Association of Maximum Troponin Levels With Diagnosis of Acute Myocardial Infarction and Elevated Risk of Mortality.

Background: Cardiac troponins I and T are highly sensitive and specific markers for acute myocardial infarction (AMI). However, a wide range of non-AMI conditions can also cause significant elevations in cardiac troponins. Given the deleterious impact of misdiagnosis of AMI, the ability to risk-stratify patients who present with an elevated troponin is paramount. We hypothesized that the maximum troponin level would be more predictive of mortality and the diagnosis of AMI than the initial troponin level or change in troponin level. Methods: Patient records from a 9-hospital system (n=30,173) in Texas were reviewed during a 24-month period in 2016-2017. Data collected for patients aged ≥40 years included International Classification of Diseases, Tenth Revision diagnoses, troponin I, demographic data (age, sex, smoking history, and chronic medical conditions), and death during hospitalization. We used logistic regression with the Firth penalized likelihood approach to determine the predictive ability of initial, maximum, and change in troponin level for mortality and the diagnosis of AMI. Results: Demographic characteristics of our cohort included a median age of 70 years, with 48.05% male and 51.95% female. The most common preexisting risk factor was hypertension in 78.81% of the cohort. Notable findings from the logistic regression include the predictive ability of maximum troponin on the odds of death by 0.7% for each unit of increase in troponin value. Also, the odds of AMI increased by 3.1% for each unit of increase in the maximum troponin value. Conclusion: Regardless of the level, a detectable amount of troponin in the serum results in a significantly elevated risk of mortality. Many patients with elevated troponin levels leave the hospital without a specific diagnosis, which can lead to poor outcomes because a detectable troponin does not represent a no-risk population. Our study demonstrates that maximum troponin level is a more sensitive and specific predictor of mortality than initial or change in troponin. Similarly, maximum troponin is the most predictive of AMI vs other causes of troponin elevation, likely because of the correlation between rising troponin levels and cardiomyocyte damage. Further studies are needed to correlate maximum troponin levels and clinical manifestations, which may be helpful in redefining AMI so that AMI can be distinguished more easily from non-AMI diagnoses.

Use of Web-Based Patient Portals in Patients With Atrial Fibrillation Is Associated With Higher Readmissions.

Background: The impact of web-based patient portals on patient outcomes-specifically hospital readmissions in patients with atrial fibrillation (AF)-remains understudied. Methods: This single-center retrospective cohort study investigated the use of an online portal system (MyChart) by patients hospitalized from January 1, 2014 to June 30, 2017 for AF. During the study period, 11,334 unique AF admissions were identified; 50.3% were MyChart users and 49.7% were non-MyChart users. Patients who experienced inpatient mortality were excluded. The study groups were analyzed for demographic variables, comorbidities, readmission rates, and the frequency of MyChart use during the 3.5-year time frame. Results: MyChart users were younger (median age, 74 years, interquartile range [IQR] 66-82 vs 77 years, IQR 68-85; P<0.0001) and more likely to be white (91.9% vs 84.6%; P<0.0001), but the sex distribution was similar between groups, with 51.8% males in the MyChart group vs 53.2% in the non-MyChart group. MyChart users had a significantly higher rate of readmission compared to non-MyChart users at 1 year (43.0% vs 32.0%, respectively; P<0.0001). MyChart users who were readmitted had a higher median number of logins to MyChart (121 [IQR 32-270.5]) than MyChart users who were not readmitted (91 [IQR 26-205]; P<0.0001). Multivariable regression analysis demonstrated that MyChart use was associated with readmission (odds ratio 1.57, 95% CI 1.49-1.70; P<0.0001). Conclusion: Among patients with AF, MyChart use was associated with higher readmissions in this single-center cohort. Use and benefit of bespoke portals require further study.

Advanced heart failure with reduced ejection fraction.

Patients suffering advanced heart failure with reduced ejection fraction (HFrEF) account for a large portion of patients admitted to hospitals worldwide. Mortality and 30-day readmission rates for HFrEF are now a focus of value-based payment models, making management of this disease a priority for hospitals, physicians, and payers alike. Angiotensin-converting enzyme inhibitors have been the cornerstone of therapy for decades. However, with treatment, the prognosis for patients with advanced HFrEF remains poor. Fortunately, advances in medical therapy and mechanical support offer some patients improvement in both survival and quality of life. We review advances in short- and long-term mechanical support and explore changes to organ allocation for cardiac transplantation. In addition, we provide a guide to facilitate appropriate referral to an advanced heart failure team.

Cardiovascular Outcomes Among Patients with Type 2 Diabetes Newly Initiated on Sodium-Glucose Cotransporter-2 Inhibitors, Glucagon-Like Peptide-1 Receptor Agonists, and Other Antidiabetic Medications.

