Initial Single-Center ST-Segment Elevation Myocardial Infarction Experience in New York Before and During the COVID-19 Pandemic.

BACKGROUND/PURPOSE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as a highly contagious and lethal virus, devastating healthcare systems throughout the world. Following a period of stability, the coronavirus disease 2019 (COVID-19) pandemic appears to be re-intensifying globally. As the virus continues to evolve, so does our understanding of its implications on ST-segment elevation myocardial infarction (STEMI). We sought to describe a single center STEMI experience at one of the epicenters during the COVID-19 pandemic. METHODS/MATERIALS: We conducted a retrospective, observational study comparing STEMI patients during the pandemic period (March 1 to August 31, 2020) to those with STEMI during the pre-pandemic period (March 1 to August 31, 2019) at NYU Langone Hospital - Long Island, a tertiary-care center in Nassau County, New York. Additionally, we describe our subset of COVID-19 patients with STEMI during the pandemic. RESULTS: The acute myocardial infarction (AMI) team was activated for 183 patients during both periods. There were a similar number of AMI team activations during the pandemic period (n = 93) compared to the pre-pandemic period (n = 90). Baseline characteristics did not differ during both periods; however, infection control measures and additional investigation were required to clarify the diagnosis during the pandemic, resulting in a signal toward longer door-to-balloon times (95.9 min vs. 74.4 min, p = 0.0587). We observed similar inpatient length of stay (LOS) (3.6 days vs. 5.0 days, p = 0.0901) and mortality (13.2% vs. 9.2%, p = 0.5876). There were 6 COVID-19-positive patients who presented with STEMI, of whom 4 were emergently taken to the cardiac catheterization laboratory with successful percutaneous coronary intervention (PCI) performed in 3 patients. The 2 patients who were not offered primary PCI expired, as both were treated medically, one with thrombolytics. CONCLUSIONS: Our single-center study, in New York, at one of the epicenters of the pandemic, demonstrated a similar number of AMI team activations, mimicking the seasonal variability seen in 2019, but with a signal toward longer door-to-balloon time. Despite this, inpatient LOS and mortality remained similar.

Snow-Shoveling-Induced Takotsubo Cardiomyopathy.

Snow shoveler's infarction is the phenomenon of increased incidence of myocardial infarction (MI) in the days following a snow storm. Followingheavy snowfall, public awareness of snow- shoveling-induced MI is heightened by news cover- age. We report a case of show-shoveling-induced chest pain with ECG changes concerning for MI. Emergent angiography revealed normal coronary arteries and apical ballooning consistent with ta- kotsubo cardiomyopathy (TCM). TCM, a transient cardiomyopathy, is often clinically indistinguishable from MI and is often induced by emotional/ physical stress. In conclusion, TCM is an alternative diagnosis to MI in patients presenting with chest pain after a period of heavy snowfall.

The impact of previous revascularization on clinical outcomes in patients undergoing primary percutaneous coronary intervention.

While the impact of prior coronary artery bypass graft surgery (CABG) on in-hospital outcomes in patients with ST-elevation myocardial infarction (STEMI) has been described, data are limited on patients with prior percutaneous coronary intervention (PCI) undergoing primary PCI in the setting of an STEMI. The aim of the present study was to assess the effect of previous revascularization on in-hospital outcomes in STEMI patients undergoing primary PCI. Between January 2004 and December 2007, a total of 1649 patients underwent primary PCI for STEMI at four New York State hospitals. Baseline clinical and angiographic characteristics and in-hospital outcomes were prospectively collected as part of the New York State PCI Reporting System (PCIRS). Patients with prior surgical or percutaneous coronary revascularization were compared to those without prior coronary revascularization. Of the 1649 patients presenting with STEMI, a total of 93 (5.6%) had prior CABG, 258 (15.7%) had prior PCI, and 1298 (78.7%) had no history of prior coronary revascularization. Patients with prior CABG were significantly older and had higher rates of peripheral vascular disease, diabetes mellitus, congestive heart failure, and prior stroke. Additionally, compared with those patients with a history of prior PCI as well as those without prior coronary revascularization, patients with previous CABG had more left main interventions (24% vs 2% and 2%; P<.001), but were less often treated with drug-eluting stents (47% vs 61% and 72%; P<.001). Despite a low incidence of adverse in-hospital events, prior CABG was associated with higher all-cause in-hospital mortality (6.5% vs 2.2%; P=.012), and as a result, higher overall MACE (6.5% vs 2.7%; P=.039). By multivariate analysis, prior CABG (odds ratio, 3.40; 95% confidence interval, 1.15-10.00) was independently associated with in-hospital mortality. In contrast, patients with prior PCI had similar rates of MACE (4.3% vs 2.7%; P=.18) and in-hospital mortality (3.1% vs 2.2%; P=.4) when compared to the de novo population. Patients with a prior history of CABG, but not prior PCI, undergoing primary PCI in the setting of STEMI have significantly worse in-hospital outcomes when compared with patients who had no prior history of coronary artery revascularization. Thus, only prior surgical - and not percutaneous - revascularization should be considered a significant risk factor in the setting of primary PCI.

