Search

We aimed to evaluate the influence of heart failure (HF) on clinical and economic outcomes among older adults ≥75 years of age during their acute myocardial infarction (AMI) admission in large population-based study from the United States. We also evaluated the clinical characteristics associated with the presence of HF and the predictors of mortality, healthcare utilization, and cost among older adults with AMI.From January 1, 2000, to December 31, 2016, AMI admission was identified using the primary diagnosis and concomitant HF was identified using any non-primary diagnoses in the Premier Healthcare Database.Of the 468,654 patients examined, 42,946 (9%) had concomitant HF during their AMI admission. These patients were older, more often female, and were more likely to be White. Patients with concomitant HF were more likely to be frail than non-HF patients (59% vs 15%, P.001). The mean (SD) Elixhauser comorbidity index was 2.6 (2.5) vs 0.4 (1.1), P .001 in the AMI with HF vs AMI only group. The use of percutaneous coronary intervention in those with AMI and HF was lower than those with AMI only (15% vs 31%, P .001). The overall mortality rate for those with HF was 12%, the median [IQR] hospital length of stay was 5 [3,9] days, and only 25% of patients were discharged home. A higher proportion of patients were discharged to rehabilitation or hospice if they had AMI and HF (Rehabilitation: 33% vs 20%, P .001; Hospice: 5% vs 3%, P .001). The mean unadjusted cost of an AMI hospitalization in patients with concomitant HF was lower ($12,411 ± $14,860) than in those without HF ($15,828 ± $19,330). After adjusting for age, gender, race, hypertension, frailty, revascularization strategy, and death, the average cost of hospitalization attributed to concomitant HF was +$1,075 (95% CI +876 to $1,274) when compared to AMI patients without HF.In patients ≥75 years of age, AMI with concomitant HF carries higher risk of death, but at ages ≥85 years, the risk difference diminishes due to other competing risks. HF was also associated with longer hospital length of stay and higher likelihood of referral to hospice and rehabilitation facilities when compared to older patients without HF. Care for these older adults is associated with increased hospitalization costs. Measures to identify HF in older adults during their AMI admission are necessary to optimize health outcomes, care delivery, and costs.

Socioeconomic disparities in cardiovascular risk factors and outcomes exist among women, particularly those of minority racial or ethnic backgrounds. Barriers to optimal cardiovascular health begin early in life-with inadequate access to effective contraception, postpartum follow-up, and maternity leave-and result in excess rates of myocardial infarction, stroke, and cardiovascular death in at-risk populations. Contributing factors include reduced access to care, low levels of income and social support, and lack of diversity among cardiology clinicians and within clinical trials. These barriers can be mitigated by optimizing care access via policy change and improving physical access to care in women with geographic or transportation limitations. Addressing structural racism through policy change and bolstering structured community support systems will be key to reducing adverse cardiovascular outcomes among women of racial and ethnic minorities. Diversification of the cardiology workforce to more closely represent the patients we serve will be beneficial to all women.

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality for women in the United States and worldwide. There has been no American College of Cardiology (ACC)/American Heart Association guideline update specifically for the prevention of CVD in women since 2011. Since then, the body of sex-specific data has grown, in addition to updated hypertension, cholesterol, diabetes, atrial fibrillation, and primary prevention guidelines. The ACC CVD in Women Committee undertook a review of the recent guidelines and major studies to summarize recommendations pertinent to women. In this update, the authors address special topics, particularly the risk factors and treatments that have led to some controversies and confusion. Specifically, sex-related risk factors, hypertension, diabetes, hyperlipidemia, anticoagulation for atrial fibrillation, use of aspirin, perimenopausal hormone therapy, and psychosocial issues are highlighted.

Background: Cardiogenic shock (CS) is a multifactorial, hemodynamically complex syndrome associated with high mortality. Despite advances in reperfusion and mechanical circulatory support, ...

