retired early, and 38.4% applied for disability. CONCLUSIONS: INOCA symptoms are associated with adverse physical, mental and social health quality of life. Increased patient awareness, physician recognition and diagnosis, and clinical trials are needed to develop evidence-based guidelines for this increasingly recognized cardiovascular disorder.

Hidden in Plain Sight: Discovering Giant Cell Aortopathy During Surgical Mitral Valve Repair.

Giant cell arteritis (GCA) is an inflammatory cranial and/or extracranial vasculitis. Although cranial GCA is widely recognized, extracranial GCA is underdiagnosed because of its nonspecific and atypical presentations. We report a case of asymptomatic extracranial GCA with ascending thoracic aortopathy discovered incidentally during surgical mitral valve repair. (Level of Difficulty: Intermediate.).

Loperamide Toxicity Revealing Apical Hypertrophic Cardiomyopathy.

Loperamide, a µ-opioid receptor agonist, can cause cardiotoxicity by inhibiting the potassium ion channel and slowing cardiomyocyte repolarization. This, in turn, can lead to frequent early afterdepolarizations, the most common mechanism of drug-induced long QT syndrome and torsades de pointes. Apical hypertrophic cardiomyopathy (AHCM) is a nonobstructive hypertrophic cardiomyopathy rarely associated with malignant arrhythmias. We present a case of loperamide-induced malignant ventricular arrhythmia revealing underlying AHCM in a 25-year-old woman with a history of sudden cardiac arrest (SCA) and opioid use. It is important to evaluate for structural heart disease in all patients presenting with SCA, regardless of presumed etiology such as drug-induced cardiotoxicity, to prevent missed opportunities for adequate treatment. Furthermore, the diagnosis of AHCM in SCA warrants further genetic evaluation for variances with a predilection for malignant arrhythmias.

Impact of Social Media and Virtual Learning on Cardiology During the COVID-19 Pandemic Era and Beyond.

Over the past decade, advances in digital trends and technology have greatly impacted the medical field with rapid delivery of and access to information. The field of cardiovascular medicine in particular has seen major technological advances and is well versed in the use of digital platforms and social media. In these unprecedented times of the COVID-19 pandemic, social media and other digital platforms are essential tools for communication, education, and delivery of information. In this review, we discuss the ways virtual learning and social media are changing medical education and research.

Robotic and per-oral endoscopic myotomy have fewer technical complications compared to laparoscopic Heller myotomy.

BACKGROUND: Achalasia is an uncommon disease treated by decreasing the lower esophageal sphincter resting pressure. This study compared the safety and efficacy of esophago-gastric myotomy via laparoscopic, robotic, and per-oral endoscopic approaches. METHODS: A retrospective review of data on patients with achalasia or other esophageal dysmotility disorder undergoing laparoscopic, robotically assisted, or per-oral endoscopic myotomy (POEM) procedures between 2013 and 2017 was performed. Patient demographics, comorbidities, procedure details, length of stay, 30-day readmission rate, and combined technical complication (full-thickness injury, conversion to open, and delayed perforation) were compared. Multiple logistic regression analysis was performed to determine which factors contributed to combined technical complication. RESULTS: There were 171 patients who underwent esophago-gastric myotomy with 161 (94.2%) having achalasia. There were 40 laparoscopic Heller myotomies with partial fundoplication, 44 robotic Heller myotomies with partial fundoplication, and 87 POEM procedures performed during the study period. Baseline statistical differences were found among the groups in regard to gastroesophageal reflux symptoms, arrhythmia, hypertension, and congestive heart failure. Laparoscopic Heller myotomy had significantly higher combined technical complications (7, 17.5%) compared to robotically assisted Heller myotomy (0, 0%) and POEM (1, 1.1%). Multivariate analysis showed that laparoscopic Heller myotomy (OR 32.22; 95% CI 2.66, 389.83; p = 0.01), myocardial infarction (OR 27.94; 95% CI 1.66, 471.10; p = 0.02), and history of smoking (OR 8.87; 95% CI 1.29, 61.15; p = 0.03) were risks for developing combined technical complications. CONCLUSION: Robotically assisted Heller myotomy and POEM are safe and efficacious treatments for achalasia with lower rates of technical complications compared to laparoscopic Heller myotomy. With the advancements in endoscopic instruments and robotic surgery, POEM and robotically assisted Heller myotomy should be considered in the treatment of achalasia and esophageal dysmotility disorders.

"Five on a Dice" Port Placement Allows for Successful Robot-Assisted Left Pneumonectomy.

Background Technology has evolved to facilitate pulmonary resection. The latest technological advances in computer-aided surgery (Da Vinci Xi) allow for more control during pulmonary resection. Case Description A 59-year-old woman presented with two primary tumors of the left upper and lower lung. After induction chemotherapy, patient had a "five on a dice" port placement and technique was used to perform successful robot-assisted pneumonectomy. The patient was discharged home on postoperative day 3 without any complications. Conclusions We have found that the "five on a dice" port placement allows for optimal control of the robot stapler and facilitates successful robot-assisted left pneumonectomy.