History Of Peripheral Arterial Disease Research Articles

Association of Sex and Race With Incident Peripheral Artery Disease Among Veterans With Normal Ankle-Brachial Indices

Reported risk of incident peripheral artery disease (PAD) by sex and race varies significantly and has not been reported in national cohorts among individuals free of baseline PAD. To evaluate the association of sex and race, as well as prevalent cardiovascular risk factors, with limb outcomes in a national cohort of people with normal baseline ankle-brachial indices (ABIs). This cohort study was conducted using data from participants in the Veterans Affairs Birth Cohort Study (born 1945-1965), with follow-up data between January 1, 2000, and December 31, 2016. Baseline demographics were collected from 77 041 participants receiving care from the Veterans Health Administration with baseline ABIs of 0.90 to 1.40 and no history of PAD. Data were analyzed from October 2019 through September 2022. Sex, race, diabetes, and smoking status. Incident PAD, defined as subsequent ABI less than 0.90, surgical or percutaneous revascularization, or nontraumatic amputation. Of 77 041 participants with normal ABIs (73 822 [95.8%] men; mean [SD] age, 60.2 [5.9] years; 13 080 Black [18.2%] and 54 377 White [75.6%] among 71 911 participants with race and ethnicity data), there were 6692 incident PAD events over a median [IQR] of 3.9 [1.7-6.9] years. Incidence rates were lower for women than men (incidence rates [IRs] per 1000 person-years, 7.4 incidents [95% CI, 6.2-8.8 incidents] vs 19.2 incidents [95% CI, 18.7-19.6 incidents]), with a lower risk of incident PAD (adjusted hazard ratio [aHR], 0.49 [95% CI, 0.41-0.59]). IRs per 1000 person-years of incident PAD were similar for Black and White participants (18.9 incidents [95% CI, 17.9-20.1 incidents] vs 18.8 incidents [95% CI, 18.3-19.4]). Compared with White participants, Black participants had increased risk of total PAD (aHR, 1.09 [95% CI, 1.02-1.16]) and nontraumatic amputation (aHR, 1.20 [95% CI, 1.06-1.36]) but not surgical or percutaneous revascularization (aHR, 1.10 [95% CI, 0.98-1.23]) or subsequent ABI less than 0.90 (aHR, 1.04 [95% CI, 0.95-1.13]). Diabetes (aHR, 1.62 [95% CI, 1.53-1.72]) and smoking (eg, current vs never: aHR, 1.76 [95% CI, 1.64-1.89]) were associated with incident PAD. Incident PAD was rare among individuals without a history of smoking or diabetes (eg, among 632 women: IR per 1000 people-years, 2.1 incidents [95% CI, 1.0-4.5 incidents]) despite an otherwise-high-risk cardiovascular profile (eg, 527 women [83.4%] with hypertension). This study found that the risk of PAD was approximately 50% lower in women than men and less than 10% higher for Black vs White participants, while the risk of nontraumatic amputation was 20% higher among Black compared with White participants.

Neurologic outcomes of carotid and other emergent interventions for ischemic stroke over 6years with dataset enhanced by machine learning.

The current mainstays of ischemic stroke treatment include the use of thrombolysis (tissue plasminogen activator [tPA]), urgent carotid endarterectomy (uCEA) or urgent carotid artery stenting (uCAS), and mechanical endovascular reperfusion/thrombectomy (MER). Scarce data describe the presenting stroke severity and neurologic outcomes for these acute ischemic stroke interventions, alone or in combination. The authors hypothesize that patients undergoing carotid interventions experience better functional neurologic outcomes than other stroke interventions. A comprehensive stroke center dataset was combined with data for stroke-related procedures, comorbidities, complications, and physician documentation collected from electronic medical record data. A total of 10,975 patient encounter records from January 1, 2015, through July 31, 2021, were retrieved. The presenting stroke severity was determined by vascular/stroke neurologists using the National Institutes of Health Stroke Scale (NIHSS). Functional neurologic outcomes were reported using the modified Rankin scale (mRS) score, which quantifies the degree of neurologic disability. Because mRS values were only available for 3627 encounters in the original dataset, the authors developed a machine learning algorithm to analyze physician documentation and assign an mRS value. After the exclusion and machine learning analysis, a total of 5170 patient encounters were included for statistical analysis. Statistical analyses included the χ2 test, one-way analysis of variance and logistic regression on 30-day complications, stroke severity, and neurologic outcomes. Patients were divided into five cohorts: (1) uCEA or uCAS (n= 189), (2) tPA alone (n= 1053), (3) MER alone (n= 418), (4) tPA+ MER (n= 199), and (5) no intervention (n= 3311). Patients undergoing uCEA/uCAS were significantly more likely to be male, smokers, and have a history of peripheral arterial disease compared with other stroke cohorts. The length of stay was shortest for patients who only received tPA or no intervention (6days), followed by uCEA/uCAS (7.2days), MER (10.2days), and tPA+ MER (8.8days) cohorts (P< .001). The 30-day mortality was highest in the MER cohort (12.2%) and lowest in the uCEA/uCAS cohort (2.6%). The uCEA/uCAS cohort compared with other cohorts had the lowest presenting stroke severity (NIHSS 4.9 vs NIHSS 6.9-16.0), and best neurologic outcomes (mRS 1.7 vs mRS 1.8-2.6). After an ischemic stroke, patients undergoing urgent carotid interventions had the lowest presenting stroke severity (NIHSS) and highest rate of independent neurologic outcomes (mRS) compared with other stroke interventions. Incoming stroke severity correlates with functional neurologic outcomes, and patients who present with an NIHSS of 10 or less who undergo uCEA/uCAS have a high likelihood of independent neurologic functional outcome (mRS of ≤2).

