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INTRODUCTION Heart failure (HF) patients may be susceptible to complications of hypertensive emergency (HTNE). Large registries have found that these patients are not on optimal antihypertensive therapy. To date, little investigation has been done on HF patients with HTNE, and their clinical risk factors/outcomes have not been well defined. METHODS We reviewed the National Inpatient Sample database to collect data on HF patient hospitalizations from 2005 to 2014. HF patients with and without a primary diagnosis of HTNE were included in the analysis. Risk factors and outcomes of HF patients with a primary diagnosis of HTNE were compared to those without HTNE. HF patients with a primary diagnosis of shock of any etiology were excluded. RESULTS Of 8,265,792 patients hospitalized with HF, 39,170 (0.5%) had HTNE. There was a threefold increase in the incidence of HTNE in HF patients over a 10-year period. The increase was more evident in females, Blacks and those

Although certain risk factors have been associated with morbidity and mortality, validated emergency department (ED) derived risk prediction models specific to coronavirus disease 2019 (COVID-19) are lacking. The objective of this study is to describe and externally validate the COVID-19 risk index (CRI). A large retrospective longitudinal cohort study was performed to analyze consecutively hospitalized patients with COVID-19. Multivariate regression using clinical data elements from the ED was used to create the CRI. The results were validated with an external cohort of 1799 patients from the MI-COVID19 database. The primary outcome was the composite of the need for mechanical ventilation or inpatient mortality, and the secondary outcome was inpatient mortality. A total of 1020 patients were included in the derivation cohort. A total of 236 (23%) patients in the derivation cohort required mechanical ventilation or died. Variables independently associated with the primary outcome were age ≥ 65 years, chronic obstructive pulmonary disease, chronic kidney disease, cerebrovascular disease, initial D-dimer > 1.1 µg/mL, platelet count

Heart failure is an inevitable end-stage consequence of significant valvular heart disease (VHD) that is left untreated and increasingly encountered in an ageing society. Recent advances in transcatheter procedures and improved outcomes after valve surgery mean that intervention can (and should) be considered in all patients - even the elderly and those with multiple comorbidities - at earlier stages of the natural history of primary VHD, before the onset of irreversible left ventricular dysfunction (and frequently before the onset of symptoms). All patients with known VHD should be monitored carefully in the setting of a heart valve clinic and those who meet guideline criteria for surgical or transcatheter intervention referred for intervention without delay. High quality evidence for the use of medical therapy in VHD is limited and achieving target doses in an elderly and comorbid population frequently challenging. Furthermore, determining whether the valve or ventricle is the principal disease driver is crucial (although the distinction is not always binary, and often unclear). Guideline-directed medical therapy remains the mainstay of treatment for secondary mitral regurgitation - although up to 50% of patients may fail to respond and should be considered for cardiac resynchronization, transcatheter or surgical valve intervention. Early and definitive management strategies are essential and should be overseen by a specialist Heart Team that includes a Heart Failure specialist. In this article, we provide an evidence-based summary of approaches to the medical treatment of VHD and clinical guidance for the best management of patients in situations where high quality evidence is lacking.

To assess host factors in pneumocystis jirovecii pneumonia (PCP)-related hospitalizations and compare outcomes between HIV and non-HIV patients.Using the National Inpatient Sample database, we identified 3384 hospitalizations with PCP (International Classification of Diseases, Ninth Revision, Clinical Modification code: 136.3) as the primary discharge diagnosis from 2005 to 2014. We evaluated hospitalizations for the following host factors: HIV, malignancies, organ transplantation, rheumatologic diseases, and vasculitides. We compared the prevalence of individual host factors among PCP hospitalizations over time, and compared intervention rates and outcomes between HIV and non-HIV patients with PCP.Among all hospitalizations for PCP, malignancy was the most prevalent host factor (46.0%, n=1559), followed by HIV (17.8%, n=604); 60.7% (n=946) of malignancies were hematologic. The prevalence of HIV among hospitalizations for PCP decreased from 25.1% in 2005 to 9.2% in 2014 (P.001), whereas the prevalence of non-HIV immunocompromising conditions increased. Compared with HIV patients, PCP patients without HIV had higher rates of bronchoscopy (52.3% vs 26.7%, P.001) and endotracheal intubation (17.0% vs 7.9%, P.001), prolonged hospitalizations (11.5 vs 8.7 days, P.001), higher hospitalization costs (86.8 vs 48.2×10The epidemiology of PCP has shifted with an increase in the prevalence of non-HIV patients who have higher intubation rates and prolonged hospitalizations compared with matched HIV patients.

In this Viewpoint, we highlight a possible hemodynamic problem arising following tricuspid valve replacement (TVR) in patients with severe chronic tricuspid regurgitation, represented by "unmasking" of pulmonary hypertension (PH) following the surgery. We share an observation that should alert cardiologists to the fact that this increasingly utilized surgery is not risk free, and careful assessment of the right ventricular function and pulmonary circulation preoperatively is extremely important, especially in patients with preexisting risk factors for PH, since TVR may lead to a sudden increase in right ventricular afterload.

Prosthetic valve infective endocarditis is a feared and potentially catastrophic complication of valvular intervention. Transcatheter aortic valve implantation has transformed the modern management of aortic stenosis and vastly altered the demographics of those patients undergoing valve replacement.As a relatively nascent development, what TAVI means for the epidemiology of infective endocarditis, how to identify those patients undergoing the procedure at greatest risk, and how best to prevent and manage the condition remains the subject of fervent research activity. In this review, we appraise relevant contemporary data discussing the incidence, microbiological profiles, associated risk factors and clinical outcomes of infective endocarditis after TAVI.Present outcomes are poor, with exceedingly high in-hospital and long-term mortality. Evidence to support surgical management in this patient group is lacking. Prevention is therefore paramount and a logical focus for future research attention.

