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Background Atrial arrhythmias are commonly noted in patients with alcohol withdrawal syndrome (AWS), requiring inpatient admission. Objective The burden of arrhythmias and the association with in-hospital outcomes are incompletely defined in patients hospitalized with AWS. Methods The nationwide inpatient sample database was accessed from September 2015 to December 2018 to identify hospitalizations for AWS. We studied a cohort of patients with arrhythmias noted during hospitalization using the appropriate International Classification of Diseases, Tenth Revision billing codes. We compared patient characteristics, outcomes, and hospitalization costs between alcohol withdrawal hospitalizations with and without documented arrhythmias. Propensity score matching (PSM) and multivariate regression were performed to control confounders and develop odds ratios (OR), respectively. Results Among 1,511,155 hospitalization with AWS, 146,825 (9.72%) had concurrent arrhythmias. After PSM, we identified 135,540 cases in each group. Hospitalizations with AWS and concurrent arrhythmias had higher in-hospital mortality (4.19% vs 1.95%, OR 1.76, confidence interval [CI] 1.67–1.85, P < .0001). The most common arrhythmia was atrial fibrillation (66.7%). Arrhythmias in AWS were also associated with poorer in-hospital outcomes, including a higher risk of acute heart failure (8.40% vs 4.58%, OR 1.97, CI 1.90–2.05, P < .0001), acute kidney injury (21.32% vs 15.27%, OR 1.39, CI 1.36–1.43, P < .0001), and acute respiratory failure (9.19% vs 5.49%, OR 1.70, CI 1.64–1.76, P < .0001) requiring intubation. The length of hospital stay (6 days vs 4 days P < .0001) and cost of hospital care ($12,615 [$6683–$27,330] vs $7860 [$4482–$15,868], P < .0001) were higher in AWS with arrhythmias. Conclusion Arrhythmia in AWS is associated with higher in-hospital mortality and poorer in-hospital outcomes.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus causing coronavirus disease 2019 (COVID-19), has affected human lives across the globe. On 11 December 2020, the US FDA granted an emergency use authorization for the first COVID-19 vaccine, and vaccines are now widely available. Undoubtedly, the emergence of these vaccines has led to substantial relief, helping alleviate the fear and anxiety around the COVID-19 illness for both the general public and clinicians. However, recent cases of vaccine complications, including myopericarditis, have been reported after administration of COVID-19 vaccines. This article discusses the cases, possible pathogenesis of myopericarditis, and treatment of the condition. Most cases were mild and should not yet change vaccine policies, although prospective studies are needed to better assess the risk-benefit ratios in different groups.

Objectives The aim of this study was to evaluate the interaction between hospital endovascular lower extremity revascularization (eLER) volume and outcomes after eLER for critical limb ischemia (CLI). Background There is a paucity of data on the relationship between hospital procedural volume and outcomes of eLER for CLI. Methods The authors queried the Nationwide Readmission Database (2013-2015) for hospitalized patients who underwent eLER for CLI. Hospitals were divided into tertiles according to annual eLER volume: low volume ( 550 eLER procedures). Stepwise multivariable regression models were used. The main outcomes were in-hospital mortality and 30-day readmission with major adverse limb events, defined as the composite of amputation, acute limb ischemia, or repeat revascularization. Results Among 145,785 hospitalizations for eLER for CLI, 5,199 (3.6%) were at low-volume eLER hospitals, 27,857 (19.1%) at moderate-volume eLER hospitals, and 112,728 (77.3%) at high-volume eLER hospitals. On multivariable analysis, there was no difference with regard to in-hospital mortality among moderate-volume hospitals (adjusted odds ratio [OR]: 0.78; 95% CI: 0.60-1.01) and high-volume hospitals (adjusted OR: 0.84; 95% CI: 0.64-1.05) compared with low-volume hospitals. There was lower risk of in-hospital major amputation (adjusted OR: 0.82; 95% CI: 0.70-0.96) and minor amputation at high- versus low-volume hospitals. The length of hospital stay was shorter and discharges to nursing facilities were fewer among moderate- and high-volume hospitals compared with low-volume hospitals. Compared with low-volume hospitals, eLER for CLI at high-volume hospitals had a lower risk for 30-day readmission with major adverse limb events (adjusted OR: 0.83; 95% CI: 0.70-0.99), while there was no difference among moderate-volume hospitals (adjusted OR: 0.92; 95% CI: 0.77-1.10). Conclusions This nationwide observational analysis suggests that annual eLER volume does not influence in-hospital mortality after eLER for CLI. However, high eLER volume (>550 eLER procedures) was associated with better rates of limb preservation after eLER for CLI.