Long-Term Risk of Carotid Stenosis and Cerebrovascular Disease after Radiation Therapy for Head and Neck Cancer

<h3>Purpose/Objective(s)</h3> The incidence of asymptomatic carotid artery stenosis (CAS) in the general population is ∼5%. CAS is a known toxicity of radiation therapy (RT) for head and neck cancer (HNC). CAS screening is not routinely performed after RT despite the increased risk of cerebrovascular disease (CVD) in this population. Here we report long-term incidence and associated risk factors for CAS and CVD after RT for HNC. <h3>Materials/Methods</h3> Records were retrospectively identified for all patients undergoing carotid ultrasound (U/S) screening following RT for HNC at a single institution between November 2000 and October 2020. Exclusion criteria included CAS or CVD prior to RT. Carotid U/S screening was obtained within 24 months of RT completion, then every three years in the absence of CAS or annually following CAS diagnosis. Asymptomatic CAS was defined as radiographic luminal narrowing ≥50%; CVD was defined as stroke or transient ischemic attack, and composite CAS was defined as asymptomatic CAS and/or CVD. Cumulative incidence estimates (CIE) of asymptomatic CAS, CVD, and composite CAS were estimated. Univariate and multivariable (MVA) Cox proportional hazards regression was used to study potential associations between clinical parameters and the CVD and composite CAS outcomes. <h3>Results</h3> Among 628 patients, median follow-up was 4.8 years (IQR 2.6 - 8.3 yr) with 97 patients followed beyond 10 yr. Median age was 61 yo. 56% of patients had a history of smoking. 61% had an oropharyngeal primary tumor (64% p16+). Squamous cell carcinoma was the most common histology (94%). 57% patients completed 70 Gy over 35 fractions, 69% received concurrent chemotherapy, and 28% were treated post-operatively. Asymptomatic CAS was identified in 111 (18%) with 50 (45%) prescribed CAS-related medication and 24 (22%) undergoing carotid endarterectomy or stenting. 5, 10, and 12-year CIE for asymptomatic CAS were 19.8%, 37.1%, and 50.2%, respectively. MVA showed that a history of peripheral arterial disease ([PAD]; HR 4.5, 95% CI 1.7 - 11.8) and myocardial infarction ([MI]; HR 3.3; 95% CI 1.1 - 9.8) were predictive of time to asymptomatic CAS. CVD events were observed in 45 (7.2%) patients, of whom 27 (60%) were found to have asymptomatic CAS. 5, 10, and 12-year CIE for CVD were 5.4%, 12.4%, and 21.7%, respectively. On MVA, male sex (HR 3.3, 95% CI 1.1 - 10) and type 2 diabetes mellitus ([DM2]; HR 2.3, 95% CI 1.2 - 4.6) were significantly associated with CVD. 5, 10, and 12-year CIE for composite CAS were 17.5%, 32.3%, and 43.6%, respectively. On MVA, male sex (HR 2.0, 95% CI 1.1 – 3.3), PAD (HR 3.1, 95% CI 1.2 - 7.8), and MI (HR 2.5, 95% CI 1.1 - 5.9) were significantly associated with composite CAS. <h3>Conclusion</h3> Long-term follow up shows a steady increase in the risk of asymptomatic CAS and CVD following RT for HNC. It is independently associated with sex, PAD, MI, and DM2. Ongoing analyses include dosimetric analysis of CAS and CVD per carotid artery and cost-effectiveness of carotid ultrasound screening.

When Can an Emergency CTA Be Dispensed with for TIA Patients?

Background: Transient ischemic attacks (TIAs) and minor strokes are often precursors of a major stroke. Therefore, diagnostic work-up of the TIA is essential to reduce the patient’s risk of further ischemic events. Purpose: With the help of this retrospective study, we aim to determine for which TIA patients a CT angiography (CTA) is not immediately necessary in order to reduce radiation exposure and nephrotoxicity. Material and Methods: Clinical and imaging data from patients who presented as an emergency case with a suspected diagnosis of TIA at a teaching hospital between January 2016 and December 2021 were evaluated. The included 1526 patients were divided into two groups—group 1, with major pathologic vascular findings in the CTA, and group 2, with minor vascular pathologies. Results: Out of 1821 patients with suspected TIA on admission, 1526 met the inclusion criteria. In total, 336 (22%) had major vascular pathologies on CTA, and 1190 (78%) were unremarkable. The majority of patients with major vascular pathologies were male and had a history of arterial hypertension, coronary heart disease, myocardial infarction, ischemic stroke, TIA, atherosclerotic peripheral vascular disease, smoking, antiplatelet medication, had a lower duration of TIA symptoms, and had lower ABCD2 scores. Conclusions: We were able to demonstrate a direct correlation between major CTA pathologies and a history of smoking, age, hyperlipidemia, history of peripheral arterial disease, and a history of stroke and TIA. We were able to prove that the ABCD2 score is even reciprocal to CTA pathology. This means that TIA patients without described risk factors do not immediately require a CTA and could be clarified in the course of treatment with ultrasound or MRI.

Socioeconomic status is not associated with unfavorable outcomes in patients with acute limb ischemia.