Although certain risk factors have been associated with increased morbidity and mortality in patients admitted with Coronavirus Disease 2019 (COVID-19), the impact of cardiac injury and high-sensitivity troponin-I (hs-cTnI) concentrations are not well described. In this large retrospective longitudinal cohort study, we analyzed the cases of 1,044 consecutively admitted patients with COVID-19 from March 9 until April 15. Cardiac injury was defined by hs-cTnI concentration >99th percentile. Patient characteristics, laboratory data, and outcomes were described in patients with cardiac injury and different hs-cTnI cut-offs. The primary outcome was mortality, and the secondary outcomes were length of stay, need for intensive care unit care or mechanical ventilation, and their different composites. The final analyzed cohort included 1,020 patients. The median age was 63 years, 511 (50% patients were female, and 403 (40% were white. 390 (38%) patients had cardiac injury on presentation. These patients were older (median age 70 years), had a higher cardiovascular disease burden, in addition to higher serum concentrations of inflammatory markers. They also exhibited an increased risk for our primary and secondary outcomes, with the risk increasing with higher hs-cTnI concentrations. Peak hs-cTnI concentrations continued to be significantly associated with mortality after a multivariate regression controlling for comorbid conditions, inflammatory markers, acute kidney injury, and acute respiratory distress syndrome. Within the same multivariate regression model, presenting hs-cTnI concentrations were not significantly associated with outcomes, and undetectable hs-cTnI concentrations on presentation did not completely rule out the risk for mechanical ventilation or death. In conclusion, cardiac injury was common in patients admitted with COVID-19. The extent of cardiac injury and peak hs-cTnI concentrations were associated with worse outcomes.

OBJECTIVE The authors sought to evaluate 10-year national trends, incidence and clinical outcomes of stroke in CS-STEMI. BACKGROUND Stroke is a devastating complication among patients with ST-elevation myocardial infarction (STEMI). Concomitant cardiogenic shock (CS) may further increase the risk of stroke. Use of percutaneous mechanical circulatory support (pMCS) devices may further increase stroke risk in CS-STEMI. No studies have evaluated the risk of stroke in contemporary CS-STEMI. METHODS We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database between 2005 and 2014. Previously validated codes for stroke were used to identify events of ischemic or hemorrhagic stroke. They were then divided into different groups: without MCS, with intra-aortic balloon pump, percutaneous ventricular assist device (PVAD, includes Impella or TandemHeart devices), or extracorporeal membrane oxygenation. RESULTS In 172,491 admissions, stroke was noted in 5,613 (3.2%). Between 2005 and 2014, we observed an increase in the events of overall stroke from 3.1% in 2005 to 5.0% in 2014 (p for the trend

Secondary mitral regurgitation (SMR) occurs as a result of multifactorial left atrioventricular dysfunction and maleficent remodelling. It is the most common and undertreated form of mitral regurgitation (MR) and is associated with a very poor prognosis. Whether SMR is a bystander reflecting the severity of the cardiomyopathy disease process has long been the subject of debate. Studies suggest that SMR is an independent driver of prognosis in patients with an intermediate heart failure (HF) phenotype and not those with advanced HF. There is also no universal agreement regarding the quantitative thresholds defining severe SMR and indeed there are challenges with echocardiographic quantification. Until recently, no surgical or transcatheter intervention for SMR had demonstrated prognostic benefit, in contrast with HF medical therapy and cardiac resynchronisation therapy. In 2018, the first two randomised controlled trials (RCTs) of edge-to-edge transcatheter mitral valve repair versus guideline-directed medical therapy in HF (Percutaneous Repair with the MitraClip Device for Severe (MITRA-FR), Transcather mitral valve repair in patients with heart failure (COAPT)) reported contrasting yet complimentary results. Unlike in MITRA-FR, COAPT demonstrated significant prognostic benefit, largely attributed to the selection of patients with disproportionately severe MR relative to their HF phenotype. Consequently, quantifying the degree of SMR in relation to left ventricular volume may be a useful discriminator in predicting the success of transcatheter intervention. The challenge going forward is the identification and validation of such parameters while in parallel maintaining a heart-team guided holistic approach.

To evaluate the association of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) initial viral load (iVL) and the incidence of myocardial injury (MCI) in hospitalized patients with SARS-CoV-2 infection, we conducted a retrospective longitudinal study of hospitalized patients who had a nasopharyngeal swab sample on admission that returned a positive result for SARS-CoV-2 by polymerase chain reaction between April 4 and June 5, 2020. The cycle threshold (Ct) value was used as a surrogate for the iVL level, with a Ct level of 36 or less for elevated iVL and greater than 36 for low iVL. Myocardial injury was defined as an elevated high-sensitivity cardiac troponin I level that was higher than the 99th percentile upper reference limit. A total of 270 patients were included. Of these, 171 (63.3%) had an elevated iVL and 88 (32.6%) had MCI. There was no significant difference in the incidence of MCI in patients with low iVL compared to those with elevated iVL (28 of 99 [28.3%] vs 60 of 171 [35.1%]; P=.25). In a multivariable model, MCI (odds ratio, 3.86; 95% CI, 1.80 to 8.34; P

Background Patients with immune thrombocytopenic purpura (ITP) admitted with acute myocardial infarction (AMI) may be challenging to manage given their increased risk of bleeding complications. There is limited evidence in the literature guiding appropriate interventions in this population. The objective of this study is to determine the difference in clinical outcomes in AMI patients with and without ITP. Methods Using the United States national inpatient sample database, adults aged ≥18 years, who were hospitalized between 2007 and 2014 for AMI, were identified. Among those, patients with ITP were selected. A propensity‐matched cohort analysis was performed. The primary outcome was in‐hospital mortality. Secondary outcomes were coronary revascularization procedures, bleeding and cardiovascular complications, and length of stay (LOS). Results The propensity‐matched cohort included 851 ITP and 851 non‐ITP hospitalizations for AMI. There was no difference in mortality between ITP and non‐ITP patients with AMI (6% vs7.3%, OR:0.81; 95% CI:0.55‐1.19; P = .3). When compared to non‐ITP patients, ITP patients with AMI underwent fewer revascularization procedures (40.9% vs 45.9%, OR:0.81; 95% CI:0.67‐0.98; P = .03), but had a higher use of bare metal stents (15.4% vs 11.3%, OR:1.43; 95% CI:1.08‐1.90; P = .01), increased risk of bleeding complications (OR:1.80; CI:1.36‐2.38; P

Paraneoplastic syndromes in lung malignancies can lead to leukemoid reaction with an elevation of eosinophils, neutrophils, and monocytes. The elevation of these three lineages together due to paraneoplastic syndromes has not been described in literature yet.

