In-hospital Myocardial Infarction Research Articles

Outcomes of pericardial complications among patients with solid and liquid cancer: Analysis of National Inpatient Sample database.

e23073 Background: Pericardial complications (PC) are common in malignancy as sequelae of metastasis, direct toxicity of radiation or chemotherapy, or pericardial infection/inflammation due to malignancy. The goal of this study was to assess the cardiovascular outcomes of pericardial complications among patients with solid and liquid cancer. Methods: The National Inpatient Sample from the years 2015 to 2018 was queried to assess cardiovascular outcomes in the setting of pericardial complications (acute pericarditis, chronic constrictive pericarditis, chronic adhesive pericarditis, hemopericardium, cardiac tamponade and other unspecified pericarditis) for patients that have any solid or liquid malignancy. Outcomes included in-hospital mortality, acute kidney injury (AKI), heart failure (HF), cardiogenic shock (CS), myocardial infarction (MI), sudden cardiac arrest (SCA), mechanical circulatory support (MCS), major adverse cardiovascular and cerebrovascular events (MACCE), and stroke. Outcomes were assessed using chi-square analysis using STATA. Results: A total of 1,183,619 cancer patients with PC (n = 20,410.00; 1.7%) and without PC (n = 1,163,209.60; 98.3%) were included. The mean age of patients with and without PC was 58 and 59 years, respectively. The average length of stay in the hospital was 14 and eight days in patients with and without PC, respectively. The most common complications were electrolyte disorders (51.2%, p = 0.000) and arrhythmias (40.4 %, p = 0.000) for patients with and without PC. Patients with PC had higher incidence of in-hospital mortality (11.7% vs 5.1%, p = 0.000), AKI (37.8% vs 22.1%, p = 0.000), HF (25.7% vs 15.5%, p = 0.000), CS (2.7% vs 0.4%, p = 0.000), MI (3.6% vs 2.0%, p = 0.000), SCA (3.2% vs 1.0%, p = 0.000), MCS (0.7% vs 0.1%, p = 0.000), and MACCE (17% vs 7.9%, p = 0.000) compared to cancer patients without PC. There was no difference in outcomes in terms of stroke (1.2% vs 1.2%, p = 0.879). The yearly trend was stable for length of stay among both groups while adjusted total hospital cost was progressively increasing from 2015 to 2018, with a greater net increase in those with PC. Yearly trends of complications were stable among both cohorts. Conclusions: Pericardial complications are prevalent in up to 1.7% of cancer patients, and they are associated with worse cardiovascular outcomes as compared to patients without pericardial complications. Patients with PC also have a higher incidence of in-hospital mortality.

Safety and Effectiveness of a Novel Microcatheter in Coronary Chronic Total Occlusions—The BIOMICS Study

BackgroundChronic total occlusion (CTO) remains the most complex anatomical subset of lesions in percutaneous coronary intervention (PCI), often requiring advanced techniques and technologies, including the use of microcatheters. MethodsThe BIOMICS study is a premarket first-in-human prospective, multicenter, open-label, single-arm trial investigating the safety and efficacy of a novel coronary microcatheter (BioMC, Biosensors International) in 100 patients with symptoms of ischemia undergoing elective CTO-PCI. The primary efficacy end point of the study was device success defined according to the CTO-ARC (Chronic Total Occlusion Academic Research Consortium) criteria namely the ability of the microcatheter to successfully facilitate placement of a guide wire beyond the occluded coronary segment. The primary safety end point was the incidence of in-hospital cardiac death or myocardial infarction at hospital discharge. ResultsHundred patients were recruited between March 2022 and January 2023. The primary efficacy end point was achieved in 75% of patients (95% CI, 65.3%-83.1%; P < .0001 for superiority compared to the prespecified performance goal of 54%). The primary safety end point of in-hospital cardiac death or myocardial infarction was observed in 2% of the patients. There were no study device-related coronary perforations or device failures. ConclusionsThe use of a novel coronary microcatheter during CTO-PCI was associated with a high device success and an excellent safety profile.

The effect of controlled vs uncontrolled hypertension on outcomes of carotid revascularization procedures