Whether socioeconomic status (SES) is associated with health outcomes in patients with acute limb ischemia (ALI) is largely unknown. We aimed to determine whether SES is associated with worse presentations and outcomes for patients with ALI. We performed a retrospective medical record review of patients who presented with ALI between April 2016 and October 2020 at a single tertiary care center. SES was quantified using individual variables (median household income, level of education, and employment) and a composite endpoint, the neighborhood deprivation index (NDI). The NDI is a standardized and reproducible index that uses census tract data (higher number indicates lower SES status). The NDI summarizes 8 domains of socioeconomic deprivation. ALI severity was categorized using the Rutherford classification. The association between SES and the severity of ALI at presentation and between SES and other health outcomes were analyzed using bivariate analysis of variance, independent t test, and multivariate logistic regression. During the study period, 278 patients were treated for ALI, of whom 211 had complete SES data available. The mean age was 64 years, 55% were men, and 57% were White. The Rutherford classification of disease severity was grade 1, 2a, 2b, and 3 for 6%, 54%, 32%, and 8% of patients, respectively. Patients with a low SES status per the NDI were more likely to have a history of peripheral arterial disease and chronic kidney disease at presentation. The ALI etiology (thrombotic vs embolic) was not associated with SES. No significant differences were seen between SES and the severity of ALI at presentation (p = 0.96) or the treatment modality (p = 0.80). No associations between SES and 30-day or 1-year mortality were observed (mean NDI, 0.15 vs 0.26, p = 0.58, and 0.20 vs 0.26, p = 0.71, respectively) or between SES and 30-day or 1-year limb loss (mean NDI, 0.06 vs 0.30, p = 0.18, and 0.1 vs 0.32, p = 0.17, respectively). Lower SES (higher NDI) was associated with increased 30-day readmission (mean NDI, 0.49 vs 0.15, p = 0.021). However, this association was not significant on multivariate analysis (odds ratio 1.4, 95% CI 0.9-2.1, p = 0.06). SES was not associated with the severity of ALI at patient presentation. Although SES was associated with the presence of peripheral arterial disease and chronic kidney disease at presentation, SES was not a predictor of short-term or 1-year limb loss and mortality. Overall, ALI presentation and treatment outcomes were independent of SES.

Predictors of Changes in Peak Oxygen Uptake After Outpatient Cardiac Rehabilitation: Importance of Cardiac Rehabilitation Attendance

ObjectiveTo determine whether the number of cardiac rehabilitation (CR) sessions attended and selected clinical characteristics were predictive of patients who exhibited improvement in peak oxygen uptake (VO2peak) after CR. Patients and MethodsUsing the Rochester Epidemiology Project records-linkage system, we identified all consecutive patients aged 18 years or older from Olmsted County, Minnesota, who underwent cardiopulmonary exercise testing before and after CR from 1999 to 2017. Regression models were created to assess the clinical predictors of VO2peak improvement (>0% baseline) after CR. ResultsThe analysis included 671 patients, of which 524 (78%) patients exhibited VO2peak improvement after CR. The significant univariate predictors of VO2peak improvement included younger age (odds ratio [OR], 0.98; 95% CI, 0.96-0.99), lower pre-CR VO2peak (OR, 0.96; 95% CI, 0.94-0.99), and no history of peripheral artery disease (OR, 0.50; 95% CI, 0.31-0.81) (all, P<.005). The significant independent predictors of VO2peak improvement from the multivariable analysis included the number of CR sessions (OR, 1.04; 95% CI, 1.02-1.05), younger age (OR, 0.96; 95% CI, 0.94-0.98), lower pre-CR VO2peak (OR, 0.92; 95% CI, 0.89-0.95), and no history of peripheral artery disease (OR, 0.47; 95% CI, 0.28-0.78) (all, P<.005). ConclusionThese findings highlight the importance of patient participation in CR sessions and individual clinical characteristics in influencing VO2peak improvement after CR in patients with cardiovascular disease.

The management of COVID-associated thrombosis by local arterial thrombolysis

The COVID-19 infection leads to profound changes in coagulation among patients affected by the disease. High prevalence of thrombotic events and its different clinical manifestations forced medical society to reevaluate the existent guidelines and to find the new applicable treatment approaches. This case study report includes a brief review of latest guidelines and scientific manuscripts, pathogenic justification of proposed treatment methods, an example of successful treatment of 56 years old male with acute limb ischemia, nonsmoker, with no previous history of peripheral arterial disease, severely affected by coronavirus infection. Ongoing pandemic makes the aspects of active surgical treatment of COVID-19 patients with associated thrombotic complications playing crucial role to decrease the number of negative consequences of infection.

Outcomes of Hospitalized Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) With and Without a History of Peripheral Artery Disease.

IntroductionPeripheral artery disease (PAD) is a common illness associated with an increased risk of complications and mortality. Gastroenterologists considering endoscopic retrograde cholangiopancreatography (ERCP) in these patients should weigh the benefits and risks carefully. Our goal is to analyze the hospital burden and complication rates in patients with PAD undergoing ERCP.MethodsUsing data from the National Inpatient Sample (NIS), patients over the age of 18 with and without PAD undergoing ERCP were identified utilizing the International Classification of Diseases (ICD)-9 codes. Primary outcomes included inpatient mortality, length of stay, and hospital charges. Secondary outcomes included rates of bile duct perforation, post-ERCP bleeding, acute pancreatitis, and cholangitis. Supplemental data, including household income and primary payer, were also analyzed. Independent t-tests were used for continuous data, chi-square tests for categorical data, and confounding variables (diabetes, age, gender, race) were controlled via multiple logistic regression.ResultsMost of the PAD group were male, while those in the non-PAD group were female (adjusted p<0.05). Mortality was higher in the PAD group (11.2% versus 8%; adjusted p<0.05). Members of the PAD group had longer lengths of stay (11.6 days versus 11 days; adjusted p<0.05) and more costly hospital stays ($108,006.49 versus $94,399.09; p<0.05). Members of the PAD group had higher rates of post-ERCP bleeding (5.2% versus 3.7%; adjusted p<0.05) and lower rates of cholangitis (6% versus 4%; adjusted p<0.05) and acute pancreatitis (6.9% versus 3.4%; adjusted p<0.05). ConclusionPatients with PAD had an increased hospital burden but had a decreased risk of post-ERCP complications, including cholangitis and pancreatitis. Physicians performing risk stratification for patients with PAD undergoing ERCP must consider these specific complications and ensure that patients undergoing this procedure are fully aware of the dangers and benefits of ERCP prior to consenting to the procedure.