OBJECTIVES Mortality following TAVI remains notable and optimizing other features of cardiovascular health following this intervention can be overlooked. Aortic pulse wave velocity (PWV) is the gold-standard for measuring arterial stiffness and is a powerful predictor of mortality. We identified the potential to calculate PWV during TAVI and aimed to use this tool to assess long-term outcome. METHODS Data from 186 patients who underwent TAVI between April 2016 and June 2017 was assessed. Invasive pressure data was simultaneously recorded from the femoral head and aortic root prior to TAVI and wave-time calculated using an automated foot-to-foot methodology. Distance was measured from the pre-TAVI CT. PWV was calculated from these values. RESULTS Median PWV was 9.92 (95% CI 9.6-10.2) m/s. Multivariate analysis revealed a relationship with PWV and age (β = 0.13, 95% CI 0.08-0.17, P

Background Currently used indices for pre-operative cardiovascular evaluation are either powerful, but complex, or simple, but with weak discriminatory power. Objectives This study sought to prospectively derive and validate a simple powerful index that can stratify the cardiovascular risk of patients undergoing noncardiac surgery. Methods The derivation cohort consisted of 3,284 prospectively enrolled adult patients undergoing noncardiac surgery at the American University of Beirut Medical Center. The validation cohort consisted of 1,167,414 patients registered in the American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. Results The primary outcome occurred in 38 patients (1.2%) in the derivation cohort. Multivariate logistic regression analysis in the derivation cohort identified 6 data elements to be included in the prediction model: age ≥75 years, history of heart disease, symptoms of angina or dyspnea, hemoglobin 3 based on the number of data elements present. The incidence of the primary outcome increased steadily across the CVRI groups in both the derivation (0%, 0.5%, 2.0%, 5.6%, and 15.7%, respectively; p Conclusions This study reports a new index for pre-operative cardiovascular evaluation which has a strong discriminatory power that can effectively stratify patients into low- (CVRI 0 to 1), intermediate- (CVRI 2 to 3), and high-risk (CVRI >3) groups. This has important implications for the efficient triage and management of patients scheduled for noncardiac surgery.

Background Hospitalization of patients infected with the severe acute respiratory syndrome virus 2 (SARS-CoV-2) have remained considerable worldwide. Patients often develop severe complications and have high mortality rates. The cycle threshold (Ct) value derived from nasopharyngeal swab samples using real time polymerase chain reaction (RT-PCR) may be a useful prognostic marker in hospitalized patients with SARS-CoV-2 infection, however, its role in predicting the course of the pandemic has not been evaluated thus far. Methods We conducted a retrospective cohort study which included all patients who had a nasopharyngeal sample positive for SARS-CoV-2 between April 4 –June 5, 2020. The Ct value was used to estimate the number of viral particles in a patient sample. The trend in initial viral load on admission on a population level was evaluated. Moreover, patient characteristics and outcomes stratified by viral load categories were compared and initial viral load was assessed as an independent predictor of intubation and in-hospital mortality. Results A total of 461 hospitalized patients met the inclusion criteria. This study consisted predominantly of acutely infected patients with a median of 4 days since symptom onset to PCR. As the severity of the pandemic eased, there was an increase in the percentage of samples in the low initial viral load category, coinciding with a decrease in deaths. Compared to an initial low viral load, a high initial viral load was an independent predictor of in-hospital mortality (OR 5.5, CI 3.1–9.7, p < 0.001) and intubation (OR 1.82 CI 1.07–3.11, p = 0.03), while an initial intermediate viral load was associated with increased risk of inpatient mortality (OR 1.9, CI 1.14–3.21, p = 0.015) but not with increased risk for intubation. Conclusion The Ct value obtained from nasopharyngeal samples of hospitalized patients on admission may serve as a prognostic marker at an individual level and may help predict the course of the pandemic when evaluated at a population level.

Objective. Supervised learning paradigms are often limited by the amount of labeled data that is available. This phenomenon is particularly problematic in clinically-relevant data, such as electroencephalography (EEG), where labeling can be costly in terms of specialized expertise and human processing time. Consequently, deep learning architectures designed to learn on EEG data have yielded relatively shallow models and performances at best similar to those of traditional feature-based approaches. However, in most situations, unlabeled data is available in abundance. By extracting information from this unlabeled data, it might be possible to reach competitive performance with deep neural networks despite limited access to labels. Approach. We investigated self-supervised learning (SSL), a promising technique for discovering structure in unlabeled data, to learn representations of EEG signals. Specifically, we explored two tasks based on temporal context prediction as well as contrastive predictive coding on two clinically-relevant problems: EEG-based sleep staging and pathology detection. We conducted experiments on two large public datasets with thousands of recordings and performed baseline comparisons with purely supervised and hand-engineered approaches. Main results. Linear classifiers trained on SSL-learned features consistently outperformed purely supervised deep neural networks in low-labeled data regimes while reaching competitive performance when all labels were available. Additionally, the embeddings learned with each method revealed clear latent structures related to physiological and clinical phenomena, such as age effects. Significance. We demonstrate the benefit of self-supervised learning approaches on EEG data. Our results suggest that SSL may pave the way to a wider use of deep learning models on EEG data., 32 pages, 9 figures

