Concordance of Guideline-Based Risk Stratification and Selection of Patients for Transcatheter Aortic Valve Implantation or Surgical Replacement.

The 2020 American Health Association/American College of Cardiology valve guidelines recommend surgical aortic valve replacement (SAVR) for symptomatic patients with aortic stenosis (AS) age <65 years and transcatheter aortic valve implantation (TAVI) for patients with AS age >80 years. We analyzed TAVI versus SAVR practice patterns using age-based recommendations. We compared 2016-to-2019 TAVI and isolated SAVR in northern New England at 5 centers according to guideline-recommended age groups. Multivariable logistic regression was performed to identify independent predictors of TAVI for the intermediate age group. The study was approved by each site's institutional review board in accordance with ongoing participation and quality improvement efforts in the Northern New England Cardiovascular Study Group. Among 4,161 patients with isolated severe AS, TAVI increased from 2016 to 2019: 55.8% versus 76.1%, p <0.01 for trend. SAVR for patients with AS age >80 years was uncommon and decreased over time: 13.1% versus 1.6%, p <0.01. TAVI utilization nearly doubled over time in young patients with AS age <65 years (14.3% vs 26.2%, p <0.01). Preference for SAVR decreased by 50% over time (p <0.01) in the intermediate age group (65 to 80 years). Independent predictors of TAVI among patients aged 65 to 80 years included older age, chronic obstructive pulmonary disease, previous stroke, and coronary artery bypass grafting, whereas vascular disease and clinical urgency favored SAVR. In conclusion, consistent with current American Health Association/American College of Cardiology guidelines, TAVI was the treatment of choice in >97% of severe patients with AS age >80 years by 2019. TAVI utilization in patients <65 years has doubled over time and thus may not reflect current guideline recommendations. TAVI is the preferred choice in those aged 65 to 80 years, especially among patients with previous stroke or coronary artery bypass grafting.

The effect of catheter ablation for ventricular arrhythmias originating from the left ventricular papillary muscles on mitral valve function.

BACKGROUND: Ablation of ventricular arrhythmias (VA) originating from the left ventricular (LV) papillary muscles (PM) has the potential to damage the mitral valve apparatus resulting in mitral regurgitation (MR). This study sought to evaluate the effect of radiofrequency (RF) ablation of a PM on MR severity. METHODS: Patients with pre- and postablation transthoracic echocardiograms who underwent PM ablation for treatment of VA were retrospectively identified and compared to similar patients who underwent VA ablation at non-PM sites. MR severity was evaluated pre- and postablation in both groups and graded as none/trace (Grade 0); mild/mild-to-moderate (Grade 1); moderate (Grade 2); moderate-to-severe/severe (Grade 3). RESULTS: A total of 45 and 49 patients were included in the PM and non-PM groups, respectively. There were no significant baseline demographic differences. The PM group had longer RF ablation times (22.3 vs. 13.3 min, p < .01) compared to the non-PM group. Most patients had low-grade MR in both groups at baseline. Change in pre- versus postablation MR within the PM group was not statistically significant by Wilcoxon rank-sum test (Figure 2, p = .46). MR severity following ablation was also evaluated using logistic regression models. The odds ratio for worsening MR in the PM group compared to non-PM was 0.19 (95% confidence interval: 0.008-4.18, p = .29) after adjusting for comorbidities, LV ejection fraction, and LV internal end-diastolic diameter. CONCLUSION: RF ablation of VA originating from PM under intracardiac echocardiography guidance did not result in clinically or statistically significant worsening of MR.

WAMAMI: emergency physicians can accurately identify wall motion abnormalities in acute myocardial infarction.