Background: The level of representation of women in cardiology remains low compared to that of men, particularly in leadership positions. We evaluated gender disparity in the authorship of Canadian Cardiovascular Society (CCS) guidelines. Methods: All CCS guidelines from 2001-2020 were identified. Gender was assessed based on pronoun use in the biographies and social media of the authors. Only primary panel authors were included in our analysis. Stratified analyses were performed based on subspecialties. Results: A total of 76 guidelines were identified, with 1172 authors (26% women, 74% men, P < 0.0001), with no significant change in percentage of women authors over 2 decades, (37.1% in 2001, 36.3% in 2020, P = 0.34). Inclusion of women as authors occurred less frequently than inclusion of men in general cardiology guidelines (20.1% vs 79.9%, P < 0.0001) and all subspecialties—heart failure (36.4% vs 63.6%, P < 0.0001), interventional cardiology (12.6% vs 87.4%, P < 0.0001), electrophysiology (20.2% vs 79.8%, P < 0.0001), and pediatric cardiology (41.7% vs 58.3%, P = 0.02). It was less likely for women to be a chair or cochair of a guideline writing committee, compared with men (20.1% vs 79.8%, P < 0.0001). There were 609 unique authors (25.6% women, 74.4% men, P < 0.0001), 542 unique medical doctorate (MD) authors (20.7% women, 79.3% men, P < 0.0001), and 67 unique non-MD authors (65.7% women, 34.3% men, P = 0.0003). Conclusions: There is a persistent shortfall in the inclusion of women authors for CCS guidelines, which has not changed over time. Further efforts are required to promote women's inclusion in leadership roles, which may lead to authorship of the guidelines. Résumé: Introduction: La représentation des femmes en cardiologie demeure faible par rapport à celle des hommes, particulièrement dans les positions de leadership. Nous avons évalué la disparité entre les sexes de la paternité des lignes directrices de la Société canadienne de cardiologie (SCC). Méthodes: Nous avons relevé toutes les lignes directrices de la SCC de 2001 à 2020. Nous avons déterminé le sexe en fonction de l'utilisation du pronom dans les biographies et les médias sociaux des auteurs. Seuls les auteurs du panel principal ont été ajoutés à notre analyse. Nous avons réalisé les analyses stratifiées en fonction des sous-spécialités. Résultats: Nous avons relevé un total de 76 lignes directrices, qui regroupaient 1 172 auteurs (26 % de femmes, 74 % d'hommes, P

The role of anticoagulation in octogenarians and nonagenarians with atrial fibrillation (AF) is controversial due to the lack of evidence from randomized controlled trials (RCTs), owing to the under representation of these patients in clinical trials. In the present meta-analysis we aim at comparing the clinical benefits and risk of anticoagulation (AC) with no AC in octogenarians and nonagenarians. We systematically searched MEDLINE/PubMed, EMBASE/Ovid, and Web of Science databases from the inception to October, 2020. Studies were eligible for inclusion if they met the following criteria: studies comparing AC with no AC in patients aged 80 or more for AF and reported thromboembolic events (TE) and bleeding outcomes. We used Mantel-Haenszel method with a Paule-Mandel estimator of Tau2 with Hartung Knapp-Sidik-Jonkman adjustment to estimate risk ratio (RR) with a 95% confidence interval (CI). Outlier analysis was used to adjust for statistical heterogeneity. A total of 10 observation studies and 1 RCT were included in the final analysis. There was no difference in the risk of TE with AC in octogenarians and nonagenarians compared with no AC, before [RR: 0.87, 95% CI 0.62–1.23, I2: 71%, GRADE confidence “very low”] and after [RR: 0.83, 95% CI 0.66–1.04, I2: 55.5%] adjusting for statistical heterogeneity among studies. In the unadjusted analysis, no difference in the risk of bleeding events was observed between both groups [RR: 1.05, 95% CI 0.62–1.77, I2: 86%, GRADE confidence “very low”]. After adjusting for heterogeneity, AC was associated with an increased risk of bleeding compared with those not receiving AC [RR: 1.57, 95% CI 1.44–1.71, I2: 0%]. AC in octogenarians was not associated with a net clinical benefit compared with no AC. This meta-analysis did not demonstrate any difference in the risk TE in octogenarians and nonagenarians with AF on AC vs. no AC, in both the adjusted and unadjusted analyses. Also, the risk of bleeding events in the unadjusted analysis was similar between both groups. The adjusted analysis showed an increased risk of bleeding in the AC group compared with no AC group. More data is needed to establish safety and efficacy of AC in this vulnerable patient population. The results of this analysis should be interpreted with caution due to the observational nature of most studies included, and the only RCT reported lower rates of TE and similar risk of bleeding.

BACKGROUND This meta-analysis aims to evaluate the utility of speckle tracking echocardiography (STE) as a tool to evaluate for cardiac sarcoidosis (CS) early in its course. Electrocardiography and echocardiography have limited sensitivity in this role, while advanced imaging modalities such as cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) are limited by cost and availability. METHODS We compiled English language articles that reported left ventricular global longitudinal strain (LVGLS) or global circumferential strain (GCS) in patients with confirmed extra-cardiac sarcoidosis versus healthy controls. Studies that exclusively included patients with probable or definite CS were excluded. Continuous data were pooled as a standard mean difference (SMD), comparing sarcoidosis group with healthy controls. A random-effect model was adopted in all analyses. Heterogeneity was assessed using Q and I2 statistics. RESULTS Nine studies were included in our final analysis with an aggregate of 967 patients. LVGLS was significantly lower in the extra-cardiac sarcoidosis group as compared with controls, SMD -3.98, 95% confidence interval (CI): -5.32, -2.64, P

Background Due to the current Coronavirus Disease 2019 (COVID-19) pandemic, there is a realization for innovation in procedures and protocols to minimize hospital stay and at the same time ensure continued evidence-based treatment delivered to the patients. We present a same-day discharge protocol for transcatheter mitral valve repair (TMVR) using MitraClip under general anaesthesia in a six-patient case series. This protocol aims to reduce the length of hospital stay, thereby minimizing potential for nosocomial COVID-19 infections and to promote safe discharge with cautious follow-up. Case summary Six patients with severe symptomatic mitral valve (MV) regurgitation underwent successful transfemoral MV repair using standard procedures. Following repair, patients were monitored on telemetry in the recovery area for 3 h, ambulated to assess vascular access stability and underwent post-procedural transthoracic echocardiogram to assess for any pericardial effusion or post-procedural prosthetic mitral stenosis. Conclusion Same-day discharge after TMVR is possible when done cautiously with close follow-up, can minimize hospital stay, improve resource utilization, and reduce risk of nosocomial COVID-19 infection.

