National Cardiovascular Data Registry Research Articles

Real-world experience utilizing the nuvision 4D intracardiac echocardiography catheter for left atrial appendage closure

Transesophageal echocardiography (TEE) has been the preferred imaging modality to help guide left atrial appendage closure. Newer technologies such as the Nuvision 4D Intracardiac echocardiography (ICE) catheter allow for real-time 3D imaging of cardiac anatomy. There are no direct comparison studies for procedural imaging between TEE and 4D ICE. To evaluate the performance and safety of left atrial appendage (LAA) closure procedures with the Watchman FLX and Amulet, guided by the Nuvision 4D ICE Catheter. This retrospective observational analysis was conducted on institutional LAAO National Cardiovascular Data Registry from January 2022 to March 2023. Patients had undergone LAA closure procedures with the Watchman FLX or Amulet device guided by TEE or a 4D ICE Catheter. The primary outcome evaluated was successful LAAO device placement. A total of 121 patients underwent LAAO device placement with 46 (38.0%) patients guided by 4D ICE during LAAO implantation. The 4D ICE group had a shorter procedural time compared with TEE guidance. Post procedural 45-day TEE post implant was also comparable for both groups with no patients in either group having incomplete closure of the left atrial appendage and peri-device leak > 5 mm. No device related complications (device related access, stroke, or pericardial effusion) occurred in either group at follow-up. There was no significant difference in device implant success or post procedural outcomes at 45 days in either the TEE or 4D ICE group. However, there was a noticeable improvement in procedural time with the 4D ICE catheter.

Ventricular Arrhythmias After Primary Percutaneous Coronary Intervention for STEMI

Currently, mortality risk for patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) with an uncomplicated postprocedure course is low. Less is known regarding the risk of in-hospital ventricular tachycardia (VT) and ventricular fibrillation (VF). To evaluate the risk of late VT and VF after primary PCI for STEMI. This cohort study included adults aged 18 years or older with STEMI treated with primary PCI between January 1, 2015, and December 31, 2018, identified in the US National Cardiovascular Data Registry Chest Pain-MI Registry. Data were analyzed from April to December 2020. Multivariable logistic regression was used to evaluate the risk of late VT (≥7 beat run of VT during STEMI hospitalization ≥1 day after PCI) or VF (any episode of VF≥1 day after PCI) associated with cardiac arrest and associations between late VT or VF and in-hospital mortality in the overall cohort and a cohort with uncomplicated STEMI without prior myocardial infarction or heart failure, systolic blood pressure less than 90 mm Hg, cardiogenic shock, cardiac arrest, reinfarction, or left ventricular ejection fraction (LVEF) less than 40%. A total of 174 126 eligible patients with STEMI were treated with primary PCI at 814 sites in the study; 15 460 (8.9%) had VT or VF after primary PCI, and 4156 (2.4%) had late VT or VF. Among the eligible patients, 99 905 (57.4%) at 807 sites had uncomplicated STEMI. The median age for patients with late VT or VF overall was 63 years (IQR, 55-73 years), and 75.5% were men; the median age for patients with late VT or VF with uncomplicated STEMI was 60 years (IQR, 53-69 years), and 77.7% were men. The median length of stay was 3 days (IQR, 2-7 days) for the overall cohort with late VT or VF and 3 days (IQR, 2-4 days) for the cohort with uncomplicated STEMI with late VT or VF. The risk of late VT or VF was 2.4% (overall) and 1.7% (uncomplicated STEMI). Late VT or VF with cardiac arrest occurred in 674 patients overall (0.4%) and in 117 with uncomplicated STEMI (0.1%). LVEF was the most significant factor associated with late VT or VF with cardiac arrest (adjusted odds ratio [AOR] for every 5-unit decrease ≤40%: 1.67; 95% CI, 1.54-1.85). Late VT or VF events were associated with increased odds of in-hospital mortality in the overall cohort (AOR, 6.40; 95% CI, 5.63-7.29) and the cohort with uncomplicated STEMI (AOR, 8.74; 95% CI, 6.53-11.70). In this study, a small proportion of patients with STEMI treated with primary PCI had late VT or VF. However, late VT or VF with cardiac arrest was rare, particularly in the cohort with uncomplicated STEMI. This information may be useful when determining the optimal timing for hospital discharge after STEMI.

