Search

Percutaneous mechanical circulatory support (pMCS) devices are increasingly used in patients with cardiogenic shock as a bridge to recovery or bridge to decision to advanced heart failure therapies. Gastrointestinal bleeding (GIB) is a common complication that can be catastrophic. Because of the paucity of data describing the association of GIB with pMCS, we analyzed this population using the United States National Inpatient Sample database. We performed a retrospective study in patients with pMCS devices who had GIB during the index hospitalization using the National Inpatient Sample. Multivariate logistic regression analysis was performed to determine independent predictors of GIB in these patients. A total of 466,627 patients were included. We observed an overall increase in the incidence of adjusted GIB from 2.9% to 3.5% (p = 0.0025) from 2005 to 2014. In comparison to patients without GIB, those with GIB had significantly higher in-hospital mortality, length of stay, and hospitalization cost. In addition to the usual co-morbid conditions, the presence of small bowel and colonic ischemia, colon cancer, diverticulosis, chronic liver disease, and peptic ulcer disease were noted to be significant predictors of GIB for all (p <0.001). In conclusion, patients with pMCS and GIB have higher in-hospital mortality, longer length of stay, and higher cost of hospitalization. Awareness of patient risk factors for bleeding and gastrointestinal disorders are important before the use of mechanical circulatory support devices because they are associated with a substantially higher risk for bleeding., (Copyright © 2022. Published by Elsevier Inc.)

Background: Literature regarding trends in incidence and mortality of ST-elevation myocardial infarction (STEMI) in emergency departments (EDs) is limited., Objective: To study the trends of incidence and mortality of STEMI., Methods: Using the National Emergency Department Sample database in the United States, we identified all ED encounters for patients presenting with STEMI using International Classification of Diseases codes. A linear p-trend was used to assess the trends., Results: Out of the 973 million ED encounters represented, 641,762 (65/100,000; mean age 69 [59-81] years, 35.8% female) adult patients were recorded with STEMI. Among the major complications associated with STEMI, a total of 49,401 (7.7%) had cardiac complications, which included acute heart failure (n = 9361, 1.6%), ventricular tachycardia or fibrillation (n = 12,267, 1.91%), conduction block (n = 20,165, 3.1%), and cardiogenic shock (n = 7608, 1.2%). There were 5675 (0.9%) patients recorded with cerebrovascular events, which included acute ischemic stroke among 5205 (0.8%) patients and 470 (0.1%) with transient ischemic attack. Acute kidney injury was recorded for 10,082 (1.6%) patients. The trend for incidence of STEMI in the ED had decreased from 7.76/10,000 in 2011 to 4.07/10,000 in 2018 (linear p-trend 0.0006). However, the yearly mortality of STEMI related to ED encounters had remained relatively steady: 7.56% in 2011 to 7.50% in 2018 (linear p-trend 0.2364)., Conclusion: Despite the fact that the number of patients presenting to the ED with STEMI has been decreasing, the mortality trends have remained steady. Further research of in-hospital STEMI may yield opportunities to reduce the risk of complications, improve patient outcomes and decrease health care burden., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background Limited data exist on the incremental value of the risk enhancers recommended in the 2018 American Heart Association/American College of Cardiology (ACC/AHA) cholesterol treatment guidelines in addition to the pooled cohort equation. Methods and Results Using pooled individual-level data from 3 epidemiological cohorts involving 22 942 participants (56% women, mean age 59 years), we evaluated the predictive ability of the risk enhancers and coronary artery calcium (CAC) score for atherosclerotic cardiovascular disease, and determined their incremental utility using the C statistic, net reclassification index, and integrated discrimination index. A total of 1960 (8.5%) atherosclerotic cardiovascular disease events were accrued over 10 years. Of the 10 risk enhancers evaluated, only 6 predicted atherosclerotic cardiovascular disease independent of the pooled cohort equation. However, the individual enhancers demonstrated little or no incremental benefit. There was more incremental value from combining the 6 enhancers into an aggregate score (hazard ratio [HR], 1.21; 95% CI, 1.08-1.37 for each additional enhancer), and having ≥3 enhancers represents an optimum threshold for incremental prediction (C statistic, 0.766; net reclassification index, 0.041; integrated discrimination index, 0.010; P ≤0.007). On the other hand, CAC was superior to individual enhancers (C statistic, 0.774; net reclassification index, 0.073; integrated discrimination index, 0.010; P <0.001), reliably reclassifies intermediate-risk participants with <3 risk enhancers (event rate, 3.5% if no CAC and 9.8% if positive CAC), but offered no reclassification among participants with ≥3 enhancers. Conclusions The individual risk enhancers evaluated in this study provided no or only marginal incremental information added to the pooled cohort equation. However, the presence of ≥3 risk enhancers reliably identified intermediate-risk patients that will benefit from statin therapy, and further CAC testing may be considered among those with <3 risk enhancers.

We assessed the trend of palliative care (PC) referrals and its effect on hospitalization cost and length of stay (LOS) in ruptured aortic aneurysm (rAA). The Nationwide Inpatient Sample from 2005 to 2014 was used to identify admissions with age ≥50 and rAA. A total of 54 134 rAA admissions were identified and 5019 (9.3%) had PC referrals. During the study period, PC referral rate increased from 0.97% to 15.3% ( P trend < .0001). Length of stay (1.7 vs 2.8 days, adjusted mean ratio [aMR] = 0.62, 95% confidence interval [CI]: 0.58-0.66), and cost (US$7778 vs US$13 575, aMR = 0.57, 95% CI: 0.52-0.63) were significantly lower in rAA admissions that did not undergo interventions. In the percutaneous repair group, LOS was similar but the cost was higher (US$61 759 vs US$52 260, aMR = 1.18, 95% CI: 1.05-1.30), whereas in surgical repair group, LOS was shorter (4.6 vs 5.9 days, aMR = 0.77, 95% CI: 0.73-0.82) but the cost was higher (US$59 755 vs US$52 523, aMR = 1.14, 95% CI: 1.02-1.28). Palliative care could shorten LOS and save hospitalization cost in rAA admissions not a candidate for repair. Further studies are required to investigate the variable effects of PC on rAA.

Recent positive results of transcatheter aortic valve replacement (TAVI) in clinical trials have sparked debate on whether TAVI should be first line for all patients with aortic stenosis. However, limited evidence exists on the clinical impact of TAVI on a national level. Using the national inpatient sample (NIS) of hospital discharges in the United States from 2001 to 2016, we evaluated the rate of AVR and associated in-hospital outcomes in pre-TAVI and TAVI era. Hierarchical mixed effect modeling was used to assess for trend and calculate risk adjusted estimates. Annual volume of AVR increased from 49,357 in 2001 to 100,050 in 2016 (103% increase). Compared with the pre-TAVI era, mean annual change in volume of AVR was higher in the TAVI era (+2.9% vs +9.4%, respectively, p <0.001). In contrast, rate of in-hospital mortality decreased from 5.4% in 2001 to 2.7% in 2016 (50% decrease). Compared with the pre-TAVI era, magnitude of mean annual change in mortality was higher in TAVI era (-4.0% vs -6.7%, respectively, p = 0.04). Unlike SAVR for which risk-adjusted rate for most outcomes seems to have plateaued, TAVI demonstrated significant improvement from 2012 to 2016 for mortality (4.6% to 1.8%), acute kidney injury (15.1% to 2.6%) and nonroutine home discharge (63.6% to 44.6%). However, no significant change in the rate of stroke (2.4% to 2.1%) and pacemaker implantation remained high (8.1% to 9.4%). Lastly, median length of stay was shorter for TAVI compared with isolated SAVR (3 vs 8 days, respectively). In conclusion, the adoption of TAVI has led to increase in volume of AVR for severe aortic stenosis in the United States with favorable short-term outcome., Competing Interests: Conflict of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Alcohol septal ablation (ASA) is indicated for symptomatic hypertrophic cardiomyopathy (HC) patients. We sought to analyze the incidence of the 30-day readmission rate, predictors, causes of readmission, and incremental healthcare resource (cost and length of stay) utilization after ASA. Nationwide Readmission Database from 2010 January to 2015 September was queried to identify 30-day unplanned readmission after ASA for HC by using the International Classification of Disease, 9th Revision, Clinical Modification. Those readmitted were similar in terms of age and sex but had higher burden of co-morbidities compared with those not readmitted within 30-days. The 30-day unplanned readmission rate was 10.4% (511/4,932) after ASA. Readmissions lead to an additional mean hospitalization cost of 8,433 US dollars and mean of 4.9 days of length of stay. Predictors of 30-day unplanned readmission were liver disease (adjusted odds ratio [aOR] 2.62, 95% confidence interval [CI] 1.22 to 5.59), renal failure (aOR 2.30, 95%CI 1.52 to 3.50), previous myocardial infarction (aOR 1.97, 95%CI 1.16 to 3.33), previous pacemaker (aOR 1.50, 95%CI 1.09 to 2.08), atrial fibrillation (aOR 1.43, 95%CI 1.08 to 1.89), Medicaid (aOR 1.74, 95%CI 1.12 to 2.68), and weekend admission (aOR 1.75, 95%CI 1.12 to 2.75). Common reasons for readmissions were atrial fibrillation (12.6%), acute on chronic systolic heart failure (12.6%), paroxysmal ventricular tachycardia (6.4%), atrioventricular block (4.9%), and HC (3.0%). Unplanned readmissions after ASA occur in patients with higher burden of co-morbidities and are mainly caused by cardiac etiologies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Chronic obstructive pulmonary disease (COPD) is a risk factor for non-ST-segment elevation-acute coronary syndromes (NSTE-ACS). Whether early invasive strategy (EIS) or ischemia-guided strategy (IGS) confers better outcomes in NSTE-ACS with COPD is largely unknown. Nationwide Inpatient Sample database of the United States was queried from 2010 to 2015 to identify NSTE-ACS with and without COPD. Early invasive strategy was defined as coronary angiogram with or without revascularization on admission day 0 or 1, whereas IGS included patients who did not receive EIS. Standardized morbidity ratio weight was used to calculate the adjusted odds ratio. A total of 228 175 NSTE-ACS admissions with COPD were identified of which 34.0% received EIS. In-hospital mortality was lower with EIS in patients with COPD (3.1% vs 5.5%, adjusted odds ratio 0.57, 95% confidence interval 0.50-0.63) compared to IGS, but the magnitude of mortality reduction observed in EIS in patients with COPD was less compared to non-COPD patients ( P interaction = .02). Length of stay was shorter (4.2 vs 4.7 days, P < .0001) but the cost was higher (US$23 804 vs US$18 533, P < .0001) in EIS in COPD. Early invasive strategy resulted in lower in-hospital mortality and marginally shorter length of stay but higher hospitalization cost in NSTE-ACS with COPD.

