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Background: There is currently little evidence for transcatheter edge-to-edge mitral valve repair (TEER) for mitral regurgitation (MR) in patients with cardiogenic shock (CS). Therefore, this study investigated the characteristics and outcomes of CS patients who underwent TEER for MR., Methods: PubMed, EMBASE were searched in July 2023. Case series and observational studies reporting clinical characteristics and outcomes in CS patients with MR who underwent TEER were included. We performed a one-group meta-analysis using a random effects model., Results: A total of 4060 patients from 7 case series and 5 observational studies were included. The mean age was 68.2 (95% confidence interval [CI]: 64.1-72.2) years, and 41.4% of patients (95% CI: 39.1%-43.7%) were female. Pre-TEER, severe MR was present in 85.3% (95% CI: 76.1%-91.3%) of patients. Mean left ventricular ejection fraction was 36.7% (95% CI: 29.2%-44.2%), and 54.6% (95% CI: 36.9%-71.2%) of patients received mechanical circulatory support. The severity of MR post-TEER was less than 2+ in 88% (95% CI: 87%-89%) of patients. In-hospital mortality was 11% (95% CI: 10%-13%), whereas 30-day and 1-year mortality rates were 15% (95% CI: 13%-16%), and 36% (95% CI: 21%-54%), respectively., Conclusions: This systematic review and meta-analysis assessed the clinical characteristics and outcomes of TEER in CS patients with MR. TEER for MR in patients with CS has been successful in reducing MR in most of the patients, but with a high mortality rate. Randomized controlled trials of TEER for MR and CS are needed., (© 2023 Wiley Periodicals LLC.)

Background: The choice of an alternative access for transcatheter aortic valve replacement (TAVR) remains controversial when transfemoral (TF) access is not feasible., Methods: We conducted a network meta-analysis to compare the outcomes of TAVR via various peripheral vascular accesses. MEDLINE and EMBASE were searched through July 2022 to identify studies that investigated outcomes in patients who underwent TAVR via TF, trans-subclavian (Tsc), transcarotid (TC), or transcaval (Tcav) access. A network meta-analysis was conducted via random-effects model. Outcomes of interest were major or life-threatening bleeding, stroke, major vascular complication, and 30-day mortality., Results: No randomized trial was identified. Our analysis included 33 observational studies that enrolled a total of 43,455 patients who underwent TAVR via TF (n = 36,202), Tsc (n = 3869), TC (n = 3066), or Tcav (n = 318) access. The risk of major or life-threatening bleeding was higher via Tsc compared with TF [odds ratio (OR); 95 % confidence interval (CI) =1.51 (1.03-2.23), p = 0.034]. The risk of stroke was higher via Tsc compared with TF and Tcav [OR (95 % CI) =2.00 (1.14-3.52), p = 0.018, OR (95 % CI) =2.43 (1.03-5.74), p = 0.044, respectively]. The risk of major vascular complications was lower via TC compared with Tsc, and Tcav and higher with Tcav compared with TF and Tsc. 30-day mortality was higher via Tsc compared with TF. Tsc was associated with higher risk of major or life-threatening bleeding compared with TF, and higher risk of stroke compared to TF and Tcav. Tcav had the highest risk of major vascular complications., Conclusion: In patients who underwent TF, Tsc, TC, or Tcav TAVR, Tsc had a higher rate of stroke compared to TF and Tcav, and major or life-threatening bleeding compared to TF. The rate of major vascular complications in Tcav was the highest among the four approaches., Competing Interests: Declaration of competing interest Dr. Latib has served on advisory boards or as a consultant for Medtronic, Boston Scientific, Philips, Edwards Lifesciences, and Abbott., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Transcatheter edge-to-edge repair (TEER) may have potential benefits in the treatment of atrial functional mitral regurgitation (AFMR), but robust evidence is currently lacking. We conducted a systematic review and meta-analysis to investigate the clinical outcomes of TEER for AFMR, including comparisons to ventricular functional MR (VFMR)., Methods: MEDLINE and EMBASE were searched through January 2023 to identify studies eligible for analysis. The primary outcome was postprocedural MR severity. Postprocedural New York Heart Association (NYHA) functional class classification and all-cause mortality were also evaluated. Outcomes were stratified into short term (postprocedure to 6 months) and long term (6 months to 2 years)., Results: A total of eight observational studies met the inclusion criteria, enrolling 539 AFMR and 3486 VFMR patients. Postprocedural MR grade ≤2 in the AFMR group was observed in 93.7% (454/491 patients; 95% confidence interval (CI), 91.1%-96.2%, I 2  = 24.3%) and 97.1% (89/93 patients; 95% CI, 92.9%-100%, I 2  = 26.4%) in short- and long-term follow-up, respectively. There was no difference in the rates of postprocedural MR grade ≤2 between AFMR and VFMR either in short-term (risk ratio [RR], 1.00 [95% CI, 0.95-1.06]; p = 0.90; I 2  = 53%) or long-term follow-up (RR, 1.08 [95% CI, 0.89-1.32]; p = 0.44; I 2  = 22%). Similarly, no difference was observed between AFMR and VFMR in the rates of postprocedural NYHA class ≤2 or all-cause mortality., Conclusion: TEER provides similar clinical outcomes for AFMR and VFMR. A high rate of MR grade ≤2 was observed in patients at both short- and long-term follow-ups. Further prospective studies with TEER versus medical therapy and/or rhythm control for AFMR are warranted., (© 2023 Wiley Periodicals LLC.)

