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Background: Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens. Methods: A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups. Results: 698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD. Conclusion: Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation.

Coronavirus 2019 (COVID-19) significantly impacted cardiac care delivery in a manner that has not been previously experienced in the United States. Attention and resources have focused on physicians, patients, and healthcare systems with little information regarding the effects on nurses and technologists in the cardiac catheterization laboratory (CCL).A national, online survey was conducted for nurses and technologists working in the CCL in the United States. The survey was self administered, anonymous, and included 45 questions assessing baseline demographics, logistical changes to workflow and responsibilities, staff preparedness, and mental health.A total of 450 respondents completed the survey, including 283 nurses (63%) and 167 technologists (37%). A total of 349 (78%) were female and mean age range was 41-50 years. Responses indicated that 68% were the primary financial provider for their families, and 74% experienced75% decrease in case volume despite a low inpatient COVID-19 census (54% of respondents with census10%). There were high rates of direct care for COVID-19 patients (47%), relocation (45%), lay-off/furloughs of part-time or per diem staff (42%), lay-offs of full-time staff (12%), and decreased work hours (65%). A total of 95% expressed decreased morale with an increase in mental distress, including depression (36%). Predictors of depression included relocation status, staff preparedness, and work hours.Logistical changes to CCL staffing resulted in relocation, lay-offs, furloughs, and diminished work hours, with financial and emotional ramifications. Particular attention should be paid to those in large urban hospitals, those at risk for relocation, layoffs, and furloughs, and when preparedness and administrative communication is perceived as poor.

Despite the continuous evolution of endovascular therapy, severe calcification remains a major issue for the minimally invasive treatment of superficial femoral artery (SFA) disease. The presence of calcium might negatively affect both the crossing of peripheral lesions and outcomes of all available treatment modalities and is therefore associated with unfavorable acute and long-term results. This manuscript summarizes the challenges raised from severe calcified atherosclerotic lesions and presents the outcomes of the various endovascular modalities in the treatment of calcified SFA disease.

BACKGROUND: Patients with rheumatoid arthritis have an increased risk for accelerated atherosclerosis. It is unknown, however, whether rheumatoid arthritis also increases in-hospital mortality after a myocardial infarction or influences the therapy patients receive. METHODS: A cross-sectional analysis of 1,112,676 patients with myocardial infarction in the 2003-2005 Nationwide Inpatient Sample was performed. RESULTS: Patients with rheumatoid arthritis were 39% more likely to receive medical therapy (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.30-1.49) than interventional therapy. By using logistic regression, we adjusted for confounding variables to determine the effect of rheumatoid arthritis on the selection of therapy and found that rheumatoid arthritis itself was associated with a 38% increased likelihood of undergoing thrombolysis (OR, 1.38; 95% CI, 1.10-1.71) and a 27% increased likelihood of undergoing percutaneous coronary intervention (OR, 1.27; 95% CI, 1.17-1.39). For the primary outcome measure, we determined that patients with rheumatoid arthritis overall had a 24% better in-hospital mortality compared with other patients with a myocardial infarction (OR, 0.76; 95% CI, 0.68-0.86), which was 34% better after adjusting for confounding variables (OR, 0.66; 95% CI, 0.59-0.74). This better in-hospital mortality was seen in patients with rheumatoid arthritis undergoing medical therapy (adjusted OR, 0.67; 95% CI, 0.59-0.75) and percutaneous coronary intervention (adjusted OR, 0.47; 95% CI, 0.32-0.70), but not in patients undergoing thrombolysis or coronary artery bypass grafting. CONCLUSIONS: Among patients with myocardial infarction, rheumatoid arthritis was associated with an increased use of thrombolysis and percutaneous coronary intervention. Moreover, patients with rheumatoid arthritis had an in-hospital survival advantage, particularly those undergoing medical therapy and percutaneous coronary intervention.

Objective Patients with rheumatoid arthritis have an increased risk for accelerated arthrosclerosis. It is not known, however, whether this disorder is associated with a higher risk of complications after coronary artery revascularization. Methods We conducted a cross-sectional study of patients in the 2003–2005 Nationwide Inpatient Sample. To determine whether patients with rheumatoid arthritis had higher in-hospital mortality after coronary artery revascularization, we used logistic regression to adjust for age, sex, race/ethnicity, income, rural–urban residency, diabetes, hypertension, hyperlipidemia, Charlson comorbidities (including myocardial infarction, congestive heart failure, and diabetes), elective admission, weekend admission, and primary payer. Results Among patients undergoing coronary artery revascularization, those with rheumatoid arthritis were 49% less likely to die while hospitalized compared with those without rheumatoid arthritis (odds ratio, 0.51; 95% confidence interval, 0.40–0.65) after adjusting for the above confounders. In subgroup analyses that adjusted for the same confounders, patients with rheumatoid arthritis also had a 61% improvement of in-patient mortality when they underwent percutaneous coronary interventions (odds ratio, 0.39; 95% confidence interval, 0.29–0.54) along with a median of 0.32 less days hospitalized (95% confidence interval, 0.28–0.34 days). Similarly, patients with rheumatoid arthritis undergoing coronary artery bypass grafting had a 31% improvement of in-patient mortality (odds ratio, 0.69; 95% confidence interval, 0.48–0.99), with a median of 1.36 less days hospitalized (95% confidence interval, 0.72–1.12 days). Conclusion Among patients undergoing coronary artery revascularization, patients with rheumatoid arthritis have an in-hospital survival advantage along with reduced days of hospitalization compared with patients without rheumatoid arthritis.