Introduction: Takotsubo Syndrome (TS) patients are at high risk of developing atrial fibrillation. We sought to investigate the outcomes and economic impact of atrial fibrillation on TS patients utilizing the National Inpatient Sample., Methods: Patients with TS were identified in the National Inpatient Sample (NIS) database between 2010 and 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and subsequently were divided into two groups, those with and without atrial fibrillation. The primary outcome was all-cause in-hospital mortality in the two groups. Secondary outcomes were in-hospital complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding factors., Results: Among the study population, the prevalence of atrial fibrillation was 17.57%. After matching, the atrial fibrillation group had no significant increase of in-hospital mortality (OR: 1.13; 95% CI: 0.94-1.35, p = 0.211). However, atrial fibrillation patients were more likely to develop cardiac arrest and ventricular arrhythmias (OR: 1.51, 95% CI: 1.26-1.80, p < 0.0001), have higher rate of major cardiac complications when combined as a single endpoint in-hospital complication (OR: 1.16, 95% CI: 1.04-1.29, p: 0.006), also they were more likely to stay longer in hospital (OR: 1.13, 95% CI: 1.08-1.19, p < 0.0001), and have increased cost of hospitalization (OR: 1.13, 95% CI 1.07-1.20, p < 0.0001)., Conclusion: Atrial fibrillation does not increase in-hospital mortality in patients presenting with TS. However atrial fibrillation is associated with an increased risk of ventricular arrhythmias, length of stay, non-routine discharges and cost of hospitalization., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest to declare., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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 < .0001) and increased length of hospital stay (6.14 vs 5.4 days; mean ratio: 1.14; CI:1.05-1.23; P = .002). More cardiovascular complications were observed in patients requiring transfusions., Conclusions: Patients with ITP admitted for AMI had a similar in-hospital mortality risk, but a significantly higher risk of bleeding complications and a longer LOS compared to those without ITP. Further studies are needed to assess optimal management strategies of AMI that minimize complications while improving outcomes in this population., (© 2019 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.)

Background: ST-segment elevation myocardial infarction complicated with cardiogenic shock (STEMI-CS) is associated with high mortality but the trends of utilization and predictors of palliative care (PC) referral in this population have not been well described., Objectives: To investigate the utilization trends and predictors of PC referral in STEMI-CS., Methods: Nationwide inpatient sample from 2005-2014 was queried to identify patients with STEMI-CS of age ≥18. PC referral was identified International Classification of Diseases, Ninth Edition Clinical Modification, V66.7., Results: A total of 33,294 admissions were identified and 1,878 (5.6%) had PC encounter. PC referral group were older and had higher comorbidities. PC consultation increased approximately 10 times over the study period in those who died (from 2.3% to 27.4%) and in those who survived (from 0.21% to 2.83%). In multivariable analysis, age, higher Exlixhauser score, no revascularization, teaching hospital, large bed hospital, mechanical circulatory support use, and lower income status were associated with increased PC referral whereas coronary artery bypass graft was associated with lower PC referral rates. Patients under PC group were more often discharged to an extended care facility and less likely discharged home., Conclusion: PC utilization increased substantially during the 10-years study period in the United States in STEMI-CS. Several baseline, procedural, hospital, and socioeconomic factors were associated with PC referral in the setting STEMI-CS., (Copyright © 2019 Elsevier Inc. All rights reserved.)