Spontaneous coronary artery dissection (SCAD) is not uncommon but remains arguably an under-diagnosed etiology for acute coronary syndrome (ACS). It occurs predominantly in young-to-middle aged women who have no or few traditional atherosclerotic cardiovascular disease risk factors. Post-infarction mechanical complications are a dreaded outcome of ACS. However, very few case reports describe these mechanical complications related to SCAD. Unsuccessful revascularization is a particular concern for patients presenting with SCAD-induced ACS, which can increase the risk for certain mechanical complications. We present a case of a middle-aged woman who presented with anterior ST-segment elevation myocardial infarction and was found to have SCAD of left anterior descending coronary artery. Two attempts at revascularization were unsuccessful. Thereafter, her clinical course was complicated by the development of heart failure as a result of a reduced ejection fraction and a left ventricular pseudoaneurysm. Importantly she also suffered a ventricular septal rupture necessitating surgical intervention. Fortunately, our patient had a favorable longer-term outcome. Current literature, including five published case reports on SCAD complicated by mechanical complications are reviewed. Clinicians must remain aware of post-infarction mechanical complications in patients with high-risk and non-revascularized SCAD., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The optimal anticoagulation strategy for patients with bioprosthetic valves and atrial fibrillation remains uncertain. We conducted a meta-analysis using updated evidence comparing direct anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with bioprosthetic valves and atrial fibrillation., Methods: Medline and Embase were searched through March 2021 to identify randomized controlled trials (RCTs) and observational studies investigating the outcomes of DOAC therapy and VKA therapy in patients with bioprosthetic valves and atrial fibrillation. The outcomes of interest were all-cause death, major bleeding, and stroke or systemic embolism., Results: Our analysis included 4 RCTs and 6 observational studies enrolling a total of 6405 patients with bioprosthetic valves and atrial fibrillation assigned to a DOAC group (n = 2142) or a VKA group (n = 4263). Pooled analysis demonstrated the similar rates of all-cause death (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.77-1.05; P = .18; I 2  = 0%) in the DOAC and VKA groups. However, the rate of major bleeding was significantly lower in the DOAC group (HR, 0.66; 95% CI, 0.48-0.89; P = .006; I 2  = 0%), whereas the rate of stroke or systemic embolism was similar in the 2 groups (HR, 0.72; 95% CI, 0.44-1.17; P = .18; I 2  = 39%)., Conclusions: DOAC might decrease the risk of major bleeding without increasing the risk of stroke or systemic embolism or all-cause death compared with VKA in patients with bioprosthetic valves and atrial fibrillation., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

There is an increasing prevalence of patients who have both liver cirrhosis (LC) and severe valvular heart disease. This combination typically poses prohibitive risk for liver transplantation. LC related malnourishment, hypoalbuminemia and hyperdynamic circulation places patients with severe LC at higher rates for significant bleeding and/or thrombosis, as well as infectious and renal complications, after either surgical or transcatheter valvular interventions. Although there remains scarce comparative evidence, the preponderance of data suggest that percutaneous strategies are preferred over surgical ones. A multidisciplinary team is ideal for identifying those patients with LC who would benefit from transcatheter valvular heart interventions., (Copyright © 2021. Published by Elsevier Inc.)

Background: For patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated., Methods: Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed., Results: This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71-0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68-0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97-1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66-0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00-1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24)., Conclusion: Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS., (© 2023 by the Texas Heart® Institute, Houston.)

Various vascular closure devices (VCDs) are commonly used for percutaneous transcatheter aortic valve replacement (TAVR). However, superiority and safety profile among them remain unclear. We compared periprocedural complications among various VCDs in patients undergoing TAVR. PubMed and EMBASE were searched through January 2022 to identify clinical studies comparing any 2 VCDs of Prostar, Proglide and MANTA in patients who underwent TAVR. Studies using surgical cut-down or alternative access other than transfemoral approach were excluded. We analyzed the odds ratios (ORs) of vascular complications (VC), bleeding, acute kidney injury and all-cause mortality using a network meta-analysis. All outcomes were defined by Valve Academic Research Consortium 2 criteria. Two randomized controlled trials and 15 observational studies were identified, yielding a total of 11,344 patients including Prostar (n = 4499), Proglide (n = 5705), or MANTA group (n = 1140). The rates of major VC and life-threatening and major bleeding were significantly lower in Proglide compared to Prostar (OR [95 % CI] = 0.54 [0.32-0.89], 0.68 [0.52-0.90], and 0.49 [0.26-0.95], respectively). There was no significant difference in major VC and bleeding between Proglide and MANTA groups. Proglide was associated with a lower rate of acute kidney injury (0.56 [0.34-0.92]) and red blood cell transfusion (0.39 [0.16-0.98]) compared to Prostar. There was no significant difference in additional interventions and 30-day overall mortality among three groups. In this network meta-analysis of VCD in patients undergoing TAVR, MANTA and Proglide had comparable outcomes while Proglide appears superior to Prostar in terms of major VC and bleeding., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Tomoki Sakata reports a relationship with AbioMed Inc. that includes: funding grants. Azeem Latib reports a relationship with Medtronic Inc. that includes: consulting or advisory. Azeem Latib reports a relationship with Boston Scientific Corp that includes: consulting or advisory. Azeem Latib reports a relationship with Philips that includes: consulting or advisory., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: Patients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear., Objective: To assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US., Design, Setting, and Participants: This cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain-MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis., Main Outcomes and Measures: In-hospital mortality and time-to-reperfusion metrics., Results: This study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P < .001) and more often received fibrinolytics (2848 [19.7%] vs 937 [2.7%]; P < .001). Compared with patients from urban settings, those in rural settings undergoing PPCI had longer median (IQR) time from first medical contact to catheterization laboratory activation (30 [12-42] minutes vs 22 [15-59] minutes; P < .001) and longer median (IQR) time from first medical contact to device (99 minutes [75-131] vs 81 [66-103] minutes; P < .001), including those who arrived directly at PPCI centers (83 [66-107] minutes vs 78 [64-97] minutes; P < .001) and those who transferred to PPCI centers from another treatment center (125 [102-163] minutes vs 103 [85-135] minutes; P < .001). Among those who transferred in, median (IQR) door-in-door-out time was longer in patients from rural settings (63 [41-100] minutes vs 50 [35-80] minutes; P < .001). Out-of-hospital cardiac arrest was more common in patients from urban vs rural settings (3099 [6.1%] vs 958 [4.9%]; P < .001), and patients from urban settings were more likely to present with heart failure (4112 [8.1%] vs 1314 [6.7%]; P < .001). After multivariable adjustment, there was no significant difference in in-hospital mortality between rural and urban groups (adjusted odds ratio, 0.97; 95% CI, 0.89-1.06)., Conclusions and Relevance: In this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain-MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.