Contemporary data on stroke predictors and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) remains limited. We analyzed National Inpatient Sample data from the year 2011 to 2018. A total of 215,938 patients underwent TAVI. Of the patients who underwent TAVI, 4579 (2.2%) suffered from stroke and 211359 (97.8%) did not have a stroke. Adjusted mortality was higher in patients who had a stroke (10.9%) as compared to patients who did not have a stroke (3.1%). Lower percentage of patients were discharged home who developed a stroke compared to patients without a stroke (10.2% vs 52.3%). Multivariate logistic regression analysis showed that at baseline, age, female sex, atrial fibrillation, chronic kidney disease and peripheral vascular disease were significant predictors of stroke. Median Cost of care ($63367 vs $48070) and length of stay (8 vs 4 days) were considerably higher for patients with stroke when compared to the comparison group (P0.01 for all). In conclusion we report that stroke is associated with increased mortality, morbidity, and resource utilization in patients undergoing TAVI. Baseline characteristics like age, gender, atrial fibrillation, chronic kidney disease and peripheral vascular disease are significant predictors of this adverse event.

Introduction The role of losartan in preventing aortic root dilatation in Marfan syndrome has been evaluated in many clinical trials; however, the results are conflicting. Methods We performed a computerized search of MEDLINE, EMBASE and COCHRANE databases through February 2019 for randomized clinical trials evaluating the effect of losartan in patients with Marfan syndrome. The main outcome was the change in the aortic root diameter in the losartan versus control groups. Results Our final analysis included seven randomized trials with a total of 1352 patients and average weighted follow-up of 37.8 months. Change in aortic root diameter was significantly smaller with losartan compared with control [weighted means: 0.44 vs. 0.58 mm, mean difference (MD) = −0.13; 95% CI −0.24 to −0.02; p = 0.02]. Subgroup analysis according to the control group showed no significant subgroup interaction when comparing losartan with beta-blockers versus with standard therapy (pinteraction= 0.27). The composite outcome of aortic surgery, dissection or mortality did not differ between the losartan and control groups (risk ratio = 1.03; 95% CI 0.72–1.49, p = 0.86). Conclusion In this meta-analysis including seven randomized trials, the use of losartan was associated with a significantly smaller change in aortic root diameter in patients with Marfan syndrome. Electronic supplementary material The online version of this article (10.1007/s40119-019-00149-3) contains supplementary material, which is available to authorized users.

Although rare, patients with variant Creutzfeldt-Jakob Disease (vCJD) in their differential diagnosis of progressive dementia and movement disorder could continue to present to hospitals for care. However, U.S.-based infection control guidelines do not fully address the possibility of vCJD. After near-misses involving increasing numbers of patients with clinical findings and epidemiologic risks compatible with vCJD, or exposures to chronic wasting disease, we sought to improve recognition and prevention of iatrogenic spread of these prion-related diseases.

Recurrent gastrointestinal bleeding (GIB) is a common complication following left ventricular assist device (LVAD) implantation. Our study aimed to estimate the comparative efficacy of different pharmacologic interventions for the prevention of GIB, through a network meta-analysis (NMA). A total of 13 observational studies comparing six strategies. Among those, 4 were for primary, and 9 were for secondary prevention of GIB. On NMA, thalidomide (Hazard ratio [HR]: 0.016, Credible interval [CrI]I: 0.00053-0.12), omega-3-fatty acid (HR:0.088, CrI: 0.026-0.77), octreotide (HR: 0.17, CrI: 0.0589-0.41) and danazol (HR:0.17, CrI: 0.059-0.41) reduced the risk of GIB. The use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker (ACEi/ARB) and digoxin were not associated with any significant reduction. Based on NMA, combining indirect treatment comparisons, thalidomide, danazol, and octreotide treatments were associated with decreased risk of recurrent GIB. Additionally, Omega 3 fatty acids were associated with a lower risk of the primary episode of GIB in the LVAD patient population.

Background The coronavirus disease 2019 (COVID-19) pandemic has resulted in drastic changes to the practice of medicine, requiring healthcare systems to find solutions to reduce the risk of infection. Using a case series, we propose a protocol for same-day discharge (SDD) for selected patients undergoing transcatheter aortic valve replacement (TAVR) using real-time remote cardiac monitoring. Six patients with severe symptomatic aortic stenosis underwent TAVR and were discharged on the same day. Case summary Six patients with symptomatic severe native or bioprosthetic aortic valve stenosis underwent a successful transfemoral TAVR using standard procedures, including the use of rapid atrial pacing to assess the need for permanent pacemaker implantation. Following TAVR, patients were monitored on telemetry in the recovery area for 3 h, ambulated to assess vascular access stability, and discharged with real-time remote cardiac monitoring if no new conduction abnormality was observed. The patients were seen by tele-visits within 2 days and 2 weeks after discharge. Discussion Amidst the COVID-19 pandemic, SDD following successful transfemoral TAVR may be feasible for selected patients and reduce potential COVID-19 exposure.

Background Outcomes of patients with implanted left ventricular assist device (LVAD) implantation experiencing a cardiac arrest (CA) are not well reported. We aimed at defining the in-hospital outcomes of patients with implanted LVAD experiencing a CA. Methods The national inpatient sample (NIS) was queried using ICD9/ICD10 codes for patients older than 18 years with implanted LVAD and CA between 2010–2018. We excluded patients with orthotropic heart transplantation, biventricular assist device (BiVAD) implantation and do not resuscitate (DNR) status. Results A total of 93,153 hospitalisations between 2010 and 2018 with implanted LVAD were identified. Only 578 of these hospitalisations had experienced CA and of those, 173 (33%) hospitalisations underwent cardiopulmonary resuscitation (CPR). The mean age of hospitalisations that experienced a CA was 60.61±14.85 for non-survivors and 56.23±17.33 for survivors (p=0.14). The in-hospital mortality was 60.8 % in hospitalisations with CA and 74.33% in hospitalisations in whom CPR was performed. In an analysis comparing survivors with non-survivors, non-survivors had more diabetes mellitus (DM) (p=0.01), and ischaemic heart disease (IHD) (p=0.04). Age, female sex, peripheral vascular disease and history of coronary artery bypass graft (CABG) were independently associated with increased mortality in our cohort. Also, ventricular tachycardia (VT) and CPR were independently associated with in-hospital mortality. During the study period, there was a significantly decreasing trend in performing CPR in LVAD hospitalisations with CA. Conclusion In conclusion, age, female sex, peripheral vascular disease, history of CABG, VT and CPR were independently associated with in-hospital mortality in LVAD hospitalisations who experienced CA.