To evaluate the impact of chronic thrombocytopenia (cTCP) on outcomes of transcatheter valvular procedures such as aortic valve implantation (TAVI), MitraClip, permanent pacemaker (PPM), implantable-cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT), left atrial appendage closure, and pericardiocentesis. Impact of cTCP on clinical outcomes following TAVI, Mitraclip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis procedures is not well described. Utilizing the National Inpatient Sample and (ICD-9-CM) procedural codes, we evaluated patients (age ≥18 years) who underwent these procedures, from January 1, 2009 to December 31, 2014, with or without cTCP as a chronic condition variable indicator. Propensity score matching model implemented to derive 2 matched groups. Propensity score matching created 47,292 and 47,351 hospitalizations matched pairs with and without cTCP, respectively. Patients with cTCP were older (mean age, 74.27 vs 72.26 years; absolute standardized differences [ASD] = 15.6) and less likely to be female (36.76% vs 43.74%, ASD = -14.31). They experienced higher in-hospital mortality (3.0% vs 2.0%; odds ratio [OR], 1.53; 95% confidence interval [CI], 1.27 to 1.83) and higher odds of vascular injury requiring surgery (2.63% vs 1.10%; OR, 2.43; 95% CI, 1.93 to 3.05). Postoperative hematoma and bleeding were 2-fold higher (4.57% vs 2.24%; OR, 2.08; 95% CI, 1.77 to 2.45) and 3-fold higher (6.34% vs 2.45%; OR, 2.69; 95% CI, 2.31 to 3.13) respectively among cTCP patients. They had greater health-care cost ($47,163 vs $35,763, p <0.0001) and longer hospital stay (mean 9.26 days vs 6.84 days, p <0.0001). In conclusion, cTCP patients had higher risk of complications after TAVI, MitraClip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis, including a 1.5-fold increased risk of in-hospital mortality., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cardiac support with left ventricular assist devices (LVAD) is a growing field. LVAD are increasingly used for patients with advanced congestive heart failure. Multiple studies have evaluated the outcomes of cardiac support with LVAD in patients with and without diabetes mellitus (DM), yet we still have conflicting results. This study aimed to assess the clinical impact of diabetes mellitus on patients undergoing cardiac support with LVAD., Methods: Diabetic patients who underwent mechanical support with LVAD between 2011 and 2014 were identified in the National Inpatient Sample (NIS) database using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The primary outcome was the effect of diabetes mellitus on inpatient mortality. Secondary outcomes were the impact of diabetes on other immediate post-LVAD complications and the cost of hospitalization. Multivariable logistic regression models analysis was performed to address potential confounding., Results: After adjusting for patient-level and hospital-level characteristics, diabetic patients who underwent cardiac support with LVAD have no significant increase in in-hospital mortality (OR: 0.79, 95% CI (0.57-1.10), p = 0.166), post-LVAD short-term complications and cost of hospitalization (OR: 0.97, 95% CI (0.93-1.01), p = 0.102)., Conclusion: Cardiac mechanical support with LVAD implantation is feasible and relatively safe in patients with diabetes and stage-D heart failure as a bridge for transplantation or as destination therapy for patients who are not candidates for transplantation. However, further trials and studies using bigger study sample and more comprehensive databases, need to be conducted for a stronger and more valid evidence., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Whether readmission to non-index hospitals (where the initial procedure was not performed) could result in adverse outcomes and increased utilization of healthcare resources compared with readmission to index hospitals after transcatheter aortic valve replacement (TAVR) remains unclear., Methods: From January 2012 to September 2015, a nationwide readmission database was queried to identify those who were older than 50 years and had endovascular TAVR, using the International Classification of Disease, 9th Revision, Clinical Modification code 35.05. Elective readmissions were excluded. In-hospital outcomes were compared between the index and non-index hospital readmissions. A multivariable logistic regression analysis was performed to identify predictors of non-index hospital readmissions., Results: A total of 6808 readmissions were identified of which 2564 (37.7%) were readmitted to non-index hospitals. Residents at smaller counties, metropolitan non-teaching hospitals, or hospitals at large metropolitan areas were predictors of non-index readmissions. In-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.20), acute myocardial infarction (aOR 0.83, p = 0.53), pacemaker placement (aOR 0.97, p = 0.90), acute kidney injury (aOR 0.98, p = 0.84), and stroke (aOR 1.03, p = 0.90) were similar between index and non-index readmissions but bleeding events requiring transfusions were more frequently observed in readmissions at non-index hospitals (aOR 1.32, p = 0.025). Hospital cost (15,410 dollars vs. 16,390 dollars, p = 0.25) and length of stay (5.70 days vs. 5.65 days, p = 0.85) were comparable between groups., Conclusions: Non-index readmissions post-TAVR was relatively common but did not result in increased hospital mortality or healthcare utilization. Our results are reassuring for TAVR recipients with limited access to index hospitals., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Safety-net hospitals (SNHs) are hospitals that serve a higher proportion of patients insured by Medicaid or uninsured and have been reported to have poor outcomes compared with non-SNHs. Procedural and clinical outcomes of ST-segment elevation myocardial infarction complicated by cardiogenic shock (STEMI-CS) at SNHs have not been well described. Nationwide Inpatient Sample from 2005 to 2011 was queried to identify STEMI-CS and age ≥18. SNHs were defined as hospitals with the highest number of inpatient stays that were paid by Medicaid or were uninsured (the top quartile). A total of 23,229 STEMI-CS of which 3,639 (15.7%) were treated at SNHs. Admissions to SNHs were younger (mean age 66.0 vs 67.2, p < 0.001), more likely men (64.0% vs 62.2%, p = 0.04), more frequently ethnic minorities (Black; 11.0% vs 6.0%, Hispanic 20.4% vs 5.8%, p < 0.001), and had higher Elixhauser ≥4 (25.8% vs 21.9%, respectively, p < 0.001). Percutaneous coronary interventions were less performed (60.4% vs 65.8%, p < 0.001) whereas administrations of thrombolysis (2.9% vs 2.1%, p = 0.001) were more frequent at SNHs. Coronary artery bypass and the use of mechanical circulatory support was similar. In-hospital mortality was significantly elevated at SNHs (36.6% vs 32.7%, adjusted odds ratio 1.24, 95% confidence interval 1.10 to 1.39) whereas new dialysis, stroke, and fatal arrhythmias were similar. The median length of stay was similar (6 vs 7 days, p = 0.58) but the median cost was higher (40,175 vs 38,012 US dollars, p = 0.01) at SNHs. SNHs had lower utilization of percutaneous coronary intervention and higher in-hospital mortality compared with non-SNHs in STEMI-CS. Further cause analysis is warranted to improve outcomes of STEMI-CS admitted at SNHs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Periprocedural outcomes of transcatheter mitral valve repair (TMVR) with Mitraclip in patients with pulmonary hypertension (PH) are not well studied., Methods: Patients who underwent TMVR with Mitraclip between 2011 and 2015 were identified using the National Inpatient Sample (NIS). All missing variables were excluded from the analysis and therefore, complete case analysis was performed., Results: A total of 1,037 patients underwent TMVR with Mitraclip between 2011 and 2015. The prevalence of PH in these patients was 32.6%. In-hospital outcomes were compared between PH group and non-PH group. Inpatient mortality after TMVR was similar between the two groups (3.2% vs. 2.1%, OR 1.57, P = 0.335). There was no statistical significance between the two groups in the rates of hemorrhage requiring transfusion (8.5% vs. 7.2%, OR 1.17, P = 0.587), cardiogenic shock (4.4% vs. 4.5%, OR 0.98, P = 0.951), acute respiratory failure (15.2% vs. 13.1%, OR 1.23, P = 0.460), postoperative sepsis (2.75% vs. 3.9%, OR 0.66, P = 0.340), postoperative deep vein thrombosis or pulmonary embolism (2.7% vs. 3.9%, OR 1.98, P = 0.348). In addition, non-routine home discharge, median hospital cost and length of stay were similar between the two groups., Conclusion: Pre-existing PH in patients undergoing TMVR with Mitraclip does not adversely affect in-hospital outcomes in this cohort of patients. Therefore, PH does not carry a prohibitive risk in selecting patients for Mitraclip procedure., (© 2018 Wiley Periodicals, Inc.)

Background: 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., Methods: We queried the 2005-2014 National Inpatient Sample databases to identify all patients aged >18 years with myocarditis in the United States., Results: 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)., Conclusion: 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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

We aimed to identify risk factors of high hospitalization cost after transcatheter aortic valve implantation (TAVI). TAVI expenditure is generally higher compared with surgical aortic valve replacement. We queried the Nationwide Inpatient Sample database from January 2011 to September 2015 to identify those who underwent endovascular TAVI. Estimated cost of hospitalization was calculated by merging the Nationwide Inpatient Sample database with cost-to-charge ratios available from the Healthcare Cost and Utilization Project. Patients were divided into quartiles (lowest, medium, high, and highest) according to the hospitalization cost, and multivariable regression analysis was performed to identify patient characteristics and periprocedural complications associated with the highest cost group. A total of 9,601 TAVI hospitalizations were identified. Median in-hospital costs of the highest and lowest groups were $82,068 and $33,966, respectively. Patients in the highest cost group were older and more likely women compared with the lowest cost group. Complication rates (68.4% vs 22.5%) and length of stay (median 10 days vs 3 days) were both approximately 3 times higher and longer, respectively, in the highest cost group. Co-morbidities such as heart failure, peripheral vascular disease, atrial fibrillation, anemia, and chronic dialysis as well as almost all complications were associated with the highest cost group. The complications with the highest incremental cost were acute respiratory failure requiring intubation ($28,209), cardiogenic shock ($22,401), and acute kidney injury ($16,974). Higher co-morbidity burden and major complications post-TAVI were associated with higher hospitalization costs. Prevention of these complications may reduce TAVI-related costs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim:: Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have become a reasonably safe procedure with acceptable morbidity and mortality rate. However, little is known regarding the incidence, trends, and predictors of palliative care (PC) consult in aortic valve replacement (AVR) patients. The main purpose of this analysis was to assess the incidence, trends, and predictors of PC consultation in AVR recipients using the Nationwide Inpatient Sample (NIS) database., Materials and Methods:: We queried the NIS database from 2005 to September 2015 to identify those who underwent TAVR or SAVR and had PC referral during the index hospitalization. Adjusted odds ratio (aOR) was calculated to identify patient demographic, social and hospital characteristics, and procedural characteristics associated with PC consult using multivariable regression analysis. We also reported the trends of PC referral in AVR recipients., Results:: A total of 522 765 admissions (mean age: 75.3 ± 7.8 years, 40.3% female) who had TAVR (1.7% transapical and 9.2% endovascular approach) and SAVR (89.2%) were identified. Inpatient mortality was 3.96%, and 0.5% patients of the total admissions had PC consultation. The PC referral for SAVR increased from 0.90 to 7.2 per 1000 SAVR from 2005 to 2015 ( P = .011), while it remained stable ranging from 9.30 to 13.3 PC consults per 1000 TAVR ( P = .86). Age 80 to 89 (aOR: 1.93), age ≥90 years (aOR: 2.57), female sex (aOR: 1.36), electrolyte derangement (aOR: 1.90), weight loss (aOR: 1.88), and do not resuscitate status (aOR: 44.4) were associated with PC consult. West region (aOR: 1.46) and Medicaid (aOR: 3.05) were independently associated with PC consult. Endovascular (aOR: 1.88) and transapical TAVR (aOR: 2.80) had higher PC referral rates compared with SAVR., Conclusions:: There was an increase in trends for utilization of PC service in SAVR admissions while it remained unchanged in TAVR cohort, but the overall PC referral rate was low in AVR recipients during the index hospitalization.

Objectives: To assess the in-hospital outcomes of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in non-teaching hospitals., Background: TAVR has become widely available in the United States. However, the comparative outcomes of TAVR vs. SAVR in non-teaching hospitals are largely under explored., Methods: We queried the Nationwide Inpatient Sample database from 2011 to September 2015 to identify those who were 50 years or above and underwent either trans-arterial TAVR or SAVR at non-teaching hospital. In-hospital clinical outcomes were compared with odds ratio (OR) in propensity-matched cohorts., Results: We identified un-weighted 957 and 7,465 SAVR admissions. In propensity-matched model, 596 admissions in each arm were included for final analysis. In-patient mortality (3.9 vs. 2.5%, OR 1.54, P = 0.34), acute kidney injury requiring dialysis (2.2 vs. 2.7%, OR 0.80, P = 0.57), stroke (2.0 vs. 3.2%, OR 0.61, P = 0.20), and pacemaker placement (8.9 vs. 6.4%, OR 1.47, P = 0.09) was similar between TAVR and SAVR. Sub-group analysis showed that female and those with prior coronary artery bypass surgery had higher risk of in-patient morality in TAVR admission. Cost was higher (59,103 vs. 53,411 dollars, P = 0.006) but length of stay was shorter in TAVR (6.9 vs. 10.2 days, P < 0.001)., Conclusions: TAVR conferred similar in-hospital mortality and major peri-procedural complications compared with SAVR in non-teaching hospitals. For those with limited access to teaching hospitals, non-teaching hospitals appear to be a reasonable option for candidates of aortic valve replacement for severe aortic stenosis., (© 2018 Wiley Periodicals, Inc.)