Background: Hemodynamic values from right heart catheterization aid diagnosis and clinical decision-making but may not predict outcomes. Mixed venous oxygen saturation percentage and pulmonary capillary wedge pressure relate to cardiac output and congestion, respectively. We theorized that a novel, simple ratio of these measurements could estimate cardiovascular prognosis., Methods: We queried Veterans Affairs' databases for clinical, hemodynamic, and outcome data. Using the index right heart catheterization between 2010 and 2016, we calculated the ratio of mixed venous oxygen saturation-to-pulmonary capillary wedge pressure, termed ratio of saturation-to-wedge (RSW). The primary outcome was time to all-cause mortality; secondary outcome was 1-year urgent heart failure presentation. Patients were stratified into quartiles of RSW, Fick cardiac index (CI), thermodilution CI, and pulmonary capillary wedge pressure alone. Kaplan-Meier curves and Cox proportional hazards models related comparators with outcomes., Results: Of 12 019 patients meeting inclusion criteria, 9826 had values to calculate RSW (median 4.00, interquartile range, 2.67-6.05). Kaplan-Meier curves showed early, sustained separation by RSW strata. Cox modeling estimated that increasing RSW by 50% decreases mortality hazard by 19% (estimated hazard ratio, 0.81 [95% CI, 0.79-0.83], P <0.001) and secondary outcome hazard by 28% (hazard ratio, 0.72 [95% CI, 0.70-0.74], P <0.001). Among the 3793 patients with data for all comparators, Cox models showed RSW best associated with outcomes (by both C statistics and Bayes factors). Furthermore, pulmonary capillary wedge pressure was superior to thermodilution CI and Fick CI. Multivariable adjustment attenuated without eliminating the association of RSW with outcomes., Conclusions: In a large national database, RSW was superior to conventional right heart catheterization indices at assessing risk of mortality and urgent heart failure presentation. This simple calculation with routine data may contribute to clinical decision-making in this population.

Durability of transcatheter heart valve (THV) is critical as the indication of transcatheter aortic valve implantation (TAVI) expands to patients with longer life-expectancy. We aimed to compare the durability of different THV systems (balloon-expandable [BE] and self-expandable [SE]) and surgical aortic valve replacement (SAVR) prosthesis. PUBMED and EMBASE were searched through February 2021 for randomized trials investigating parameters of valve durability after TAVI and/or SAVR in severe aortic stenosis. A network meta-analysis using random-effect model was performed. Synthesis was performed with 5-year follow-up data for echocardiographic outcomes and the longest available follow-up data for clinical outcomes. Ten trials with a total of 9,388 patients (BE-THV: 2,562; SE-THV: 2,863; SAVR: 3,963) were included. Follow-up ranged from 1 to 6 years. SE-THV demonstrated significantly larger effective orifice area, lower mean aortic valve gradient (AVG), and less increase in mean AVG at 5-year compared with BE-THV and SAVR. Structural valve deterioration (SVD) was less frequent in SE-THV compared with BE-THV and SAVR (HR 0.14, 95% CI 0.07 to 0.27; HR 0.34, 95% CI 0.24 to 0.47, respectively). Total moderate-severe aortic regurgitation and reintervention was more frequent in BE-THV (HR 4.21, 95% CI 2.40 to 7.39; HR 2.22, 95% CI 1.16 to 4.26, respectively), and SE-THV (HR 7.51, 95% CI 3.89 to 14.5; HR 2.86, 95% CI 1.59 to 5.13, respectively) compared with SAVR. In conclusion, TAVI with SE-THV demonstrated favorable forward-flow hemodynamics and lowest risk of SVD compared with BE-THV and SAVR at mid-term. However, both THV systems suffer an increased risk of AR and re-intervention, and long-term data from newer generation valves is warranted., Competing Interests: Disclosures The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Dr. Azeem Latib reports the following disclosures: consultant (honoraria) ‐ Edwards Lifesciences, Abbott Vascular; Boston Scientific, Medtronic, Philips, WL Gore; Scientific Advisory Boards (equity) ‐ Tioga, Supira, NeoChord, CorFlow, ICS, VVital, and Institutional Funding to Montefiore Medical Center from ‐ Edwards Lifesciences, Medtronic, Abbott Vascular, Boston Scientific. Dr. Lars Søndergaard has received consultant fees and institutional research grants from Abbott, Boston Scientific and Medtronic. Dr. Guilherme Attizzani has received research grants, functions as a consultant and is on the advisory board of Medtronic. Dr. Duane Pinto reports the following disclosures: consultant (honoraria)- Abbott Vascular, Abiomed, Boston Scientific, Magenta, Medtronic, NuPulseCV, Inari, Terumo, Teleflex. Institutional Funding to Beth Israel Deaconess Medical Center from- Abiomed, Medtronic, Boston Scientific, Abbott Vascular. The other authors report no conflicts., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: We aimed to investigate the invasive hemodynamic changes with transcatheter mitral valve replacement (TMVR) in patients with severe mitral stenosis due to severe mitral annular calcification., Background: The hemodynamic response to TMVR in patients with mitral stenosis related to degenerative mitral annular calcification has not been fully elucidated., Methods: We conducted retrospective review of patients who underwent successful transseptal TMVR with balloon-expandable valves for symptomatic severe mitral stenosis due to mitral annular calcification at our institution between January 2014 and February 2020. Invasive hemodynamic measurements were obtained both before valve implantation (predeployment) and after (postdeployment)., Results: Eighteen patients (age 72 ± 10 years, 44% female) were included for the analysis. There was a significant reduction in mean left atrial pressure (23.7 ± 5.6 mmHg versus 20.6 ± 4.8 mmHg; p = .01), left atrial v-wave (mean 39.3 ± 10.2 mmHg versus 32.9 ± 9.9 mmHg; p = .01), and an increase in systemic mean blood pressure (72.6 mmHg ±11.2 versus 79.5 ± 9.9 mmHg; p = .02) postdeployment compared to predeployment. Patients who had symptom improvement at 30-day follow-up tended to have greater reduction in mean left atrial pressure (4.4 ± 4.4 mmHg versus 0.5 ± 5.2 mmHg; p = .16) and v-wave (8.6 ± 9.0 mmHg versus 0.7 ± 8.4 mmHg; p = .10) compared to those who did not experience improvement of symptoms., Conclusions: Transseptal TMVR for severe mitral stenosis due to mitral annular calcification is associated with reductions in mean left atrial pressure and left atrial v-wave, and an increase in systemic arterial pressure., (© 2020 Wiley Periodicals LLC.)