Background Minorities and women are underrepresented in cardiovascular research. Whether their higher enrollment can be predicted or influences research site performance is unclear. Methods We evaluated 104 sites that enrolled 4,184 patients in the U.S. Platinum Diversity (PD) and Promus Element Plus (PE Plus) studies (2012 to 2016). Research sites were ranked from lowest to highest minority and female enrollment, respectively. United States Census Bureau division and core-based statistical area (CBSA) populations were determined for each site and the following study performance metrics compared across quartiles of minority and female enrollment, respectively: (1) study subject enrollment rate (SER), (2) time to first patient enrolled, (3) rate of follow-up visits not done, (4) rate of follow-up visits out of window, and (5) protocol deviation rate (PDR). Multivariable regression was used to predict SER and PDR. Results Minority enrollment varied by region (P = .025) and population (P = .024) with highest recruitment noted in the Pacific, West South Central, South Atlantic, Mid-Atlantic and East North Central divisions. Female enrollment bore no relationship to region (P = .67) or population (P = .40). Median SER was similar in sites withi the highest vs lowest quartile of minority enrollment (SER of 4 vs 5 patients per month, respectively, P =0.78) and highest vs. lowest female enrollment (SER of 4 vs 4, respectively, P = .21). Median PDR was lower in sites within the highest vs lowest minority enrollment (0.23 vs 0.50 PDs per patient per month, respectively, P = .01) and highest vs. lowest female enrollment (0.28 vs. 0.37 PDs per patient per month, respectively, P = .04). However, this relationship did not persist after multivariable adjustment. All other site performance metrics were comparable across quartiles of minority and female enrollment. Conclusions Minority, but not female enrollment, correlated with research site geographic region and surrounding population. High enrollment of minorities and women did not influence study performance metrics. These findings help inform future strategies aimed at increasing clinical trial diversity. Trial Registration The PD and PE Plus studies are registered at www.clinicaltrials.gov under identifiers NCT02240810 and NCT01589978, respectively. Key Points Question: Does the enrollment of more Blacks, Hispanics and women in US cardiovascular research studies influence the overall rate of study subject enrollment and/or other key study site performance metrics and can diverse enrollment be predicted? Findings: In this pooled analysis of 104 sites that enrolled 4,184 patients in the Platinum Diversity and Promus Element Plus Post-Approval Studies, we found that the enrollment of higher proportions of underrepresented minorities and women was univariately associated with lower protocol deviation rates while having no effect on other site performance metrics. A site's geographic location and surrounding population predicted minority, but not female enrollment. Meaning: These findings suggest that cardiovascular research subject diversity may be predicted from site characteristics and enhanced without compromising key study performance metrics. These insights help inform future strategies aimed at improving clinical trial diversity.

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.

BACKGROUND: Skeletal muscle wasting, or sarcopenia, affects a significant proportion of patients undergoing transcatheter aortic valve replacement (TAVR). However, its influence on post-TAVR recovery and 1-year health-related quality of life (HR-QOL) remains unknown. We examined the relationship between skeletal muscle index (SMI), post-TAVR length of hospital stay (LOS), and 1-year QOL. METHODS: The study sample consisted of 300 consecutive patients undergoing TAVR from 2012 to 2018 who had pre-TAVR computed tomographic scans suitable for analysis of body composition. Skeletal muscle mass was quantified as cm(2) of skeletal mass per m(2) of body surface area from the cross-sectional computed tomographic image at the third lumbar vertebra. Sarcopenia was defined using established sex-specific cutoffs (women: SMI < 39 cm(2)/m(2); men: < 55 cm(2)/m(2)). Multivariable linear regression analysis was used to determine the relationship between SMI, LOS, and HR-QOL using the Kansas City Cardiomyopathy Questionnaire. RESULTS: Sarcopenia was present in most (59%) patients and associated with older age (82 vs 76 years; P < .001) and lower body mass index (27 vs 33 kg/m(2); P < .001). There were no other differences in baseline clinical or echocardiographic characteristics among the 4 quartiles of SMI. SMI was positively correlated with LOS and 1-year QOL. After adjusting for age, gender, race, and body mass index, SMI remained a significant predictor of both LOS (P = .01) and 1-year QOL (P = .012). For every 10 cm(2)/m(2) higher SMI, there was an 8-point increase in Kansas City Cardiomyopathy Questionnaire score, a difference that is clinically meaningful. CONCLUSIONS: Sarcopenia is prevalent in TAVR patients. Higher SMI is associated with shorter LOS and better 1-year HR-QOL. To achieve optimal TAVR benefits, further study into how body composition influences post-TAVR recovery and durable improvement in QOL is warranted.