421-P: Differential Prognostic Burden of Lower-Limb Amputation and Cardiovascular Disease on the Risk of All-Cause Death in People with Type 1 Diabetes

Background: Nontraumatic lower-limb amputation (LLA) and cardiovascular disease (CVD) both result in reduced life expectancy in patients with type 1 diabetes, but the differential burden between these conditions is unknown. We compared the effects of LLA and CVD on the risk of all-cause death in people with type 1 diabetes. Methods: We used pooled data from the SURGENE, GENEDIAB, and GENESIS prospective cohorts. Data were divided into: 1) absence of CVD (myocardial infarction and/or stroke) nor LLA, 2) history of CVD alone without LLA, 3) LLA alone without CVD or 4) CVD and LLA at baseline. Participants with baseline history of peripheral artery disease were excluded from groups 1 and 2. The study endpoint was all-cause death. Results: Among 1169 (male 55%, age 40 ± 13 years, diabetes duration 23 ± years) participants, LLA, CVD or 2 combined conditions were present at baseline in 62 (5.3%) , 49 (4.2%) and 20 (1.7%) subjects, respectively. All-cause death occurred in 3 (26%) subjects during 17-year follow-up. The risk of all-cause death increased in subjects withbaseline history of LLA (adjusted HR 2.26 [95% CI, 1.56 - 3.28], p&amp;lt;0.0001) or CVD (2.00 [1.34 - 3.01], p=0.0008) versus no condition, with an additive effect in those with two combined conditions (5.32 [3.14 - 9.00], p&amp;lt;0.0001) . No incremental risk of death was observed in people with CVD versus LLA (0.87 [0.54 - 1.41]) . Compared with no condition, LLA and CVD were similarly associated with reduced life expectancy during follow-up: 3.38 (95% CI, 1.87 -4.88) and 2.79 (1.26 - 4.32) years, respectively. Combined conditions expose to 7. (4.76 - 9.31) less years of life expectancy (all p&amp;lt;0.0001) . Conclusion: LLA and CVD conferred a similar and heavy burden regarding mortality in type 1 diabetes population. Our findings encourage a careful consideration of people with type 1 diabetes and LLA as it is usually done for those with CVD, in terms of management of risk factors, treatments and prevention. Disclosure M.Camoin: None. O.Bourron: Other Relationship; Novo Nordisk. A.Scheen: Advisory Panel; AstraZeneca, Eli Lilly and Company, Merck Sharp &amp; Dohme Corp., Speaker's Bureau; AstraZeneca, Boehringer Ingelheim International GmbH, Novo Nordisk. R.Roussel: None. M.Marre: Board Member; AstraZeneca, Consultant; Novo Nordisk. K.Mohammedi: Board Member; Lilly, Novo Nordisk, Sanofi, Research Support; Cyclerion Therapeutics, Inc., Speaker's Bureau; Abbott, AstraZeneca. G.Velho: None. P.Saulnier: Consultant; Grünenthal Group, Research Support; AstraZeneca, Novo Nordisk, Sanofi. L.Potier: Board Member; Boehringer Ingelheim International GmbH, Lilly, Novo Nordisk, Consultant; AstraZeneca, Sanofi. Y.Abouleka: None. C.Carpentier: None. S.Dubois: None. A.Larroumet: Consultant; Lilly Diabetes, Novo Nordisk, Sanofi. V.Rigalleau: None.

Prognostic factors in patients with acute mesenteric ischemia – a novel tool for determining patient outcomes

Abstract Objective Acute mesenteric ischemia (MI) is a devastating disease with poor prognosis. Due to the multitude of underlying factors and broad clinical presentation, prediction of outcomes remains poor. Here, we aimed to identify factors governing survival in MI and develop a novel prognostic tool. Methods The present study is a monocentric retrospective analysis of patients with suspected MI undergoing imaging between January 2014 and December 2019. Primary endpoint was identification of factors influencing survival in patients undergoing surgery for confirmed MI, secondary endpoint was the development of a predictive nomogram to aid in determination of patient prognosis. Results 539 patients underwent CT imaging for suspected MI, 216 of which had radiological indication of MI and 137 of those had subsequently confirmed MI. Factors associated with confirmed ischemia were increasing age, nausea/vomiting, history of peripheral arterial disease and presence of pneumatosis intestinalis and dilated bowel loops. 125 patients underwent surgery, 58 of which survived, and 67 died (median 9 days after diagnosis, IQR: 22). Baseline characteristics, including time from diagnosis to surgery were not different among patients, and outcomes were not affected by the presence of a surgical senior consultant or daytime of the operation. A minimally invasive approach was attempted more often in survivors (25.9% vs. 10.4%, p=0.024), however, in all but 1 patient (1.7%) conversion to open surgery was performed following detection of ischemia. Increasing age and ASA score, type 2 diabetes, decreased haemoglobin and pH, increased creatinine, radiological atherosclerosis, vascular occlusion (versus non-occlusive MI) and affection of the colon (compared to small bowel ischemia only) were independently associated with impaired survival. Based on a multivariate model, we developed a nomogram for survival prediction, which showed adequate power upon internal validation (C-index = 0.738, Figure 1). Conclusion Acute MI remains a condition with high mortality. Here, we identified factors affecting survival after MI, namely colonic involvement, vascular co-morbidities and increasing age. Minimally invasive surgical approaches have not yet gained widespread acceptance in treatment of confirmed MI. Our novel nomogram might prove helpful in outcome prediction of patients with MI.