Background: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI)., Objectives: The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI., Methods: A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization., Results: As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received PPCI and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients)., Conclusions: COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations., Competing Interests: Funding Support and Author Disclosures This work was supported by an American College of Cardiology Accreditation Grant, Saskatchewan Health Research Foundation (SHRF), and grants from Medtronic and Abbott Vascular to SCAI. Dr. Garcia has received institutional research grants from Edwards Lifesciences, BSCI, Medtronic, and Abbott Vascular; has served as a consultant for Medtronic and BSCI; and has served as a proctor for Edwards Lifesciences. Dr. Saw has received unrestricted research grant support from the Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, National Institutes of Health, AstraZeneca, Abbott Vascular, St. Jude Medical, Boston Scientific, and Servier; has received salary support from the Michael Smith Foundation for Health Research; has received speaker honoraria from AstraZeneca, Abbott Vascular, Boston Scientific, and Bayer; has received consultancy and advisory board honoraria from AstraZeneca, Boston Scientific, Abbott Vascular, Gore, Abiomed, and Baylis; and has received proctorship honoraria from Abbott Vascular and Boston Scientific. Dr. Jaffer has received research grants from Siemens, Canon, Shockwave, and Teleflex; has served as a consultant for Boston Scientific, Siemens, Biotronik, and Magenta Medical; owns equity interest in Intravascular Imaging; and Massachusetts General Hospital has patent licensing arrangements with Canon, Terumo, and Spectrawave, and Dr. Jaffer has a right to receive licensing royalties. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. All rights reserved.)

Background: Physiology-guided percutaneous coronary intervention (PCI) has demonstrated to improve clinical outcomes. Previous trials showed the agreement between iFR and FFR is approximately 80%, however the details of discordance pattern remain to be elucidated., Methods: We retrospectively reviewed 1024 consecutive intermediate stenotic lesions for which functional evaluation using both iFR and FFR were performed between January 2015 and June 2016. The lesions were classified into 4 groups according to iFR and FFR concordance [(iFR+/FFR+) and (iFR-/FFR-)] or discordance [(iFR+/FFR-) and (iFR-/FFR+)]., Results: Our study evaluated 451 lesions, 264 lesions (58.5%) from men and 187 lesions (41.5%) from women. iFR was similar between women and men, however FFR was significantly higher in women than men. The rate of discordance between iFR and FFR was 21.3% (iFR+/FFR- 12.4% and iFR-/FFR+ 8.9%) in overall cohort. The prevalence of overall concordance and discordance were similar between men and women, however iFR+/FFR- discordance was significantly higher in women (17.1% vs. 9.1%) whereas iFR-/FFR+ discordance was significantly higher in men (11.3% vs. 4.8%). In multivariable analysis, female sex and older age were significantly associated with iFR+/FFR- discordance (odds ratio 1.88 and 1.48, respectively). Conversely, younger age, higher stenosis, and concomitant chronic total occlusion were independent predictors for iFR-/FFR+ discordance (odds ratio 0.67, 1.82, and 4.32, respectively)., Conclusions: Despite similar prevalence of overall concordance and discordance between men and women, iFR+/FFR- discordance was higher in women and iFR-/FFR+ discordance was higher in men. Multivariable analysis showed female sex to be independent predictor of iFR+/FFR- discordance., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Ventriculoatrial (VA) conduction is a critical component in many arrhythmias, has a diagnostic value in electrophysiology study (EPS), and is implicated in pacemaker-mediated arrhythmias. This study sought to characterize retrograde conduction during EPS and to utilize it as a diagnostic tool in patients without AV block., Methods and Results: Patients with intact AV conduction undergoing EPS were included in this study to systematically evaluate baseline VA conduction. If absent, parahisian pacing was used to determine the level of block (nodal or infranodal). Recovery of VA conduction with increased sympathetic activity was assessed with isoproterenol infusion. Baseline characteristics and electrophysiological data were collected and analyzed. Among the 801 patients studied, VA conduction was present in 98% (81% at baseline and 17% after isoproterenol infusion). Parahisian pacing demonstrated that the block was at the AV node level among 150 patients with VA dissociation at baseline. Among patients presenting with supraventricular tachycardia (SVT), 98.7% with atrioventricular nodal reentrant tachycardia (AVNRT) had VA conduction at baseline versus 82.7% presenting with other SVT (atrial fibrillation excluded), P < 0.001. Thus, the absence of VA conduction at baseline during an EPS for SVT carries a negative predictive value (NPV) of 96.9% for AVNRT., Conclusions: VA conduction is present in most patients (98%) with intact AV conduction. The level of VA dissociation when present at baseline is always at the level of the AV node. Patients with SVT presenting for EPS that lacked VA conduction at baseline were unlikely to have AVNRT.

Introduction: Previous studies have reported lower rates of coronary angiography and revascularization, and significantly higher mortality among patients infected with human immunodeficiency virus (HIV) presenting with acute myocardial infarction (AMI). This observational study was designed to evaluate characteristics and inpatient outcomes of patients with seropositive HIV infection presenting with AMI., Methods: Using the National Inpatient Sample (NIS) database, we identified patients (admissions) with a primary diagnosis of myocardial infarction and a co-occurring HIV. We described baseline characteristics and outcomes. Our primary outcomes of interest were prevalence of coronary angiography, revascularization (percutaneous coronary intervention (PCI) or CABG), and mortality., Results: From 2010 to 2014, of about 2,977,387 patients with a primary diagnosis of AMI, 10,907 (0.4%) were HIV seropositive. Patients with HIV were younger and more likely to be African American or Hispanic. Coronary angiography and revascularization were performed more frequently in the HIV population. The higher prevalence of revascularization was driven by a higher incidence of PCI. In a multivariable model, patients with HIV were no more likely to undergo revascularization than the general population. This was also the case for PCI. Unadjusted all-cause mortality was lower among patients with HIV. After controlling for confounders, this finding was not significant (OR 0.97, 95% CI 0.75-1.25, p = 0.79). The length of stay between both groups was comparable., Conclusion: In this current analysis, we did not note any treatment bias or difference in the rate of in-hospital total mortality for HIV-seropositive patients presenting with AMI compared with the general population.