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality for women in the United States and worldwide. There has been no American College of Cardiology (ACC)/American Heart Association guideline update specifically for the prevention of CVD in women since 2011. Since then, the body of sex-specific data has grown, in addition to updated hypertension, cholesterol, diabetes, atrial fibrillation, and primary prevention guidelines. The ACC CVD in Women Committee undertook a review of the recent guidelines and major studies to summarize recommendations pertinent to women. In this update, the authors address special topics, particularly the risk factors and treatments that have led to some controversies and confusion. Specifically, sex-related risk factors, hypertension, diabetes, hyperlipidemia, anticoagulation for atrial fibrillation, use of aspirin, perimenopausal hormone therapy, and psychosocial issues are highlighted.

To determine the incidence, prognosis, and predictors of major Valve Academic Research Consortium (VARC-2) vascular complications (VCs) and percutaneous vascular closure device failure (PCDF) following contemporary percutaneous transfemoral transcatheter aortic valve replacement (TF-TAVR).Limited data exists on the incidence and predictors of VCs and PCDFs following percutaneous TF-TAVR using contemporary 14-16 French (F) sheaths.We recorded clinical and procedural characteristics, computer tomography (CT) angiographic data, 30-day VCs, mortality, and length of stay (LOS) in all consecutive percutaneous TF-TAVRs at a single center from June 2016 to October 2018. CT measures included common femoral artery (CFA) and external iliac artery (EIA) diameters, sheath to CFA and EIA ratios (SFAR and SEIAR), depth of CFA, extent and location of CFA calcification and pelvic vessel tortuosity (2 bends ≥90°). Multivariable regression was used to predict major VCs and percutaneous closure device failure (PCDF), respectively.The final sample consisted of 303 percutaneous TF-TAVRs. Median age was 80 years, 51% were male, 86% Caucasian, 33% had diabetes mellitus (DM) and mean STS score was 5.8 ± 3.8%. Baseline characteristics were similar in patients with vs. without VCs, other than coronary artery disease (CAD) (69% vs. 54%, respectively; p = 0.029) and DM (21% vs. 36%, respectively; p = 0.02). There were 65 (21%) vascular complications: 19 major VCs [6.3%], 29 minor [VCs 9.6%] and 17 PCDFs [5.6%]. Overall, 30-day mortality was low (2.6%). Major VCs were associated with higher mortality (42% vs. 0%, p 0.0001) while minor VCs (3% vs. 0%, mortality p = 0.99) and PCDFs (3% vs. 0% mortality, p = 0.99) were not. PCDFs were associated with a longer median LOS (4 vs. 3 days, p = 0.02). The independent predictors of major VCs were pelvic vessel tortuosity (OR 3.1; 95% CI 1.1-9.2) and presence of CAD (OR 8.2; 95% CI 1.8-37). Female gender showed a strong trend toward increased risk (OR 3.4; CI 0.84-14; p = 0.086). There were no independent predictors of PCDF.Contemporary percutaneous TF-TAVR is associated with a low risk of mortality, major VCs and PCDFs. Major VCs confer increased mortality and PCDFs prolong LOS. Pelvic vessel tortuosity and a history of CAD predict major VCs; there were no predictors of PCDFs. These results provide a contemporary update on the incidence and implications of these important vascular complications in the current era of percutaneous TF-TAVR using 14-16F vascular sheaths.