Supervised learning paradigms are often limited by the amount of labeled data that is available. This phenomenon is particularly problematic in clinically-relevant data, such as electroencephalography (EEG), where labeling can be costly in terms of specialized expertise and human processing time. Consequently, deep learning architectures designed to learn on EEG data have yielded relatively shallow models and performances at best similar to those of traditional feature-based approaches. However, in most situations, unlabeled data is available in abundance. By extracting information from this unlabeled data, it might be possible to reach competitive performance with deep neural networks despite limited access to labels. Here we report results using self-supervised learning (SSL), a promising technique for discovering structure in unlabeled data, to learn representations of EEG signals. Specifically, we consider a contrastive approach and provide results on two clinically-relevant problems: EEG-based sleep staging and pathology detection. Results report that linear classifiers trained on SSL-learned features consistently outperformed purely supervised deep neural networks in low-labeled data regimes while reaching competitive performance when all labels were available. Our results suggest that self-supervision may pave the way to a wider use of deep learning models on EEG data.

COVID-19 pandemic resulted in considerable morbidity and mortality. We analyzed 345 Electrocardiograms of 100 COVID-19 patients admitted to our tertiary care center in Detroit, during the initial month of Covid-19. Findings were correlated with mortality, cardiac injury and inflammatory markers. Our cohort included 61% males and 77% African Americans. The median age and BMI were 66 years (57-74) and 31 kg/m2 (26.1-39), respectively. We observed atrial arrhythmias in 29% of the patients (17% new onset), First degree heart block in 12%, ST-T segment changes in 17%, S1Q3T3 pattern in 19%, premature ventricular complexes in 23%, premature atrial complexes in 13%, Q waves in 27%, T wave inversion in 42% of the cases. While presence of premature atrial complexes or left atrial abnormality correlated with mortality (P = 0.02 & 0.03, respectively), other findings did not show significant correlation in this small cohort of patients.

Managers of food service operations standardise various aspects of operations to sustain consistent service quality. Frontline employees in these operations are expected to carry out tasks as per standards. Standards demand that frontline employees regulate their behaviours and emotions to complete their duties. Therefore, referring to the organisational role theory and the emotion regulation theory as the directing basis, this study examined the impact of job standardisation on emotional labour, as well as the effect of emotional labour on emotional exhaustion and job satisfaction of frontline employees in the hospitality sector. This study also examined the mediating effect of emotional labour on the relation between job standardisation, on one hand, and emotional exhaustion and job satisfaction on the other hand. The data collection was carried out in food service operations in Lebanon. Structural equation modelling (SEM) was used to assess the relations. The results showed that job standardisation negatively affected emotional labour and that emotional labour had a positive effect on emotional exhaustion and a negative effect on job satisfaction. Furthermore, emotional labour mediated the relation between job standardisation and emotional exhaustion and job satisfaction. Practical and theoretical implications and directions for future research are also provided.

We report a downward trend in the initial SARS-CoV-2 viral load in nasopharyngeal swab samples of hospitalized patients with COVID-19 in Detroit, Michigan, coinciding with a decrease in the number of deaths during April-June 2020. A gradual decrease in the initial viral load reflected the downward progression of the pandemic.

Introduction: Periodontal disease (PD) is an acquired disorder characterized by inflammation of the gums, resulting eventually in loss of teeth. Epidemiological studies have shown a link between PD and cardiovascular diseases (CVDs). The aim of this study is to evaluate differences in the prevalence of CVD amongst US patients with PD of different age, race and sex. Method: Using the US national in-patient sample database (NIS) from 2005-2014, patients with PD and CVD were identified. Results: 155,732 hospitalizations with PD were included in the study, of which 36.5% had at least one CVD. Ischemic heart disease was the most prevalent CVD (17.6%), followed by heart failure (10.9%), atrial fibrillation/flutter (10.1%) and cerebrovascular disease (CRVD) (9.7%). The overall in-hospital mortality was higher in PD patients with CVD (2.6% vs 1.2%, p Conclusion: CVD is prevalent in patients with PD and is more common in males and among Asians and Pacific Islanders. Higher mortality was reported among hospitalized PD patients with CVD. An increase in trend in the prevalence of AF, HF, and CRVD was noted across all age groups. This may require age, race, and gender specific strategies in PD patients for primary prevention of different CVD.

Papillary muscle rupture (PMR) or chordae tendinae rupture (CTR) is a rare but lethal complication after ST elevation myocardial infarction (STEMI). Due to the rarity of this condition, there are limited studies defining its epidemiology and outcomes. This is a retrospective study from Nationwide Inpatient Sample database from 2002 to 2014 of patients with STEMI and PMR/CTR. Outcomes of interest were incidence of in-hospital mortality, cardiogenic shock (CS), utilization of mechanical circulatory support (MCS) devices and mitral valve procedures (MVPs) among patients with and without rupture. We also performed simulation using the cardiovascular model to better understand the hemodynamics of severe mitral regurgitation and effects of different medications and device therapy. We identified 1,888 patients with STEMI complicated with PMR/CTR. Most of the patients were >65 years of age (65.3%), male (63.6%), and white (82.3%). They had significantly higher incidence of CS, cardiac arrest, and utilization of MCS devices. In-hospital mortality was higher in patients with rupture (41% vs. 7.40%, p < 0.001) which remained unchanged over the study period. Hospitalization cost and length of stay was also higher in them. MVP and revascularization led to better survival rates (27.9% vs. 60.6%, adjusted OR: 0.14; 95% CI: 0.10-0.19; p < 0.001). Despite significant advancement in the revascularization strategy, PMR/CTR after STEMI continues to portend poor prognosis with high inpatient mortality. Cardiogenic shock is a common presentation and is associated with significantly inpatient mortality. Future studies are needed determine the best strategies to improve outcomes in patients with STEMI with PMR/CTR and CS.