The optimal treatment strategy for coronary chronic total occlusion (CTO) has not been well established. The benefit of percutaneous coronary intervention (PCI) was inferred mainly from observational studies comparing successful versus failed PCI without a control group receiving optimal medical therapy (OMT). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing PCI using drug-eluting stent (DES) versus OMT alone in patients with CTO. Eight studies were identified: 3 RCTs and 5 observational studies. Among a total of 4784 included patients, 2461 patients underwent PCI and 2323 patients received OMT. There was a significant association between PCI and lower cardiac mortality (odds ratio = 0.62; 95% confidence interval 0.42-0.93; P = .02). There was no significant difference between PCI and OMT regarding major adverse cardiac events, recurrent myocardial infarction (MI), repeat revascularization, or stroke. In the RCT subset (1399 patients), there was no significant difference between PCI and OMT regarding clinical outcomes. Compared with OMT alone, PCI with DES for CTO was associated with lower cardiac mortality, mainly driven by observational studies, without significant difference in recurrent MI or repeated revascularization. Further RCTs are needed to investigate the role of PCI for management of patients with CTO.

Background: Currently, there is no clear consensus regarding the optimal waiting period before permanent pacemaker implantation in patients with conduction disorders following an inferior myocardial infarction., Hypothesis: We aimed to elucidate the contemporary practice pattern of pacing, especially the timing of pacemaker implantation, for sinoatrial node and atrioventricular (AV) conduction disorders following an inferior ST-elevation myocardial infarction (STEMI)., Methods: Using the National Inpatient Sample database from 2010 to 2014, we identified patients with a primary diagnosis of inferior STEMI. Primary conduction disorders were classified into: (a) high-degree AV block (HDAVB) consisting of complete AV block or Mobitz-type II second-degree AV block, (b) sinoatrial node dysfunction (SND), and (c) no major conduction disorders., Results: Among 66 961 patients, 2706 patients (4.0%) had HDAVB, which mostly consisted of complete AV block (2594 patients). SND was observed in 393 patients (0.6%). Among the 2706 patients with HDAVB, 267 patients (9.9%) underwent permanent pacemaker. In patients with HDAVB, more than one-third (34.9%) of permanent pacemakers were placed within 72 hours after admission. The median interval from admission to permanent pacemaker implantation was 3 days (interquartile range; 2-5 days) for HDAVB vs 4 days (3-6 days) for SND (P < .001). HDAVB was associated with increased in-hospital mortality, whereas SND was not., Conclusions: In patients who developed HDAVB following an inferior STEMI, only one in 10 patients underwent permanent pacemaker implantation. Despite its highly reversible nature, permanent pacemakers were implanted relatively early., (© 2019 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.)

Objectives: Patients with cirrhosis have increased bleeding risk due to coagulopathy and platelet sequestration, as well as inherent cardiovascular risk. We aim to assess the impact of cirrhosis on the revascularization rates and in-hospital outcomes in patients with acute myocardial infarction (AMI)., Methods: We queried the National Inpatient Sample Database from 2010 to 2014 and identified hospitalizations with a primary diagnosis of AMI (n = 612,547); of these, a total of 3135 patients had a concomitant diagnosis of cirrhosis. We compared clinical outcomes between patients with cirrhosis and a propensity-score matched cohort without cirrhosis (n = 3086)., Results: Patients with cirrhosis had a lower rate of ST-elevation MI (18.9% vs 26.7% in the cohort with no cirrhosis; P<.001), a lower rate of coronary angiography (51.4% vs 63.9% in the cohort with no cirrhosis; P<.001), and lower rates of revascularization by percutaneous coronary intervention (PCI) (28.7% vs 39.2% in the cohort with no cirrhosis; P<.001) or coronary artery bypass grafting (6.0% vs 12.9% in the cohort with no cirrhosis; P<.001). Gastrointestinal and postprocedural hemorrhage was more common in patients with cirrhosis (12.3% vs 7.1% in the cohort with no cirrhosis; P<.001), regardless of revascularization status, and cirrhosis patients also had a higher in-hospital mortality rate (8.7% vs 6.9% in the cohort with no cirrhosis; P<.01). PCI was independently associated with lower mortality in patients with cirrhosis (odds ratio, 0.57; 95% confidence interval, 0.33-0.98; P=.04)., Conclusion: Patients with cirrhosis presenting with AMI were highly selected to undergo coronary angiography and subsequent revascularization, and had higher mortality than those without cirrhosis. However, PCI was independently associated with lower mortality in patients with cirrhosis, although to less effect than non-cirrhotics, perhaps due to higher bleeding rates.

Background: Symmetrically inverted or biphasic T waves in anterior precordial leads, Wellens' sign, have been shown to represent impending infarction of left anterior descending (LAD) territory among unstable angina patients in the studies published more than 3 decades ago, when non-ST-segment elevation myocardial infarction (NSTEMI) was not a recognized entity. The clinical implication of Wellens' sign in the contemporary NSTEMI cohort has not been clarified., Methods: We performed a retrospective analysis of all NSTEMI patients who underwent coronary angiography between January 2013 and June 2014. Wellens' sign was defined as either symmetrically inverted T waves (≥ 0.10 mV) or biphasic T waves in both leads V2 and V3. Coronary angiograms were reviewed and culprit lesions were determined for each patient., Results: A total of 274 patients were included in the final analysis, of whom 24 (8.8%) had Wellens' sign. Among these 24 patients, 16 had a LAD culprit (eight proximal), two had a non-LAD culprit, and six had non-obstructive coronary artery disease. Patients with Wellens' sign were more likely to have LAD culprit (66.7% vs. 19.6%, P < 0.001) and proximal LAD culprit (33.3% vs. 14.4%, P = 0.035) than those without it. Wellens' sign had a sensitivity of 24.6% and a specificity of 96.2% to predict LAD culprit., Conclusions: Our study revealed that: 1) Wellens' sign was seen in 8.8% of the patients with NSTEMI; 2) Two-thirds of patients with Wellens' sign had LAD culprit and one-third had proximal LAD culprit; and 3) Sensitivity and specificity of Wellens' sign to predict LAD culprit were 24.6% and 96.2%, respectively., Competing Interests: None.