Determinants of bare-metal stent use in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Bare-metal stent (BMS) use in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has been associated with higher rates of adverse cardiac events, including target lesion and target vessel revascularization. The purpose of the present study was to determine which clinical characteristics predict BMS use in patients with STEMI undergoing primary PCI. Data were prospectively collected from all patients who underwent primary PCI for STEMI between January 1, 2004 and December 31, 2007 at four New York State academic medical centers. Demographics, baseline medical history, procedural characteristics, and in-hospital outcomes were compared in patients receiving DESs versus BMSs. Of the 1394 patients studied, a total of 290 (20.8%) patients received a BMS while 1104 (79.2%) received a DES. Patients receiving a BMS were more likely to have higher rates of prior coronary artery bypass graft surgery, prior PCI, peripheral vascular disease, and diabetes mellitus, and were more likely to be Hispanic and uninsured. They were also more likely to present with stent thrombosis and worse left ventricular ejection fraction (LVEF). Patients receiving a BMS had significantly longer hospital length of stay and a trend toward higher all-cause in-hospital mortality. In multivariate analysis, independent predictors of BMS use included uninsured status (versus private insurance) (odds ratio [OR], 2.81; 95% confidence interval [CI], 1.70-4.67), peripheral vascular disease (OR, 1.96; 95% CI, 1.08- 3.56), and LVEF (OR, 0.98; 95% CI, 0.97-0.99). In conclusion, in this analysis of a contemporary cohort of patients undergoing primary PCI, lack of health insurance, peripheral vascular disease, and worse LVEF were independently associated with higher rates of BMS implantation in patients with STEMI undergoing primary PCI.

Impact of severity of renal dysfunction on determinants of in-hospital mortality among patients undergoing percutaneous coronary intervention.

BACKGROUND: Chronic kidney disease (CKD) is a known prognostic indicator of poor outcomes following percutaneous coronary intervention (PCI) for coronary artery disease. However, it is unclear whether other predictors of mortality differ among patients with varying degrees of renal impairment. Thus, we aimed to identify determinants of in-hospital mortality which are specific to patients with preserved renal function, moderate CKD, or end stage renal disease (ESRD) on dialysis, undergoing PCI. METHODS: The study population included 25,018 patients who underwent PCI between January 1, 2004, and December 31, 2007, at four New York State hospitals. The primary endpoint of the study was in-hospital mortality. RESULTS: A total of 474 (1.9%) patients had ESRD on dialysis, 6,596 (26.4%) had moderate CKD (GFR<60 ml/min/1.73 m(2) ), and 17,948 (71.7%) had preserved renal function (GFR>60 ml/min/1.73 m(2) ). Patients with ESRD and moderate CKD were older, more often male, and had higher rates of prior coronary revascularization, peripheral vascular disease, congestive heart failure, prior stroke, and diabetes than those with preserved function. All-cause in-hospital mortality rates were significantly higher in patients with ESRD and moderate CKD compared to patients with GFR >60 ml/min/1.73 m(2) (2.1% and 1.3%, respectively vs. 0.3%, p < 0.001). In multivariable analysis, ESRD (OR: 3.68, 95% CI 1.62-8.36) and moderate CKD (OR: 2.92, 95% CI 1.91-4.46) were independently associated with higher rates of in-hospital mortality. Independent predictors of mortality were markedly distinct in each group and included female gender and myocardial infarction within the past 72 hr in the ESRD group, versus left ventricular ejection fraction, peripheral vascular disease, congestive heart failure, emergency PCI, and absence of prior PCI in the moderate CKD group and age, prior bypass graft surgery, congestive heart failure, emergency PCI, and absence of prior myocardial infarction in patients with preserved renal function. CONCLUSIONS: Patients with moderate CKD or ESRD undergoing PCI have an approximately threefold increase in the risk of in-hospital mortality compared with patients with preserved renal function, with radically different mortality predictors existing for varying levels of renal function.

Association of health insurance status with presentation and outcomes of coronary artery disease among nonelderly adults undergoing percutaneous coronary intervention.