F-10 | Predictors of Adverse Events Following Endovascular Revascularization of Acute Limb Ischemia: Outcomes of the National Cardiovascular Data Registry Peripheral Vascular Intervention Registry

F-10 | Predictors of Adverse Events Following Endovascular Revascularization of Acute Limb Ischemia: Outcomes of the National Cardiovascular Data Registry Peripheral Vascular Intervention Registry

Implementation of a Multidimensional Strategy to Reduce Post-PCI Bleeding Risk.

The American College of Cardiology Reduce the Risk: PCI Bleed Campaign was a hospital-based quality improvement campaign designed to reduce post-percutaneous coronary intervention (PCI) bleeding events. The aim of the campaign was to provide actionable evidence-based tools for participants to review, adapt, and adopt, depending upon hospital resources and engagement. We used data from 8 757 737 procedures in the National Cardiovascular Data Registry between 2015 and 2021 to compare patient and hospital characteristics and bleeding outcomes among campaign participants (n=195 hospitals) and noncampaign participants (n=1384). Post-PCI bleeding risk was compared before and after campaign participation. Multivariable hierarchical logistic regression was used to determine the adjusted association between campaign participation and post-PCI bleeding events. Prespecified subgroups were examined. Campaign hospitals were more often higher volume teaching facilities located in urban or suburban locations. After adjustment, campaign participation was associated with a significant reduction in the rate of bleeding (bleeding: adjusted odds ratio, 0.61 [95% CI, 0.53-0.71]). Campaign hospitals had a greater decrease in bleeding events than noncampaign hospitals. In a subgroup analysis, the reduction in bleeding was noted in non-ST-segment-elevation acute coronary syndrome and ST-segment-elevation myocardial infarction patients, but no significant reduction was seen in patients without acute coronary syndrome. Participation in the American College of Cardiology Reduce the Risk: PCI Bleed Campaign was associated with a significant reduction in post-PCI bleeding. Our results underscore that national quality improvement efforts can be associated with a significant impact on PCI outcomes.

Predicting Major Adverse Events in Patients Undergoing Transcatheter Left Atrial Appendage Occlusion.

The National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry (LAAO) includes the vast majority of transcatheter LAAO procedures performed in the United States. The objective of this study was to develop a model predicting adverse events among patients undergoing LAAO with Watchman FLX. Data from 41 001 LAAO procedures with Watchman FLX from July 2020 to September 2021 were used to develop and validate a model predicting in-hospital major adverse events. Randomly selected development (70%, n=28 530) and validation (30%, n=12 471) cohorts were analyzed with 1000 bootstrapped samples, using forward stepwise logistic regression to create the final model. A simplified bedside risk score was also developed using this model. Increased age, female sex, low preprocedure hemoglobin, no prior attempt at atrial fibrillation termination, and increased fall risk most strongly predicted in-hospital major adverse events and were included in the final model along with other clinically relevant variables. The median in-hospital risk-standardized adverse event rate was 1.50% (range, 1.03%-2.84%; interquartile range, 1.42%-1.64%). The model demonstrated moderate discrimination (development C-index, 0.67 [95% CI, 0.65-0.70] and validation C-index, 0.66 [95% CI, 0.62-0.70]) with good calibration. The simplified risk score was well calibrated with risk of in-hospital major adverse events ranging from 0.26% to 3.90% for a score of 0 to 8, respectively. A transcatheter LAAO risk model using National Cardiovascular Data Registry and LAAO Registry data can predict in-hospital major adverse events, demonstrated consistency across hospitals and can be used for quality improvement efforts. A simple bedside risk score was similarly predictive and may inform shared decision-making.

First Experience With Amulet in the United States: Early Insights From EMERGE LAA Postapproval Study.