Differential prognostic burden of cardiovascular disease and lower-limb amputation on the risk of all-cause death in people with long-standing type 1 diabetes

BackgroundCardiovascular disease (CVD) and nontraumatic lower-limb amputation (LLA) each results in reduced life expectancy in patients with type 1 diabetes, but the differential burden between these conditions is unknown. We compared the effects of CVD and LLA on the risk of mortality in people with type 1 diabetes.MethodsWe used pooled data from the SURGENE, GENEDIAB, and GENESIS prospective cohorts. Data were divided into: 1/absence of CVD (myocardial infarction and/or stroke) nor LLA, 2/history of CVD alone without LLA, 3/LLA alone without CVD or 4/both conditions at baseline. Participants with baseline history of peripheral artery disease were excluded from groups 1 and 2. The study endpoint was any death occurring during follow-up, regardless of the causes.ResultsAmong 1169 participants (male 55%, age 40 ± 13 years, diabetes duration 23 ± 11 years), CVD, LLA or both were present at baseline in 49 (4.2%), 62 (5.3%) and 20 (1.7%) subjects, respectively. All-cause death occurred in 304 (26%) participants during 17-year follow-up, corresponding to 18,426 person-years and an incidence rate of 16 (95%CI, 15–18) per 1000 person-years. The risk of death increased in individuals with baseline history of CVD (adjusted HR 2.00 [95% CI 1.34–3.01], p = 0.0008) or LLA (2.26 [1.56–3.28], p < 0.0001), versus no condition, with an additive effect in people with both conditions (5.32 [3.14–9.00], p < 0.0001). No incremental risk of death was observed in people with CVD versus LLA (0.87 [0.54–1.41]). Compared with no condition, CVD and LLA were similarly associated with reduced life expectancy during follow-up: 2.79 (95% CI 1.26–4.32) and 3.38 (1.87–4.88) years, respectively. Combined conditions expose to 7.04 (4.76–9.31) less years of life expectancy (all p < 0.0001).ConclusionsCVD and LLA conferred a similar burden regarding mortality in type 1 diabetes population. Our findings encourage a careful consideration of people with type 1 diabetes and LLA as usually recommended for those with CVD, in terms of management of risk factors, treatments and prevention.

FC098: Arteriovenous Access and Outcomes in Incident Hemodialysis Patients: Is Fistula First Approach Still Holding?

Abstract BACKGROUND AND AIMS Vascular access choice for patients with high risk of arteriovenous (AV) access failure has been sparking growing controversy as recent studies show similar survival and morbidity across patients receiving arteriovenous (AV) fistula or graft. We assessed hospitalization and mortality risks associated with access type in patients who started hemodialysis with a catheter without previous AV access creation in France, overall and by subgroups of age, sex and comorbidities. METHOD Longitudinal study of 18 800 incident hemodialysis patients from 2010 through 2018, based on the linkage of the French REIN registry of kidney replacement therapy (KRT) with the national health administrative database (SNDS). First-line AV access (fistula or graft) was ascertained from SNDS procedures codes. Hospitalizations were also identified through the SNDS, whereas mortality data was obtained from the REIN Registry. We used joint frailty models to estimate hazard ratios (HR) and 95% confidence intervals (CI) of recurrent hospitalization and death associated with AV grafts, compared with AV fistulæ. These models accounted for dependence between hospitalization and death. We further estimated propensity scores for first-line AV graft placement and used inverse probability weighting (IPW) to obtain weighted HR (wHR), accounting for potential indication bias. RESULTS Among studied patients, 35% were women, 45% had diabetes, 26% had history of heart failure and 19% had history of peripheral artery disease. More than half started dialysis urgently (52%). Patients with first-line AV graft (5%) were older than those with AV fistula (72 ± 14 versus 68 ± 15 years, respectively), and required more frequently assistance to walk (29% versus 17%). IPW resulted in covariate balance (absolute standardized difference &amp;lt;10%) within the overall population and the subgroups of interest (except for the timing of AV access creation in patients aged &amp;lt;70). Over a median follow-up of 48 months (IQR 27–48), hospitalization rates were 334 and 310 per 100 patient-years in the AV graft and fistula groups, respectively; mortality rates were 16 and 13 per 100 patient-years. Patients with AV graft had a 14% higher hazard of all-cause hospitalization (HR 1.14, 95% CI 1.08–1.20), which was only slightly attenuated in IPW analysis (wHR 1.11, 1.09–1.13). AV access type was not associated with mortality—HR 1.03 (0.89–1.19), wHR 1.11 (0.85–1.46). Results were consistent for most subgroups, except that the highest hazard of hospitalization with AV grafts compared to fistulæ was much attenuated in patients with diabetes, heart failure or peripheral artery disease with respect to patients without these comorbidities (Figure 1). CONCLUSION In patients starting hemodialysis with a catheter without previous AV access creation, the fistula first approach is associated with similar mortality, but lower risk of hospitalization compared to first-line AV graft. This may, however, not be the case for patients with a poor vascular condition, i.e. those with diabetes or peripheral artery disease, who have a similar hospitalization risk with either graft or fistula.