Introduction: Takotsubo cardiomyopathy (TTCM), an entity first described in Japan over two decades ago following myocardial stunning cases without evidence of coronary stenosis, has emerged as a unique entity with global recognition. We sought to investigate the extent and magnitude of regional variations in its outcomes., Method: We used the National Inpatient Sample (NIS) of the Agency for Healthcare Research and Quality (2010-2014). Risk-adjusted rates of outcomes across the US geographical regions were calculated by fitting a Poisson regression model with a robust error variance under generalized estimating equations. Discrete numeric variables with over-dispersed count distributions -length of stay and continuous variables with a right skewed spread- cost of hospitalization were modeled using a generalized linear regression with a negative binomial function and gamma function respectively., Result: We found significant regional variations in-patient mortality. While there was significantly higher risk of in-hospital death in the West (5.28 [4.34-6.44]) vs 4.40 [3.57-5.43] vs 4.10 [3.38-498] vs 4.78 [3.96-5.77]), there was a different pattern of variation in the length of days with longer hospital stay in the Northeast. Likewise, the risk-adjusted rate of non-routine home discharges was highest for Northeast. The West had the highest cost of hospitalization (West: $40,217 vs. South: $28,465) CONCLUSION: Significant geographic variation exists in the cost of hospitalization and in-hospital mortality of TTCM across the US. Understanding this variation requires a detailed understanding of the processes of care and identification of effective strategies to eliminate these disparities., (Copyright © 2018 Elsevier Inc. All rights reserved.)

One of the major causes of mortality in systemic lupus erythematosus (SLE) is acute myocardial infarction. Whether in-hospital outcomes and management of ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are different in SLE patients compared with those without SLE from large, recent dataset is unclear. We queried the Nationwide Inpatient Database from 2005 to 2014 and identified STEMI and NSTEMI admissions with and without SLE. The primary outcome was in-hospital mortality. Secondary outcomes were revascularization strategy (percutaneous coronary intervention, coronary artery bypass surgery, or thrombolytics), medical therapy rates (no reperfusion), and major adverse clinical events. A propensity-matched cohort was created to compare these outcomes. Odds ratio (OR) was calculated from the propensity-matched cohort. A total of 321,048 STEMI admissions, of which 1,001 (0.31%) and 572,971 NSTEMI admissions, of which 2,134 (0.37%) were SLE, were identified. In those with STEMI, 882 SLE and non-SLE admissions were propensity-matched. In-hospital mortality (9.1% vs 11.8%, OR 0.75, p = 0.07), revascularization strategy, medical therapy rates, and major adverse events were similar. Similarly, in those with NSTEMI, 1,770 SLE and 1,775 non-SLE were matched. In-hospital mortality (4.1% vs 4.50%, OR 0.90, p = 0.51), coronary artery bypass surgery, medical therapy rates, and major adverse events were mostly similar but the rate of percutaneous coronary intervention was higher in SLE (32.9% vs 29.6%, OR 1.16, p = 0.04). For both STEMI and NSTEMI, hospital cost and length of stay were similar between SLE and non-SLE cohorts. From a large administrative database in the United States, revascularization strategies and in-hospital outcomes of acute coronary syndrome were mostly similar between SLE and non-SLE., (Copyright © 2018. Published by Elsevier Inc.)

Candidates for transcatheter aortic valve implantation (TAVI) are generally older with multiple co-morbidities and are therefore susceptible to nonelective admissions before scheduled TAVI. Frequency, predictors, and outcomes of TAVI after nonelective admission are under-explored. We queried the Nationwide Inpatient Sample database, an administrative database, from January 2012 to September 2015 to identify hospitalization in those age ≥50 who had transarterial TAVI. A propensity-matched cohort was created to compare the outcomes between nonelective and elective admission who had TAVI. The primary outcome was in-hospital mortality. A total of 9,521 TAVI admissions were identified during the study period. Of these admissions, 22.3% were nonelective admissions. Pulmonary circulation disorders (adjusted odds ratio [aOR] 1.38), anemia (aOR 1.54), congestive heart failure (aOR 1.37), chronic kidney disease (aOR 1.28; all p <0.001), and atrial fibrillation (aOR 1.17, p = 0.006) were independent risk factors for nonelective admission. In a propensity-matched cohort (1,683 admissions in each cohort), in-hospital mortality was similar (4.0% vs 2.8%, p = 0.052). Nonelective admissions had higher rates of acute myocardial infarction (5.2% vs 0.7%), fatal arrhythmia (9.4% vs 6.0%), acute kidney injury (25.9% vs 17.1%), respiratory failure requiring intubation (0.26% vs 0.19%), cardiogenic shock (5.1% vs 2.1%; all p <0.001), and bleeding requiring transfusion (13.1% vs 10.1%, p = 0.006) during the index-hospitalization. Hospital length of stay (11.4 days vs 6.5 days, p <0.001) and hospital cost ($68,669 vs $57,442, p <0.001) were both increased in nonelective admissions. Nonelective admission accounted for approximately one-fifth of total TAVI with significantly different cohort profiles. Our results suggest that nonelective TAVI has higher adverse outcomes and increased health resource utilization. Expedition in TAVI process in high-risk cohorts may result in better outcomes., (Copyright © 2018. Published by Elsevier Inc.)

Background: Atrial fibrillation (AF) is associated with increased all-cause mortality in the general population. However, the impact of AF on the in-hospital outcomes of acute myocarditis (AM) patients is not well characterized., Methods: Patients (age ≥ 18 years) with a primary diagnosis of AM in the National Inpatient Sample from 2007 to 2014 were included, using the ICD-9-CM diagnostic codes. We compared the in-hospital outcomes between the AF group and propensity score-matched control group without AF., Results: AF was reported in 602 (9%) of the AM patients. Compared to those without AF, AM patients with AF experienced higher in-hospital mortality (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.7, P = 0.02). AF was associated with higher risk of cardiogenic shock (OR 1.9, 95% CI 1.3-2.8, P < 0.001), cardiac tamponade (OR 5.6, 95% CI 1.2-25.3, P = 0.002) and acute kidney injury (OR 1.6, 95% CI 1.1-2.1, P = 0.02). Furthermore, patients with AF were more likely to have non-routine hospital discharge (31.6% vs 38.4% P = 0.02), longer length of stay and higher cost of hospitalization., Conclusions: AF was associated with increased risk of in-hospital mortality and complications in patients admitted to the hospital with acute myocarditis., (© 2018 Wiley Periodicals, Inc.)

A significant proportion of patients with acute myocarditis experience sudden cardiac death presumably due to cardiac arrhythmia. In this study, we explore the burden, the predictors of arrhythmia in acute myocarditis and the association between arrhythmias and adverse in-hospital outcomes. After evaluating the frequency of various tachyarrhythmias and bradyarrhythmia in myocarditis population, we built a logistic model to determine the independent predictors of arrhythmias in myocarditis and a 1:1 propensity-matched analysis to examine the impact of arrhythmias. Overall, cardiac arrhythmias were identified in 33.71% of the hospitalized myocarditis cases. Ventricular tachycardia and atrial fibrillation were most common arrhythmias. There were increased odds of in-hospital mortality, cardiogenic shock, use of mechanical circulatory support, pacemaker implantation, and nonroutine hospital discharges in the arrhythmia cohorts. Length of stay and cost of hospitalization were also significantly higher. A significant proportion of patients with myocarditis have cardiac arrhythmias. As the occurrence of arrhythmias in myocarditis is associated with worse outcomes, it may be important to risk stratify patient to identify those who will benefit from early intervention., (Copyright © 2018. Published by Elsevier Inc.)