Background: Outcomes of coronary artery bypass grafting (CABG) versus (vs) percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndromes (ACS) with unprotected left main (ULM) as culprit vessel are not well represented in major clinical trials. We performed a meta-analysis and meta-regression of studies that compared the outcomes of CABG vs PCI in ULM in ACS. Methods: Medline, EmCare, CINHAL, Cochrane database, and Google Scholar were searched for studies comparing CABG vs PCI in patients who presented with ACS and was found to have ULM as culprit vessel. Our primary outcome was mortality at longest follow up. Our secondary Outcome was repeat revascularization at longest follow up. We used PM method with HKSJ adjustment to estimate risk ratio (RR) with 95% confidence interval (CI). Heterogeneity was assessed using I 2 statistics. Multivariable meta-regression analysis was used to account for heterogeneity. History of smoking, diabetes, hypertension and previous PCI was used for multivariable regression. R version 3.6.2 was used for all statistical analysis. Results: A total of 8 studies met our inclusion criteria. The follow up period varied from 6 months to 10 years. There was no significant difference in the risk of mortality between CABG vs PCI; RR: 1.31, CI: 0.76 - 2.27, I 2 = 71%. However, the PCI as compared to CABG was associated with higher risk repeat revascularization at longest follow up; RR: 2.64, 95% CI: 1.56 to 4.46, I 2 = 60%. Meta-regression analysis reported previous PCI to be associated with lower mortality with CABG [P value =0.01], while history of diabetes was associated with higher mortality with CABG [P value Conclusion: CABG vs PCI in ULM in ACS is associated with similar risk of mortality. Previous PCI and non-diabetics were associated with higher mortality with PCI as compared to CABG. However PCI as compared to CABG was associated with higher risk of repeat revascularizations.

Background: Cardiac sarcoidosis (CS) affects 35% of patients with pulmonary sarcoidosis (PS). CS presentation varies from asymptomatic patients to sudden cardiac death. The current screening modalities like EKG and conventional echocardiography lack sensitivity for early detection of CS. Speckle tracking echocardiography (STE) has shown potential for early detection of subclinical myocardial damage in patients with PS. We aimed to investigate the role of STE in early detection of CS. Methods: We queried Medline, EmCare, CINAHL, Cochrane Database and Google Scholar for articles investigating the role of left ventricle global longitudinal strain (LVGLS) in asymptomatic patients with PS versus (vs) controls. Studies that included patients with suspected or proven CS, patients with cardiac symptoms, arrhythmias, coronary artery disease or valvular abnormalities were excluded. The standard mean difference (SMD) in GLS for both groups was pooled using random effects model. Results: Our search yielded a total of 9 studies with a total of 967 patients with PS undergoing screening for CS. In individual studies, the baseline characteristics were not significantly different between both groups. Overall, the studies had more females than males. All patients in our cohort had preserved ejection fraction (EF) and no cardiac symptoms. The LVGLS was significantly decreased in the PS group as compared to controls, SMD: -3.98, (95% CI: -5.32 to -2.64; p-value 2 = 94.70%, Figure 1. Conclusion: As compared to controls, patients with PS with no clinically suspected or proven CS, and normal EF, have impaired LVGLS. More studies are warranted to investigate the role of LVGLS in CS screening.

Background: Octogenarians and nonagenarians are under-represented in major clinical trials studying the role of anticoagulation (AC) in atrial fibrillation (AF). These patients are at an increased risk of bleeding owing to their frailty, their propensity for falls, and frequently impaired kidney function. We performed a meta-analysis of studies that investigated the role of AC in these patients. Methods: We queried Medline, EmCare, CINHAL, Cochrane Database, and Google Scholar for studies investigating the role of AC for AF in octogenarians and nonagenarians. Our primary efficacy outcome was major thromboembolism (TE), and secondary safety outcome was major bleeding (MB). We used the PM method with HKSJ adjustment to estimate risk ratio (RR) with a 95% confidence interval (CI). Heterogeneity was assessed using Higgin’s I 2 . R version 3.6.2 was used for statistical analysis. Heterogeneity was addressed using outlier analysis. dmetar() package in R was used, and the pooled estimate was re-calculated, excluding the outliers. Results: Ten observational studies, including a total of 34,697 patients were included. There was no difference in the risk of TE [RR: 0.82, 95% CI: 0.49-1.38, I 2 =74%] or MB [RR: 1.00, 95% CI: 0.55-1.83, I 2 =88%] between the AC and Non-AC group. However, the pooled estimates were associated with considerable heterogeneity. Outlier analysis identified two studies "Perera et al., 2009" and "Yamashita et al., 2016" as an outlier for pooled estimation of TE, while [1] "Siu et al., 2014", "Bertozzo et al., 2016", "Ekerstad et al., 2018" and "Alnsasra et al., 2018" were outliers in the pooled estimate of MB. Following exclusion of outliers for each endpoint, the reanalyzed RR for TE and MB were [RR: 0.94, 95% CI: 0.82- 1.09, I 2 =0%] and [RR: 1.57, 95% CI: 1.41- 1.74, I 2 =0%]. Conclusion: There was no difference in the risk of TE, while the risk of MB increased with the use of AC for AF in octogenarians and nonagenarians.