BackgroundHypertension (HTN) has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled HTN (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population. MethodsWe studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from the Vascular Quality Initiative. Patients were stratified into two groups: those with cHTN and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure of <130/80 mm Hg. Patients with uHTN had a blood pressure of ≥130/80 mm Hg. Our primary outcomes were in-hospital stroke, death, myocardial infarction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension or HTN, reperfusion syndrome, prolonged length of stay (LOS) (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis. ResultsA total of 34,653 CEA (uHTN, 11,347 [32.7%]), 8199 TFCAS (uHTN, 2307 [28.1%]), and 17,309 TCAR (uHTN, 4990 [28.8%]) patients were included in this study. There was no significant difference in age between patients with cHTN and patients with uHTN for each carotid revascularization procedure. However, compared with patients with cHTN, patients with uHTN had significantly more comorbidities. uHTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR], 1.56; 95% confidence interval [CI], 1.30-1.87; P < .001), TFCAS (aOR, 1.59; 95% CI, 1.21-2.08; P < .001), and TCAR (aOR, 1.39; 95% CI, 1.12-1.73; P = .003) compared with cHTN. Additionally, uHTN was associated with a prolonged LOS after all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR, 1.82; 95% CI, 1.39-2.37; P < .001), in-hospital death (aOR, 3.73; 95% CI, 2.25-6.19; P < .001), reperfusion syndrome (aOR, 6.24; 95% CI, 3.57-10.93; P < .001), and extended LOS (aOR, 1.87; 95% CI, 1.51-2.32; P < .001) compared with CEA. There was no statistically significant difference between the outcomes of TCAR compared with CEA. ConclusionsThe results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with cHTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. Additionally, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be safer interventions. Patients with uTHN with symptomatic carotid disease treated with CEA or TCAR have better outcomes compared with those treated with TFCAS.

Comparison between Invasive Intervention and Conservative Treatment in Patients with In-Hospital Myocardial Infarctions: Results from the Regional Myocardial Infarction Registry of Saxony-Anhalt (RHESA) Study.

Background/Objectives: In-hospital myocardial infarctions (AMIs) are less often treated with invasive intervention, compared to out-of-hospital AMIs. We aimed to identify the determinants of invasive intervention in patients with in-hospital AMIs and assess its association with mortality, compared to conservative treatment. Methods: This was a cross-sectional study of in-hospital AMIs in The Regional Myocardial Infarction Registry of Saxony-Anhalt. Patients' characteristics and outcomes were compared based on the treatment strategy (invasive intervention vs. conservative treatment). Logistic regression was performed to assess the determinants of invasive intervention (vs. conservative treatment) and its association with 30-day mortality. Results: Nearly 67% of the patients (259/386) received invasive intervention, and the rest were treated conservatively. Those who were treated with an invasive intervention were younger and had a lower proportion of chronic heart failure than those treated conservatively. Age > 75 years compared to younger patients, pre-existing heart failure, and higher heart rate upon presentation were associated with lower odds of receiving invasive intervention. Hypertension (OR = 2.86, 95% CI [1.45-5.62]) and STEMI vs. NSTEMI (1.96, [1.10-3.68]) were associated with higher odds of invasive intervention. The adjusted odds of 30-day mortality were lower with invasive intervention compared to conservative treatment (0.25, [0.10-0.67]). Conclusions: One-third of the patients with in-hospital AMIs received conservative treatment. Younger age, absence of heart failure, lower heart rate, hypertension, and STEMI were determinants of invasive intervention usage. Invasive intervention had lower odds of 30-day mortality, but longitudinal studies are still needed to assess the efficacy of conservative vs. invasive strategies in in-hospital AMIs.

Nationwide trends of balloon pulmonary angioplasty and pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (2012-2019).

Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of a pulmonary embolus that occurs in approximately 1%-3% of patients. Pulmonary thromboendoarterectomy (PTE) can be a curative procedure, but balloon pulmonary angioplasty (BPA) has emerged as an option for poor surgical candidates. We used the National Inpatient Sample to query patients who underwent PTE or BPA between 2012 and 2019 with CTEPH. The primary outcome was a composite of in-hospital mortality, myocardial infarction, stroke, tracheostomy, and prolonged mechanical ventilation. Outcomes were compared between low- and high-volume centers, defined as 5 and 10 procedures per year for BPA and PTE, respectively. During our study period, 870 BPA and 2395 PTE were performed. There was a 328% relative increase in the number of PTE performed during the study period. Adverse events for BPA were rare. There was an increase in the primary composite outcome for low-volume centers compared to high-volume centers for PTE (24.4% vs. 12.1%, p = 0.003). Patients with hospitalizations for PTE in low-volume centers were more likely to have prolonged mechanical ventilation (20.0%% vs. 7.2%, p < 0.001) and tracheostomy (7.8% vs. 2.6%, p = 0.017). In summary, PTE rates have been rising over the past 10 years, while BPA rates have remained stable. While adverse outcomes are rare for BPA, patients with hospitalizations at low-volume centers for PTE were more likely to have adverse outcomes. For patients undergoing treatment of CTEPH with BPA or PTE, referral to high-volume centers with multidisciplinary teams should be encouraged for optimal outcomes.

Safety of Perioperative Maintenance of Antiplatelet Agents in Elderly Patients Undergoing Lung Cancer Surgery.