Failure to rescue (FTR), death after major complications, has been well described in the surgical literature as a source of different outcomes in different hospitals. However, FTR has not been investigated in transcatheter aortic valve implantation (TAVI). Our aim was to assess the difference of in-patient mortality and FTR in different TAVI volume hospitals. We queried the Nationwide Inpatient Sample database from 2011 to 2015 to identify patients who had transarterial TAVI. FTR was calculated as those who had in-patient mortality with at least one with major perioperative complications. Hospitals were divided into three groups according to annual TAVI volume, the lowest quintile (≤30/year), second to fourth quintile (31 to 130/year), and highest quintile (≥130/year). Multivariate analysis was used to calculate risk adjusted in-patient mortality rate and FTR and was compared between these different volume hospitals. A total of 48,886 TAVI procedures were identified (10,407, 28,811, and 9,668 in low, intermediate, and high volume centers, respectively). Mean age, percentage of woman, and Elixhauser co-morbidity index was similar across different TAVI volume hospital. The incidence of major perioperative complications did not differ in different volume hospitals. Adjusted rate of in-patient mortality (2.3%, 1.87%, and 1.57% for low, intermediate, and high volume center, respectively, p <0.001) were significantly less with greater hospital volume but FTR (8.24%, 8.20%, and 6.12% for low, intermediate, and high volume center, respectively, p = 0.29) were the same in the three groups. Our results suggest that FTR does not explain the variation of in-hospital mortality in different hospital volumes., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

It is unknown if transcatheter aortic valve implantation (TAVI) is a safe alternative to surgical aortic valve replacement (SAVR) in patients <65 years old. Data from the National Inpatient Sample database were utilized. Patients from 2011 to 2015, ages 18 to 64 years old (inclusive) who underwent TAVI and SAVR were included. Patients who underwent SAVR and who also received a concomitant nonaortic valve surgery were excluded. A propensity score analysis was used. A total of 18,970 (528 TAVI and 18,442 SAVR) patients were identified. Patients who underwent TAVI were older (57 ± 7 vs 54 ± 10 years old, p <0.001) with more frequent co-morbidities. Overall in-hospital mortality was similar between TAVI and SAVR (odds ratio [OR] = 0.52, p = 0.12). Postprocedure stroke (OR = 0.50, p = 0.24), acute kidney injury (OR = 0.98, p = 0.89), acute myocardial infarction (OR = 0.48, p = 0.08), and vascular complication requiring surgery (OR = 0.20, p = 0.11) were similar between patients who underwent TAVI and SAVR. Bleeding requiring transfusion (OR = 0.32, p <0.01) was less frequent in patients who underwent TAVI, but new pacemakers (OR = 1.7, p = 0.02) were more frequent in these patients. Patients who underwent TAVI had shorter hospital stays (7.9 vs 10.0 days, p <0.001) and were more likely to be discharged to home. Cost between TAVI and SAVR was similar ($49,014 vs $42,907, respectively, p = 0.82). In the <65 years old patient population, TAVI also conferred similar overall in-hospital mortality compared with patients who underwent SAVR. TAVI resulted in fewer major complications, shorter hospital stay, and more frequent discharge to home, but higher rates of pacemaker implantation compared with SAVR. Therefore, TAVI appears to be a safe alternative to SAVR in patients <65 years old., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The objective of this study was to evaluate the financial implications and the impact of pre-existing atrial fibrillation (AF) on in-hospital outcomes in patients who underwent transcatheter aortic valve implantation (TAVI) using the Nationwide Inpatient Sample (NIS) database. We identified patients who underwent TAVI from 2011 to 2014. The primary end point was the effect of pre-existing AF on in-hospital mortality. Secondary end points included periprocedural cardiac complications, stroke, and hemorrhage requiring transfusion. We also assessed length of stay (LOS) and cost of hospitalization. A mixed-effect logistic model was used for clinical end points, and a linear mixed model was used for cost and LOS. In 6,778 patients who underwent TAVI (46.1% women and 81.4 ± 8.5 years old), the incidence of AF was 43.3%. After adjusting for patient- and hospital-level characteristics, pre-existing AF was not found to influence in-hospital mortality (odds ratio 1.05, 95% confidence interval 0.80 to 1.36). AF was associated with an increased risk of periprocedural cardiac complications (odds ratio 1.46, 95% confidence interval 1.22 to 1.75), longer LOS (p <0.001) and an increased cost of hospitalization (US$51,852 vs US$49,599). In conclusion, pre-existing AF did not impact in-hospital mortality in TAVI patients but was associated with increased cardiac complications, a longer hospital LOS, and a higher cost of hospitalization., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Evidence exists for racial/ethnic differences in left ventricular mass index (LVMI). How this translates to future cardiovascular disease (CVD) events is unknown., Hypothesis: The impact of racial/ethnic differences in LVMI on incident cardiovascular outcomes could have potential implications for the optimization of risk stratification strategies., Methods: Using the prospectively collected database of the Multi-Ethnic Study of Atherosclerosis (MESA) involving 4 racial/ethnic groups (non-Hispanic Whites, Chinese, Blacks, and Hispanics) free of CVD at baseline, we assessed for racial/ethnic differences in the relationship between LVMI and incident CVD using a Cox model., Results: 5004 participants (mean age, 62 ± 10 years; 48% male) were included in this study. After an average follow-up of 10.2 years, 369 (7.4%) CVD events occurred. Significant racial/ethnic differences existed in the relationship between LVMI and incident CVD (P for interaction = 0.04). Notably, the relationship was strongest for Chinese (HR per 10-unit increase in LVMI: 1.7, 95% CI: 1.1-2.8) and Hispanics (HR per 10-unit increase in LVMI: 1.9, 95% CI: 1.5-2.2). Non-Hispanic Whites demonstrated the lowest relationship (HR: 1.3, 95% CI: 1.1-1.5). LVMI values of 36.9 g/m 2.7 , 31.8 g/m 2.7 , 39.9 g/m 2.7 , and 41.7 g/m 2.7 were identified as optimal cutpoints for defining left ventricular hypertrophy (LVH) for non-Hispanic Whites, Chinese, Blacks, and Hispanics, respectively. In secondary analysis of LVH (vs no LVH) using these optimal cutpoints, we found a similar pattern of association as above (P for interaction = 0.04). For example, compared with those without LVH, Chinese with LVH had HR: 5.3, 95% CI: 1.6-17, whereas non-Hispanic Whites with LVH had HR: 1.6, 95% CI: 1.2-2.1 for CVD events., Conclusions: Among 4 races/ethnicities studied, LVMI has more prognostic utility predicting future CVD events for Chinese and Hispanics and is least significant for non-Hispanic Whites., (© 2018 Wiley Periodicals, Inc.)

Background: Chronic obstructive pulmonary disease (COPD) patients are at increased risk of respiratory related complications after cardiac surgery. It is unclear whether transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) results in favorable outcomes among COPD patients., Methods and Results: Patients were identified from the Nationwide Inpatient Sample database from 2011 to 2014. Patients with age ≥60, COPD, and either went transarterial TAVR or SAVR were included in the analysis. A 1:1 propensity-matched cohort was created to examine the outcomes. A matched pair of 1210 TAVR and 1208 SAVR patients was identified. Respiratory-related complications such as tracheostomy (0.8% versus 5.8%; odds ratio [OR], 0.14; P <0.001), acute respiratory failure (16.4% versus 23.7%; OR, 0.63; P =0.002), reintubation (6.5% versus 10.0%; OR, 0.49; P <0.001), and pneumonia (4.5% versus 10.1%; OR, 0.41; P <0.001) were significantly less frequent with TAVR versus SAVR. Use of noninvasive mechanical ventilation was similar between TAVR and SAVR (4.1% versus 4.8%; OR, 0.84; P =0.41). Non-respiratory-related complications, such as in-hospital mortality (3.3% versus 4.2%; OR, 0.64; P =0.035), bleeding requiring transfusion (9.9% versus 21.7%; OR, 0.38; P <0.001), acute kidney injury (17.7% versus 25.3%; OR, 0.63; P <0.001), and acute myocardial infarction (2.4% versus 8.4%; OR, 0.19; P <0.001), were significantly less frequent with TAVR than SAVR. Cost ($56 099 versus $63 146; P <0.001) and hospital stay (mean, 7.7 versus 13.0 days; P <0.001) were also more favorable with TAVR than SAVR., Conclusions: TAVR portended significantly fewer respiratory-related complications compared with SAVR in COPD patients. TAVR may be a preferable mode of aortic valve replacement in COPD patients., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Objectives: To assess the in-hospital mortality and complications in female between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR)., Background: Female is one of the risk factors for increased adverse events in cardiac surgery., Methods and Results: Nationwide Inpatient Sample database was queried from 2011 to 2014 for patients who underwent TAVR or SAVR in female patients. The primary endpoint was in-hospital all-cause mortality and second endpoints were perioperative complications. We performed a propensity score analysis to calculate the adjusted odds ratio (OR) for each outcome. Patients who had concomitant cardiac surgery and those who had TAVR or SAVR mainly for aortic regurgitation were excluded. Our query from 2011 to 2014 resulted in a total of 3,067 TAVR and 18,594 SAVR in female patients. TAVR patients were in general elder and had a higher burden of comorbidities. The primary endpoint was similar between TAVR and SAVR (4.2% vs. 3.9%, OR 1.0, P = 0.89). Compared to SAVR, female TAVR patients had less hemorrhage requiring transfusion (12% vs. 21%, OR 0.41, P < 0.001), perioperative cardiac arrest and nonfatal myocardial infarction (9.8% vs. 17%, OR 0.38, P < 0.001), respiratory complication (1.6% vs. 4.4%, OR 0.28, P < 0.001), post-op sepsis (1.7% vs. 2.9%, OR 0.65, P = 0.03), acute myocardial infarction (3.0% vs. 4.9%, OR 0.60, P < 0.001), and acute kidney injury (15% vs. 18%, OR 0.62, P < 0.001). Conversely, female TAVR patients had significantly increased risk of new pacemaker implantation (11% vs. 5.9%, OR 1.7, P < 0.001) and use of extracorporeal membrane oxygenation (0.66% vs. 0.24%, OR 2.8, P < 0.001). TAVR patients had less nonroutine discharge. The median hospital cost was significantly higher in TAVR than SAVR (median $51,274 vs. $43,677, P < 0.001) but the length of stay was shorter (mean 7.8 days vs. 10.5 days)., Conclusions: TAVR may be a better option for those patients with underlying comorbidities that predispose them at higher risk for complications that was less observed in TAVR group. However, higher cost and increased risk of need for extracorporeal membrane oxygenation, although rare, should be taken into consideration upon deciding the optimal mode for aortic valve replacement., (© 2017 Wiley Periodicals, Inc.)