The Food and Drug Administration approved the Amulet occluder (Abbott) after demonstrating safety and effectiveness in the Amulet IDE (AMPLATZER Amulet LAA Occluder) trial. The aim of the EMERGE Left Atrial Appendage study is to evaluate early postapproval outcomes of the Amulet occluder in the United States using data from the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry. Patients with a commercial Amulet occluder implant attempt between Food and Drug Administration approval (August 14, 2021) and December 31, 2022, were included. The safety composite endpoint included all-cause death, ischemic stroke, systemic embolism, or device/procedure-related events requiring open cardiac surgery or endovascular intervention between device implantation and 7days or hospital discharge (whichever is later). Major adverse events through 45days were also reported and stratified by operator experience (early [<10 cases], moderate [10-29 cases], and high [30+ cases]). A total of 5,499 patients underwent attempted Amulet occluder implantation. Implant success was 95.8%, and complete closure was 97.2% post-left atrial appendage occlusion and 87.1% at 45days. A safety composite endpoint event occurred in 0.76% patients. Any major adverse event occurred in 2.9% and 5.7% of patients in-hospital and through 45days, respectively, driven by major bleeding and pericardial effusion (PE) requiring intervention. PE requiring surgery or percutaneous intervention decreased significantly with increasing experience both in-hospital (early vs high operator experience 1.8% vs 1.1%; P = 0.006) and at 45days (2.3% vs 1.5%; P = 0.012). The EMERGE Left Atrial Appendage study demonstrates favorable safety and effectiveness of theAmulet occluder in the real-world setting. More experienced operators had improved implant success and fewerPEs,suggesting a learning curve effect implanting this dual occlusive mechanism device.

Association Between Cardiovascular Event Type and Smoking Cessation Rates Among Outpatients With Atherosclerotic Cardiovascular Disease: Insights From the NCDR PINNACLE Registry.

It is unclear how the type of an atherosclerotic cardiovascular disease (ASCVD) event potentially influences patients' likelihood of smoking cessation. Using 2013 to 2018 data from the US based National Cardiovascular Data Registry Practice Innovation and Clinical Excellence outpatient cardiac registry, we identified patients who were current smokers at a clinic visit and followed them over time for a subsequent ASCVD event. Self-reported smoking status was assessed at each consecutive visit and used to determine smoking cessation after each interim ASCVD event (myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, stroke/transient ischemic attack, peripheral artery disease). We constructed separate multivariable Cox models with nonproportional hazards to examine the association of each interim ASCVD event with smoking cessation, compared with not having an interim ASCVD event. We estimated the relative association of ASCVD event type with smoking cessation using contrast tests. Analyses were stratified by presence versus absence of ASCVD at baseline. Across 530 cardiology practices, we identified 1 933 283 current smokers (mean age 62±15, male 54%, ASCVD at baseline 50%). Among the 322 743 patients who had an interim ASCVD event and were still smoking, 41 336 (12.8%) quit smoking by their first subsequent clinic visit, which was higher among those with baseline ASCVD (13.4%) as compared with those without baseline ASCVD (11.5%). Each type of ASCVD event was associated with an increased likelihood of smoking. Patients who had an myocardial infarction, underwent coronary artery bypass graft (hazard ratio, 1.60 [95% CI, 1.55-1.65]), or had a stroke or transient ischemic attack were more likely to quit smoking as compared with those who underwent elective percutaneous coronary intervention or had a new diagnosis of peripheral artery disease (hazard ratio, 1.20 [95% CI, 1.17-1.22]). Only 13% of patients reported smoking cessation after an ASCVD event, with the type of event being associated with the likelihood of smoking cessation, prompting the need for patient-centered interventions.

Impact of sex on Transcatheter aortic valve replacement outcomes: Results of a single-center study

BackgroundEarly studies on transcatheter aortic valve replacement (TAVR) outcomes showed that female sex was associated with better survival. With increased use of new-generation valves, the impact of sex on contemporary TAVR outcomes is less well known. MethodsRetrospective analysis using institutional National Cardiovascular Data Registry STS/ACC TVT data was performed on all patients undergoing TAVR at Yale New Haven Hospital from July 2012 to August 2019. New-generation valves were Evolut PRO, Evolut R, and SAPIEN 3. Old-generation valves were CoreValve, SAPIEN, and SAPIEN XT. Log-rank test and Kaplan-Meier curves were used to compare sex differences in survival up to 1 year after TAVR. Cox modeling was used to adjust for baseline and procedural characteristic differences. Results927 consecutive patients (41.4% women) underwent TAVR. Women were older (82.8 vs 80.6 years old; p < 0.001) with higher STS mortality scores compared with men (7.6% vs 6.4%; p < 0.001) despite lower prevalence of cardiovascular comorbidities including coronary artery disease, peripheral artery disease, and smoking. Most cases used transfemoral access (90.5%) and new-generation devices (72.3%). Women received smaller valves compared with men (20–26 mm: 78.0% vs 32.9%; 29–34 mm: 22.1% vs 67.1%; overall p < 0.0001). There were no statistically significant differences between sexes in both unadjusted and adjusted 1-year mortality. ConclusionOur data show no significant difference in 1-year survival between sexes using primarily new generation valves. Further studies should reassess the impact of sex on TAVR outcomes and whether newer technologies like new valve design and sizes, and CT imaging may have eliminated sex-based disparities.