Introduction: Malignancy is a common cause of morbidity and mortality in the United States and around the world and the second leading cause of death in the United States. There is little data on the impact of metastatic cancer on the risk of hemorrhagic stroke or mortality among patients undergoing fibrinolytic therapy (FT) for acute PE., Methods: Using the National Inpatient Sample (NIS) database, we extracted admissions with a primary diagnosis of acute pulmonary embolism that underwent FT from 2010 to 2014. We performed a case control matched analysis between patients with and without metastatic cancer. Our primary outcome of interest was Mortality and our secondary outcome of interest was hemorrhagic stroke (HS)., Results: Of the 883,183 patients with a primary diagnosis of acute PE between 2010 and 12014, 23,690 patients (2.7%) underwent FT. After exclusion, 22,592 patients were included in the analysis. Of these, 941 patients (4.2%) were reported to have metastatic cancer. There was a higher incidence of cerebrovascular accidents and intubation/mechanical ventilation in the metastatic cancer arm. Mortality was significantly higher in the metastatic cancer arm with no difference in the incidence of HS. In multivariate regression analysis, among all patients that underwent FT for acute PE, metastatic cancer was associated with a significant odds for mortality (OR 1.91, 95% CI 1.11-5.82, p < .001)., Conclusion: The presence of metastatic cancer in patients undergoing fibrinolytic therapy for acute pulmonary embolism is associated with increase mortality., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: We aimed to investigate the current practice patterns of permanent pacing, especially the timing of implantation, for high-degree AV block (HDAVB) following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR)., Background: Comparative data regarding current practice patterns of permanent pacing for HDAVB between TAVI and SAVR is limited., Methods: Using the National Inpatient Sample database, we identified patients who underwent TAVI or SAVR between 2012 and 2014. The incidence of HDAVB, the rate of permanent pacemaker implantation, and the timing of implantations were compared between TAVI and SAVR groups., Results: We identified 33 690 and 202 110 patients who underwent TAVI and SAVR, respectively. HDAVB occurred in 3480 patients (10.3%) in the TAVI group and 11 405 patients (5.6%) in the SAVR group (P < 0.001). Among the patients who developed HDAVB, patients in the TAVI group were more likely to undergo permanent pacemaker implantation than those in the SAVR group (74.1% vs 64.7%; P < 0.001). The median interval from TAVI to pacemaker implantation was 2 days (interquartile range 1-3 days) vs 5 days (interquartile range 3-7 days) from SAVR to pacemaker implantation (P < 0.001). Among the patients who developed HDAVB, TAVI was associated with higher rates of permanent pacemaker implantation after adjusting for other comorbidities (odds ratio 1.41:95% confidence interval 1.13-1.77; P = 0.003)., Conclusions: HDAVB occurred more commonly after TAVI compared to SAVR. HDAVB after TAVI compared to SAVR was associated with a higher rate of permanent pacemaker implantation at an earlier timing from the index procedure., (© 2018 Wiley Periodicals, Inc.)

Purpose of Review: Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics., Recent Findings: The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient's clinical characteristics as well as the complexity of the coronary anatomy.

Hemorrhagic stroke (HS) is a feared complication of Fibrinolytic therapy (FT). Risk assessment scores may help in risk stratification to reduce this complication. Patients (admissions) ≥18 years with a primary diagnosis of ST-elevation myocardial infarction (STEMI) who received systemic thrombolysis were extracted from Nationwide Inpatient Sample database and stratified and compared based on CHA 2 DS 2 VASC score 0 to 3, 4 to 6, and 7 to 9 as low, intermediate and high risk, respectively. The primary outcomes of interest were HS and mortality. We performed logistic regression analysis with a composite of HS and mortality as the primary end point. Of the 917,307 admissions with a primary diagnosis of STEMI, 39,579 (4.3%) underwent FT. The median score was 3 (interquartile range 1 to 5). The rate of HS significantly increased in the risk category compared with the low and intermediate groups (0.5% and 0.6% vs 4.1%; p <0.001). Mortality increased with increasing risk category (3.8% vs 10.5% vs 20.7%; p <0.001). Compared with the low-risk group patients in the intermediate (odds ratio 2.11 95% confidence interval [CI] 1.56 to 2.85; p <0.001) and high risk groups (odds ratio 3.47 95% CI 1.68 to 7.2; p <0.001) were more likely to experience the composite end point of HS or inpatient mortality. CHA 2 DS 2 VASC score performed better at predicting mortality (area under curve 0.67, 95% CI 0.64 to 0.7; p = 0.014) than HS (area under curve 0.6 95% CI 0.52 to 0.69; p = 0.021). In conclusion, patients with high CHA 2 DS 2 VASC score (7 to 9) are at a higher risk of hemorrhagic stroke and death after FT for STEMI. CHA 2 DS 2 VASC score performed better at predicting mortality than hemorrhagic stroke in this cohort., (Copyright © 2018. Published by Elsevier Inc.)

Takotsubo cardiomyopathy (TC) is definitively diagnosed following the exclusion of acute coronary syndrome. We aimed to examine the rate of coronary angiography in patients diagnosed with TC and also the outcome of patients with TC diagnosed with or without coronary angiography. We analyzed the National Inpatient Sample database from 2010 to 2014 and identified patients hospitalized with a primary diagnosis of TC. We compared in-hospital mortality between patients who underwent coronary angiography and those who did not. We also evaluated the association between coronary angiography and in-hospital mortality using a propensity score-adjusted multivariable analysis. Among 22 818 patients diagnosed with TC, 87.4% underwent coronary angiography and 12.6% did not. Patients who did not undergo coronary angiography had a higher in-hospital mortality than those who did (3.0% vs 0.9%; P < .001). Increased mortality in patients who did not undergo coronary angiogram was observed in both male (8.0% vs 2.8%; P = .03) and female patients (2.6% vs 0.7%; P < .001) and in patients 61 to 80 years old and ≥81 years old, but not in patients ≤60 years old. Multivariable analysis demonstrated that the lack of coronary angiography was independently associated with higher in-hospital mortality (adjusted odds ratio: 2.92; 95% confidence interval: 1.52-5.65; P = .001).