Background: Evidence suggests that medical service offerings vary by hospital teaching status. However, little is known about how these translate to patient outcomes. We therefore sought to evaluate this gap in knowledge in patients undergoing Transcatheter aortic valve replacement (TAVR) in the United States., Methods: This study was conducted using the National Inpatient Sample (NIS) in the United States from 2011 to 2014. Teaching status was classified, as teaching vs. nonteaching and endpoints were clinical outcomes, length of stay and cost. Procedure-related complications were identified via ICD-9 coding and analysis was performed via mixed effect model., Results: An estimated 33,790 TAVR procedures were performed in the U.S between 2011 and 2014, out of which 89.3% were in teaching hospitals. Mean (SD) age was 81.4 (8.5) and 47% were females. There was no significant difference between teaching versus nonteaching hospitals in regards to the primary outcome of in-hospital mortality and secondary outcomes of several cardiovascular and other end points except for a high rates of acute kidney injury (AKI) (OR: 1.34 [95% CI, 1.04-1.72]) and lower rate for use of mechanical circulatory support devices in teaching vs. nonteaching centers. The mean length of stay was significantly higher in teaching hospitals (7.7 days) vs. nonteaching hospitals (6.8 days) (P = 0.002) and so was the median cost of hospitalization (USD 50,814 vs. USD 48, 787, P = 0.02) for teaching vs. nonteaching centers., Conclusion: Most TAVR related short-term outcomes including all cause in-hospital mortality are about the same in teaching and nonteaching hospitals. However, AKI, length of hospital stay and TAVR related cost were significantly higher in teaching than nonteaching hospitals. There was more use of mechanical circulatory support in nonteaching than teaching hospitals., (© 2017 Wiley Periodicals, Inc.)

Background: Peripartum cardiomyopathy (PPCM) is associated with significant morbidity and mortality. Arrhythmogenic causes of death have been implicated in a significant number of patients. However, there is a dearth of systematic studies evaluating the burden of arrhythmias in PPCM., Methods: We used the Healthcare Utilization Project, Nationwide Inpatient Sample database (2007-2012) and identified 9841 hospitalizations for women aged ≥18years with a primary diagnosis of PPCM. Frequency of arrhythmias, utilization of electrophysiologic procedures, length of stay, hospitalization costs and outcomes associated with arrhythmias were determined., Results: Mean age was 30.05±6.69years. Arrhythmias were present in 18.7% of hospitalized PPCM cohort. Ventricular tachycardia was the most common arrhythmia and was noted in 4.2%. Approximately 2.2% of cases experienced cardiac arrest. Electrical cardioversion was performed in 0.3%, Catheter ablation in 1.9%, PPM implantation in 3.4% and ICD in 6.8% of hospitalizations for PPCM with arrhythmias. In-hospital mortality was 3-times more frequent in arrhythmia cohort (2.1% vs. 0.7%). Hospitalization costs were significantly higher in PPCM with arrhythmias. Elixhauser comorbidity score (adjusted OR:1.10; 95%CI:1.02-1.18; p=0.016), in-hospital mortality (adjusted OR:2.35; 95%CI:1.38-4.02; p=0.002), cardiogenic shock (adjusted OR:2.61; 95%CI:1.44-4.72; p=0.002), utilization of balloon pump (adjusted OR:13.4; 95%CI: 2.55-70.53; p<0.001), Swan-Ganz catheterization (adjusted OR:3.12; 95%CI:1.21-8.06; p=0.019), and coronary angiography (adjusted OR:1.79; 95%CI:1.19-2.70; p=0.005) were significantly associated with arrhythmias in PPCM., Conclusions: Arrhythmias were present in 18.7% of PPCM related hospitalizations. Morbidity, in-hospital mortality, length of inpatient stay, hospitalization costs and cardiac procedure utilization were significantly higher in the arrhythmia cohort., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Central obesity is a known cardiovascular risk factor and measures of visceral obesity are known to predict atherosclerosis. This study sought to explore the association between various anthropometric measures and markers of subclinical atherosclerosis (MoSCA) among low risk healthy individuals. Multi-Ethnic Study of Atherosclerosis (MESA) is a population-based study of Caucasian (38%), Afro-American (28%), Chinese (22%) and Hispanic (12%) subjects, aged 45-84 years, free from clinical cardiovascular disease. We performed a post hoc analysis of the limited access dataset of MESA subjects to evaluate the association between carotid intima media thickness and coronary artery calcium score (CACS), as MoSCA and various measures of obesity. Multivariable regression analyses adjusted for traditional cardiovascular risk factors, ethnicity and C-reactive protein were performed. Each unit increase in waist-hip ratio was strongly associated with increase in both common and internal carotid intima media thickness (beta: 0.12, 95% confidence interval (CI): 0.06 to 0.18, p < 0.001 and beta: 0.23, 95% CI: 0.03 to 0.43, p = 0.021, respectively). Measures of central obesity were superior to body mass index as demonstrated by their consistent association with each category of CACS when compared to the reference category (CACS = 0). Compared to body mass index, measures of visceral obesity were significantly associated with MoSCA in this multiethnic healthy population. Waist-hip ratio seems to be more consistent in its association with various MoSCA compared to other anthropometric measures.

Background: The studied associations between serum uric acid (sUA) and cardiovascular disease (CVD) events have been controversial. We sought to evaluate the association between sUA and CVD mortality, including its ability to reclassify risk in a multiethnic nationally representative population free of clinical CVD and diabetes at baseline., Methods: The study cohort included 11,009 adults enrolled as a part of the National Health and Nutrition Examination Survey (NHANES) III. Multivariate Cox proportional hazard analysis was performed to evaluate sUA as a predictor of CVD and coronary heart disease (CHD) mortality. Discriminative and recalibrative properties of sUA for CHD deaths were also assessed over traditional CVD risk factors. Net reclassification index (NRI) was calculated by comparing regression models incorporating traditional CVD risk factors with and without sUA., Results: sUA was not predictive of either CVD mortality [model 4: hazards ratio (HR) 1.06, 95% confidence interval (CI) 0.96-1.16, p = 0.27] or CHD mortality (model 4: HR 1.06, 95% CI 0.94-1.19, p = 0.32). Addition of sUA to traditional CVD risk factors resulted in no significant increment in c-statistic, receiver-operating characteristics-area under curve, absolute NRI (0.5%, 95% CI -1.9 to 2.9%, p = 0.68), or intermediate NRI (2.5%, 95% CI -1.6 to 6.6%, p = 0.24) for prediction of hard CHD deaths., Conclusions: sUA was not an independent predictor of both CVD and CHD mortality. Ethnicity did not influence the association of sUA with CVD mortality. Furthermore, sUA did not add to risk assessment beyond traditional CVD risk factors., (© The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: This study sought to explore the relationship between cystatin C (CysC) and anthropometric measures of obesity and the influence of this association on mortality [cardiovascular disease (CVD), coronary heart disease, and all-cause] in a nationally representative population free of CVD, diabetes mellitus, and macroalbuminuria (MA)., Methods: The study cohort included 4577 adult participants of the Third National Health and Nutrition Examination Survey (NHANES). Spearman correlation analysis was performed to ascertain the association between various anthropometric measures and CysC. Formal statistical analyses of the interaction term between anthropometric measures and CysC for outcomes were performed followed by stratified multivariate Cox proportional hazard analyses., Results: A moderate degree of association was seen between CysC and measures of visceral adiposity as represented by waist-to-height ratio (WHR) and waist circumference (WC) and only a weak association between CysC and body mass index (BMI). CysC was predictive of all study outcomes in individuals with normal anthropometric measurements only., Conclusions: CysC correlated better with measures of visceral adiposity (WC and WHR) compared to BMI and appears to be a better predictor of adverse cardiovascular outcomes among those with anthropometric measures not suggestive of obesity compared to those with abnormal measures of anthropometry.