Cardiovascular Predictors of Intracerebral Hematoma Expansion

BackgroundThere is limited evidence on the effect and relevance of cardiovascular parameters on the cerebrovascular system when an intracerebral hemorrhage (ICH) occurs. While recent studies evaluating this relationship are conflicting, one evaluating the effect of systolic cardiac function on clinical outcomes in ICH patients, found low cardiac ejection fractions to be associated with poor clinical outcomes. Our primary objective was to study such correlations and identify various cardiovascular disease states that may be associated with hematoma expansion. MethodsThis is an IRB-approved single-center retrospective study utilizing our institutional “Get with the Guidelines”-Stroke registry between 2013 and 2017. Patients included were older than 18 years of age, admitted with an acute ICH, and had an echocardiogram during their hospitalization. Univariate and multivariate logistical regression analyses were used to identify cardiovascular predictors of hematoma expansion. ResultsTwo-hundred forty-nine patients were identified from our GWTG-S registry that met initial inclusion criteria. Of these patients, a history of peripheral arterial disease (PAD) (p = 0.015), presence of aortic stenosis (AS) on the echocardiogram (p = 0.025), and a positive spot sign on the CT-angiogram (CTA) of the head (p < 0.001) were found to be independently associated with ICH expansion. Both a history of hypertension and elevated blood pressure on presentation were not significant predictors. Additionally, patients with a history of congestive heart failure had decreased odds of hematoma expansion (p = 0.027). ConclusionThis exploratory study highlights potential novel cardiac predictors of hematoma expansion, including PAD and AS, which warrant further study. Larger prospective studies are needed to further investigate such associations to ultimately optimize cardio-cerebral health.

Levosimendan in patients undergoing cardiac surgery: does timing matter?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Levosimendan (LEV) is an inotropic drug that improves myocardial contractility without increasing oxygen requirement and its use in cardiac surgery has been questioned. Early meta-analysis showed that it was associated with reduced mortality, however recent randomized trials failed to show a benefit of this drug in some specific subsets of patients. Purpose This study sought to evaluate if the timing of the initiation of LEV infusion could have impact in short-term prognosis. Methods This was an unicenter retrospective study of patients submitted to a cardiac surgery between December 2009 and December 2018 and who did LEV during hospitalization. Three groups were established upon the beginning of LEV administration: preoperative, intraoperative and postoperative. Statistical comparisons between groups are presented below in this order. Results Out of 141 patients, 40,4% belonged to the preoperative group, 31,2% to the intraoperative group and 28,4% to the postoperative group. Demographic data was balanced between the three groups with the exception of past history of peripheral artery disease (3,6% vs 15,9% vs 2,5%, p=0,024) and previous cardiac surgery (19,3% vs 4,5% vs 2,5%, p=0,009). The type of cardiac surgery, whether with or without cardiopulmonary bypass, was similar in all groups. Left ventricular ejection fraction was not significantly different (36,9±12,3% vs 41,2±12,5% vs 42,2±12,2%, p=0,080) and the same happened with the proportion of patients with right ventricle dysfunction (12,3% vs 9,1% vs 10%, p=0,865). Moreover, total dose of LEV and its infusion duration were not different (p=0,117 and p=0,242, respectively). Compared to the postoperative group, preoperative and intraoperative initiation was not independently associated with a significantly lower risk of in-hospital cardiogenic shock requiring inotropic drugs (adjusted OR 0,84 (95% CI 0,23-3,06) and 1,04 (95% CI 0,30-3,60), respectively) or mechanical circulatory support (adjusted OR 1,29 (95% CI 0,18-9,34) and 0,57 (95% CI 0,06-5,64)), myocardial infarction (adjusted OR 1,25 (95% CI 0,16-9,87) and 1,46 (95% CI 0,20-10,51)) and death (adjusted OR 1,85 (95% CI 0,28-12,18) and 4,41 (95% CI 0,81-24,00)). However, preoperative LEV was associated with less acute kidney injury (adjusted OR 0,36 (95% CI 0,14-0,93)) compared to postoperative initiation. Still, the need for renal replacement therapy didn’t differ significantly between all groups. Overall, subgroup analysis showed identical results independently of biventricular systolic function, type of surgery and need of cardiopulmonary bypass. Conclusions In this heterogeneous population submitted to a cardiac surgery, timing of LEV initiation did not have a significant impact on short-term in-hospital major adverse outcomes, independently of biventricular systolic function and type of surgery.

Minimally invasive direct coronary artery bypass after percutaneous coronary intervention.

