Lipid-Lowering Therapy Utilization and Dosage Among Patients with Acute Coronary Syndrome Events: A Retrospective Cohort from 12 Community Hospitals.

Introduction: Clinical practice guidelines recommend initiating a high-intensity LLT and continued monitoring of low-density lipoprotein cholesterol (LDL-C) following acute coronary syndrome (ACS). We used real-world data to describe LLT utilization after discharge and 1-year adherence. The reduction in LDL-C was also evaluated. Methods: Data were extracted from electronic health records (EHRs) from 12 hospitals in a large community healthcare system in midwestern United States between 2013 and 2019. Data on eligible patients recently discharged with an ACS event were linked to pharmacy claims data to describe LLT fill rates and 1-year post-discharge adherence. Adherence was reported as the proportion of days covered ≥80%. Results: Of the 10,589 eligible patients, 49% filled a high-intensity statin at discharge and only 36% were adherent at 1 year. The mean (SD) age was 66.1±13.3, 39.3% were females, 58.8% were Caucasian, and 53.0% had Medicare. There was a clear trend for greater fill rates at discharge among patients with higher LDL-C values than those with lower values (p<0.01). Key predictors of high-intensity (versus medium-intensity) LLT use within 21 days after an ACS event included ACS type (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.52-0.67 for NSTEMI versus STEMI), age group (OR: 0.59; 95% CI: 0.48-0.72 for >75 years versus <65 years), and statin use before index ACS event (OR: 1.56; 95% CI: 1.23-1.88). Conclusion: This real-world study found that despite recommendations in clinical practice guidelines, high-intensity LLT fill rates at discharge and 1-year adherence to LLT remain suboptimal. Clinical characteristics, including ACS type and LDL-C values, were strong predictors of filling and adherence to guideline-recommended therapy. Age, sex, and race/ethnicity disparities were observed in discharge fill rates and 1-year adherence. These results highlight the need for continued efforts at the patient and provider levels to improve LLT adherence among ACS patients.

Short and long term failure of the modular oncology knee prosthesis.

This retrospective study investigated the modes of implant failure in 80 patients with modular oncology knee prostheses. Twenty patients (25%) required revision: 12 (60%) for stem loosening, 6 (30%) for bearing failure, and 2 (10%) for infection. Patients with bone sarcomas survived longer; however, long-term prosthetic survivorship was a problem. A higher failure rate was found in patients with tibial tumors and with adjuvant treatment of chemotherapy. This study demonstrates for improved long-term survivorship of modular oncology knee prostheses, there must be improvement in the methods of stem fixation, prosthetic materials, and bearing mechanics.

Aortic Valve Predilatation with a Small Balloon, without Rapid Pacing, prior to Transfemoral Transcatheter Aortic Valve Replacement.

OBJECTIVES: The aim of this study is to assess the feasibility and clinical outcome of transcatheter aortic valve replacement (TAVR) using aortic valve predilatation (AVPD) with a small, nonocclusive balloon. BACKGROUND: Balloon aortic valvuloplasty (BAV) under rapid pacing is generally performed in TAVR to ensure the passage and sufficient deployment of the prosthesis in the stenotic AV. BAV may cause serious complications, such as left ventricular stunning or cerebrovascular embolism. METHODS: A cohort of 50 consecutive patients with severe aortic stenosis underwent transfemoral TAVR with the Edwards Sapien 3-heart valve. All patients underwent AVPD with a small, nonocclusive balloon (12 × 60 or 14 × 60 mm) without rapid pacing. Procedural data and clinical outcomes were analyzed. RESULTS: The mean age of the cohort was 81 ± 6 years and the mean logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 13 ± 9. Crossing the AV and prosthesis implantation was successful in all cases. The postprocedural mean AV gradient was 12 ± 5 mmHg. There were no cases of aortic regurgitation ≥ grade 2. No periprocedural stroke occurred. One patient (2%) with chronic atrial fibrillation displayed a transient Wernicke aphasia occurring more than 24 hours after TAVR. Mortality was 0% at 30 days after procedure. CONCLUSION: In TAVR, AVPD with a small, nonocclusive balloon can be safely performed. By avoiding rapid pacing, this technique may be a valid alternative to traditional BAV. Whether or not the use of APVD without rapid pacing translates into less periprocedural complications needs to be assessed in future studies.

Impact of Cerebrovascular Events Older Than One Year on Ischemic and Bleeding Outcomes With Cangrelor in Percutaneous Coronary Intervention.

BACKGROUND: Cangrelor is a potent intravenous adenosine diphosphate-receptor antagonist that in the CHAMPION trials reduced the 48-hour and 30-day rates of ischemic events during percutaneous coronary intervention without an increase in severe bleeding. METHODS AND RESULTS: CHAMPION PCI (A Clinical Trial to Demonstrate the Efficacy of Cangrelor), CHAMPION PLATFORM (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), and CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) were 3 randomized, double-blind, double-dummy trials in which cangrelor was compared with clopidogrel during percutaneous coronary intervention. The effect of cangrelor on ischemic events and bleeding was analyzed in the subgroup of patients with a history of cerebrovascular events at least 1 year prior to randomization; the Breslow-Day test was used to test for interaction of treatment effect in subgroups with and without such a history. The primary efficacy end point was a composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours. Among 24 910 randomized patients, 1270 patients (5.1%) had a cerebrovascular event >1 year old, including 650 assigned to cangrelor and 620 assigned to clopidogrel. Consistent with the overall trial results, the rate of the primary efficacy end point was 4.3% in the cangrelor group versus 5.3% in the clopidogrel group (odds ratio 0.80; 95% confidence interval 0.48-1.34; P=0.40; P for interaction =0.97), and the rate of GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) severe bleeding was 0.3% in both groups (P=0.97; P for interaction =0.81). CONCLUSIONS: Among patients in the CHAMPION trials with a prior cerebrovascular event at least 1 year before the percutaneous coronary intervention, the efficacy and bleeding profile of cangrelor compared with clopidogrel was similar to that in the overall trial.

Successful combined use of Impella Recover 2.5 device and intra-aortic balloon pump support in cardiogenic shock from acute myocardial infarction.

Ventricular assist devices (VADs) and intra-aortic balloon pumps (IABPs) are important tools that provide hemodynamic support to patients in cardiogenic shock. The Impella Recover 2.5 is a percutaneous VAD that provides temporary circulatory support. We report the case of a patient who required the combined support of both an IABP and the Impella device.