Non-high-density lipoprotein cholesterol (non-HDLc) is an independent predictor of cardiovascular disease risk, with elevated levels signifying an increased risk beyond low-density lipoprotein. Previous data have shown inconsistent association of lipid subfractions with progression of coronary artery calcium (CAC), a surrogate marker of incident cardiovascular disease. We sought to evaluate the association between non-HDLc and development (incident) and progression of CAC in a cohort of multiethnic asymptomatic subjects. The cohort (n = 5,705) was derived from the limited access data set of the Multi-Ethnic Study of Atherosclerosis obtained from the National Heart Lung and Blood Institute. Multivariable regression analysis was performed to derive the association between non-HDLc and incident CAC (n = 2,927) and non-HDLc and progression of CAC (n = 2,778). In the population without CAC at baseline, non-HDLc, especially >190 mg/dl, was independently associated with incident CAC (relative risk 1.40, 95% confidence interval 1.09 to 1.79, p = 0.008) after adjustments with age, gender, race, systolic blood pressure, antihypertension medication use, smoking, diabetes, lipid-lowering therapy use, follow-up duration, and waist-hip ratio. Similarly, among those with CAC at baseline, non-HDLc levels >190 mg/dl were associated with significant CAC progression in the overall population (β 16.4, 95% confidence interval -5.63 to 27.2, p = 0.003) after adjustments. In conclusion, non-HDLc levels, especially >190 mg/dl, are consistently associated with increased risk of CAC progression. Our results suggest that among lipid fractions, non-HDLc may be best suited for the prediction of future CAC progression., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Limited information is available about gender and ethnic differences in red cell distribution width (RCDW) with regard to its relation to mortality in a population free of cardiovascular (CV) disease and diabetes. To assess gender and ethnic differences in RCDW and their effect on the association between RCDW and mortality, the Third National Health and Nutritional Examination Survey (n = 15,460, 1988 to 1994) data were examined. Multivariate adjusted Cox proportional hazard analysis was performed to assess effect of gender and ethnicity on the association between RCDW and mortality (total, CV disease, and coronary heart disease [CHD]). RCDW (mean ± SE) was greater in black women (13.1 ± 0.03) and men (13.4 ± 0.02) compared to women of white (12.9 ± 0.02) and other (13.0 ± 0.07) ethnicities and men of white (13.3 ± 0.02) and other (13.3 ± 0.07) ethnicities, respectively (p <0.001). The interaction between RCDW and gender was statistically significant for all study outcomes (p <0.001) but nonsignificant for RCDW and ethnicity. After adjusting for key variables, RCDW in women was associated with adjusted hazard ratios of 1.22 (95% confidence interval [CI] 1.14 to 1.31) for all-cause mortality, 1.17 (95% CI 1.07 to 1.28) for CV deaths, and 1.18 (95% CI 1.03 to 1.35) for CHD deaths; in men, adjusted hazard ratios were 1.29 (95% CI 1.20 to 1.38) for all-cause mortality, 1.27 (95% CI 1.17 to 1.37) for CV deaths, and 1.25 (95% CI 1.13 to 1.39) for CHD deaths (p <0.05 for all). In conclusion, blacks and men have significantly greater RCDWs compared to whites and women. Greater RCDW is associated with a greater risk of mortality in men compared to women, whereas no effect modification is observed by ethnicity., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Red cell distribution width (RDW) is an independent predictor of the 10-year estimated risk of coronary heart disease (CHD) events. However, RDW's association with peripheral artery disease (PAD) - a CHD risk equivalent - has not been evaluated to date. In this cross-sectional study, we examined 6950 participants of the National Health and Nutrition Examination Survey, 1999-2004. PAD was defined as an ankle-brachial index below 0.9 (n = 618). RDW was divided into quartiles (Q) (Q1: ≤ 12.2; Q2: 12.3-12.5; Q3: 12.6-13.0; Q4: ≥ 13.1) and PAD risk was compared across these quartiles using adjusted multivariate logistic regression. A graded increase in prevalent PAD with increasing RDW quartiles was observed (4.2% in Q1 vs 13.9% in Q4; test of trend p < 0.001). Risk of PAD was significantly higher (odds ratio (OR) 1.19, 95% confidence interval (CI): 1.06-1.34; p = 0.003) after adjusting for age, sex, race, body mass index, hypertension, hyperlipidemia, diabetes, smoking, estimated glomerular filtration rate, C-reactive protein, hemoglobin, mean corpuscular volume, and nutritional factors (folate, iron and vitamin B(12)) deficiencies with each unit (0.1) increase in RDW. Upon receiver-operating characteristics analysis, the predictive accuracy of the American College of Cardiology / American Heart Association (ACC/AHA)-defined PAD screening criteria (for a high-risk population) was 0.657 at best, but improved significantly (0.727) after addition of RDW (p < 0.0001). In conclusion, higher levels of RDW are independently associated with a higher risk of PAD and can significantly improve the risk prediction beyond that estimated by ACC/AHA-defined PAD screening criteria.

Introduction: We sought to evaluate the ability of various metabolic syndrome definitions in predicting primary cardiovascular disease (CVD) outcomes in a vast multiethnic U.S. cohort., Methods: This study included 6,814 self-identified men and women aged 45-84 years enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA) study. Gender-stratified analyses were performed to calculate hazard ratios of CVD, stroke, and mortality associated with various metabolic syndrome definitions and their individual constructs., Results: The hazard ratios [95% confidence interval (CI)] for all-cause CVD in men were 2.90 (2.18-3.85), 2.64 (1.98-3.51), 2.16 (1.62-2.88), 2.56 (1.91-3.44), 1.82 (1.35-2.46), and 2.92 (2.15-3.95) for the National Cholesterol Education Program (NCEP), American Heart Association (AHA), World Health Organization (WHO), International Diabetes Federation (IDF), European Group for the Study of Insulin Resistance (EGIR), and the newly defined consensus criteria. Hazard ratios in women were 2.11 (1.41-3.15), 2.17 (1.45-3.27), 2.04 (1.37-3.06), 1.91 (1.27-2.88), 1.85 (1.23-2.79), and 2.08 (1.37-3.14), respectively. Metabolic syndrome was strongly associated with stroke risk only in males. In men, all constitutive metabolic syndrome components were continuously and strongly associated with CVD. In women, high-density lipoprotein and triglycerides did not appear to be associated with short term CVD risk., Conclusion: We found the newly defined consensus criteria for metabolic syndrome to be similarly predictive of cardiovascular events when compared to existing definitions. Significant gender differences exist in the association between metabolic syndrome, its individual components, and CVD.

Almost 50% of patients with congestive heart failure (HF) have preserved ejection fraction (PEF). Data on the effect of HF-PEF on atrial fibrillation outcomes are lacking. We assessed the prognostic significance of HF-PEF in an atrial fibrillation population compared to a systolic heart failure (SHF) population. A post hoc analysis of the National Heart, Lung, and Blood Institute-limited access data set of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial was carried out. The patients with a history of congestive HF and a preserved ejection fraction (EF >50%) were classified as having HF-PEF (n = 320). The patients with congestive HF and a qualitatively depressed EF (EF <50%) were classified as having SHF (n = 402). Cox proportional hazards analysis was performed. The mean follow-up duration was 1,181 ± 534 days/patient. The patients with HF-PEF had lower all-cause mortality (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.46 to 0.85, p = 0.003) and cardiovascular mortality (HR 0.56, 95% CI 0.38 to 0.84, p = 0.006), with a possible decreased arrhythmic end point (HR 0.39, 95% CI 0.16 to 1.006, p = 0.052) than did the patients with SHF. No differences were observed for ischemic stroke (HR 1.08, 95% CI 0.48 to 2.39, p = 0.86), rehospitalization (HR 0.89, 95% CI 0.75 to 1.07, p = 0.24), or progression to New York Heart Association class III-IV (odds ratio 0.80, 95% CI 0.42 to 1.54, p = 0.522). In conclusion, although patients with HF-PEF have better mortality outcomes than those with SHF, the morbidity appears to be similar., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Metabolic syndrome poses a significant risk for cardiovascular disease. Recently, glycosylated hemoglobin (HbA1c) has been included in the diagnostic criteria for diabetes mellitus and prediabetes. We sought to determine if HbA1c is associated with prevalent metabolic syndrome in nondiabetic U.S. adults., Methods: A total of 9,022 nondiabetic participants of National Health and Nutrition Examination Surveys 1999-2008 (age, 47.5 ± 18.3 years, 51% females) were divided into quintiles (Q) of HbA1c: Q1 (reference), ≤5%; Q2, 5.1%-5.3%; Q3, 5.4%-5.5%; Q4, 5.6%-5.7%; and Q5, ≥5.8%. Modified National Cholesterol Education Program Adult Treatment Panel III criteria were used to identify metabolic syndrome (n=2,821; 31.3%). Unadjusted and adjusted multivariate logistic regression analysis was performed to assess the risk of metabolic syndrome., Results: A graded increase in odds of having prevalent metabolic syndrome with increase from each quintile of HbA1c compared to Q1 was observed after adjusting for age, sex, race, body mass index (BMI), total cholesterol, lipid-lowering therapy, current smoking, family history of diabetes, C-reactive protein, and fasting insulin. Stratified analysis based on gender, ethnicity, and BMI showed similar results. The HbA1c value of ≥5.4% remained appropriate cutoff for predicting metabolic syndrome in Caucasians and Hispanics, whereas ≥5.6% provided the best accuracy for African Americans based on receiver operating characteristics analysis., Conclusion: HbA1c much below the level for prediabetes was associated with prevalence of the metabolic syndrome in a cohort of nondiabetic U.S. adults. HbA1c can be considered as a surrogate marker for metabolic syndrome in nondiabetics.