Background Acute myopericarditis can be caused by a myriad of infectious and non-infectious aetiologies, however, it is often considered to be due to self-limiting viral infection. Salmonella spp. myopericarditis is rare and the few cases in the literature suggest significant associated morbidity and mortality. Case summary A 44-year-old man presented with fever, dyspnoea, and chest pain. He was found to have a large pericardial effusion with clinical signs of tamponade and sepsis. Therapeutic pericardiocentesis was performed and ceftriaxone and levofloxacin were administered. Fully sensitive Salmonella enterica serovar Enteritidis (S. Enteritidis) was isolated in his pericardial fluid and he made a full recovery after a 4-week course of ciprofloxacin. A new diagnosis of type 2 diabetes mellitus was made on admission. A follow-up cardiac magnetic resonance (CMR) scan was suggestive of myocarditis which was unexpected given a normal Troponin T level on presentation. Discussion We report a rare case of S. Enteritidis myopericarditis. Our case is notable as the patient was immunocompetent apart from newly diagnosed diabetes. This case highlights the value of CMR imaging in assessing for myocarditis and ventricular function.

Objectives This study addresses the incidence, trends, and impact of nosocomial infections (NI) on the outcomes of patients admitted with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (STEMI-CS) using the United States National Inpatient Sample (NIS) database. Methods We analyzed data from 105,184 STEMI-CS patients using the NIS database from the years 2005-2014. NI was defined as infections of more than or equal to three days, comprising of central line-associated bloodstream infection (CLABSI), urinary tract infection (UTI), hospital-acquired pneumonia (HAP), Clostridium difficile infection (CDI), bacteremia, and skin related infections. Outcomes of the impact of NI on STEMI-CS included in-hospital mortality, length of hospital stay (LOS) and costs. Significant associations of NI in patients admitted with STEMI-CS were also identified. Results Overall, 19.1% (20,137) of patients admitted with STEMI-CS developed NI. Trends of NI have decreased from 2005-2014. The most common NI were UTI (9.2%), followed by HAP (6.8%), CLABSI (1.5%), bacteremia (1.5%), skin related infections (1.5%), and CDI (1.3%). The strongest association of developing a NI was increasing LOS (7-9 days; OR: 1.99; 95% CI: 1.75-2.26; >9 days; OR: 4.51; 95% CI: 4.04-5.04 compared to 4-6 days as reference). Increased mortality risk among patients with NI was significant, especially those with sepsis-associated NI compared to those without sepsis (OR: 2.95; 95% CI: 2.72-3.20). Patients with NI were found to be associated with significantly longer LOS and higher costs, irrespective of percutaneous mechanical circulatory support placement. Conclusions NI were common among patients with STEMI-CS. Those who developed NI were at a greater risk of in-hospital mortality, increased LOS and costs.

Background Cardiovascular comorbidities and complications, including right ventricular dysfunction, are common and are associated with worse outcomes in patients with COVID-19. The data on the clinical utility of 12-lead electrocardiograms (ECG) to aid with prognosis is limited. Objectives We aim to assess the association of new right heart strain patterns on presenting 12-lead electrocardiogram (RHS-ECG) with outcomes in patients hospitalized with COVID-19. Methods We retrospectively evaluated records from 480 patients who were consecutively admitted with COVID-19. ECGs obtained at the time of presentation in the emergency department (ED) were considered as index ECGs. RHS-ECG was defined by any new right axis deviation, S1Q3T3 pattern, or ST depressions with T-wave inversions in leads V1-3 or II, III, aVF. Multivariable logistic regression was performed to assess whether RHS-ECG is independently associated with our primary outcomes. Results ECGs from the ED were available for 314 patients who were included in the analysis. Most patients were in sinus rhythm, with sinus tachycardia being the most frequent dysrhythmia. RHS-ECG findings were present in 40 (11%) patients. RHS-ECG was significantly associated with the incidence of adverse outcomes and an independent predictor of mortality (adjOR, 15.2 (95% [CI, 5.1-45.2]; P, Graphical abstract, Cardiovascular complications are associated with worse outcomes in COVID-19. The present study evaluates the likelihood of critical illness in patients who have new right heart strain patterns on presenting 12-lead electrocardiogram (RHS-ECG). RHS-ECG was defined by any new right axis deviation, S1Q3T3 pattern, or ST Depressions with T-wave inversions in leads V1-3 or II, III, aVF. Our results revealed that RHS-ECG was the strongest independent predictor of mechanical ventilation and mortality in multivariable analysis with a powerful discriminatory ability as early as the ED encounter. A structured approach is warranted for patients admitted with RHS-ECG.

An increasing number of stage D heart failure patients are supported with left ventricular assist devices (LVADs), and the management of LVAD patients who require noncardiac surgery (NCS) presents unique challenges. Using the 2010-2014 National Inpatient Sample, we identified all adult cases of LVAD patients undergoing noncardiac surgeries using ICD-9-CM codes. We estimated inpatient mortality, bleeding complications, stroke, length of stay (LOS), and cost of hospitalization of the admissions related to NCS using mixed effects logistic and linear mixed regressions, respectively. A total of 30,323 patients with LVADs underwent 3,216 noncardiac surgeries (73.5% urgent) during the study period. LVAD recipients undergoing NCS had higher burden of certain comorbidities such as history of end-stage renal disease, pulmonary circulation disorders, peripheral vascular disease, and obesity. The most frequent NCS were general surgery, which included breast, endocrine, skin/burn, noncardiac transplantation, and abdominal surgeries (47.9%). In-hospital mortality was 7.7% with the highest rates observed among cases of neurologic surgeries. Vascular surgeries had the highest rates of ischemic stroke and gastrointestinal bleeding. Patients who underwent NCS had higher LOS and cost of hospitalization compared with LVAD recipients admitted to reasons other than NCS. Although bleeding complication trends have decreased, ischemic stroke and in-hospital mortality rates have increased overall during the study period. Urgent or emergency surgery was an independent predictor of mortality (OR 3.1, 95% CI 1.9-5). A significant burden of complications occurs after noncardiac surgeries in LVAD recipients.