Background: Long term outcomes of culprit multi-vessel and left main patients who presented with Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS) and underwent either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) are not well defined. Randomized trials comparing the two modalities constituted mainly of patients with stable coronary artery disease (SCAD). We performed a meta-analysis of studies that compared the long term outcomes of CABG vs. PCI in NSTE-ACS. Methods: Medline, EmCare, CINAHL, Cochrane databases were queried for relevant articles. Studies that included patients with SCAD and ST-elevation myocardial infarction were excluded. Our primary outcome was major adverse cardiac events (MACE) at 3-5 years, defined as a composite of all-cause mortality, stroke, re-infarction and repeat revascularization. The secondary outcome was re-infarction at 3 to 5 years. We used the Paule-Mandel method with Hartung-Knapp-Sidik-Jonkman adjustment to estimate risk ratio (RR) with 95% confidence interval (CI). Heterogeneity was assessed using Higgin’s I 2 statistics. All statistical analysis was carried out using R version 3.6.2 Results: Four observational studies met our inclusion criteria with a total number of 6695 patients. At 3 to 5 years, the PCI group was associated with a higher risk of MACE as compared to CABG, (RR): 1.52, 95% CI: 1.28 to 1.81, I 2 =0% (PANEL A). The PCI group also had a higher risk of re-infarctions during the period of follow up, RR: 1.88, 95% CI 1.49 to 2.38, I 2 =0% (PANEL B). Conclusion: In this meta-analysis, CABG was associated with a lower risk of MACE and re-infarctions as compared to PCI during 3 to 5 years follow up period.

Background: The optimum revascularization modality in multi-vessel and left main disease patients presenting with non-ST elevation acute coronary syndrome (non-STE-ACS) is not well studied. The current recommendations are based on studies that primarily included patients with stable angina. Patients with non-STE-ACS were under-represented in clinical trials. We performed a meta-analysis of studies comparing coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in non-STE-ACS, and reporting 30 days major adverse cardiac events (MACE). Methods: We searched Medline, EmCare, CINAHL, Cochrane database, and Google Scholar for relevant articles. We excluded studies that included patients with stable coronary artery disease and ST elevation myocardial infarction. Our primary outcome was 30 days MACE defined as all-cause death, stroke, repeat revascularization and re-infarction. We used the Paule-Mandel method with the Hartung-Knapp-Sidik-Jonkman adjustment to estimate risk ratio (RR) with a 95% confidence interval (CI). Heterogeneity was assessed using Higgin’s I 2 statistics. To account for heterogeneity, a meta-regression analysis was performed. Results: Five observational studies met our inclusion criteria summing to a total number of 7161 patients. At 30 days, there was no difference between CABG vs. PCI in terms of MACE, RR: 0.96, 95% CI 0.38 to 2.39, I 2 = 81% (Panel A). A meta-regression analysis reported that a history of PCI was associated with a lower risk of MACE with CABG compared to PCI (Panel B). Conclusion: At 30 days, there was no difference in MACE between the CABG and PCI groups. However, a history of PCI was associated with a lower risk of MACE in patients who underwent CABG.

There is a paucity of data on the outcomes and revascularization strategies for critical limb ischemia (CLI) among patients with chronic kidney disease (CKD). Hence, we conducted a nationwide analysis to evaluate the trends and outcomes of hospitalizations for CLI with CKD. The National Inpatient Sample database (2002–2015) was queried for hospitalizations for CLI. The trends of hospitalizations for CLI with CKD were reported, and endovascular versus surgical revascularization strategies for CLI with CKD were compared. The main study outcome was in-hospital mortality. The analysis included 2,139,640 hospitalizations for CLI, of which 484,224 (22.6%) had CKD. There was an increase in hospitalizations for CLI with CKD (Ptrend = 0.01), but a reduction in hospitalizations for CLI without CKD (Ptrend = 0.01). Patients with CLI and CKD were less likely to undergo revascularization compared with patients without CKD. CLI with CKD had higher rates of in-hospital mortality (4.8% vs 2.5%, adjusted odds ratio (OR) 2.01; 95% CI 1.93–2.11) and major amputation compared with no CKD. Revascularization for CLI with CKD was associated with lower rates of mortality (3.7% vs 5.3%, adjusted-OR 0.78; 95% CI 0.72–0.84) and major amputation compared with no revascularization. Compared with endovascular revascularization, surgical revascularization for CLI with CKD was associated with higher rates of in-hospital mortality (4.7% vs 2.7%, adjusted-OR 1.67; 95% CI 1.43–1.94). In conclusion, this contemporary observational analysis showed an increase in hospitalizations for CLI among patients with CKD. CLI with CKD was associated with higher in-hospital mortality compared with no CKD. Compared with endovascular therapy, surgical revascularization for CLI with CKD was associated with higher in-hospital mortality.