Objectives: The purpose of this study was to examine whether adding homocysteine (Hcy) to a model based on traditional cardiovascular disease (CVD) risk factors improves risk classification., Background: Data on using Hcy to reclassify individuals in various risk categories beyond traditional approaches have not been adequately scrutinized., Methods: We performed a post hoc analysis of the MESA (Multi-Ethnic Study of Atherosclerosis) and NHANES III (National Health and Nutrition Examination Survey III) datasets. Hcy was used to predict composite CVD and hard coronary heart disease (CHD) events in the MESA study and CVD and CHD mortality in the NHANES III survey using adjusted Cox-proportional hazard analysis. Reclassification of CHD events was performed using a net reclassification improvement (NRI) index with a Framingham risk score (FRS) model with and without Hcy., Results: Hcy level (>15 μmol/l) significantly predicted CVD (adjusted hazard ratio [aHR]: 1.79, 95% confidence intervals [CI]: 1.19 to 1.95; p = 0.006) and CHD events (aHR: 2.22, 95% CI: 1.20 to 4.09; p = 0.01) in the MESA trial and CVD (aHR: 2.72, 95% CI: 2.01 to 3.68; p < 0.001) and CHD mortality (aHR: 2.61, 95% CI: 1.83 to 3.73; p < 0.001) in the NHANES III, after adjustments for traditional risk factors and C-reactive protein. The level of Hcy, when added to FRS, significantly reclassified 12.9% and 18.3% of the overall and 21.2% and 19.2% of the intermediate-risk population from the MESA and NHANES cohorts, respectively. The categoryless NRI also showed significant reclassification in both MESA (NRI: 0.35, 95% CI: 0.17 to 0.53; p < 0.001) and NHANES III (NRI: 0.57, 95% CI: 0.43 to 0.71; p < 0.001) datasets., Conclusions: From these 2 disparate population cohorts, we found that addition of Hcy level to FRS significantly improved risk prediction, especially in individuals at intermediate risk for CHD events., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

BACKGROUND Left ventricular ejection fraction (EF) in post-myocardial infarction (MI) patients is a strong predictor of adverse cardiovascular events. Although resting EF as measured by transthoracic echocardiography (TTE), contrast ventriculography (CNV), and radionuclide angiography (RNA) exhibit high correlation, there is only modest agreement between these modalities. This study sought to explore whether modality of EF assessment influences prognostication of post-MI patients with normal or slightly reduced EF. METHODS AND RESULTS The National Heart, Lung, and Blood Institute (NHLBI) limited access dataset of the Prevention of Events with Angiotensin Converting Enzyme Inhibition (PEACE) Trial (1996-2003, n=8290) comparing trandolapril versus placebo was used. The cohort was partitioned into TTE (n=2582), RNA (n=816), and CNV (n=1155) groups based on modality of EF assessment. EF was a significant predictor of cardiovascular mortality (HR 0.97, 95% CI 0.95 to 0.98; p<0.005) and all cause mortality (HR 0.98, 95% CI 0.97 to 0.99; p=0.0002) on multivariate analysis in this population with preserved or mildly depressed EF. Although CNV, TTE, and RNA groups differed significantly in terms of baseline variables, no appreciable differences were noted between RNA (HR 1.13, 95% CI 0.85 to 1.50; ns) and CNV (HR 1.13, 95% CI 0.99 to 1.27; ns) groups, compared with TTE for all cause mortality. Similarly, no significant differences were observed for cardiovascular mortality between RNA (HR 1.23, 95% CI 0.82 to 1.84; p=0.31) and CNV (HR 1.14, 95% CI 0.78 to 1.67, p=0.49) versus TTE. CONCLUSION EF is a significant predictor of all-cause mortality and cardiovascular mortality in patients with preserved or mildly depressed EF. Modalities of EF measurement are interchangeable and do not play a significant role in prognostication in a post-MI population.

Introduction: Microalbuminuria (MA), a renal marker of vascular injury, is an independent predictor of cardiovascular (CV) events. Red cell distribution width (RDW), an emerging CV risk predictor, has not been evaluated for its association with MA., Methods: We evaluated 8,499 participants of the National Health and Nutrition Examination Survey (NHANES) 1999-2006, where RDW was evaluated as a continuous variable and in quartiles (Q(1) ≤ 12.1, Q(2) 12.2-12.5, Q(3) 12.6-13 and Q(4) >13). Multivariate adjusted logistic regression analysis was performed to estimate the odds of having MA (n = 1,736; adjusted for traditional CV risk factors, race, BMI, estimated glomerular filtration rate, hemoglobin, mean corpuscular volume, high-sensitivity C-reactive protein and nutritional factors deficiencies of iron, folate and vitamin B(12))., Results: The prevalence of MA increased with increasing RDW (13.52% in Q(1) vs. 30.02% in Q(4), p < 0.001). The odds of having MA for those in Q(4) was 2.49 (95% CI: 1.95-3.18, p < 0.001) compared to those in Q(1) after the adjustments. No effect modification was observed by covariates on the association between RDW and MA., Conclusion: Elevated RDW is independently associated with a higher risk of MA. An interaction between chronic inflammation, oxidative stress, neurohumoral overactivity and endothelial dysfunction may explain this association and the attendant elevated CV/renal risk., (© 2011 S. Karger AG, Basel)

Lipid-lowering therapy (LLT) decreases mortality in select patient populations. LLT has also been shown to have antiarrhythmic effects, thus favorably influencing the incidence and recurrence of atrial fibrillation (AF). However, data are lacking regarding the effect of LLT on mortality in patients with AF. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study was the one of the largest multicenter trials comprising of 4,060 patients with AF at high risk for stroke and death. This is a post hoc analysis of the National Heart, Lung, and Blood Institute limited-access dataset of AFFIRM patients who were on LLT at the time of randomization (n = 913). The control group consisted of AFFIRM patients who were not on LLT (n = 3,147). Cox proportional hazards analysis was performed controlling for baseline differences. The end point was all-cause mortality, cardiovascular mortality, and ischemic stroke. A separate analysis was carried out for the combined end point of death, ventricular tachycardia, ventricular fibrillation, cardiac arrest, ischemic stroke, major bleeding, systemic embolism, pulmonary embolism, and myocardial infarction. Patients on LLT were younger and on more cardioactive medications but also had more cardiovascular morbidities. On multivariate analysis, LLT use was associated with lower all-cause mortality (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.62 to 0.95, p = 0.01), cardiovascular mortality (HR 0.71, 95% CI 0.53 to 0.95, p = 0.02), ischemic stroke (HR 0.56, 95% CI 0.36 to 0.89, p = 0.01), and combined end point (HR 0.81, 95% CI 0.69 to 0.96, p = 0.01). In conclusion, a decrease in mortality and adverse cardiovascular events was observed using LLT in AF.

Background: Data from cohort studies, predominantly in Caucasians, have identified obesity as a major risk factor for coronary artery disease (CAD), irrespective of sex. In contrast, reports examining the effects of obesity on mortality in African Americans suggest a weak relationship between body mass index (BMI) and mortality, particularly among women. Data correlating body weight with angiographic severity of CAD is sparse in minority populations. We sought to investigate ethnic-sex differences in the influence of obesity on the extent and severity of CAD., Methods: We studied 640 patients (66.9% African American) who underwent coronary angiography at a tertiary care center. Cardiovascular risk factor profiles and CAD burden, quantified by the Duke Myocardial Jeopardy scoring system, a validated prognostication tool, were compared across ethnic and sex groups., Results: Clustering of major cardiovascular risk factors, a higher prevalence of obesity classes II and III, and a statistically significant inverse correlation between BMI and Duke scores were observed among the cohort of African American women. General linear model analysis and stepwise multiple linear regression analysis revealed Duke score to be negatively associated with BMI and higher classes of obesity after adjustment for age and other cardiovascular risk factors in African American women but not in other subgroups., Conclusions: The observed inverse relationship between BMI and angiographic severity of CAD in African American women is novel and appears to support prior data on the weak association between BMI and cardiovascular mortality in this subgroup.

Cocaine is an extremely powerful reinforcing psychostimulant with highly addictive properties. Over the last few decades, cocaine addiction has attained epidemic proportions in North America, imposing a tremendous burden on society and the health care system. The cardiovascular complications of cocaine abuse are adrenergic mediated and range from cocaine-associated acute coronary syndromes to aortic dissection and sudden cardiac death. Concomitant alcohol and cigarette smoking exacerbate the cardiotoxicity of cocaine. This contemporary review discusses the spectrum of cardiac complications arising from cocaine use, operant pathophysiologic mechanisms and controversies surrounding the pharmacotherapy of cocaine-associated acute coronary syndromes.