OBJECTIVE: The ability to identify wall motion abnormalities may be useful for emergency clinicians, but is not typically evaluated in point-of-care echocardiograms. We sought to determine if emergency physicians with basic training in emergency echocardiography could identify regional wall motion abnormalities (RWMA) in patients admitted with ST-elevation myocardial infarction (STEMI). METHODS: We prospectively enrolled patients with admitted with STEMI. Resident physicians with basic training in emergency ultrasound, blinded to other patient data, performed a point-of-care echocardiogram to evaluate for RWMA. If present, they also recorded the suspected territory of the RWMA. We calculated test performance characteristics and compared the agreement between point-of-care and comprehensive echocardiogram for RWMA and territory. RESULTS: 75 patients with STEMI were enrolled, and 62% had a RMWA. RWMA were identified with excellent test performance characteristics (sensitivity 88% (95% CI 75-96); specificity 92% (95% CI 75-99)). There was substantial agreement between the point-of-care echocardiogram and reference standard (K = 0.79; 95% CI: 0.64-0.94). CONCLUSIONS: Emergency physicians with core training in point-of-care echocardiography can accurately identify RMWA.

Derivation and Validation of the CREST Model for Very Early Prediction of Circulatory Etiology Death in Patients Without ST-Segment-Elevation Myocardial Infarction After Cardiac Arrest.

BACKGROUND: No practical tool quantitates the risk of circulatory-etiology death (CED) immediately after successful cardiopulmonary resuscitation in patients without ST-segment-elevation myocardial infarction. We developed and validated a prediction model to rapidly determine that risk and facilitate triage to individualized treatment pathways. METHODS: With the use of INTCAR (International Cardiac Arrest Registry), an 87-question data set representing 44 centers in the United States and Europe, patients were classified as having had CED or a combined end point of neurological-etiology death or survival. Demographics and clinical factors were modeled in a derivation cohort, and backward stepwise logistic regression was used to identify factors independently associated with CED. We demonstrated model performance using area under the curve and the Hosmer-Lemeshow test in the derivation and validation cohorts, and assigned a simplified point-scoring system. RESULTS: Among 638 patients in the derivation cohort, 121 (18.9%) had CED. The final model included preexisting coronary artery disease (odds ratio [OR], 2.86; confidence interval [CI], 1.83-4.49; P≤0.001), nonshockable rhythm (OR, 1.75; CI, 1.10-2.77; P=0.017), initial ejection fraction<30% (OR, 2.11; CI, 1.32-3.37; P=0.002), shock at presentation (OR, 2.27; CI, 1.42-3.62; P<0.001), and ischemic time >25 minutes (OR, 1.42; CI, 0.90-2.23; P=0.13). The derivation model area under the curve was 0.73, and Hosmer-Lemeshow test P=0.47. Outcomes were similar in the 318-patient validation cohort (area under the curve 0.68, Hosmer-Lemeshow test P=0.41). When assigned a point for each associated factor in the derivation model, the average predicted versus observed probability of CED with a CREST score (coronary artery disease, initial heart rhythm, low ejection fraction, shock at the time of admission, and ischemic time >25 minutes) of 0 to 5 was: 7.1% versus 10.2%, 9.5% versus 11%, 22.5% versus 19.6%, 32.4% versus 29.6%, 38.5% versus 30%, and 55.7% versus 50%. CONCLUSIONS: The CREST model stratified patients immediately after resuscitation according to risk of a circulatory-etiology death. The tool may allow for estimation of circulatory risk and improve the triage of survivors of cardiac arrest without ST-segment-elevation myocardial infarction at the point of care.

Instrumental variable analysis to compare effectiveness of stents in the extremely elderly.