Minimally invasive direct coronary artery bypass (MIDCAB) with the left internal thoracic artery (LITA) provides excellent long-term results for isolated left anterior descending coronary artery (LAD) disease. We tried to evaluate the impact of the previous percutaneous coronary intervention (p-PCI) for LAD on the clinical outcomes of MIDCAB in this study. A total of 197 patients with isolated LAD disease underwent MIDCAB in our center from February 2009 to May 2020. 51 patients had the p-PCI for LAD and 146 patients did not. The primary outcome was the major adverse cardiovascular event (MACE). The incidences of the perioperative outcomes were comparable between the two groups (p > .05). The median follow-up time was 48.0 months (interquartile range, 25.9-85.5 months). The incidences of MACE (p < .001) and myocardial infarction or recurrent angina (p < .001) were significantly higher in the p-PCIgroup than those in the non-PCI group. The estimated 5-year freedom from MACE in the p-PCI group was significantly lower (56.1%, 95% confidence interval [CI]: 41.2%-71.0% vs. 83.4%, 95% CI: 76.7%-90.1%, p < .001). The previous LAD-PCI (hazard ratio [HR]: 2.664, 95% CI: 1.471-4.822, p = .001) and the history of peripheral arterial disease (HR: 3.145, 95% CI: 1.085-9.113, p = .035) were the independent predictors of MACE. The p-PCI group had a higher diseased graft rate than the non-PCI group (10.9% vs. 2.3%, p = .046). The previous LAD-PCI may deteriorate the outcomes of MIDCAB in patients with isolated LAD disease.

Effects of cardiac surgical support on long-term outcomes of emergent or complex percutaneous coronary intervention cases: a sub-analysis of the SHINANO 5-year registry

Significant improvements in percutaneous coronary intervention (PCI) technology have enabled cardiovascular procedures to be performed without onsite cardiac surgery facilities. However, little is known about the association between onsite cardiac surgical support and long-term outcomes of PCI, particularly among emergent and complex cases. We investigated whether the presence or absence of cardiovascular surgery affects the long-term prognosis after PCI, emergent and complex elective cases. The SHINANO 5-year registry, a prospective, observational, and multicenter cohort study registry in Nagano, Japan, consecutively included 1665 patients who underwent PCI between August 2012 and July 2013. The procedures were performed at 11 hospitals with onsite cardiac surgery facilities [onsite surgery (+) group; n = 1257] and 8 hospitals without onsite cardiac surgery facilities [onsite surgery (−) group; n = 408]. The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiac and cerebrovascular events [MACCE: all-cause death, Q-wave myocardial infarction, non-fatal stroke, and target lesion revascularization]. The onsite surgery group (+) had a lower rate of emergent PCI and ST-segment elevation myocardial infarction (40.8% vs. 51.7%, p < 0.01 and 24.9% vs. 39.2%, p < 0.01, respectively), and a higher prevalence of hemodialysis and history of peripheral artery disease (7.6% vs. 2.45%, p < 0.01 and 12.1% vs. 6.9%, p < 0.01, respectively). However, the Kaplan–Meier analysis showed no difference in the 5-year mortality rate (16.4% vs. 15.2%, p = 0.421) and MACCE incidence (31.6% vs. 28.9%, p = 0.354) between the groups. Also, there were no differences in the mortality rate and incidence of MACCE among emergent cases of ST-segment elevation myocardial infarction and complex elective cases who underwent PCI. Long-term outcomes of PCI appear to be comparable between institutions with and without onsite cardiac surgical facilities.

New-onset atrial fibrillation in chronic coronary syndrome outpatients: Insights from the international CLARIFY registry

Although the association of atrial fibrillation (AF) and coronary artery disease is a growing public health concern, data in patients with chronic coronary syndrome (CCS) is scarce. We aimed to describe the incidence rate and predictors of new-onset AF in CCS outpatients as well as its association with major adverse cardiovascular events (MACE) using a large-scale registry. The international ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease (CLARIFY), provides real-world data from 32,703 outpatients with CCS from 45 countries. Our analysis included 29,001 patients without prior AF at baseline. Over the median 5-year follow-up, 1453 (5%) had a new-onset AF diagnosed with an annual incidence rate of around 1%. Independent predictors of AF were increased age, treated hypertension, history of peripheral artery disease and an alcohol intake ≥ 1 drink per week. Left ventricular ejection fraction value and a high triglyceride level were independent predictors of lower new-onset AF rate. As rhythmic status was a variable that changed during follow-up, incident AF was included as a time-varying covariate in the Cox regression model. Compared to CCS patients without AF, those with new-onset AF had a higher rate of MACE, including the composite endpoint of cardiovascular death, non-fatal myocardial infarction or non-fatal stroke, hazard ratio (HR) 2.52 (95% CI 2.11-3.01); cardiovascular death, HR 3.22 (2.63-3.94); stroke, HR 2.80 (2.01-3.91); all cause death, HR 2.64 (2.23-3.11); hospitalization for heart failure, HR 9.38 (8.02-10.97); major bleeding, HR 4.33 (2.94-6.39), P < 0.001 for each and myocardial infarction, HR 1.55 (1.08-2.22), P < 0.016 ( Table 1 , Fig. 1 ). New-onset AF is strongly associated with the risk of MACE and should be considered as a prognostic turning point in CCS patients. Many predictors have been identified which presence should lead to broader screening for arrhythmias in CCS patients.