The maintenance of antiplatelet therapy increases the risk of bleeding during lung cancer surgery. Conversely, the perioperative interruption of antiplatelet therapy may result in serious thrombotic complications. This study aimed to investigate the safety of continuing antiplatelet therapy in the context of lung cancer surgery. We retrospectively reviewed a cohort of 498 elderly patients who underwent surgery for lung cancer. These patients were categorized into 2 groups: group N, which did not receive antiplatelet therapy, and group A, which did. Group A was subsequently subdivided into group Am, where antiplatelet therapy was maintained, and group Ai, where antiplatelet therapy was interrupted. We compared the incidence of bleeding-related and thrombotic complications across the 3 groups. There were 387 patients in group N and 101 patients in group A (Ai: 70, Am: 31). No significant differences were found in intraoperative blood loss, thoracotomy conversion rates, transfusion requirements, volume of chest tube drainage, or reoperation rates for bleeding control between groups N and A or between groups Am and Ai. The duration of hospital stay was longer for group A compared to group N (7 days vs. 6 days, p=0.005), but there was no significant difference between groups Ai and Am. The incidence of cardiovascular or cerebrovascular complications did not differ significantly between groups Ai and Am. However, group Ai included a severe case of in-hospital ST-elevation myocardial infarction. The maintenance of antiplatelet therapy was found to be safe in terms of perioperative bleeding and thrombotic complications in elderly lung cancer surgery patients.

Annual operator volume and procedural outcomes of chronic total occlusions treated with percutaneous coronary interventions: analysis based on 14,899 patients.

Low operator and institutional volume is associated with poorer procedural and long-term clinical outcomes in patients treated with percutaneous coronary interventions (PCI). This study was aimed at evaluating the relationship between operator volume and procedural outcomes of patients treated with PCI for chronic total occlusion (CTO). Data were obtained from the national registry of percutaneous coronary interventions (ORPKI) collected from January 2014 to December 2020. The primary endpoint was a procedural success, defined as restoration of thrombolysis in myocardial infarction (TIMI) II/III flow without in-hospital cardiac death and myocardial infarction, whereas secondary endpoints included periprocedural complications. Data of 14,899 CTO-PCIs were analyzed. The global procedural success was 66.1%. There was a direct relationship between the annual volume of CTO-PCIs per operator and the procedural success (OR: 1.006 [95% CI: 1.003-1.009]; P<0.001). The nonlinear relationships of annualized CTO-PCI volume per operator and adjusted outcome rates revealed that operators performing 40 CTO cases per year had the best procedural outcomes in terms of technical success (TIMI flow II/III after PCI), coronary artery perforation rate and any periprocedural complications rate (P<0.0001). Among the other factors associated with procedural success, the following can be noted: multi-vessel, left main coronary artery disease (as compared to single-vessel disease), the usage of rotablation as well as PCI within bifurcation. High-volume CTO operators achieve greater procedural success with a lower frequency of periprocedural complications. Higher annual caseload might increase the overall quality of CTO-PCI.

Impact of acute silent ischemic lesions on clinical outcomes of carotid revascularization.

Previous literature has established an association between acute silent ischemic lesions (ASILs) and elevated susceptibility to future adverse clinical outcomes. The present study endeavors to scrutinize the prognostic significance of preprocedural ASILs, as detected through diffusion-weighted imaging and apparent diffusion coefficient metrics, in relation to subsequent adverse events-namely, stroke, myocardial infarction, and all-cause death-following carotid revascularization in a cohort of patients with symptomatic carotid stenosis. Subjects were extracted from a comprehensive retrospective dataset involving symptomatic carotid stenosis cases that underwent carotid revascularization at a tertiary healthcare institution in China, spanning January 2019 to March 2022. Of the 2663 initially screened patients (symptomatic carotid stenosis=1600; asymptomatic carotid stenosis=1063), a total of 1172 individuals with symptomatic carotid stenosis were retained for subsequent analysis. Stratification was implemented based on the presence or absence of ASILs. The primary endpoint constituted a composite measure of in-hospital stroke, myocardial infarction, or all-cause death. Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) treatment modalities were individually subjected to propensity score-matched analyses. Among the 584 subjects who underwent CEA, 91 ASIL-positive and 91 ASIL-negative (NASIL) cases were propensity score-matched. Notably, the ASIL cohort demonstrated a statistically significant augmentation in the risk of primary outcomes relative to the NASIL group [10.99 vs. 1.10%; absolute risk difference, 9.89% (95% CI: 3.12-16.66%); RR, 10.00 (95% CI: 1.31-76.52); P =0.01]. Similarly, within the 588 CAS-treated patients, 107 ASIL-positive and 107 NASIL cases were matched, revealing a correspondingly elevated risk of primary outcomes in the ASIL group [9.35 vs. 1.87%; absolute risk difference, 7.48% (95% CI: 1.39-13.56%); RR, 5.00 (95% CI: 1.12-22.28); P =0.02]. ASILs portend an elevated risk for grave adverse events postcarotid revascularization, irrespective of the specific revascularization technique employed-be it CEA or CAS. Thus, ASILs may serve as a potent biomarker for procedural risk stratification in the context of carotid revascularization.

Impact of Magnesium on In-Hospital Ami Outcomes in Bangladesh.