BACKGROUND: Cardiovascular disease (CVD) remains the most prevalent cause of morbidity and mortality in patients with type 2 diabetes (T2D) and is a primary driver for health care costs associated with diabetes management. Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have demonstrated significant reductions in cardiovascular endpoints in clinical trials compared with placebo. However, it is uncertain whether these findings can be applied to the broader T2D population because these trials specifically included high-risk patients with established CVD. OBJECTIVE: To evaluate and compare cardiovascular outcomes among adults with T2D newly initiated on SGLT-2is, GLP-1 RAs, and other antidiabetic medications (oADMs) in a real-world setting. METHODS: This retrospective new-user cohort study used administrative claims and electronic health record data from an integrated delivery network in Texas. Patients aged ≥18 years with T2D and ≥1 prescription claim for an SGLT-2i, a GLP-1 RA, or an oADM filled between April 2013 and December 2018 were included. Patients were divided into three 1:1 propensity-matched groups according to index medication identified. Primary outcomes were heart failure hospitalization and a composite end-point of myocardial infarction, stroke, unstable angina, or coronary revascularization. Cox proportional hazards regression was used to compare cumulative incidence of all outcome variables. RESULTS: Among 9,477 patients, 1,134 were initiated on SGLT-2is, 1,072 on GLP-1 RAs, and 7,271 on oADMs. Patients initiating SGLT-2is versus oADMs had significantly lower risk of the composite endpoint (HR = 0.64, 95% CI = 0.46-0.90), heart failure hospitalization (HR = 0.56, 95% CI = 0.39-0.81), and unstable angina requiring hospitalization (HR = 0.56, 95% CI = 0.39-0.81). Patients initiating GLP-1 RAs compared with oADMs had significantly lower risk of the composite endpoint (HR = 0.71, 95% CI = 0.52-0.98) and unstable angina requiring hospitalization (HR = 0.60, 95% CI = 0.41-0.86). No differences in cardiovascular outcomes were found between SGLT-2is and GLP-1 RAs. CONCLUSIONS: Both SGLT-2is and GLP-1 RAs showed significant reductions in the composite outcome and unstable angina requiring hospitalization versus oADMs. However, only SGLT-2is were associated with a lower risk for heart failure hospitalizations. Nevertheless, cardiovascular outcomes were similar between SGLT-2is and GLP-1 RAs. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to report.

Inpatient Mortality and 30-Day Readmission Rates Associated with Troponin Testing in Patients without Acute Myocardial Infarction.

OBJECTIVE: Troponin values above the threshold established to diagnose acute myocardial infarction (AMI; >99th percentile) are commonly detected in patients with diagnoses other than AMI. The objective of this study was to compare inpatient mortality and 30-day readmission rate in patients with troponin I (TnI) above and below the 99th percentile in those with type 1 AMI and type 2 myocardial injury. METHODS: Between January 1, 2016 and December 31, 2016, there were 56,895 inpatient hospitalizations; of these 14,326 (25.2%) patients received troponin testing. We evaluated mortality and readmissions in the entire cohort based on the primary discharge International Classification of Diseases, Tenth Edition (ICD-10) diagnosis and grouped into type 1 AMI versus other diagnoses comprising the type 2 AMI group (including ICD-10 codes for congestive heart failure, sepsis, and other). Among those with TnI drawn, we evaluated in-hospital mortality and 30-day readmissions based on troponin values > 99th percentile (≥ 0.1 ng/ml). RESULTS: Among the entire cohort, the inpatient mortality rate was significantly higher in those with TnI testing (5.0%, 95% CI 4.6%-5.3%) compared to those without testing (0.7%, 95% CI 0.6%-0.7%, P < 0.01). In the tested cohort 3,743 (26%) patients had troponin levels above the 99th percentile (> 0.1 ng/ml), and 10,583 (74%) had troponin levels below the 99th percentile (≤ 0.1 ng/ml). Comparing type 2 AMI with type 1 AMI and troponin testing, TnI values ≥ 0.1 ng/ml were associated with higher inpatient mortality (11.6% vs. 3.9%) and 30-day readmission rates (16.9% vs. 10.7%). CONCLUSIONS: A higher inpatient mortality and 30-day readmission rates were found in patients with type 2 AMI compared to type 1 AMI group.

Usefulness of Released Cardiac Myosin Binding Protein-C as a Predictor of Cardiovascular Events.