Background— In Europe, interhospital transfer of ST-elevation myocardial infarction (STEMI) patients for primary percutaneous coronary intervention (PCI) from non–PCI-capable (STEMI-referral) to PCI-capable (STEMI-accepting) facilities has been shown to be a superior reperfusion strategy compared with on-site fibrinolysis. The feasibility of such programs in the United States remains poorly defined. Methods and Results— We describe an observational cohort of 230 consecutive presumed STEMI patients who underwent interhospital transfer between January 2005 and March 2007 among 6 STEMI-referral and 2 STEMI-accepting hospitals in rural central Illinois. A standard treatment protocol using rapid interhospital transfer for primary PCI or rescue PCI after full-dose intravenous fibrinolysis (in event of unanticipated transfer delays) was initiated by the STEMI-referral emergency department physician. Three time intervals were evaluated: STEMI-referral care (door 1 to departure), transport time (door 1 departure to STEMI-accepting hospital arrival [door 2]), and STEMI-accepting hospital care (door 2 to balloon). Primary PCI was performed in 165 STEMI-confirmed patients (87.7%), whereas fibrinolysis was required in 16 patients (8.5%), with 56% undergoing rescue PCI. The median door 1–to-departure time was 46 minutes (25th and 75th percentiles, 32 and 62 minutes); approximately two thirds of this delay was attributable to the wait for transport arrival and departure. The transport and door 2–to-balloon times were 29 minutes (25th and 75th percentiles, 25 and 35 minutes) and 35 minutes (25th and 75th percentiles, 32 and 46 minutes), respectively. The door 1–to-balloon time was 117 minutes (25th and 75th percentiles, 98 and 137 minutes), with 12.2% and 58% of patients achieving a time of ≤90 and ≤120 minutes, respectively. No adverse clinical events occurred during interhospital transport. Conclusion— In rural US communities, emergency department physician–initiated interhospital transfer of STEMI patients for primary or rescue PCI is feasible and was safely executed with achievement of timely reperfusion when performed within coordinated healthcare networks.

A 67-year-old man underwent percutaneous balloon valvuloplasty for bioprosthetic tricuspid stenosis. He had undergone two tricuspid valve replacements over a period of 39 years and became symptomatic. After the valvuloplasty, his symptoms were resolved. Stenosis of a bioprosthetic tricuspid valve can be successfully and safely treated with balloon valvuloplasty.

Randomized trials of drug-eluting stents (DES) excluded patients with severe renal insufficiency. We sought to evaluate the impact of baseline renal function on clinical outcomes in recipients of coronary DES.We retrospectively reviewed our hospital databases to identify consecutive patients who underwent DES implantations between May 2003 and December 2004, subgrouped among 4 ranges of glomerular filtration rate (GFR) betweenor = 90 ml per minute and30 ml per minute, in 30 ml per minute decrements, and 1 group treated with long-term dialysis. Clinical follow up was obtained at 6 months, 1 year and annually thereafter.Our study group included 2,758 patients with long-term outcomes recorded over a mean follow up of 706 +/- 273 days. The rates of in-hospital adverse events increased significantly as GFR decreased, though no major adverse event occurred among the dialyzed patients. Actuarial survival analyses up to 2 years revealed significant between-groups differences in rates of major adverse cardiac events (MACE) and death (both p0.001), while the differences in target vessel revascularization (TVR) rates did not reach statistical significance (p = 0.069). By Cox regression analysis, a GFR60 ml per minute remained a significant predictor of 2-year mortality (p0.001) and MACE (p0.001), but not TVR (p = 0.839).In conclusion, low rates of TVR were observed over 2 years in DES recipients with a wide range of renal function. Low rates of TVR were countered by high rates of death and MACE among renally insufficient patients over the long term.

Background and Aims: Cardiovascular disease (CVD) is the leading cause of death among women. Consistent with studies documenting that aspirin (ASA) use decreases the risk of CVD events in certain groups, the American Heart Association (AHA) published specific evidence based guidelines for ASA use in women. This paper evaluates the self-reported use of ASA among women and examined characteristics of those most likely to be adhering to clinical guidelines. Methods: Data from 127 healthcare centers across the U.S. using a commercial, web-based CVD risk assessment tool (HeartAware™) were analyzed. Volunteer respondents answered questions about their CVD risk factors, the presence or absence of coronary, cerebral, peripheral arterial disease, diabetes, and medication use including daily ASA. Individuals who, based on the AHA 2007 guidelines should be taking ASA (for primary and secondary prevention) were included in the analysis. Univariate and multivariate logistic regression analyses were performed to identify factors significantly associated with ASA intake. Results: Of the 21,199 women who should be on ASA based on guideline information, only 42% reported the use for primary prevention and 68% for secondary prevention. Multivariate regression analysis found that African Americans (OR = 0.61, 95% CI 0.53–0.70, p