Background: Coronary artery disease (CAD) is a major cause of death globally. Bangladesh has a high prevalence of CAD, especially in urban areas. Acute myocardial infarction (AMI) is a serious condition that occurs when there’s a blockage in the coronary arteries. Electrolyte imbalances, such as magnesium deficiency, can worsen AMI. Objectives: To evaluate the association between serums magnesium level on in-hospital acute myocardial infarction outcomes. Study Design and Methods: This prospective study recruited 110 patients diagnosed with AMI in Dhaka, Bangladesh. Researchers measured serum magnesium levels, monitored patients, and recorded clinical outcomes. Results: The study found that patients with lower magnesium levels were more likely to experience complications such as arrhythmias, cardiogenic shock, and left ventricular dysfunction. Conclusion: The study highlights the importance of monitoring magnesium levels in AMI patients. However, more research is needed to determine the optimal magnesium level and its impact on patient outcomes.

Implementing a comprehensive STEMI protocol to improve care metrics and outcomes in patients with in-hospital STEMI: an observational cohort study

BackgroundPatients who experience in-hospital ST-segment elevation myocardial infarction (iSTEMI) represent a uniquely high-risk cohort owing to delays in diagnosis, prolonged time to reperfusion and increased mortality. Quality initiatives aimed at...

Prevalence and outcomes of acute coronary syndrome patients with and without standard modifiable risk factors undergoing percutaneous coronary intervention

Abstract Background Prevention strategies in acute coronary syndrome (ACS) have focused on patients with standard modifiable risk factors (SMuRFs; diabetes, hypercholesterolaemia, hypertension, and current smoking). There is increasing awareness that SMuRF-less patients may represent a unique subset of patients experiencing ACS. Purpose To investigate the prevalence, characteristics, and outcomes of SMuRF-less ACS patients compared to those with SMuRFs undergoing percutaneous coronary intervention (PCI) in a major city in Australia. Methods We analysed data from adult (≥18 years) ACS patients receiving PCI between 2005 and 2020 using a PCI Registry which contains data for all patients undergoing coronary intervention at one of six major hospitals. Patients with a known history of coronary artery disease were excluded. Overall clinical characteristics and outcomes for those with and without SMuRFs were examined. The primary outcome was 30-day all-cause mortality. Secondary outcomes included in-hospital outcomes, myocardial infarction (MI), revascularisation, and major adverse cardiovascular and cerebrovascular (MACCE) events at 30 days. Long-term mortality was investigated using Cox-proportional hazards regression. Results From 1 January 2005 to 31 December 2020, 2,727 (14.4%) of 18,988 patients were SMuRF-less. Mean (± standard deviation [SD]) age was similar between patients with and without SMuRFs (63±13 vs 63±12 years) and there were more females with SMuRFs (25% vs 20%, p&amp;lt;0.001). SMuRF-less patients were less likely to have a history of cerebrovascular disease (1.2% vs 4.2%, p&amp;lt;0.001), peripheral vascular disease (0.6% vs 3.0%, p&amp;lt;0.001), and chronic lung disease (8.6% vs 10.1%, p=0.014). They were more likely to present with out-of-hospital cardiac arrest (6.6% vs 3.9%, p&amp;lt;0.001) and ST-elevation MI (59% vs 51%, p&amp;lt;0.001). The left anterior descending artery was the target lesion in 46% of SMuRF-less patients compared to 39% of those with SMuRFs. During hospital stay, SMuRF-less patients were more likely to experience post-procedural cardiogenic shock (4.5% vs 3.6%, p=0.019) and arrhythmia (11.2% vs 9.9%, p=0.029). At 30 days, all-cause mortality did not differ between those with and without SMuRFs (3.2% vs 3.6%, p=0.290). Similarly, there were no differences in 30-day MI, revascularisation, and MACCE. During mean follow-up of approximately 7 years, being SMuRF-less was associated with a 12% decreased rate of mortality (adjusted Hazard Ratio 0.88 [95% confidence interval 0.78, 0.99], p=0.035). Conclusions Despite differences in characteristics (rates of cardiac arrest and ST-elevation MI), no difference in 30-day outcomes was observed among those with and without SMuRFs. However, SMuRF-less patients had lower hazard for long-term mortality. These findings suggest SMuRF-less patients may have novel risk factors and improved long-term outcome warranting further research.

Impact of the COVID-19 Pandemic on Infective Endocarditis Management and Outcomes: Analysis of a National Clinical Database

COVID-19 has widely affected health care delivery, but its impact on the management of infective endocarditis (IE), including valve surgery, is uncertain. We compared the national trends in admissions, demographics, and outcomes of IE before and after COVID-19 onset, using a national sample of IE admissions between 2016 and 2022 from the Vizient Clinical Database. The pre-COVID-19 and post-COVID-19 time periods were separated by the start of the second quarter of 2020, the time during which the COVID-19 pandemic was declared. For all admissions and for admissions involving valve surgery, pre-COVID-19 versus post-COVID-19 baseline characteristics and outcomes were compared using 2-sample t tests or chi-square tests. Propensity score-matched cohorts were similarly compared. Before COVID-19, there were 82,867 overall and 11,337 valve-related surgical admissions, and after COVID-19, there were 45,672 overall and 6,322 valve-related surgical admissions. In the matched analysis for all admissions, the in-hospital mortality increased from 11.4% to 12.4% after COVID-19 onset (p <0.001); in-hospital stroke (4.9% vs 6.0%, p <0.001), myocardial infarction (1.3% vs 1.4%, p=0.03), and aspiration pneumonia (1.8% vs 2.4%, p <0.001) also increased, whereas other complications remained stable. In the matched analysis of surgical admissions, there was decreased in-hospital mortality (7.7% vs 6.7%, p=0.03) and intensive care unit stay (8.5 ± 12.5 vs 8.0 ± 12.6 days, p=0.04); other outcomes remained stable. In conclusion, patients admitted with IE after COVID-19 were more medically complex with worsened outcomes and mortality, whereas patients who underwent valve surgery had stable outcomes and improved mortality despite the pandemic.