Background This meta-analysis aims to evaluate the utility of speckle tracking echocardiography (STE) as a tool to evaluate for cardiac sarcoidosis (CS) early in its course. Electrocardiography and echocardiography have limited sensitivity in this role, while advanced imaging modalities such as cardiac magnetic resonance (CMR) and 18F-Fluorodeoxyglucose–Positron Emission Tomography (FDG-PET) are limited by cost and availability. Methods We compiled English language articles that reported left ventricular global longitudinal strain (LVGLS) or global circumferential strain (GCS) in patients with confirmed extra-cardiac sarcoidosis versus healthy controls. Studies that exclusively included patients with probable or definite CS were excluded. Continuous data were pooled as a standard mean difference (SMD) between the sarcoidosis group and controls. A random effect model was adopted in all analyses. Heterogeneity was assessed using Q and I2 statistics. Results Nine studies with 967 patients were included in our analysis. LVGLS was significantly lower in the extra-cardiac sarcoidosis group as compared to controls, SMD -3.98, 95% confidence interval (CI): -5.32, -2.64, p< 0.001, also was significantly lower in patients who suffered Major Cardiac Events(MCE), -3.89, 95% CI -6.14, -1.64, p< 0.001 . GCS was significantly lower in the extra-cardiac sarcoidosis group as compared to controls, SMD: -3.33, 95% CI -4.71, -1.95, p< 0.001 Conclusion LVGLS and GCS were significantly lower in extra-cardiac sarcoidosis patients despite not exhibiting any cardiac symptoms. LVGLS correlates with MCEs in CS. Further studies are required to investigate the role of STE in the early screening of CS.

Background: Right ventricular failure (RVF) following Left Ventricular Assist Device (LVAD) implantation is associated with worse outcomes. Prediction and early identification of RVF with speckle-tracking echocardiography (STE) has been proposed. Methods: We queried multiple databases for articles reporting on pre-operative/intraoperative global longitudinal strain (GLS) and free-wall strain (FWS) in LVAD recipients. We performed a systematic review and meta-analysis of published literature. The standard mean difference (SMD) in GLS and FWS in patients with and without RVF postoperatively was pooled using random effects model. Results: Fifteen studies, with a total of 967 LVAD recipients were included. There was statistically significant difference in GLS among patients who did and did not develop RVF; SMD= -3.09 (95% CI: -4.62 to -1.57; p-value

To evaluate the impact of pulmonary hypertension (PH) on percutaneous coronary intervention (PCI) outcomes and 30-day all-cause readmissions by analyzing a national database.We queried the 2014 National Readmissions Database to identify patients undergoing PCI using International Classification of Diseases, Ninth Revision, Clinical Modification codes. These patients were then subcategorized based on the coded presence or absence of PH and further analyzed to determine the impact of PH on clinical outcomes, health care use, and 30-day readmissions.Among 599,490 patients hospitalized for a PCI in 2014, 19,348 (3.2%) had concomitant PH. At baseline, these patients were older with a higher burden of comorbidities. Patients with PH had longer initial hospitalizations and higher 30-day readmission rates and mortality than their non-PH counterparts. This was largely driven by cardiac causes, most commonly heart failure (20.3% vs 9.0%, P.001) and non-ST-segment elevation myocardial infarction. Recurrent coronary events (17.5% vs 9.5%, P.05) including ST-segment elevation myocardial infarction predominated in the non-PH group.Patients with PH undergoing PCI are a high-risk group in terms of mortality and 30-day readmission rates. Percutaneous coronary intervention in patients with PH is associated with higher rates of recurrent heart failure and non-ST-segment elevation myocardial infarction, rather than recurrent coronary events or ST-segment elevation myocardial infarction. This perhaps indicates a predominance of demand ischemia and heart failure syndromes rather than overt atherothrombosis in the etiology of chest pain in these patients.

Background: Mortality after AMI is on the decreasing trend; however, this favorable trend is not observed in the young, especially women. Therefore, we conducted a retrospective analysis using the Nationwide Inpatient Sample (NIS) to identify sex-based outcomes following AMI in young with diabetes. Methods: NIS 2010–2014 was used to identify all patients with AMI using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Men (N = 30,950) and women (N = 17,928) patients diagnosed with diabetes were identified and stratified as young if age >18 and Results: Young women with AMI and concomitant diabetes having a higher burden of overall traditional and non-traditional comorbidities. NSTEMI was the major presentation in women as compared to men. Young women with AMI and concomitant diabetes were less likely to receive revascularization with PCI [51.1% vs. 58.2%; OR 0.86, CI 0.78–0.94] or CABG [7.9% vs. 10.1%; OR 0.64, CI 0.54–0.75]. Adjusted all-cause in-hospital mortality did not differ significantly between the two groups [OR 1.06, CI 0.74–1.52]. Women had lower odds of developing cardiogenic shock, ventricular arrhythmias, and AKI, and were more likely to develop major bleeding requiring transfusion, and mitral regurgitation. Conclusion: There were significant differences between young men and women with diabetes in terms of baseline characteristics and clinical presentation, use of revascularization, and cardiac complications, yet overall, in-hospital mortality does not appear to differ. More studies are needed to identify the interaction of sex and diabetes in young AMI population, and areas for practice improvement.

We present a unique case of vancomycin-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome masquerading as elusive endocarditis. A 37-year-old female actively using intravenous drugs presented with worsening right upper extremity pain, fever, and chills. Workup revealed methicillin-resistant staphylococcus aureus (MRSA) bacteremia and multiple right-sided septic pulmonary emboli. Echocardiogram was negative for vegetation. Vancomycin was initiated for bacteremia management suspected secondary to right upper extremity abscesses. However, despite resolution of abscesses, fevers persisted, raising suspicion for endocarditis not detected by echocardiogram. On hospital day 25, the patient began showing signs of DRESS syndrome, ultimately manifesting as transaminitis, eosinophilia, and a diffuse, maculopapular rash. Vancomycin was switched to Linezolid and she improved on high dose steroids. The persistent fevers throughout this hospital course were thought to be an elusive endocarditis before DRESS syndrome fully manifested. Although Vancomycin-induced DRESS is uncommon, this case highlights the importance of identifying early signs of significant adverse effects.

