Balancing Hemostasis With Thrombosis: A Challenging Case of Pregnancy With a Mechanical Mitral Valve.

A 32-year-old pregnant woman with a mechanical mitral valve was admitted with vaginal bleeding and was found to have placenta previa. During her hospital stay, she developed acute valvular thrombosis. She underwent an emergency cesarean section followed by successful mechanical valve replacement.

Sex Differences and Temporal Trends in Revascularization and Outcomes of ST-Elevation Myocardial Infarction in Older Adults in the United States.

BACKGROUND: Previous studies have suggested that in-hospital mortality is higher in younger women with ST-segment elevation myocardial infarction (STEMI) than in men. However, more coronary artery disease diagnoses occurred in patients older than 60 years. AIM OF THE STUDY: This study sought to investigate the temporal trends and sex differences in revascularization and in-hospital outcomes in older STEMI patients. METHODS: National Inpatient Sample databases from 2005-2014 were utilized to identify all STEMI patients with age greater than 60 years old. We studied the temporal trends and sex differences in revascularization therapies and in-hospital mortality. RESULTS: From 2005-2014, there were 192,204 older adults diagnosed with STEMI. Older women with STEMI were less likely to receive reperfusion (percutaneous coronary intervention (PCI) adjusted OR: 0.90; 95% CI: 0.87-0.92) compared to older men. Also, the adjusted odds ratio comparing the likelihood of receiving PCI between women and men decreased by an annual average of 0.9% (p = 0.028). Older women had higher in-hospital mortality than men (adjusted OR: 1.12; 95% CI: 1.08 to 1.17). There was no significant change of adjusted in-hospital mortality in both genders (all p >0.05). CONCLUSIONS: Older women were less likely to receive revascularization for STEMI, and this gap was increasing during the study period. Older women had higher in-hospital mortality as compared with older men, but there was no significant temporal change for both genders. These findings present an opportunity to bridge the gender-gap in providing care to older patients with STEMI.

Diastolic dysfunction in women with ischemia and no obstructive coronary artery disease: Mechanistic insight from magnetic resonance imaging.

BACKGROUND: Ischemia with no obstructive coronary artery disease (INOCA) is prevalent in women and is associated with increased risk of developing heart failure with preserved ejection fraction (HFpEF); however, the mechanism(s) contributing to this progression remains unclear. Given that diastolic dysfunction is common in women with INOCA, defining mechanisms related to diastolic dysfunction in INOCA could identify therapeutic targets to prevent HFpEF. METHODS: Cardiac MRI was performed in 65 women with INOCA and 12 reference controls. Diastolic function was defined by left ventricular early diastolic circumferential strain rate (eCSRd). Contributors to diastolic dysfunction were chosen a priori as coronary vascular dysfunction (myocardial perfusion reserve index [MPRI]), diffuse myocardial fibrosis (extracellular volume [ECV]), and aortic stiffness (aortic pulse wave velocity [aPWV]). RESULTS: Compared to controls, eCSRd was lower in INOCA (1.61 ± 0.33/s vs. 1.36 ± 0.31/s, P = 0.016); however, this difference was not exaggerated when the INOCA group was sub-divided by low and high MPRI (P > 0.05) nor was ECV elevated in INOCA (29.0 ± 1.9% vs. 28.0 ± 3.2%, control vs. INOCA; P = 0.38). However, aPWV was higher in INOCA vs. controls (8.1 ± 3.2 m/s vs. 6.1 ± 1.5 m/s; P = 0.045), and was associated with eCSRd (r = -0.50, P < 0.001). By multivariable linear regression analysis, aPWV was an independent predictor of decreased eCSRd (standardized ß = -0.39, P = 0.003), as was having an elevated left ventricular mass index (standardized ß = -0.25, P = 0.024) and lower ECV (standardized ß = 0.30, P = 0.003). CONCLUSIONS: These data provide mechanistic insight into diastolic dysfunction in women with INOCA, identifying aortic stiffness and ventricular remodeling as putative therapeutic targets.

Comparing the Real-World Effectiveness of Competing Colonoscopy Preparations: Results of a Prospective Trial.

OBJECTIVES: National societies provide little guidance regarding which colonoscopy bowel preps are best tolerated and most effective; this reflects a lack of comparative effectiveness studies that directly evaluate the available preps in a "real-world" setting. To address this gap, we conducted a prospective, commercially unfunded comparative effectiveness study of currently available bowel preps and measured their impact on bowel cleansing. METHODS: We included patients aged ≥18 years, who presented for an outpatient colonoscopy at a large medical center serving more than 70 academic and community-based endoscopists who are free to prescribe the bowel prep of their choice. The primary outcome was bowel cleansing quality as measured by the Boston Bowel Preparation Scale. We performed regression models with random effects on the outcomes to adjust for confounding. RESULTS: Approximately 4,339 colonoscopies were performed by 75 endoscopists. Magnesium citrate, MiraLAX with Gatorade, MoviPrep, OsmoPrep, Prepopik/Clenpiq, and Suprep all had significantly higher prep tolerability compared with GoLYTELY (all P < 0.05). For bowel cleansing, Suprep (7.28 ± 1.66; P < 0.001), MoviPrep (7.11 ± 1.62; P = 0.004), and MiraLAX with Gatorade (7.09 ± 1.64; P < 0.001) had higher total Boston Bowel Preparation Scale scores compared with GoLYTELY (6.67 ± 1.87); there were no significant differences among the remaining preps. Split-prep dosing was associated with better cleansing; however, men, opioid and tricyclic antidepressent users, and patients with diabetes and cirrhosis had worse cleansing (all P < 0.05). CONCLUSIONS: In this prospective, real-world comparative effectiveness study of available bowel preps, we found that MiraLAX with Gatorade, MoviPrep, and Suprep were prospectively associated with superior tolerability and bowel cleansing.