Cardiac myosin binding protein-C (cMyBP-C) is a heart muscle-specific thick filament protein. Elevated level of serum cMyBP-C is an indicator of early myocardial infarction (MI), but its value as a predictor of future cardiovascular disease is unknown. Based on the presence of significant amount of cMyBP-C in the serum of previous study subjects independent of MI, we hypothesized that circulating cMyBP-C is a sensitive indicator of ongoing cardiovascular stress and disease. To test this hypothesis, 75 men and 83 women of similar ages were recruited for a prospective study. They underwent exercise stress echocardiography to provide pre- and poststress blood samples for subsequent determination of serum cMyBP-C levels. The subjects were followed for 1 to 1.5 years. Exercise stress increased serum cMyBP-C in all subjects. Twenty-seven primary events (such as death, MI, revascularization, invasive cardiovascular procedure, or cardiovascular-related hospitalization) and 7 critical events (CE; such as death, MI, stroke, or pulmonary embolism) occurred. After adjusting for sex and cardiovascular risk factors with multivariate Cox regression, a 96% sensitive prestress cMyBP-C threshold carried a hazard ratio of 8.1 with p = 0.041 for primary events. Most subjects (6 of 7) who had CE showed normal ejection fraction on echocardiography. Prestress cMyBP-C demonstrated area under receiver operating curve of 0.91 and multivariate Cox regression hazard ratio of 13.8 (p = 0.000472) for CE. Thus, basal cMyBP-C levels reflected susceptibility for a variety of cardiovascular diseases. Together with its high sensitivity, cMyBP-C holds potential as a screening biomarker for the existence of severe cardiovascular diseases.

Frequency of Troponin Testing in Inpatient Versus Outpatient Settings.

Troponin elevation is required to diagnose acute myocardial infarction (AMI), yet elevated values are often encountered in noncardiac disease states. We evaluated inpatient (IP) and outpatient (OP) encounters at 14 hospitals in calendar year 2014 and found that troponin assays were performed during 12% of all OP visits and 29% of all IP visits: 82,853 encounters in all. We employed an expert panel to estimate the likelihood of AMI based on primary International Statistical Classification of Diseases and Related Health Problems, 9th edition diagnoses. We compared IP and OP testing, finding that AMI would not be expected in most IP encounters. Sepsis was the most common diagnosis associated with IP troponin testing. We found an association between troponin testing in patients with sepsis and utilization of electrocardiography, echocardiography, and cardiac catheterization. Our data indicate that troponin testing has expanded beyond patient populations in whom AMI might be expected.

Burnout Among Cardiologists.

Burnout is a loss of enthusiasm for work, cynicism, and a low sense of accomplishment. Loss of autonomy and authority, complex regulatory requirements, report cards, quality metrics, the rise of large integrated health care systems, and the demise of solo practice are just a few realities of medical practice that contribute to physician burnout. Physicians suffering burnout often focus on compensation and perceived status as antidotes, although evidence suggests they play no role. Randomized controlled trials suggest that interventions designed to improve coping and resiliency including cognitive behavioral therapy and physical and mental relaxations to reduce stress can be effective. Reduced work hours have also been shown to mitigate burnout. Successful prevention and management requires adaptations by both physicians and the health care systems in which they work. We believe that burnout also involves a loss of faith in the practice of medicine itself. Advances in cardiovascular medicine have led to large reductions in mortality and morbidity. However, the disruptive changes to health care that accompanied this success have contributed to physician alienation. In conclusion, we believe that to overcome burnout, cardiologists should dedicate themselves to a collective mission of patient care and work to restore faith in their profession.

Daily cardiac catheterization procedural volume and complications at an academic medical center.

BACKGROUND: Over 1,000,000 cardiac catheterizations (CC) are performed annually in the United States. There is a small risk of complication that has persisted despite advances in technology. It is unknown whether daily CC procedural volume can influence this risk. In an effort to improve outcomes at our academic medical center, we investigated the relationship between daily CC volume and complication rates. METHODS: We obtained data from both the National Cardiovascular Data Registry (NCDR) Cath-PCI and Lumedx© databases reviewing the records of patients undergoing scheduled, non-emergent CC at our facility between January 2005 to June 2013. Daily CC volume was analyzed as were complications including death, post-procedure MI, cardiogenic shock, heart failure, stroke, tamponade, bleeding, hematoma and acute kidney injury (AKI). RESULTS: 12,773 patients were identified who underwent 16,612 CCs on 2,118 days. The average age was 63 years (SD 12.4; range, 18-95). 61% were men. A total of 326 complications occurred in 243 patients on 233 separate days (2.0% CC complication rate). The average volume per day was 7.8 CCs. We found a low correlation between daily complications and CC volume (Spearman's rho =0.11; P<0.01) though complication rates were lowest on days with 6-11 procedures; higher rates were found on slower and busier days. CONCLUSIONS: We observed a U-shaped association between CC volume and rates of CC complications. The lowest complication rates were found on days with 6-11 procedures a day. The highest complication rate was seen with >11 procedures a day.