BACKGROUND: Evaluating novel therapies is challenging in the extremely elderly. Instrumental variable methods identify variables associated with treatment allocation to perform adjusted comparisons that may overcome limitations of more traditional approaches. METHODS AND RESULTS: Among all patients aged ≥85 years undergoing percutaneous coronary intervention in nonfederal hospitals in Massachusetts between 2003 and 2009 (n=2690), we identified quarterly drug-eluting stent (DES) use rates as an instrumental variable. We estimated risk-adjusted differences in outcomes for DES versus bare metal stents using a 2-stage least squares instrumental variable analysis method. Quarterly DES use ranged from 15% to 88%. Unadjusted 1-year mortality rates were 14.5% for DES versus 23.0% for bare metal stents (risk difference, -8.5%; P<0.001), an implausible finding compared with randomized trial results. Using instrumental variable analysis, DES were associated with no difference in 1-year mortality (risk difference, -0.8%; P=0.76) or bleeding (risk difference, 2.3%; P=0.33) and with significant reduction in target vessel revascularization (risk difference, -8.3%; P<0.0001). CONCLUSIONS: Using an instrumental variable analysis, DES were associated with similar mortality and bleeding and a significant reduction in target vessel revascularization compared with bare metal stents in the extremely elderly. Variation in use rates may be useful as an instrumental variable to facilitate comparative effectiveness in groups underrepresented in randomized trials.

Comparison of bare-metal stents and drug-eluting stents in coronary ostial lesions (from the National Heart, Lung, and Blood Institute Dynamic Registry).

We compared the effectiveness of drug-eluting stents (DESs) to bare-metal stents (BMSs) in ostial lesions from an unrestricted patient cohort with 3-year follow-up. DESs have proved more effective at decreasing repeat revascularization rates compared to BMSs in patients with uncomplicated coronary artery disease. Whether DESs provide similar benefits in ostial lesions is not clearly defined. We analyzed data from 775 patients in the National, Heart, Lung, and Blood Institute Dynamic Registry undergoing stenting of ostial lesions with DESs or BMSs. Patients were followed for 3 years for the occurrence of myocardial infarction (MI), repeat revascularization (coronary bypass surgery/repeat percutaneous coronary intervention), and death. In total 439 patients had 464 ostial lesions treated with BMSs and 336 patients had 351 ostial lesions treated with DESs. Adjusted DES versus BMS 3-year hazard ratios were 1.03 (95% confidence interval 0.60 to 1.78, p = 0.90) for death, 1.40 (0.83 to 2.37, p = 0.21) for MI, and 0.81 (0.59 to 1.11, p = 0.19) for repeat revascularization. In patients undergoing percutaneous coronary intervention for aorto-ostial disease (n = 200), death and repeat revascularization did not differ between stent types, but DES-treated patients had more MI during follow-up. For coronary ostial disease (n = 574), 3-year observed rates of death or MI did not differ; however, repeat revascularization was more common in the BMS group. In conclusion, use of DESs for ostial lesions was associated with no difference in the hazard of death, MI, or overall rates of repeat revascularization compared to BMS use.

Quality of care and outcomes among patients with acute myocardial infarction by level of kidney function at admission: report from the get with the guidelines coronary artery disease program.

BACKGROUND: Many patients admitted for acute myocardial infarction (AMI) have chronic renal insufficiency. We studied the impact of chronic renal insufficiency on mortality and quality of inpatient care for AMI from the American Heart Association's Get With The Guidelines-Coronary Artery Disease Program. HYPOTHESIS: We hypothesized that mortality and quality of inpatient care would not vary with renal function. METHODS: We examined in-hospital AMI performance measures by renal function based on glomerular filtration rate (GFR). Severity of renal insufficiency was categorized as normal (GFR ≥ 90 mL/min/1.73 m(2)), mild (GFR 60-90 mL/min/1.73 m(2)), moderate (GFR 30-60 mL/min/1.73 m(2)), severe (GFR 15-30 mL/min/1.73 m(2)), and kidney failure (GFR ≤ 15 mL/min/1.73 m(2) or dialysis). A total of 21721 patients from 291 sites were studied, with most data collected in 2008 to 2009. Multivariable regression analysis after adjusting for patient characteristics was performed and generalized estimating equations were used to account for within-hospital clustering. In-hospital mortality and quality of inpatient care were assessed. RESULTS: Renal insufficiency was present in 82.0 percent of AMI patients. The adjusted odds ratio vs normal renal function for mortality increased with worsening renal function: 1.45 for mild renal insufficiency (95% confidence interval [CI]: 1.03-2.05, P = 0.03); 3.36 for moderate renal insufficiency (95% CI: 2.31-4.89, P < 0.0001); 5.43 for severe renal insufficiency (95% CI: 3.70-7.95, P < 0.0001); and 6.35 for kidney failure (95% CI: 4.48-9.01, P < 0.0001). Patients with renal insufficiency received less inpatient and discharge guideline-recommended therapy for AMI. CONCLUSIONS: Among AMI patients, mortality and guideline-recommended inpatient therapy correlated inversely with renal function. Adjusted mortality was equally poor among patients with severe renal dysfunction and on dialysis.

