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

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

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

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

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

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

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

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

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

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

Left ventricular hypertrophy (LVH) can lead to subendocardial ischemia by altering the coronary blood flow and its transmural myocardial distribution in the setting of increased oxygen demand. We hypothesized that electrocardiographic LVH predicts nonsignificant coronary artery disease (CAD) in patients with non-ST-segment elevation myocardial infarction (NSTEMI). We performed a retrospective analysis of 406 consecutive patients with NSTEMI who underwent coronary angiography. The LVH was diagnosed using Sokolow-Lyon and Cornell voltage criteria. Nonsignificant CAD was defined as stenosis less than 50% in the left main and 70% in any other coronary arteries. Of the 406 patients, 100 (25%) patients had electrocardiographic LVH and 99 (24%) patients had nonsignificant CAD. Patients with electrocardiographic LVH had a higher prevalence of nonsignificant CAD (32% vs 22%, P = .04) and a lower rate of in-hospital revascularization (45% vs 69%, P < .001) than those without LVH. On multivariate analysis, electrocardiographic LVH was an independent predictor of nonsignificant CAD (odds ratio 1.94; 95% confidence interval 1.12-3.35; P = .02). In conclusion, electrocardiographic LVH is an independent predictor of nonsignificant CAD and associated with a lower rate of in-hospital revascularization in patients with NSTEMI., (© The Author(s) 2015.)