Association of stroke or death with severity of carotid lesion calcification in patients undergoing carotid artery stenting

ObjectiveCarotid artery stenting (CAS) for heavily calcified lesions is controversial due to concern for stent failure and increased perioperative stroke risk. However, the degree to which calcification affects outcomes is poorly understood, particularly in transcarotid artery revascularization (TCAR). With the precipitous increase in TCAR use and its expansion to standard surgical-risk patients, we aimed to determine the impact of lesion calcification on CAS outcomes to ensure its safe and appropriate use. MethodsWe identified patients in the Vascular Quality Initiative who underwent first-time transfemoral CAS (tfCAS) and TCAR between 2016 and 2021. Patients were stratified into groups based on degree of lesion calcification: no calcification, 1% to 50% calcification, 51% to 99% calcification, and 100% circumferential calcification or intraluminal protrusion. Outcomes included in-hospital and 1-year composite stroke/death, as well as individual stroke, death, and myocardial infarction outcomes. Logistic regression was used to evaluate associations between degree of calcification and these outcomes. ResultsAmong 21,860 patients undergoing CAS, 28% patients had no calcification, 34% had 1% to 50% calcification, 35% had 51% to 99% calcification, and 3% had 100% circumferential calcification/protrusion. Patients with 51% to 99% and circumferential calcification/protrusion had higher odds of in-hospital stroke/death (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.02-1.6; P = .034; OR, 1.9; 95% CI, 1.1-2.9; P = .004, respectively) compared with those with no calcification. Circumferential calcification was also associated with increased risk for in-hospital myocardial infarction (OR, 3.5; 95% CI, 1.5-8.0; P = .003). In tfCAS patients, only circumferential calcification/protrusion was associated with higher in-hospital stroke/death odds (OR, 2.0; 95% CI, 1.2-3.4; P = .013), whereas for TCAR patients, 51% to 99% calcification was associated with increased odds of in-hospital stroke/death (OR, 1.5; 95% CI, 1.1-2.2; P = .025). At 1 year, circumferential calcification/protrusion was associated with higher odds of ipsilateral stroke/death (12.4% vs 6.6%; hazard ratio, 1.64; P = .002). ConclusionsAmong patients undergoing CAS, there is an increased risk of in-hospital stroke/death for lesions with >50% calcification or circumferential/protruding plaques. Increasing severity of carotid lesion calcification is a significant risk factor for stroke/death in patients undergoing CAS, regardless of approach.

Comparison between In-Hospital and Out-of-Hospital Acute Myocardial Infarctions: Results from the Regional Myocardial Infarction Registry of Saxony-Anhalt (RHESA) Study.

Risk factors and outcomes of in-hospital ST elevation myocardial infraction (STEMI) are well explored. Recent findings show that non-ST elevation myocardial infarction (NSTEMI) accounts for the majority of in-hospital infarctions (IHMIs). Our aim was to identify differences between IHMI and out-of-hospital myocardial infraction (OHMI) in terms of risk factors, treatment and outcomes, including both STEMI and NSTEMI. We analyzed the Regional Myocardial Infarction Registry of Saxony-Anhalt dataset. Patient characteristics, treatments and outcomes were compared between IHMI and OHMI. The association between clinical outcomes and myocardial infarction type was assessed using generalized additive models. Overall, 11.4% of the included myocardial infractions were IHMI, and the majority were NSTEMI. Patients with IHMI were older and had more comorbidities than those with OHMI. Compared to OHMI, in-hospital myocardial infarction was associated with higher odds of 30-day mortality (OR = 1.85, 95% CI 1.32-2.59) and complications (OR = 2.36, 95 % CI 1.84-3.01). We provided insights on the full spectrum of IHMI, in both of its classifications. The proportion of IHMI was one ninth of all AMI cases treated in the hospital. Previously reported differences in the baseline characteristics and treatments, as well as worse clinical outcomes, in in-hospital STEMI compared to out-of-hospital STEMI persist even when including NSTEMI cases.

Pre-hospital and in-hospital ST-elevation myocardial infarction from 2008 to 2020 in Australia

Pre-hospital and in-hospital ST-elevation myocardial infarction from 2008 to 2020 in Australia

Antegrade versus Retrograde Approach for Recanalization of Ostial or Stumpless Coronary Chronic Total Occlusion.