Purpose: Catheter ablation (CA) is an effective treatment for atrial fibrillation (AF). The differences in complication rates and outcomes between women and men remain poorly studied. We aimed to study the sex differences in morbidity and mortality associated with CA in AF., Methods: Using weighted sampling from the National Inpatient Sample database, women and men with a primary diagnosis of AF and a primary procedure of CA (2004-2013) were identified. We compared the following outcomes based on the sex: (1) major complications [post-procedure transfusion, cardiac drain or surgery, pulmonary embolism, cerebrovascular accident, major cardiac events, kidney failure requiring dialysis, and sepsis], (2) overall complications (minor and/or major complications), and (3) in-hospital mortality., Results: Among 85,977 patients who underwent CA for AF, 27821 (32.4%) were women. Overall complications were more frequent among women versus among men (12.4% versus 9.0%; p < 0.001), as well as major complications (4.7% versus 2.7%; p < 0.001). However, there was no difference in mortality (0.3% versus 0.2%; p = 0.22). After adjusting for other factors, women were more likely than men to have major complication (odds ratio 1.48, 95% CI 1.21-1.82; p < 0.001). Prior CABG was associated with lower risk of major complications in both sexes (odds ratio in the overall cohort 0.27, 95% CI 0.12-0.61; p = 0.002), mostly driven by the reduction in tamponade and pericardial drain., Conclusions: Among patients who underwent catheter ablation for AF, the female sex was associated with higher rate of complications compared to male but no difference in mortality. Prior CABG was associated with a significant reduction of major complications in both sexes.

Background: Pharmacologic reperfusion therapy is a recommended and effective strategy in patients with ST-elevation myocardial infarction (STEMI) when percutaneous coronary intervention (PCI) is not available. This study investigates temporal trends and outcomes of fibrinolytic therapy (FT) in elderly patients with STEMI., Methods: Using the Nationwide Inpatient Sample database, we extracted patients ≥80 years a primary diagnosis of STEMI admitted between 2010 and 2014. Using ICD codes, we identified patients who underwent FT. We performed temporal trend analysis, then compared characteristics and inpatient outcomes in the FT group versus no-FT group. Our primary outcome of interest was hemorrhagic stroke (HS). We also assessed the impact of HS on mortality and discharge to skilled nursing facility (SNF)., Results: Of the 917,307 patients with STEMI, 16.1% (n = 147,874) were aged 80 or older. Primary PCI was performed in 46.2%, 2.4% underwent FT, and 51.3% had neither pharmacologic nor mechanical revascularization. The rate of FT increased (1.9%-2.4%) in a nonlinear trend over the five years of the study. The FT group was eight times more likely to suffer HS (P < 0.001). FT was an independent predictor of HS (OR 7.90, 95% CI 4.36-14.30; P < 0.001), whether they underwent PCI or not. HS was an independent predictor of mortality and SNF discharge., Conclusion: FT in patients 80 years or older presenting with STEMI was associated with an eight-fold increase in HS and no associated mortality advantage, both with or without PCI. These data underscore the increased risk of FT in the elderly., (© 2018 Wiley Periodicals, Inc.)

Characteristics of conduction disorders after ST-elevation myocardial infarction (STEMI) have been well described. In contrast, limited data are available on the incidence, treatment trends, and prognostic impact of conduction disorders after non-ST-elevation myocardial infarction (NSTEMI). Using the National Inpatient Sample database, we compared the characteristics and outcomes of conduction disorders in patients with a primary diagnosis of STEMI versus NSTEMI between 2010 and 2014. Conduction disorders were classified into‬ high-degree AV block (HDAVB), consisting of complete AV block or Mobitz type II second-degree AV block, and sinoatrial node dysfunction (SND). We identified 135,468 STEMI patients and 281,928 NSTEMI patients. In contrast to the STEMI cohort where HDAVB was more common than SND (2.4% vs 0.5%), SND was observed more often in the NSTEMI cohort, presenting in 2,417 patients (0.9%), followed by HDAVB in 1,745 patients (0.6%). In patients who developed HDAVB, NSTEMI patients were more likely to undergo permanent pacemaker implantation than STEMI patients (30.0% vs 11.6%; p < 0.001). The rate of permanent pacemaker implantation for SND was comparable between STEMI and NSTEMI patients (33.9% vs 30.5%; p = 0.10). In the NSTEMI cohort, patients who developed HDAVB had higher in-hospital mortality than those without any major conduction disorders (16.6% vs 3.8%; p < 0.001). In conclusion, SND was more common than HDAVB in the NSTEMI cohort, in contrast to the predominance of HDAVB observed in the STEMI cohort. About one-third of patients who developed HDAVB after NSTEMI underwent pacemaker implantation, suggesting lower rates of spontaneous resolution of HDAVB, when compared with STEMI patients., (Copyright © 2018. Published by Elsevier Inc.)

Background: Patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) are at increased risk for subsequent ischemic events., Hypothesis: Short-term dual antiplatelet therapy (DAPT) (≤6 months) is inferior to standard or long-term DAPT in patients who undergo PCI for ACS events., Methods: We conducted a systematic review and meta-analysis of randomized controlled trials that compared short-term (≤6 months) to long-term (≥12 months) DAPT after PCI for ACS. We searched MEDLINE, EMBASE, SCOPUS, and the Cochrane Central Register of Controlled Trials database., Results: Ten randomized controlled trials, including a total of 12 696 patients, met our inclusion criteria. For short-term DAPT, duration of therapy ranged from 3 to 6 months, while long-term DAPT ranged from 12 to 24 months. The majority of studies used clopidogrel and second-generation drug-eluting stents. No statistically significant difference was found between short-term and long-term DAPT with regard to myocardial infarction (odds ratio 1.21; 95% confidence interval 0.94-1.57; P = 0.14), stent thrombosis (odds ratio 1.54; 95% confidence interval 1.00-2.38; P = 0.052), or major bleeding events (odds ratio 0.74; 95% confidence interval 0.49-1.11; P = 0.14). There was no significant difference in all-cause mortality, cardiac death, or net adverse cardiac and cerebrovascular events., Conclusions: Our meta-analysis demonstrated that short-term DAPT (<6 months) after PCI for ACS was not associated with increased risk of myocardial infarction or stent thrombosis when compared to long-term DAPT., (© 2018 Wiley Periodicals, Inc.)