Background: CYP2C19 polymorphisms affect clopidogrel metabolism and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). Although FDA recommended pharmacogenetic testing and alternative antiplatelet agents in CYP2C19 loss-of-function (LoF) allele carriers, implementation in practice has been minimal. Our goal is to personalize antiplatelet therapy using point-of-care (POC) assay to genotype patients immediately prior to PCI in a hospital cardiac catheterization lab. Methods: Appropriate P2Y 12 receptor antagonist therapy following non-emergent PCI based on bedside genetic testing (SpartanRx system) was initiated at Inova Heart and Vascular institute catheterization laboratory in February 2017. Patients were genotyped using buccal swab technique before proceeding to the catheterization laboratory. A best practice advisory (BPA) was implemented into the EPIC EMR prescription medication ordering system based on genotype. Poor (*2/*2, and *2/*3) and intermediate metabolizers (*1/*2, *1/*3, and *2/*17) were recommended more potent P2Y12 inhibitor therapy using BPA. Demographics, BPA compliance and 1 year outcomes including major adverse cardiac events (Cardiovascular death, MI, Ischemic stroke) and NACE (MACE + major bleeding) were collected. Results: Between 2/2017 to 12/2017, 1050 patients underwent POC genetic testing. The frequency of poor, intermediate, extensive, and ultra-rapid metabolizer status was 2.9%, 26.8%, 42.5%, and 27.9%, respectively. The highest percentage of poor metabolizers were observed in Middle-Eastern (12.1%) and Asian (8.9%) populations as compared to African Americans (n=3.4%) and Caucasians (1.1%). In patients treated with PCI (n=429), 28.9% were intermediate (n=112) or poor (n=12) clopidogrel metabolizers, with 87.1% of these patients receiving ticagrelor (n=84) or prasugrel (n=24) based on the BPA from genotype consortium. MACE (0.7%) and NACE (0.9%) rates were minimal as compared to historical controls (5-10%). Conclusions: CYP2C19 genotyping at the bedside facilitated early personalization of antiplatelet therapy according to BPA and is associated with low one year MACE and NACE rates.

Remodeling of the radial artery (RA) after transradial percutaneous coronary intervention (TRI) is under studied.To examine the impact of TRI on RA diameter and intimal-medial thickness (IMT) in men and women using 55 Mhz ultrahigh frequency duplex ultrasound (UHFDU).We performed UHFDU at 24 h and 90 days after non-emergent TRI in 41 patients (25 men, 16 women). Changes in RA diameter, IMT and RA injury were compared by patient gender. Multivariate linear regression was used to determine the predictors of RA diameter and IMT.Of the 41 patients, mean age was 66 ± 9.8. Baseline RA diameter was larger in men vs. women (3.1 ± 0.40 mm vs. 2.8 mm ± 0.36, p = 0.02), however there were similar reductions in 90-day diameter (-0.57 ± 0.32 mm vs. -0.64 ± 0.40 mm, respectively; p = 0.48). Baseline IMT was also similar in men and women (0.28 ± 0.04 vs. 0.27 ± 0.06 mm; p = 0.37) and there were 0.073 ± 0.11 mm (26%) and 0.05 ± 0.080 mm (19%) increases in IMT noted, respectively (p 0.0001 vs. baseline, p = 0.48 for men vs. women). Although UHFDU occasionally detected limited access site intimal tears (12%) at 90 days, frank dissections (2.4%), pseudoaneurysms (2.4%) and total occlusions (4.9%) were infrequent. Female gender correlated with smaller RA diameter at follow-up and there were no predictors of IMT.Following TRI, there is a 20% reduction in RA diameter and a 20-25% increase in IMT. Only gender predicted RA diameter. As a simple, noninvasive method to accurately depict the RA healing response following TRI, UHFDU may inform future clinical investigation in this area.

Papillary muscle rupture (PMR) is a rare and catastrophic complication of acute myocardial infarction (AMI) associated with high operative mortality. We report a case series of three patients with AMI complicated by PMR managed with a VA-ECMO and Impella (ECPELLA) mechanical circulatory support (MCS

It is unknown if minority enrollment affects research site performance We evaluated 104 sites enrolling 4,184 patients in 2 US coronary stent registries (2012-2016). Sites were grouped into quartiles of low to high % minority enrollment (diversity index: D1: lt 4.8% minorities; D2: 4.9-23%