With an aging population and significant overlap of risk factors, the cohort of patients with acute coronary syndrome (ACS) and concomitant atrial fibrillation (AF) is a sizable and growing one, with implications on cardiac reserve, anticoagulation and antiplatelet therapies, and related complications. The present study uses a large national database to analyze the impact of AF on patients admitted with an ACS. We queried the 2012 to 2014 National Readmissions Database to identify patients admitted with an ACS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. These patients were then subcategorized based on the presence or absence of AF. Analysis of their initial hospitalization, 30-day readmissions and healthcare utilization and the economic burden was performed. Among 1,558,205 patients with ACS, 270,966 (17.4%) were noted to have concomitant AF. At baseline, these patients were older and more likely female, with a significantly higher burden of comorbidities. Patients with AF had longer and more complicated index hospitalizations with significantly higher mortality rates (8.6% vs 4.6%). Coronary artery bypass graft was the preferred method of revascularization in patients with AF as compared to percutaneous coronary intervention. The 30-day readmissions were higher in the AF group (15.6 vs 10.8%), largely driven by noncardiac causes. This was associated with higher healthcare utilization with longer hospitalizations during index admission. Patients admitted with ACS and concomitant AF is a high-risk population with increased in-hospital complications and mortality, as well as short term readmissions. Coronary artery bypass graft appears favored over percutaneous coronary intervention for revascularization in patients with AF.

Traditionally ST-elevation myocardial infarction (STEMI) with multivessel coronary artery disease is treated with percutaneous coronary intervention (PCI) to culprit lesion only. The benefit of multivessel (MV) PCI among STEMI patients without cardiogenic shock is unclear.PubMed, EMBASE, and Cochrane Database were searched from 1996 to 2019, for studies of patients with STEMI without cardiogenic shock, who underwent PCI. Only randomized controlled trials comparing culprit PCI to MV PCI vs culprit vessel PCI were included for pairwise meta-analysis. All-cause mortality, cardiac mortality, reinfarction, revascularization and major adverse cardiovascular events (MACE) were compared. Trial sequential analysis (TSA) was performed for outcome variables.Nine randomized controlled trials contributed 6930 patients meeting inclusion criteria. Three thousand three hundred seventy-six underwent MV PCI, and 3554 underwent culprit PCI. Our analysis demonstrated no significant difference in all-cause mortality. MV PCI had a lower risk of cardiac mortality, reinfarction, MACE and repeat revascularization compared to culprit PCI (P values0.05). TSA showed futility for further trials to detect all-cause mortality benefit and lack of firm evidence of benefit in cardiac mortality and re-infarction, but firm evidence of benefit in revascularization and MACE.In conclusion, MV PCI strategy was beneficial in reducing cardiac mortality, reinfarction, repeat revascularization, and MACE but there was no all-cause mortality benefit when compared to culprit only PCI strategy. Evidence for benefit in cardiac mortality and re-infarction is not robust per TSA.

Introduction We present a case of COVID-19 causing hypercoagulability and inflammatory stress leading to STEMI in a patient who went on to develop persistent cardiogenic shock requiring LVA) implantation. Case Report 57-year-old lady developed COVID-19 infection in May 2020. In June 2020, she presented with chest pain, was noted to have STEMI on EKG, complicated by cardiac arrest with ROSC in 14 minutes. She was in cardiogenic shock as well and was started on veno-arterial ECMO. She underwent left anterior descending artery stent placement. Further hospitalization was complicated by persistent cardiogenic shock and complete heart block and underwent pacemaker and cardiac-defibrillator implantation. She developed pulmonary edema, acute kidney injury requiring hemodialysis, shock liver, and persistent cardiogenic shock. She was weaned off VA-ECMO after 4 days but continued to have severely reduced cardiac function. RHC revealed severe volume overload, pulmonary venous hypertension, low cardiac output, and right heart dysfunction. Echo showed severe LV dysfunction with an EF of 15%. A femoral intra-aortic balloon pump(IABP) was placed on July 7, 2020. An attempt was made to wean her off of IABP on July 10th,however, it was unsuccessful and she was transitioned to axillary intra-aortic balloon pump. She remained IABP dependent thereafter and on July 15th, given persistent cardiogenic shock, decision was made to pursue advanced heart failure therapies. After multi-disciplinary discussion, the decision to pursue LVAD implantation was made. She underwent a successful LVAD implantation on July 20th . She failed an extubation trial and underwent tracheostomy on July 23rd . Post LVAD, she developed atrial fibrillation and was started on digoxin and amiodarone. Her symptoms improved and she was subsequently discharged to rehabilitation in late August on amiodarone, digoxin, metoprolol, prasugrel, warfarin, spironolactone and lisinopril. The detailed timeline is shown in figure 1. Summary Hypercoagulability and severe inflammatory stress leading to life-threatening illness is a significant complication of COVID-19 infection. A low threshold for suspecting and treating hypercoagulability and inflammatory induced myocardial ischemia and injury and cardiogenic shock is a reasonable strategy to decrease acute as well as chronic morbidity and mortality.

Background Cardiac dysrhythmias are a common cause of hospitalization in patients with left ventricular assist device (LVAD). There is limited data on the incidence of VT over time and associated mortality in patients with LVAD. We aimed to identify the incidence of VT post LVAD implant and associated in hospital mortality. Methods Subjects with history of LVAD who had cardiac dysrhythmias as a primary diagnosis were identified from the National Inpatient Sample (NIS) dataset of the Healthcare Cost and Utilization Project (HCUP) for the years 2005-2017 using ICD-9 and10 codes. We also identified the in-hospital outcomes of VT. We excluded patients with history of orthotropic heart transplant and history of biventricular assist device (BiVAD). Associated morbidities and in-hospital outcomes were evaluated. Results A total of 15131 LAVD hospitalizations were identified and 703 patients hospitalized with a primary diagnosis of cardiac dysrhythmias. The median age of patients was 60 years (IQR 51-67), and 57.8% were White. VT was the primary cause of hospitalization in 542 patients (77.5%), followed by atrial fibrillation and flutter, 126(17.9%), then paroxysmal supraventricular tachycardia, 24(3.4%) . Among patients who had VT, 62 patients (11.4%) had cardiac arrest, 2 (0.4%) needed CPR, 17(3.1%) had cardiogenic shock, 4(0.7%) had acute myocardial infarction, 4(0.7%) had acute stroke, 2(0.4%) had brain death, 13 (2.4%) needed mechanical ventilation, 42 (7.7%) had ICD implanted. There was no significant increase in incidence of hospitalization for VT in LVAD patients over the study period.(Std. J-T Statistic 1.371, p = 0.170). Figure 1. The overall in hospital death in these patients was 13(1.8%). Conclusion In LVAD patient VT was found to be most common arrhythmia causing hospitalization but overall mortality was low.