Outcomes of atherectomy in patients undergoing lower extremity revascularisation.

There is a paucity of real-world data on the in-hospital (IH) and post-discharge outcomes in patients undergoing lower extremity peripheral vascular intervention (PVI) with adjunctive atherectomy. In this retrospective, registry-based study, we evaluated IH and post-discharge outcomes among patients undergoing PVI, treated with or without atherectomy, in the National Cardiovascular Data Registry PVI Registry. The IH composite endpoint included procedural complications, bleeding or thrombosis. The primary out-of-hospital endpoint was major amputation at 1 year. Secondary endpoints included repeat endovascular or surgical revascularisation and death. Multivariable regression was used to identify predictors of atherectomy use and its association with clinical endpoints. A total of 30,847 patients underwent PVI from 2014 to 2019, including 10,971 (35.6%) treated with atherectomy. The unadjusted rate of the IH endpoint occurred in 524 (4.8%) of the procedures involving atherectomy and 1,041 (5.3%) of non-atherectomy procedures (p=0.07). After adjustment, the use of atherectomy was not associated with an increased risk of the combined IH endpoint (p=0.68). In the 6,889 (22.4%) patients with out-of-hospital data, atherectomy was associated with a reduced risk of amputation (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI]: 0.51-0.85; p<0.01) and surgical revascularisation (aHR 0.63, 95% CI: 0.44-0.89; p=0.017), no difference in death rates (p=0.10), but an increased risk of endovascular revascularisation (aHR 1.21, 95% CI: 1.06-1.39; p<0.01) at 1 year. The use of atherectomy during PVI is common and is not associated with an increase in IH adverse events. Longitudinally, patients treated with atherectomy undergo repeat endovascular reintervention more frequently but experience a reduced risk of amputation and surgical revascularisation.

Non-Obstructing Coronary Artery Ischemia, An Underdiagnosed Silent Killer

Dear Madam, Ischemia due to Non-Obstructing Coronary Arteries (INOCA), formerly known as Prinzmetal Angina, is a condition that affects a significant number of people, especially in Pakistan. I have encountered several cases where patients exhibit stable angina symptoms, despite having normal or near-normal coronary angiograms. Among about 400,000 patients with suspected ischemic heart disease, the American College of Cardiology National Cardiovascular Data Registry found that only 37.6% had obstructive coronary artery disease, and 39.2% had no evidence of coronary artery disease. The exact prevalence of INOCA is not well-known. (1) Moreover, a prior research study found that heart failure patients of South Asian origin had a higher prevalence of INOCA compared to other populations. (2) A recent meta-analysis revealed that approximately 50% of the patients with nonobstructive coronary artery disease had coronary microvascular disease (CMD) and/or coronary artery spasms, suggesting that a significant number of INOCA patients are not appropriately diagnosed in routine clinical practice. (3) This shows us the importance of INOCA and also suggests that we need to improve the diagnosis protocols that Pakistani physicians commonly use. INOCA and myocardial infarction with non-obstructive coronary artery disease (MINOCA) are underrecognized and underdiagnosed conditions with cardiovascular health implications. These conditions are associated with a higher risk of death from cardiovascular causes in Pakistan, as well as a greater burden on the healthcare system, due to frequent hospital admissions for persistent chest pain and invasive coronary angiographies that often yield negative results. We have to dive more into Invasive coronary angiography by doing the Comprehensive Physiologic Assessment, using a pressure sensing guidewire to measure FFR (Fractional Flow reserve) and CFR (Coronary Flow Reserve) to evaluate Epicardial Stenosis and Microvascular Angina respectively. Later on, CFT can also be performed to confirm the diagnosis of coronary microvascular dysfunction. (4) To ensure that we do not miss INOCA, we should also consider other tests that do not involve inserting a catheter into the heart. These tests include Transthoracic echocardiography, Cardiac MRI, and Cardiac PET. By doing these tests, we can determine if the patient has INOCA and what type of INOCA they have. These will help us to tailor our management plan in the best possible way and also help us to guide the patients on how to reduce their risk factors.