This research aimed to evaluate the procedural and in-hospital clinical outcomes of percutaneous coronary intervention (PCI) for ostial or stumpless chronic total occlusion (CTO) utilizing both the antegrade-only and retrograde approaches. A comprehensive retrospective examination was conducted on the procedural and in-hospital clinical outcomes of 89 consecutive patients subjected to ostial or stumpless CTO PCI at our institution between April 2015 and October 2022. The antegrade-only technique demonstrated a superior technical success rate (92.0% vs 71.9%, p = 0.041) and procedural success rate (92.0% vs 68.8%, p = 0.022) in comparison to the retrograde approach (RA). The RA group presented a notably elevated Japanese-CTO (J-CTO) score relative to the antegrade-only approach group (2.45±0.73 vs 1.64±0.70, p < 0.001). The antegrade-only approach group manifested an increased frequency of microchannels at the proximal stump relative to the RA group (56.0% vs 10.9%, p < 0.001). In-hospital major adverse cardiac events (MACE) and in-hospital myocardial infarction (MI) were observed more prevalently in the RA group (18.8% vs 0, p = 0.003; 15.6% vs 0, p = 0.008; respectively). A J-CTO score below 2 and the manifestation of microchannels at the proximal stump were identified as predictors for successful antegrade-only approach PCI for ostial or stumpless CTO (OR: 2.79 [95% CI: 1.92-5.03, P =0.003]; OR: 2.89 [95% CI: 1.32-6.03, P =0.001]; respectively). Relative to RA PCI for ostial or stumpless CTO, the antegrade-only approach is utilized for less complex CTO lesions and is associated with a diminished probability of in-hospital MACE.

Sex Differences in the Diagnosis, Management, and Outcomes of Suspected Non-ST-Elevation Acute Coronary Syndromes Meeting Rapid Rule-Out Criteria.

(1) Background: patients who meet current rapid rule-out criteria for myocardial infarction (MI) are considered low risk, yet their management remains nebulous, especially among women. We aimed to examine sex differences in the diagnosis, management, and outcomes of patients meeting the rapid rule-out criteria. (2) Methods: by simulating application of the rapid rule-out MI criteria, we analyzed consecutively triaged men and women with suspected NSTE-ACS who had high-sensitivity cardiac troponin T (hs-cTnT) values that met criteria (n = 11,477), in particular, those who were admitted (n = 3775). (3) Results: men constituted ~55% of triaged patients who met the rule-out criteria, whether admitted or discharged. Men were more likely to be admitted (33.7% vs. 31.9%, p = 0.04), more commonly with hs-cTnT values between level of detection (LOD, 5 ng/ml) and the 99th percentile (59.4% of all admissions vs. 40.5% for women), whereas women were more likely to be admitted with values < level of blank (LOB, 3 ng/mL; 22.9% vs. 9.2% for men). Thirty-day mortality (1 man and 1 woman) and in-hospital MI (9 men vs. 1 woman) were uncommon among admitted patients, yet resource utilization during 3-4 hospitalization days was substantial for both sexes, with men undergoing coronary angiography (6.8% vs. 2.9%) and revascularization (3.4% vs. 1.1%) more commonly. Long-term survival for both men and women, whether admitted or discharged, was significantly worse for hs-cTnT values between LOD and the 99th percentile, even after adjusting for age and cardiovascular comorbidities. (4) Conclusions: reporting actual hs-cTnT values < 99th percentile allows for better risk stratification, especially for women, possibly closing the sex gap.

Increased Preoperative Stress Test Utilization is Not Associated With Reduced Adverse Cardiac Events in Current US Surgical Practice.

To measure the frequency of preoperative stress testing and its association with perioperative cardiac events. There is persistent variation in preoperative stress testing across the United States. It remains unclear whether more testing is associated with reduced perioperative cardiac events. We used the Vizient Clinical Data Base to study patients who underwent 1 of 8 elective major surgical procedures (general, vascular, or oncologic) from 2015 to 2019. We grouped centers into quintiles by frequency of stress test use. We computed a modified revised cardiac risk index (mRCRI) score for included patients. Outcomes included in-hospital major adverse cardiac events (MACEs), myocardial infarction (MI), and cost, which we compared across quintiles of stress test use. We identified 185,612 patients from 133 centers. The mean age was 61.7 (±14.2) years, 47.5% were female, and 79.4% were White. Stress testing was performed in 9.2% of patients undergoing surgery, and varied from 1.7% at lowest quintile centers, to 22.5% at highest quintile centers, despite similar mRCRI comorbidity scores (mRCRI>1: 15.0% vs 15.8%; P =0.068). In-hospital MACE was less frequent among lowest versus highest quintile centers (8.2% vs 9.4%; P <0.001) despite a 13-fold difference in stress test use. Event rates were similar for MI (0.5% vs 0.5%; P =0.737). Mean added cost for stress testing per 1000 patients who underwent surgery was $26,996 at lowest quintile centers versus $357,300 at highest quintile centers. There is substantial variation in preoperative stress testing across the United States despite similar patient risk profiles. Increased testing was not associated with reduced perioperative MACE or MI. These data suggest that more selective stress testing may be an opportunity for cost savings through a reduction of unnecessary tests.