Characteristics of patients with diabetes and a history of myocardial infarction initiating PCSK9 and SGLT2 inhibitors

Study objectiveProprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk for atherosclerotic cardiovascular disease (ASCVD) events in patients with diabetes and ASCVD. We assessed factors associated with initiating either medication among patients with diabetes and a prior myocardial infarction (MI). Setting/participantsUS adults ≥19 years old with private health insurance (MarketScan) or government health insurance (Medicare) who had diabetes and a prior MI and initiated a PCSK9i or an SGLT2i in 2017 or 2018. Main outcome measuresPCSK9i or SGLT2i initiation was identified using pharmacy claims. ResultsOverall, 8102 patients initiated a PCSK9i (n = 1501; 18.5%) or an SGLT2i (n = 6601; 81.5%). Patients with 2 and ≥3 versus 1 prior MI (risk ratio [RR]: 1.32 [95%CI: 1.17–1.48] and 1.68 [1.41–2.01], respectively), prior coronary revascularization (1.47 [1.31–1.64]), prior stroke (1.28 [1.06–1.56]), history of peripheral artery disease (1.27 [1.14–1.41]), receiving cardiologist care (1.51 [1.36–1.67]) or taking ezetimibe (2.57 [2.35–2.82]) were more likely to initiate a PCSK9i versus an SGLT2i. Patients with a history of short-term (RR 1.07 [95%CI 1.05–1.09]) or long-term (1.07 [1.04–1.09]) diabetes complications, and taking a low/moderate- and high-intensity statin dosage (1.61 [1.51–1.70] and 1.68 [1.58–1.77], respectively) were more likely to initiate an SGLT2i versus a PCSK9i. Among patients who initiated a PCSK9i, 2.9% subsequently initiated an SGLT2i; 0.8% who initiated an SGLT2i subsequently initiated a PCSK9i. ConclusionThe decision to initiate PCSK9i or SGLT2i is explained by having very high cardiovascular disease risk for those initiating PCSK9i and diabetes complications for those initiating SGLT2i.

Impact of computed-tomography defined sarcopenia on outcomes of older adults undergoing transcatheter aortic valve implantation

BackgroundThe adoption of Computed tomography (CT)-defined sarcopenia to risk stratify transcatheter aortic valve implantation (TAVI) candidates remains limited by a lack of both standardized definition and evidence of independent value over currently adopted mortality prediction tools. Methods391 consecutive TAVI patients with pre-procedural CT scan were included (81 ​± ​6 years, 57.5% male, STS-PROM score 4.4 ​± ​3.6%) and abdominal muscle retrospectively quantified. The two definitions of radiologic sarcopenia previously adopted in TAVI studies were compared (psoas muscle area [PMA] at the L4 vertebra level: “PMA-sarcopenia”; indexed skeletal muscle area at the L3 vertebra level: “SMI-sarcopenia”). The primary endpoint was longer available-term all-cause mortality. Secondary endpoints were Valve Academic Research Consortium-2-defined in-hospital and 30-day outcomes. ResultsSMI- and PMA-sarcopenia were present in 192 (49.1%) and 117 (29.9%) patients, respectively.After a median of 24 (12–30) months follow-up, 83 (21.2%) patients died. PMA-(adj-HR 1.81, 95%CI 1.12–2.93, p ​= ​0.015), but not SMI-sarcopenia (adj-HR 1.23, 95%CI 0.76–2.00, p ​= ​0.391), was associated with all-cause mortality independently of age, sex and in-study outcome predictors (atrial fibrillation, hemoglobin, history of peripheral artery disease, cancer and subcutaneous adipose tissue). PMA-defined sarcopenia provided additive prognostic value over current post-TAVI mortality risk estimators including STS-PROM (p ​= ​0.001), Euroscore II (p ​= ​0.025), Charlson index (p ​= ​0.025) and TAVI2-score (p ​= ​0.020). Device success, early safety, clinical efficacy and 30-day all-cause death were unaffected by sarcopenia status regardless of definition. ConclusionsPMA-sarcopenia (but not SMI-sarcopenia) is predictive of 2 year mortality among TAVI patients. The prognostic information provided by PMA-sarcopenia is independent of the tools currently adopted to predict post-TAVI mortality in clinical practice.

Outcomes of Combined Transcatheter Aortic Valve Replacement and Peripheral Vascular Intervention in the United States.

The aim of this study was to compare the prevalence and real-world outcomes of patients who require peripheral vascular intervention during the same hospitalization as transcatheter aortic valve replacement (TAVR) compared with TAVR alone. There are limited data on the prevalence and outcomes of combined TAVR and percutaneous peripheral vascular intervention. All patients who underwent TAVR in 2016 and 2017 were identified using the Nationwide Readmissions Database. Outcomes of patients undergoing TAVR alone were compared with those of patients undergoing combined TAVR and peripheral intervention, TAVR and peripheral intervention with and without a history of peripheral artery disease, and alternative-access TAVR with transfemoral TAVR in individuals undergoing peripheral intervention. The primary outcome was in-hospital mortality. A total of 99,654 hospitalizations were identified, among which 4,397 patients (4.42%) underwent peripheral intervention during the same admission as TAVR. Patients who required peripheral intervention had increased mortality (4.2% vs 1.5%; P< 0.001), stroke (3.5% vs 1.8%; P< 0.001), acute kidney injury (17.6% vs 10.8%; P< 0.001), blood transfusion (16.0% vs 11.3%; P< 0.001), 30-day readmission (16.3% vs 12.1%; P< 0.001), median length of stay (4days [IQR: 2-8days] vs 3days [IQR: 2-5days]; P< 0.001), and hospitalization charges. Compared with patients undergoing peripheral intervention to facilitate transfemoral TAVR, alternative-access TAVR was associated with increased mortality (4.6% vs 3.0%; P=0.036), acute kidney injury (22.7% vs 14.3%; P< 0.001), median length of stay (5days [IQR: 3-10days] vs 4days [IQR: 2-7days]; P< 0.001), and 30-day readmission (18.1% vs 15.5%; P=0.012). Peripheral vascular intervention may be used to facilitate transfemoral access or as a bailout for vascular complications during TAVR. Combined TAVR and peripheral intervention is associated with an increased risk for adverse events, though outcomes are better compared with alternative-access TAVR using a nonfemoral approach.