Revascularization for left main and multivessel coronary artery disease in the drug-eluting stent era: integration of recent drug-eluting stent trials.

As older patients comprise a greater proportion of the population, the incidence of multivessel and left main coronary artery disease is increasing. Given the improvements in percutaneous coronary intervention, more patients are suitable for this revascularization strategy. However, the optimal revascularization strategy remains a moving target. Numerous trials, extending from the bypass surgery versus medical therapy era to the most current drug-eluting stent versus bypass surgery era, provide information to select the most appropriate revascularization strategy. The objective of this review is to summarize these data.

Testosterone supplementation in heart failure: a meta-analysis.

BACKGROUND: Low testosterone is an independent predictor of reduced exercise capacity and poor clinical outcomes in patients with heart failure (HF). We sought to determine whether testosterone therapy improves exercise capacity in patients with stable chronic HF. METHODS AND RESULTS: We searched Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (1980-2010). Eligible studies included randomized controlled trials (RCTs) reporting the effects of testosterone on exercise capacity in patients with HF. Reviewers determined the methodological quality of studies and collected descriptive, quality, and outcome data. Four trials (n=198; men, 84%; mean age, 67 years) were identified that reported the 6-minute walk test (2 RCTs), incremental shuttle walk test (2 RCTs), or peak oxygen consumption (2 RCTs) to assess exercise capacity after up to 52 weeks of treatment. Testosterone therapy was associated with a significant improvement in exercise capacity compared with placebo. The mean increase in the 6-minute walk test, incremental shuttle walk test, and peak oxygen consumption between the testosterone and placebo groups was 54.0 m (95% CI, 43.0-65.0 m), 46.7 m (95% CI, 12.6-80.9 m), and 2.70 mL/kg per min (95% CI, 2.68-2.72 mL/kg per min), respectively. Testosterone therapy was associated with a significant increase in exercise capacity as measured by units of pooled SDs (net effect, 0.52 SD; 95% CI, 0.10-0.94 SD). No significant adverse cardiovascular events were noted. CONCLUSIONS: Given the unmet clinical needs, testosterone appears to be a promising therapy to improve functional capacity in patients with HF. Adequately powered RCTs are required to assess the benefits of testosterone in this high-risk population with regard to quality of life, clinical events, and safety.

Transesophageal echocardiography of the descending thoracic aorta: establishing an accurate anatomic marker using the celiac artery.

OBJECTIVE: We performed transesophageal echocardiography (TEE) and computed tomography (CT) on patients with aortic pathology to describe a more anatomically coherent marker on TEE studies by using the celiac artery as a reference. BACKGROUND: As there are no anatomic markers for the eight-vertebrae long descending thoracic aorta, aortic disease (AD) is routinely reported as a distance from the dental incisors in TEE studies. This method does not provide an anatomically accurate location of AD relative to recognizable anatomy. METHODS: Ten patients referred for contrast CT and TEE for evaluation of embolic events were studied. Twenty-seven focal aortic lesions found on TEE were measured relative to their distance from the celiac artery. The agreement among the two methods of quantification of aortic lesions from the celiac artery was assessed by univariate regression analysis and by the Bland-Altman method. Difference in the mean values between the two groups was analyzed by paired t-test. RESULTS: The P value for the two-tailed t-test for the difference between the two modalities was 0.122. The Pearson coefficient for comparison of CT and TEE data was 0.98. The coefficient of determination for TEE versus CT data was 0.96. CONCLUSIONS: The TEE CA reference marker proves to be an accurate method for localizing disease in the descending thoracic aorta relative to CT findings. Reporting of aortic disease relative to this marker is more clinically applicable than the current method of measurement. The CA reference marker should be routinely reported in TEE studies to enhance the diagnosis of aortic disease.