The Impact of Preprocedural Statin Use on Acute Kidney Injury and Mortality in Patients Undergoing Peripheral Vascular Intervention

Current evidence suggests that statins may be protective against acute kidney injury (AKI) following angiography. We sought to assess the effect of statin use on outcomes following peripheral vascular intervention (PVI). We identified all patients undergoing PVI in the Vascular Quality Initiative (VQI) from 2003 to 2020 and excluded patients with history of dialysis or prior renal transplant. We compared postintervention outcomes in patients who were on preoperative statin medications to those who were not on a statin prior to PVI. Outcomes of interest were in-hospital AKI, myocardial infarction (MI), and in-hospital and 30-day mortality, assessed by multivariable logistic regression. Outcomes were also stratified by pre-existing chronic kidney disease (glomerular filtration rate [GFR] <60 and ≥60 mL/min/1.73m2). Among 110,266 patients, 81,807 (74%) were on preoperative statins and 28,459 (26%) were not. Patients receiving statins had lower rates of post-procedure AKI compared with those not taking statins (0.93% vs 1.1%; odds ratio [OR], 0.85; 95% confidence interval [CI], 0.74-0.97), as well as lower rates of in-hospital mortality (0.56% vs 1.0%; OR, 0.54; 95% CI, 0.47-0.63) and 30-day mortality (1.3% vs 2.4%; OR, 0.55; 95% CI, 0.49-0.61). After adjustment, statin use was associated with lower odds of AKI (adjusted OR [aOR], 0.79; 95% CI, 0.63-0.99), in-hospital MI (aOR, 0.65; 95% CI, 0.44-0.97), in-hospital mortality (aOR, 0.58; 95% CI, 0.43-0.78), and 30-day mortality (aOR, 0.68; 95% CI, 0.54-0.86). After stratifying by preoperative renal function, there was no association between statin usage and AKI in patients with normal GFR ≥60 mL/min/1.73m2 (aOR, 1.14; 95% CI, 0.20-6.31). However, in patients with GFR <60 mL/min/1.73m2, statin use was associated with 22% lower odds of developing AKI after PVI (aOR, 0.78; 95% CI, 0.62-0.98), as well as lower odds of in-hospital MI (aOR, 0.63; 95% CI, 0.42-0.95), in-hospital mortality (aOR, 0.56; 95% CI, 0.42-0.76), and 30-day mortality (aOR, 0.69; 95% CI, 0.54-0.87) (Table I). Pre-procedural statin use is associated with lower incidence of AKI following PVI, as well as lower in-hospital MI, in-hospital mortality, and 30-day mortality rates, particularly in patients with pre-existing renal dysfunction. Statins should be considered for renal protection prior to PVI, in addition to the current strategies of pre-hydration and minimization of contrast usage. Despite current guidelines and evidence of clinical benefits, statins continue to be significantly underused in the vascular population. Additional work is needed to improve the adoption of statins in patients with peripheral vascular disease.TableAdjusted odds ratios (aORs) for outcomes following peripheral vascular intervention (PVI) in patients on statins vs patients not on statins as reference groupEndpointPrimary cohort (N = 110,266)GFR ≥60 mL/min/1.73m2 (n = 70,752)GFR <60 mL/min/1.73m2 (n = 39,514)aOR [95% CI]P-valueaOR [95% CI]P-valueaOR [95% CI]P-valueIn-hospitalAKI0.79 [0.63-0.99].0450.14 [0.20-6.31].8830.78 [0.61-0.98].037In-hospitalMI0.65 [0.44-0.98].0380.81 [0.04-18.57].8960.63 [0.42-0.95].028In-hospital mortality0.58 [0.43-0.78]<.001a–0.56 [0.42-0.76]<.00130-day mortality0.68 [0.54-0.86].0010.04 [0.02-0.72]a.0290.69 [1.92-1.23].001AKI, Acute kidney injury; CI, confidence interval; GFR, glomular filtration rate; MI, myocardial infarction.All models adjusted for age, sex, race/ethnicity, smoking status, chrnic obstructive pulmonary disease, hypertension, diabetes, coronary artery disease, congestive heart failure, preoperative medications (aspirin, P2Y12 inhibitor, anticoagulation), procedure urgency, disease severity, contrast volume used, use of CO2 contrast, and use of contrast-induced nephritis prophylaxis; GFR was also included in the primary model.Boldface P-values indicate statistical significance.aAll in-hospital deaths occurred in patients not on statins in the normal GFR subgroup. Open table in a new tab

Transcarotid Revascularization Outcomes Are Not Affected by the Choice of Antiplatelet with Aspirin