Acute myocardial infarction from a lower-middle income country-A comprehensive report on performance measures and quality metrics using National Cardiovascular Data Registry.

Epidemic of cardiovascular disease (CVD) is widely projected in South Asian population and estimated to get double in two decades. Ischemic heart disease (IHD) is one of the spectrums of CVD and acute myocardial infarction (AMI) being the common manifestations of IHD. National Cardiovascular Data Registry (NCDR) is a registry data that measure their practices and improve quality of care. In this project we aim to see our performance trends in the care of IHD including AMI patients over two year's period. A cross sectional study conducted at the Aga Khan University Hospital, Karachi, Pakistan. All patients aged 18 years and above admitted to adult Cardiology units with chest pain and acute coronary syndrome are eligible to be included in NCDR data set. Data on demographics and initial characteristics of patients were extracted from NCDR institutional dataset. The data was then compared between 2019 and 2020 on performance, quality, and efficiency metrics. In 2019 to 2020, 1542 patients with acute coronary syndrome and stable ischemic heart disease were admitted. Out of these, 1042 patients (67.8%) were males. According to our data, the 2020 mortality rate was about 5.25%. In 2019 and 2020, bleeding rates were 1.1% and 1.6%, respectively. Our data showed 100% PCI in 90 minutes in 2019 while 87% in 2020. According to the appropriateness criteria for PCI, 80% were appropriate, while 20% were possibly appropriate in both years. The median length of stay following a procedure was 2 days in 2019 and 1 day in 2020. This study described the common and unique characteristics of patients with myocardial infarction representing population from South Asian region. Overall, the procedural performance measure and outcome metrics are up to the international benchmarks. Cultural, financial, and pandemic effects identified certain challenges.

Abstract 18298: 10-Year Trends of In-Hospital Outcomes of Patients That Underwent Percutaneous Coronary Intervention for Cardiogenic Shock Complicating Acute Coronary Syndrome

Background: Cardiogenic shock complicating acute coronary syndrome (CS-ACS) is a life-threatening condition and percutaneous coronary intervention (PCI) remains a fundamental approach in its management. In recent years, notable advancements have emerged, including the utilization of mechanical circulatory support (MCS) devices and an enhanced understanding of patient selection for PCI. This study aims to assess the temporal trends in patient background and outcomes of patients who underwent PCI for CS-ACS. Methods: The Keio interhospital Cardiovascular Studies (KiCS)-PCI registry prospectively collects approximately 200 variables, which were defined in accordance with the National Cardiovascular Data Registry (NCDR), from the major teaching hospitals in Tokyo metropolitan area in Japan. Between 2009 and 2019, 24,671 consecutive cases were registered, 10,053 patients (40.7%) undergoing PCI for ACS, of which 870 patients (8.5%) had CS-ACS. We stratified CS-ACS patients into 4-time frame groups (T1: 2009-2011, T2: 2012-2013, T3: 2014-2016, and T4: 2017-2019), and examined the temporal trends in patient risk profiles using the NCDR score (ranging 0-100, reflecting predicted mortality rates). Additionally, we assessed the incidence and types of employed MCS as well as the in-hospital mortality rate. Results: During the study period, the proportion of CS-ACS remained stable, accounting for 8.0% in T1 to 8.2% in T4 of ACS-related PCI cases. The calculated NCDR risk score demonstrated minimal variation, ranging from 70.6 in T1 to 70.1 in T4. There was a notable decrease in the utilization of MCS (66.5% in T1 to 56.7% in T4), mainly driven by a reduction in the use of intra-aortic balloon pump (70.3% to 55.0%, p for trend&amp;lt;0.001), with a increase in the concomitant use of veno-arterial-extracorporeal membrane oxygenation (27.6% to 36.2%, p for trend&amp;lt;0.001). However, the in-hospital mortality rate for CS-ACS patients remained persistently high at 30%. Conclusion: Over the past decade, there have been notable changes in the peri-procedural management of CS-ACS, albeit no significant improvements in patient outcomes was observed. The result calls for additional efforts to enhance their management.