Clinical factors associated with successful weaning from Impella support in cardiogenic shock (CS) remain unknown. Patients >18 years old were treated with Impella 2.5, CP, or 5.0 for CS from 1/3/17-6/30/19. Clinical characteristics, laboratory and hemodynamic markers at 24 and 48 hours post

CYP2C19 polymorphisms affect clopidogrel metabolism and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). The use of a point-of-care (POC) assay to routinely genotype patients immediately prior to PCI in a hospital cardiac catheterization lab has shown to be feasible

Background— Women Methods and Results— Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated the association of sex and age on cardiovascular-related outcomes in10 963 patients (3797 women, 394 P =0.003), driven largely by higher rates of repeat revascularizations for target vessel or target lesion failure (coronary artery bypass graft surgery: 8.9% versus 3.9%, P P =0.005, adjusted hazard ratio 1.6, 95% confidence interval 1.2–2.2). At 5 years, young women remained at higher risk for repeat procedures (coronary artery bypass graft surgery: 10.7% versus 6.8%, P =0.04, adjusted hazard ratio 1.71, 95% confidence interval 1.01–2.88; repeat PCI [target vessel]: 19.7% versus 11.8%, P =0.002, adjusted hazard ratio 1.8, 95% confidence interval 1.24–2.82). Compared with older women, younger women remained at increased risk of major adverse cardiovascular events, whereas all outcome rates were similar in older women and men. Conclusions— Young women, despite having less severe angiographic coronary artery disease, have an increased risk of target vessel and target lesion failure. The causes of this difference deserve further investigation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00005677.

Prior studies suggest that younger women are at higher risk for major adverse events following PCI; however, little is known about the association between race and adverse outcomes in this population. We evaluated 3797 women undergoing PCI in the NHLBI Dynamic Registry and compared 1 year outcomes

Management of coronary artery disease (CAD) has evolved over the past decade, but there are few prospective studies evaluating long-term outcomes in a real-world setting of evolving technical approaches and secondary prevention. The aim of this study was to determine how the mortality and morbidity of CAD has changed in patients who have undergone percutaneous coronary intervention (PCI), in the setting of co-morbidities and evolving management. The National Heart, Lung, and Blood Institute Dynamic Registry was a cohort study of patients undergoing PCI at various time points. Cohorts were enrolled in 1999 (cohort 2, n = 2,105), 2004 (cohort 4, n = 2,112), and 2006 (cohort 5, n = 2,176), and each was followed out to 5 years. Primary outcomes were death, myocardial infarction (MI), coronary artery bypass grafting, repeat PCI, and repeat revascularization. Secondary outcomes were PCI for new obstructive lesions at 5 years, 5-year rates of death and MI stratified by the severity of coronary artery and co-morbid disease. Over time, patients were more likely to have multiple co-morbidities and more severe CAD. Despite greater disease severity, there was no significant difference in death (16.5% vs 17.6%, adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.74 to 1.08), MI (11.0% vs 10.6%, adjusted HR 0.87, 95% CI 0.70 to 1.08), or repeat PCI (20.4% vs 22.2%, adjusted HR 0.98, 95% CI 0.85 to 1.17) at 5-year follow-up, but there was a significant decrease in coronary artery bypass grafting (9.1% vs 4.3%, adjusted HR 0.44, 95% CI 0.32 to 0.59). Patients with 5 co-morbidities had a 40% to 60% death rate at 5 years. There was a modestly high rate of repeat PCI for new lesions, indicating a potential failure of secondary prevention for this population in the face of increasing co-morbidity. Overall 5-year rates of death, MI, repeat PCI, and repeat PCI for new lesions did not change significantly in the context of increased co-morbidities and complex disease.

A 65-year-old woman with hypertension and dyslipidemia presented with rest chest pain in the setting of 2 mm ST depression in ECG leads V3-V6 and a troponin T level (TnT) of 0.92 ng/mL (normal

Prior studies suggest that younger women are at higher risk for adverse events following PCI; however, no long-term, multi-center assessments exist. We evaluated 10,963 patients undergoing PCI enrolled in the NHLBI-sponsored Dynamic Registry and compared long-term outcomes in women < 50 years (n=