Over one-third of transcarotid revascularization (TCAR) patients demonstrate mild to severe resistance to clopidogrel resulting in an increase in hematologic testing and potential healthcare costs. This investigation was completed to determine if the choice of the second antiplatelet in addition to aspirin affected perioperative outcomes. Consecutive carotid stenting procedures identified from the Vascular Quality Initiative (VQI) from January 2016 to September 2016 were captured. We excluded patients with nonatherosclerotic disease, intracranial disease, and tandem lesions. Two cohorts of patients maintained on dual antiplatelet therapy were compared consisting of aspirin + clopidogrel (AC) and aspirin + prasugrel/ticagrelor (APT). A 1:1 propensity score match including procedure characteristics, age, gender, race, symptomatic status, diabetes, coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, chronic obstructive pulmonary disease, dialysis, smoking status, prior ipsilateral or contralateral coronary artery stenting/carotid endarterectomy, contralateral occlusion, preoperative anticoagulation, urgency, protamine use, and physician case volume was completed to compare perioperative results. Within the specified study period, we captured 38,813 carotid stenting patients on AC and 2346 patients maintained on APT (Table I). Of the AC patients, 25,293 received TCAR while the remaining 13,520 underwent transfemoral stenting. Similarly, 1308 APT patients underwent TCAR and 1038 received transfemoral stenting. Before propensity matching, the crude results noted that APT patients were more likely to experience in-hospital mortality (0.5% vs 1.1%; P < .01), but there was no difference in ipsilateral stroke (1.2% vs 1.1%; P = .62), any stroke (1.5% vs 1.4%; P = .84), or myocardial infarction (MI) (0.5% vs 0.7%; P = .31). After adjustment with our propensity match (Table II), 2047 unique subject pairs were generated. There was no statistical difference with respect to in-hospital mortality (0.6% vs 0.9%; P = .30), ipsilateral stroke (1.4% vs 1.0%; P = .41), any stroke (1.5% vs 1.3%; P = .85), MI (0.8% vs 0.8%; P = .84), or stent thrombosis (0.1% vs 0.3%; P = .18). Additionally, there was no difference in the combined outcomes of stroke/death (1.9% vs 2.0%; P = .63) or stroke/death/MI (2.6% vs 2.7%; P = .74). As testing for antiplatelet resistance has become more prominent in the last several years, we evaluated and noted no variability between study groups before or after a procedure date in 2019. No difference in perioperative stroke, death, and/or stent occlusion are noted after TCAR in patients maintained on AC compared to APT. Therefore, routine testing for clopidogrel resistance is an unnecessary healthcare cost which can be eliminated.Table IACAPTP valuen = 38,813 (94.3)2346 (5.7)Prasugrel346 (14.75)Ticagrelor2000 (85.2)Procedure<.001 Transcarotid artery revascularization25,293 (65.2)1308 (55.7) Transfemoral carotid artery stenting13,520 (34.8)1038 (44.3)Surgery year<.001 2016706 (1.8)37 (1.6) 20173044 (7.8)139 (5.9) 20184666 (12.0)199 (9.5) 20197066 (18.2)379 (16.2) 20207560 (19.5)457 (19.5) 20219836 (25.3)716 (30.5) September 20225935 (15.3)419 (17.9)AC, Aspirin + clopidogrel; APT, aspirin + prasugrel/ticagrelor. Open table in a new tab Table IIBefore PSM (crude outcomes)1:1 PSM (adjusted outcomes)aACAPTP valueACAPTOR (95% CI)bP valuen = 38,813 (94.3)2346 (5.7)n = 2047n = 2047In-hospital outcomes Death204 (0.5)25 (1.1)<0.0113 (0.6)19 (0.9)1.49 (0.70-3.18).30 Ipsilateral stroke457 (1.2)25 (1.1)0.6229 (1.4)21 (1.0)0.77 (0.42-1.43).41 Stroke549 (1.45)32 (1.40)0.8430 (1.5)27 (1.3)0.94 (0.53-1.67).85 MI204 (0.5)16 (0.7)0.3117 (0.8)16 (0.8)0.93 (0.45-1.91).84 Stroke/death680 (1.8)50 (2.1)0.1838 (1.9)41 (2.0)1.13 (0.69-1.83).63 Stroke/death/MI844 (2.2)65 (2.8)0.0653 (2.6)56 (2.7)1.08 (0.70-1.65).74 Bleeding requiring intervention229 (0.6)15 (0.6)0.7611 (0.5)14 (0.7)1.28 (0.56-2.84).54 Immediate restenosis/occlusion63 (0.2)7 (0.3)0.122 (0.1)6 (0.3)3.0 (0.60-14.8).18AC, Aspirin + clopidogrel; APT, aspirin + prasugrel/ticagrelor; CI, confidence interval; MI, myocardial infarction; OR, odds ratio; PSM, propensity score matching.Values are number (%) unless otherwise stated.aNo interaction between antiplatelet regimen and type of procedure in predicting outcome and between antiplatelet regimen and surgeries performed before or after 2019 (P > .10). Open table in a new tab