Background Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI). Objective We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI. Methods We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation. Results Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs. Conclusions Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.

Background The American University of Beirut ( AUB )‐ HAS 2 Cardiovascular Risk Index is a newly derived index for preoperative cardiovascular evaluation. It is based on 6 data elements: history of heart disease; symptoms of angina or dyspnea; age ≥75 years; hemoglobin dL ; vascular surgery; and emergency surgery. In this study we analyze the performance of this new index and compare it with that of the Revised Cardiac Risk Index in a broad spectrum of surgical subpopulations. Methods and Results The study population consisted of 1 167 278 noncardiac surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. Each patient was given an AUB ‐ HAS 2 score of 0, 1, 2, 3, or >3, depending on the number of data elements present. The performance of the AUB ‐ HAS 2 index was studied in 9 surgical specialty groups and in 8 commonly performed site‐specific surgeries. Receiver operating characteristic curves were constructed for the AUB ‐ HAS 2 and Revised Cardiac Risk Index measures, and the areas under the curve were compared. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. The AUB ‐ HAS 2 score was able to stratify risk in all surgical subgroups ( P AUB ‐ HAS 2 score of 0 had an event rate of AUB ‐ HAS 2 index was superior to that of the Revised Cardiac Risk Index in all surgical subgroups ( P Conclusions This study extends the validation of the AUB ‐ HAS 2 index to a broad spectrum of surgical subpopulations and demonstrates its superior discriminatory power compared with the commonly utilized Revised Cardiac Risk Index.

Life-threatening arrhythmias (LTAs) can trigger sudden cardiac death or provoke implantable cardioverter-defibrillator (ICD) discharges that escalate morbidity and mortality. Longitudinal myofibrils predominate in the subendocardium, which is uniquely sensitive to arrhythmogenic triggers. In this study, we test the hypothesis that mitral annular systolic velocity (S'), a simple routinely obtained tissue Doppler index of LV long-axis systolic function, might predict lethal arrhythmias irrespective of left ventricular ejection fraction (LVEF).This is a retrospective analysis of data from 302 patients (mean age, 68 years; LVEF, 32%; 77% male; 52% ischemic; 35% primary prevention; and 53% cardiac resynchronization therapy defibrillator [CRT-D]) who were followed up (median, 15 months) at two centers after receipt of an ICD or CRT-D for diverse indications. S', averaged from tissue Doppler-derived medial and lateral mitral annular velocities, was correlated with the primary outcome of time to sustained ventricular tachycardia (VT) or fibrillation (VF) needing device therapy.The median S' was 5.1 (interquartile range, 4.0-6.2) cm/sec and lower in CRT-D than ICD subjects (4.5 [3.8-5.6] cm/sec vs 5.5 [4.8-6.8] cm/sec, P .001). Fifty-six (19%) subjects had LTA. Each 1 cm/sec higher S' correlated to a 30% decreased risk of LTA (hazard ratio = 0.70; 95% CI, 0.57-0.87; P = .001) independently of age, sex, β-blocker use, center, ICD use, and LVEF. Adding S' to the baseline Cox model improved net reclassification (P = .02). An S'5.6 cm/sec was the best cutoff and linked to a 58% lower LTA risk than an S' ≤ 5.6 cm/sec (95% CI, 0.23-0.85; P = .02).A higher S' is associated with a reduced probability of LTA in cardiac device recipients irrespective of LVEF and may have the potential to be used clinically to titrate medical, device, and ablative therapies to mitigate future arrhythmic risk.

Tobacco smoking contributes to about six million deaths per year and is predicted to increase in the future. Several pharmacological interventions are used for smoking cessation. Trials using nicotine replacement therapy (NRT) in acute coronary syndrome (ACS) showed inconclusive results. Furthermore, three trials using bupropion in patients admitted with ACS failed to show improvement in smoking cessation compared with placebo. Interestingly, only one trial using varenicline was successful in achieving smoking abstinence in the acute setting. With regard to behavioural interventions, a meta-analysis found that telephone counselling was successful in both the acute and stable settings, with greater effect in the acute setting. The best results for smoking cessation were found in trials that used a combination of pharmacological and behavioural interventions. The objective of this report is to review the results of studies on interventions used for smoking cessation after an ACS.

Purpose In-hospital mortality of patients with cardiogenic shock complicating ST-elevation myocardial infarction (STEMI-CS) ranges from 30% to 50%. The impact of nosocomial infection(NI) is not well addressed in these patients. Methods We queried the 2005-2014 Nationwide Inpatient Sample database to identify patients with STEMI-CS. Incidence of hospital-mortality, acute kidney injury (AKI), length of stay (LOS), cost of hospitalization and NI such as bloodstream infections due to central venous catheters (BI), bacteremia, ventilator-associated pneumonia (VAP), and clostridium difficile (CDI) infection among patients with and without mechanical circulatory support (MCS) use (intra-aortic balloon pump [IABP], Impella/TandemHeart [PVAD], and extra corporeal membrane oxygenation [ECMO]) were analyzed. Results We identified 172486 cases of STEMI-CS, of which 53% required MCS. Among STEMI-CS cases 6104 (3.5%) developed NI and 3977 cases required MCS. The rates of NI were increased among patients with MCS (p Conclusion NI are more frequent among patients with STEMI-CS requiring MCS and are associated with increased rates of AKI, LOS, and costs, but do not affect in-hospital mortality.