OBJECTIVE: The aim of this study was to determine if insurance status is associated with adverse outcomes in patients with coronary artery disease. METHODS: A cohort of 13,456 patients who underwent percutaneous coronary intervention (PCI) between January 1, 2004, and December 31, 2007, at 4 New York State teaching hospitals was retrospectively studied. The primary outcome of interest was in-hospital mortality from any cause. RESULTS: Of the 13,456 patients studied, 11,927 (88.6%) were insured by private carriers, 1,036 (7.7%) patients were covered by Medicaid, and 493 (3.7%) were uninsured. Uninsured and Medicaid patients tended to be younger and more often nonwhite and Hispanic. They had a higher prevalence of congestive heart failure and worse left ventricular function. Compared with privately insured patients, uninsured and Medicaid patients had increased all-cause mortality (1.2% and 0.9%, respectively, vs 0.3%; P < .001). For all patients, lack of insurance (OR 3.02, 95% CI 1.10-8.28) and Medicaid (OR 4.39, 95% CI 1.93-9.99) were independently associated with mortality. Lack of insurance (OR 5.02, 95% CI 1.58-15.93) and Medicaid (OR 4.55, 95% CI 1.19-17.45) were also independently associated with increased mortality in patients undergoing emergent PCI. CONCLUSION: Lack of insurance and Medicaid insurance are both independently associated with an increased risk of in-hospital mortality after PCI for coronary artery disease.

Effect of gender and race on outcomes in dialysis-dependent patients undergoing percutaneous coronary intervention.

We aimed to determine whether gender and race are independently associated with in-hospital major adverse cardiac and cerebrovascular events (MACCE) and hospital length of stay in chronic dialysis patients undergoing percutaneous coronary intervention (PCI). Cardiovascular disease is the leading cause of mortality in patients with end-stage renal disease requiring dialysis. Whether gender or race independently influences the outcomes in patients undergoing PCI is not fully understood. The study population included 474 chronic dialysis patients who underwent PCI at 4 New York State teaching hospitals from January 1, 2004 to December 31, 2007. The primary end point of the study was the composite of in-hospital MACCE, defined as all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke. The secondary end points included in-hospital all-cause mortality and hospital length of stay. Of the 474 chronic dialysis patients, 172 (36.3%) were women. The women undergoing PCI were more likely to be black or Hispanic and had a greater left ventricular ejection fraction. The women had significantly greater rates of in-hospital MACCE (5.8% vs 1.7%, p=0.013) and mortality (4.7% vs 0.7%, p=0.006). No significant difference in the MACCE rates was found between the black and white patients (4.9% vs 2.2%, respectively, p=0.125), although black patients showed a trend toward greater in-hospital mortality (4.1% vs 1.2%, p=0.069). After adjustment for the baseline clinical and procedural characteristics, female gender was an independent predictor of MACCE (odds ratio 7.41, 95% confidence interval 1.81 to 30.27) and all-cause mortality (odds ratio 13.23, 95% confidence interval 1.55 to 113.25), but race was not. No significant difference in the hospital length of stay was observed by either gender or race. In conclusion, in this study, female gender was independently associated with a greater risk of MACCE and all-cause mortality in dialysis-dependent patients undergoing PCI. Although being a black woman was an independent predictor of mortality, race per se was not an independent predictor of in-hospital mortality.

Patient awareness of stent type, risk of cardiac events, and symptoms of myocardial infarction among PCI patients: a missed educational opportunity?

BACKGROUND: Timely and successful treatment of myocardial infarction (MI) requires accurate recognition by the patient of the signs and symptoms. As patients who have undergone percutaneous coronary intervention (PCI) remain at risk for cardiac events, it is important that they have a basic understanding of their cardiac status. METHODS: We surveyed 80 consecutive patients following elective PCI using a simple multiple-choice questionnaire. Type of stent (bare metal or drug-eluting), how they perceive the procedure would affect their cardiovascular health, their perceived risk of a future MI, and whether they recalled specific education on how to recognize symptoms of an MI were queried. RESULTS: 45% (n = 36) of patients were unaware of stent type. 10% stated PCI was performed to relieve symptoms of angina, 30% (n = 24) stated it would prevent MI, 56.3% (n = 45) stated that it would both prevent MI and reduce symptoms of angina, while 3.8% stated it would do neither. 86.3% (n = 69) stated they remained at risk for MI despite the procedure. However, 42.5% (n = 34) of patients did not perceive to have received specific education on the signs and symptoms of MI during their hospital stay. CONCLUSIONS: Patient understanding of stent type, expected cardiovascular outcomes, and recognition of MI post-PCI appears low in the real-world setting. A systematic approach to post-PCI education should be incorporated into routine care, in order to capitalize on the educational opportunity afforded by this high risk population.

Age-related decline in postextrasystolic potentiation in patients with aortic stenosis.

In aortic stenosis (AS), postextrasystolic potentiation (PESP), a measure of contractile reserve, has been demonstrated by an increased aortic valve gradient (AVG) after a ventricular extrasystole (VE). We studied age-related changes in PESP in 20 consecutive patients (age, 65-89 years) with significant AS (aortic area