Background Extracorporeal membrane oxygenation (ECMO) utilization in children is recommended in refractory septic shock. However in adults there are no official recommendation to guide this treatment. Most of the existing evidence consists of small observational and single center experiences. We aimed to investigate the trend of use and outcomes of ECMO in patients with combined septic and cardiogenic shock. Methods We queried the unweighted national inpatient sample (NIS) for patients older than 18 years old, who carried both diagnoses of septic shock and cardiogenic shock during index hospitalization and received ECMO treatment for the years 2004-2017 using ICD-9&10 codes. Results We identified 29,178 patients with combined septic and cardiogenic shock in between 2004 and 2017. Of those, 424 (0.1%) patients underwent ECMO. There was a statistically significant increasing trend of ECMO use over the years of study (Std. J-T Statistic 4.338, p Conclusion ECMO is being increasingly used in patients with combined septic and cardiogenic shock, more data is needed to further guide this treatment modality in this patient population.

Background Atrioventricular block (AVB) is known complication of acute myocarditis. Data is limited on the role of trans-venous pacing in acute myocarditis with atrioventricular block. Aim We aimed to evaluate the clinical characteristics and outcomes of patients requiring temporary trans-venous pacing for AVB in acute myocarditis. Methods We queried the national inpatient sample (NIS) from 2002 through 2015, unweighted, for patients older than 18 years old who carried a diagnosis of acute myocarditis using ICD-9 codes. Outcomes in patient who had trans-venous pacing were evaluated. Results We identified 10,106 patients with acute myocarditis from 2002-2015. Of them, 5573 (55.1%) were idiopathic, 283 (2.8%) were septic, 103 (1.0%) were toxic, 89 (0.9%) were acute rheumatic, and 4058 (40.2%) were unspecified myocarditis. AVB occurred in 393 patients (3.9%) of which 134 (34.1%) patients needed trans-venous pacing (table 1 show distribution of trans-venous pacing according to the types of acute myocarditis). In patient who required trans-venous pacing; median age was 42 years (IQR 29-54), median length of stay was 6 days (IQR 4-9), median cost of hospital charge was $47,520 (IQR $28,265-$103,530), 64.9% were male, and 72.8% were White. In hospital death occurred in 5 patient (3.7%), 12 (9.0%) had septicemia, 2 (1.5%) had cardiac tamponade, 10 (7.5%) had ventricular arrhythmias, 18 (13.4%) needed permanent pacemaker, and 13 (9.7%) had cardiogenic shock. Conclusion Heart block is not uncommon in acute myocarditis and one third of patients require temporary pacing, however AVB is transient in most patient with less than a fifth of patients requiring permanent pacemaker.

Introduction Heart failure patients with difficult to manage volume status and recurrent heart failure exacerbation benefit from CardioMemsTM placement. This helps in remote monitoring of pulmonary artery (PA) pressure and diuretic dosing can be changed on the basis of these readings preventing hospitalizations. During the COVID-19 pandemic, a stay-at-home order was issued by the state government, which may have led to heart failure deterioration secondary to poor follow up and change in dietary habits. Hypothesis We aim to evaluate changes in the mean PA pressure during stay-at-home order during COVID-19 pandemic as patients are not seen in clinic and there are presumed changes in dietary habits. Methods We identified 26 patients with a history of CardioMemsTM implant using our heart failure clinic database. We extracted their daily available PA pressure reading before the COVID-19 pandemic and during pandemic. Results The characteristics of the patients are described in Table 1. 26 cases with were identified with sufficient CardioMemsTM readings. Average age was 69.7 years with 38.5% females. There were 54% patients with systolic heart failure. Number of COVID-19 cases rose to almost 700 in 1 month. With regression analysis, we observed a trend towards increase in the mean PA pressure readings during the pandemic (R2 = 0.09, P-value

Streptobacillus moniliformis is a pleomorphic bacillus found in the oral cavity of rodents. Rat bite can transmit these bacteria to humans and can lead to bacteremia as well as infective endocarditis. We present an unusual case rat-bite endocarditis and septic emboli. 24 year-old-female presented

Primary cardiac malignancy is uncommon. Angiosarcoma (AS) accounts for the most aggressive subset. Manifestations can be crude and the diagnosis may be delayed. Rapid progression results in a dismal prognosis. A 49-year-old male presented with syncope. He was found to have hemopericardium on echo

Leukostasis is an emergency caused by compromise of tissue perfusion due to hyperleukocytosis in acute myeloid leukemia (AML). Typically it affects lungs and brain, with cardiac involvement being exceedingly rare. We present a case of AML presenting as acute coronary syndrome secondary to

Transcatheter aortic valve replacement (TAVR) is an evolving treatment for symptomatic aortic stenosis (AS). We present a case of aorta to right ventricle (RV) fistula as a rare complication of TAVR. 90-year-old male with history of systolic heart failure and severe AS presented to hospital with