Background There is scarce evidence reflecting the clinical outcomes in patients with Idiopathic Thrombocytopenic Purpura (ITP) and Acute Myocardial Infarction (AMI). The ITP patient population is at higher risk of bleeding complications due to low platelet counts and difficulty in managing their antiplatelet and anticoagulation therapy. In our study, we sought to assess clinical outcomes of ITP patients admitted with AMI using the US national inpatient sample (NIS) database. Purpose To determine difference in in-hospital mortality, clinical complications, and length of stay (LOS) in AMI patients with and without ITP. Methods We identified adults aged ≥18 years hospitalized from 2005 to 2014 with AMI as their primary diagnosis utilizing ICD-9 codes 410.0 to 410.92. Patients with ITP were identified using ICD-9 code 287.31. The primary outcome was in-hospital mortality. Secondary outcomes included coronary revascularization procedures (PCI and CABG), and in-hospital complications including bleeding (intracranial, epistaxis, GI, and GU bleeding, hematoma, and bleeding requiring transfusion), cardiac complications, transfusions, acute ischemic stroke (AIS), and LOS. A propensity-matched cohort accounting for demographic characteristics, comorbidities, and cardiovascular risk factors, was created to compare these outcomes. Patients with secondary causes of ITP such as HIV, pregnancy, sepsis, SLE, malignancy were excluded. Results A total of 1108034 AMI admissions, of which 1002 with ITP, were identified. In the unmatched group, patients with ITP were older, and had more comorbidities (diabetes mellitus; hypothyroidism; atrial fibrillation; previous history of cardiovascular, peripheral, and end stage renal disease; all p Conclusion In the large population of patients included in the NIS database, patients with ITP admitted with AMI, have a significantly higher rate of bleeding complications, undergo less PCI and have a longer LOS compared to AMI patients without ITP. There are no current guidelines by ACC/AHA/ESC regarding management of patients with AMI and thrombocytopenia. These results warrant further investigation through randomized controlled trials including patients with thrombocytopenia to assess long term outcomes and to define optimal management in this population.

Background Life threatening arrhythmias (LTA) can trigger sudden cardiac death, or provoke implantable cardioverter defibrillator (ICD) discharges that escalate morbidity and mortality. Longitudinal myofibrils predominate in the subendocardium which is uniquely sensitive to arrhythmogenic triggers. Objectives To test the hypothesis that mitral annular systolic velocity (S'), a tissue Doppler index of LV long-axis systolic function, might predict lethal arrhythmias irrespective of LVEF. Methods We analysed data from diverse ICD and cardiac resynchronization therapy defibrillator (CRT-D) patients at 2 London centres. Channelopathies were excluded. S' was averaged from medial and lateral mitral annuli velocities. Primary outcome was time to sustained ventricular tachycardia (VT) or fibrillation (VF) needing device therapy. Results In 302 patients (mean age 68 years, LVEF 32%, 77% male, 52% ischemic, 35% primary prevention, and 53% CRT-D), median S' was 5.1 (IQR: 4.0–6.2) cm/s and lower in CRT-D than ICD subjects. After a median follow-up of 15 months, 56 (19%) subjects had LTA and those who did had a lower S' than those who did not (4.6±1.4 cm/s vs. 5.4±1.7 cm/s, P=0.003-Fig A). Each 1cm/s lower S' correlated to a 43% increased risk of LTA (HR: 0.70, 95% CI: 0.57–0.87, P=0.001) independently of age, gender, β-blocker use, centre, ICD use and LVEF. Adding S' to the baseline model improved net reclassification (P=0.02) implying incremental utility (Fig B). An S' ≤5.6cm/s was the best cut-off, conferring a 2.4-fold higher LTA risk than an S'>5.6 cm/s (95% CI: 1.17–4.37, P=0.02–Fig C). Conclusion A lower S' forecasts an enhanced probability of LTA in cardiac device recipients irrespective of LVEF, and could be used to titrate medical, device and ablative therapies to mitigate future arrhythmic risk.

The authors sought to compare the diagnostic accuracy of quantitative perfusion maps to visual assessment (VA) of first-pass perfusion images for the detection of multivessel coronary artery disease (MVCAD).VA of first-pass stress perfusion cardiac magnetic resonance (CMR) may underestimate ischemia in MVCAD. Pixelwise perfusion mapping allows quantitative measurement of regional myocardial blood flow, which may improve ischemia detection in MVCAD.One hundred fifty-one subjects recruited at 2 centers underwent stress perfusion CMR with myocardial perfusion mapping, and invasive coronary angiography with coronary physiology assessment. Ischemic burden was assessed by VA of first-pass images and by quantitative measurement of stress myocardial blood flow using perfusion maps.In patients with MVCAD (2-vessel [2VD] or 3-vessel disease [3VD]; n = 95), perfusion mapping identified significantly more segments with perfusion defects (median segments per patient 12 [interquartile range (IQR): 9 to 16] by mapping vs. 8 [IQR: 5 to 9.5] by VA; p 0.001). Ischemic burden (IB) measured using mapping was higher in MVCAD compared with IB measured using VA (3VD mapping 100 % (75% to 100%) vs. first-pass 56% (38% to 81%) ; 2VD mapping 63% (50% to 75%) vs. first-pass 41% (31% to 50%); both p 0.001), but there was no difference in single-vessel disease (mapping 25% (13% to 44%) vs. 25% (13% to 31%). Perfusion mapping was superior to VA for the correct identification of extent of coronary disease (78% vs. 58%; p 0.001) due to better identification of 3VD (87% vs. 40%) and 2VD (71% vs. 48%).VA of first-pass stress perfusion underestimates ischemic burden in MVCAD. Pixelwise quantitative perfusion mapping increases the accuracy of CMR in correctly identifying extent of coronary disease. This has important implications for assessment of ischemia and therapeutic decision-making.