Background: Bleeding complications are associated with unfavorable outcomes in patients with acute coronary syndrome (ACS). Compared to Whites, several studies demonstrated a higher risk of bleeding in Asians who present with acute myocardial infarction. To date, the efficacy and safety of ticagrelor in East Asian population have not been well established., Methods: We conducted a systematic review and meta-analysis of randomized controlled trials that compared ticagrelor and clopidogrel in East Asian patients with acute coronary syndrome (ACS). We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrial.gov database., Results: Three randomized controlled trials, including a total of 1552 patients, met our inclusion criteria. Study countries included Japan, South Korea, and China. All studies defined primary efficacy endpoint and major bleeding events in accordance with the PLATO definition. Ticagrelor was associated with a numerically lower, albeit statistically nonsignificant, risk of primary efficacy endpoint defined as a composite of death from vascular causes, myocardial infarction, or stroke (odds ratio 0.84; 95% confidence interval 0.43-1.63; p = 0.60). Ticagrelor was associated with a significantly higher risk of PLATO-defined major bleeding compared to clopidogrel (odds ratio 1.52; 95% confidence interval 1.04-2.23; p = 0.03)., Conclusions: Our meta-analysis demonstrated that ticagrelor was associated with a higher risk of major bleeding compared to clopidogrel in East Asian patients with ACS. Further studies evaluating the role of ticagrelor in management of ACS in East Asian patients are warranted., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Anatomical SYNTAX score (SS1) and SYNTAX score II (SS2) are often utilized to determine the optimal revascularization strategy. Although US veterans have unique characteristics that may affect outcomes after revascularization, the prognostic values of SS1 and SS2 in veterans have not yet been validated. We performed a retrospective analysis of consecutive veteran patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main and/or 3-vessel disease from 2009 to 2014. SS1 and SS2 were calculated for each patient. The primary outcome was all-cause mortality. The prognostic values of SS1 and SS2 were compared by receiver operating characteristic curve analysis. The predicted 4-year mortality derived from SS2 was compared with the observed 4-year mortality estimated from Kaplan-Meier analysis. After exclusion, 286 patients (99% male) were included. Among 286 patients, 79 patients (27.6%) had left main disease, 151 (52.8%) underwent PCI, and 135 (47.2%) underwent CABG. Overall mortality was 27.6% at a median follow-up of 5.0 years. SS2 had better discriminative ability for all-cause mortality than SS1 (c-index 0.79 vs 0.52, p <0.001). Observed and predicted 4-year mortality correlated well in patients with low and intermediate SS2 in both PCI and CABG cohorts, but observed mortality was higher than predicted in the PCI cohort with high SS2 (observed 54.7% vs predicted 40.5%). In conclusion, observed and predicted 4-year mortality derived from SS2 correlated well in patients with low and intermediate SS2, but SS2 underestimated mortality in the PCI cohort with high SS2., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Bleeding is a major complication in patients presenting with ST-segment elevation myocardial infarction (STEMI). Several studies suggested that Asians are more susceptible to bleeding when treated with antiplatelets, anticoagulants, and thrombolytic agents. In our study, we aimed to investigate the association between Asian ethnicity and bleeding events in patients who presented with STEMI. We analyzed the Nationwide Inpatient Sample database from 2002 to 2013 and identified patients hospitalized with a primary diagnosis of STEMI. We compared clinical outcomes between patients of Asian and white ethnicity. Primary outcome was inhospital major bleeding defined as a composite of intracranial hemorrhage and blood transfusions for bleeding events. After exclusions, an estimated 1 695 680 white and 46 563 Asian patients with STEMI were included in the analysis. Asian patients had a higher incidence of inhospital major bleeding (3.6% vs 2.2%, P < .001) without a significant difference in inhospital mortality (9.3% vs 8.7%, P = .06). Asian ethnicity was an independent predictor for major bleeding (estimated odds ratio: 1.32; 95% confidence interval: 1.16-1.51; P < .001). This increased risk of bleeding would warrant further investigation of optimal treatment strategies tailored for patients with STEMI of Asian ethnicity.

Introduction: This study compared inpatient outcomes related to the use of these two devices among patients who developed cardiogenic shock not due to acute myocardial infarction or coronary revascularization., Methods: We extracted admission-level records of patients with a diagnosis of cardiogenic shock who underwent either PVAD or IABP implantation from the National Inpatient Sample (NIS) database from 2010 to 2014. Our outcomes of interest were mortality and length of stay., Results: Inpatient mortality was significantly higher in the PVAD cohort. In multivariate analysis, PVAD use in these patients was associated with higher mortality. There was no difference in the length of stay between both groups among patients that survived to discharge., Conclusion: In our analysis of the NIS database, the use of PVADs in patients with cardiogenic shock of non-ischemic origin was associated with higher mortality when compared to IABP use., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Studies have reported sex differences in the management of patients with acute myocardial infarction (AMI) in the general population. This observational study is designed to evaluate whether sex differences exist in the contemporary management of human immunodeficiency virus (HIV) patients admitted for diagnosis of AMI., Hypothesis: There is no difference in management of HIV patients with AMI., Methods: Using the National Inpatient Sample database, we identified patients with a primary diagnosis of AMI and a secondary diagnosis of HIV. We described baseline characteristics and outcomes using NIS documentation. Our primary areas of interest were revascularization and mortality., Results: Among 2 977 387 patients presenting from 2010 to 2014 with a primary diagnosis of AMI, 10907 (0.4%) had HIV (mean age, 54.1 ± 9.3 years; n = 2043 [18.9%] female). Females were younger, more likely to be black, and more likely to have hypertension, diabetes, obesity, and anemia. Although neither males nor females were more likely to undergo coronary angiography in multivariate analysis, revascularization was performed less frequently in females than in males (45.4% vs 62.7%; P < 0.01), driven primarily by lower incidence of PCI. In a multivariate model, females were less likely to undergo revascularization (OR: 0.59, 95% CI: 0.45-0.78, P < 0.01), a finding driven solely by PCI (OR: 0.64, 95% CI: 0.49-0.83, P < 0.01). All-cause mortality was similar in both groups., Conclusions: AMI was more common in males than females with HIV. Females with HIV were more likely to be younger and black and less likely to be revascularized by PCI., (© 2018 Wiley Periodicals, Inc.)