Drug-eluting stents in the elderly.

OPINION STATEMENT: The introduction of drug-eluting stents (DES) in 2003 has had a great impact on the management of coronary artery disease in the United States. The application of DES to older adults, the population with the highest prevalence of and worst prognosis for coronary artery disease, remains relatively more controversial. Dual-antiplatelet therapy, which is recommended for at least 12 months after DES placement, is particularly problematic for older patients because of greater age-related bleeding risks. Unfortunately, few current data are available to gauge the balance of risk and benefit in elderly community-dwelling DES patients. Although trial data show a benefit for DES among elderly patients, many older adults typically are excluded from randomized trials because of comorbidities, making generalizability of DES safety based on trial data less certain. New, more potent thienopyridines may place the elderly at a particularly elevated bleeding risk. There is a fine balance between efficacy and safety for older DES patients that still needs to be clarified. As the population ages, these issues become more pervasive and of widespread concern. This review summarizes the current literature on DES therapy in the elderly, with a focus on effectiveness and safety profiles of DES versus bare metal stents.

Radiation safety among cardiology fellows.

Cardiology fellows can be exposed to high radiation levels during procedures. Proper radiation training and implementation of safety procedures is of critical importance in lowering physician health risks associated with radiation exposure. Participants were cardiology fellows in the United States (n = 2,545) who were contacted by e-mail to complete an anonymous survey regarding the knowledge and practice of radiation protection during catheterization laboratory procedures. An on-line survey engine, SurveyMonkey, was used to distribute and collect the results of the 10-question survey. The response rate was 10.5%. Of the 267 respondents, 82% had undergone formal radiation safety training. Only 58% of the fellows were aware of their hospital's pregnancy radiation policy and 60% knew how to contact the hospital's radiation safety officer. Although 52% of the fellows always wore a dosimeter, 81% did not know their level of radiation exposure in the previous year and only 74% of fellows knew the safe levels of radiation exposure. The fellows who had received formal training were more likely to be aware of their pregnancy policy, to know the contact information of their radiation safety officer, to be aware of the safe levels of radiation exposure, to use dosimeters and RadPad consistently, and to know their own level of radiation exposure in the previous year. In conclusion, cardiology fellows have not been adequately educated about radiation safety. A concerted effort directed at physician safety in the workplace from the regulatory committees overseeing cardiology fellowships should be encouraged.

Association of insurance status with inpatient treatment for coronary artery disease: findings from the Get With the Guidelines program.