OBJECTIVES To assess the safety and efficacy of first-line transcatheter aortic valve implantation (TAVI) in patients presenting with acute decompensated aortic stenosis (ADAS). BACKGROUND ADAS is common and is often treated medically or using balloon aortic valvuloplasty in the first instance. This temporizing measure results in suboptimal outcomes. In the current era, TAVI provides an alternative option. METHODS Consecutive patients who had either a TAVI for ADAS or electively were included in the study. The primary outcome was procedural and 30-day mortality and hospital length of stay (LOS). Secondary outcomes included 1-year mortality and procedural complications. RESULTS Of note, 893 patients (mean age 83 ± 7, 50.5% male) underwent TAVI (19% ADAS, 81% elective). ADAS patients were more unwell with worse echocardiographic parameters than elective patients. ADAS patients of 55.9% were known to have significant aortic stenosis prior to their decompensation. Procedural mortality was not different between the ADAS and elective cohorts (1.2 vs. 0.7%; p = .62). The ADAS cohort had a higher 30-day mortality (5.3 vs. 1.1%; p = .002) and longer LOS (31.9 ± 20.7 days vs. 6.1 ± 6.5 days; p

Myocarditis may be associated with hemodynamic instability and portends a poor prognosis when associated with cardiogenic shock (CS). There are limited data available on the incidence of in-hospital mortality, CS, and utilization of mechanical circulatory support (MCS) devices in these patients.We queried the 2005-2014 National Inpatient Sample databases to identify all patients aged18 years with myocarditis in the United States.The number of reported cases of myocarditis per 1 million gradually increased from 95 in 2005 to 144 in 2014 (Pfor trend.01). The trend and incidence of endomyocardial biopsy remained the same despite the increase in clinical diagnosis. Overall, in-hospital mortality was 4.43% of total admissions without a change in overall trend over the study period. We also observed a significant increase in the incidence of CS from 6.94% in 2005 to 11.99% in 2014 (Pfor trend.01). There was a parallel increase in the utilization of advanced MCS devices during the same time period such as extracorporeal membrane oxygenation or percutaneous cardiopulmonary support (0.32% in 2005 to 2.1% in 2014; P.01) and percutaneous ventricular assist devices such as Impella/tandem heart (0.176% in 2005 to 1.75% in 2014; P.01).Although the incidence of myocarditis has increased in the last decade, the in-hospital mortality has remained the same despite increases in the incidence of CS, possibly reflecting the benefits of increased usage of advanced MCS devices. We noted that increasing age, presence of multiple comorbidities and CS were associated with an increase in in-patient mortality.

Background Reverse Takotsubo cardiomyopathy is characterized by transient myocardial hypokinesia affecting predominantly the basal myocardial wall. It is a rare variant of Takotsubo cardiomyopathy affecting younger patients. Case Report We report a case of a young man who having consumed methamphetamines presented with cardiogenic shock and severe left ventricular systolic dysfunction, affecting predominantly the basal segments with sparing of the apex. After inotropic support, the left ventricular ejection fraction improved. Why Should an Emergency Physician Be Aware of This? It is important that emergency physicians are aware of the danger of methamphetamine consumption, and how it can lead to potentially fatal acute cardiac syndromes, including reverse Takotsubo cardiomyopathy and cardiogenic shock.

The impact of nosocomial infections(NI) in patients with STEMI and cardiogenic shock (STEMI-CS) is not well addressed. Using the 2005-2014 Nationwide Inpatient Sample database patients with STEMI-CS were identified. Incidence of mortality, acute kidney injury (AKI), length of stay (LOS), cost, and

An increasing number of stage D heart failure patients are supported with left ventricular assist devices (LVADs), and the management of LVAD patients who require noncardiac surgery (NCS) presents unique challenges. Using the 2010-2014 National Inpatient Sample, we identified all adult cases of

The hemodynamic changes arising in the pulmonary circulation following surgical Tricuspid Valve (TV) replacement in cases of isolated Tricuspid Regurgitation (TR) has not been well described. A 63-year-old man with a history of interstitial lung disease and hepatitis C presented with progressive

With newer antiretroviral therapies (ART), life expectancy of patients with HIV has increased. This led to an increased burden of cardiovascular diseases (CVD). To date, data on the race and gender-based trends and prevalence of various subtypes of CVD and CV mortality is scarce. Using the US

Background: Limited data are available on the predictors of mortality in patients hospitalized with acute myocardial infarction (AMI) in developing countries. In this study, we analyze the predictors for in­-hospital mortality in patients hospitalized with AMI (ST segment elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI)) in a large tertiary referral university hospital in Lebanon. Methods: This was a retrospective study of 503 patients admitted to the American University of Beirut Medical Center with AMI (228 with STEMI and 275 with NSTEMI). Results: The in-hospital mortality rate was 7.8%. The multivariate predictors of mortality in the overall population were similar to what has been reported in large registries in the USA and Europe. They included older age (> 65 years) (OR = 2.99, 95% CI = 1.22 - 7.36, P = 0.02), systolic blood pressure < 100 mm Hg (OR = 2.75, 95% CI = 1.12 - 6.76, P = 0.03), history of stroke (OR = 4.28, 95% CI = 1.29 - 14.17, P = 0.02), history of coronary artery bypass graft (CABG) (OR = 2.68, 95% CI = 1.15 - 6.23, P = 0.02), heart failure (OR = 3.92, CI = 1.62 - 9.49, P = 0.002) and ejection fraction (EF) < 35% (OR = 2.32, 95% CI = 1.05 - 5.14, P = 0.04). In a separate analysis of STEMI and NSTEMI patients, age, heart failure and a low EF continued to be multivariate predictors of mortality in both subgroups. In addition, prior stroke was an added predictor in STEMI patients, and prior CABG was an added predictor in NSTEMI. Conclusion: Predictors of in-hospital mortality in patients hospitalized with AMI in a tertiary referral university hospital in the Middle East are similar to what has been reported in large registries in the USA and Europe. Cardiol Res. 2018;9(5):293-299 doi: https://doi.org/10.14740/cr772w