BACKGROUND: Prior studies have documented that patients' health insurance status can impact use of guideline-based care as well as acute outcomes for coronary artery disease. Whether insurance status remains a contemporary influence among centers participating in a national quality improvement initiative is unknown. METHODS: We analyzed data from 237,779 admissions with coronary artery disease from 527 hospitals participating in the Get With The Guidelines-Coronary Artery Disease Program from 2000 to 2008. Insurance status was Medicare (48.8%), Private/Health Maintenance Organization (HMO) (34.9%), Medicaid (8.2%), and No Insurance Documented (NID) (8.2%). Quality of care was measured using standard quality indicators covering acute treatment and discharge measures, utilization of invasive procedures, length of stay, and mortality. Relationship between different insurance types was examined using generalized estimating equation logistic regression and propensity-score matching adjusting for demographics, comorbidities and hospital characteristics. RESULTS: After propensity matching, full compliance with all eligible measures (deficit-free care) relative to Private/HMO was lower for Medicare (P < .0001) and Medicaid (P < .0001) and higher for the NID group (P = .0312). The acute reperfusion times were comparable among the groups. Compared with the Private/HMO group, all three groups had higher generalized estimating equation-adjusted mortality (OR, 1.15; 95% CI, 1.08-1.21; P < .001; OR, 1.18; 95% CI, 1.09-1.29; P < .001 and OR, 1.13; 95% CI, 1.01-1.25; P = .026), for Medicare, Medicaid, and NID, respectively. After propensity matching, mortality for Medicare was similar (P = .1197) and higher for NID (P = .0015) and Medicaid (P = .0015) groups. CONCLUSIONS: These findings suggest that among centers participating in a national quality improvement initiative patient insurance status may be associated with differences in cardiovascular care and outcomes.

Usefulness of hand-carried ultrasound to predict elevated left ventricular filling pressure.

Detection of increased left ventricular filling pressure (LVFP) is paramount in the evaluation and treatment of patients with left heart failure, yet difficult to assess directly at the bedside. Although inferior vena cava (IVC) examination can detect increased right atrial pressure, a used surrogate for high LVFP, this assumption has not been directly tested. We evaluated whether assessment of IVC size and respirophasic variation could be used to predict increased LVFP. Seventy-two patients with chronic heart failure underwent right heart catheterization and limited echocardiographic examination focused on the IVC. IVC size and collapsibility were evaluated for their ability to predict a wedge pressure>or=15 mm Hg. In conclusion, an IVC maximum dimension of 2.0 cm and IVC collapsibility of 45% were the optimal cutoffs to predict an increased pulmonary capillary wedge pressure, with sensitivities of 75% and 83% and specificities of 83% and 71%, respectively.

Comparison of hand-carried ultrasound assessment of the inferior vena cava and N-terminal pro-brain natriuretic peptide for predicting readmission after hospitalization for acute decompensated heart failure.

OBJECTIVES: We sought to compare the value of serial assessment with hand-carried ultrasound (HCU) of the inferior vena cava (IVC) with brain natriuretic peptide (BNP) to identify patients with acute decompensated heart failure (ADHF) who will be readmitted or seek emergency department treatment after hospital discharge. BACKGROUND: Congestive heart failure (CHF) is a leading cause for hospitalization and, once hospitalized, patients with CHF frequently are readmitted. To date, no reliable index exists that can be used to predict whether patients with ADHF can be discharged with low readmission likelihood. METHODS: A total of 75 patients who were admitted with a primary diagnosis of ADHF were followed. All patients were assessed at admission and discharge with the use of routine clinical evaluation, BNP measurement, and HCU evaluation of the IVC by physicians with limited training in ultrasound. RESULTS: During the 30-day follow-up, 31 patients were rehospitalized or presented to the emergency department. Patients who were subsequently readmitted could not be differentiated from those who were not readmitted by their demographics, comorbidities, vital signs, presence of symptoms/signs suggestive of persistent congestion, hospital length of stay, or net volume removal. Routine laboratory tests, including assessment of renal function, also failed to predict readmission with the exception of serum sodium. Although admission BNP was similar in patients readmitted and not readmitted, pre-discharge log-transformed BNP was greater in patients who subsequently were readmitted. Patients who required repeat hospitalization had a larger IVC size on admission as well as at discharge. In addition, patients who were readmitted had persistently plethoric IVCs with lower IVC collapsibility indexes. At discharge, only serum sodium, log-transformed BNP, IVC size, and collapsibility were statistically significant predictors of readmission. CONCLUSIONS: This study confirms that, once hospitalized, patients with CHF frequently are readmitted. Bedside evaluation of the IVC with a HCU device at the time of admission and discharge, as well as pre-discharge BNP, identified patients admitted with ADHF who were more likely to be readmitted to the hospital.