DAPT Is Comparable to OAC Following LAAC With WATCHMAN FLX: A National Registry Analysis.

Left atrial appendage occlusion (LAAO) is an approved alternative for stroke prevention in atrial fibrillation for patients with an "appropriate rationale" to avoid long-term oral anticoagulation (OAC). Many patients undergoing LAAO are at high risk of bleeding. This study sought to investigate whether dual antiplatelet therapy (DAPT) is a safe alternative to OAC (direct oral anticoagulation [DOAC] or warfarin) with aspirin after LAAO. Using National Cardiovascular Data Registry LAAO registry data, patients undergoing Watchman FLX (Boston Scientific) implantation (August 5, 2020-September 30, 2021) were included in 1:1 propensity-matched analyses comparing discharge medication regimens (DAPT, DOAC/aspirin, or warfarin/aspirin). A composite endpoint (death, stroke, major bleeding, and systemic embolism), its components, and device-related thrombus between discharge and 45days were evaluated. In 49,968 patients implanted with the Watchman FLX during the study period, the mean age was 77 years, and 40% were women. Postimplant DOAC/aspirin was prescribed in 24,497 patients, warfarin/aspirin in 3,913, and DAPT in 4,155. DAPT patients had more comorbid conditions than patients receiving OAC/aspirin. After propensity score matching, the 45-day composite endpoint rates were similar among the groups (DAPT=3.44% vs DOAC/aspirin: 4.06%; P = 0.13 and DAPT=3.23% vs warfarin/aspirin: 3.08%; P = 0.75). Death, stroke, and device-related thrombus were also similar; major bleeding was slightly increased in DOAC/aspirin patients (DAPT=2.48% vs DOAC/aspirin=3.25%; P = 0.04 and DAPT=2.25% vs warfarin/aspirin=2.22%; P = 0.93). In a large registry, DAPT had a similar safety profile compared with current Food and Drug Administration-approved postimplant drug regimens of OAC with aspirin following LAAO with the Watchman FLX. Shared decision making for nonpharmacologic stroke prevention should include a discussion of postprocedure medical therapy options.

Capabilities of the Treadmill Test in Modern Cardiological Practice

Many publications in recent years have been dedicated to the search for the best preliminary method of diagnosing coronary artery disease (CAD), where the availability of technology and staff experience are the determining factors. According to the National Cardiovascular Data Registry of the American College of Cardiology, 58.4% of patients referred for coronary angiography after functional testing do not have significant coronary artery stenoses. European guidelines for the diagnosis and management of patients with chronic coronary syndrome recommend the use of imaging diagnostic tests instead of exercise electrocardiography for the diagnosis of obstructive CAD.&#x0D; The aim. To analyze the capabilities of the exercise electrocardiography test for patients in modern cardiological practice.&#x0D; Materials and methods. A treadmill test was performed on 406 patients, among whom 317 (78.07%) were men, 89 (21.9%) were women, the mean age was 44.7±17.3 years. The test was carried out according to the Bruce protocol on the Valiant Ergometric Treadmill.&#x0D; Results. The patients were divided into groups depending on the area of diagnostic search: verification of CAD in cardiac pain (n=184); evaluation of the long-term results of cardiac surgery (n=74); visualization of myocardial ischemia in borderline stenoses of coronary arteries (n=4); screening in the presence of additional CAD risk factors (n=49); in the case of heart rhythm disorders in order to decide on further treatment tactics and evaluation of the effectiveness of the antiarrhythmic treatment (n=34); evaluation of the coronary artery in patients with congenital heart defects (n=7); determination of tolerance to physical exertion (n=54). Among the examined patients, there were 48 (11.8%) with positive, 246 (60.5%) with negative, and 112 (27.5%) with doubtful treadmill test. Among 48 patients with a positive treadmill test, myocardial revascularization was performed in 41 (85.4%) cases.&#x0D; Conclusions. Exercise electrocardiography is an affordable tool for diagnostic research which, with its high-quality performance and interpretation, can be an alternative to modern imaging techniques.

Contemporary Methods for Predicting Acute Kidney Injury After Coronary Intervention

BackgroundAcute kidney injury (AKI) is the most common complication after percutaneous coronary intervention (PCI). Accurately estimating patients’ risks not only creates a means of benchmarking performance but can also be used prospectively to inform practice. ObjectivesThe authors sought to update the 2014 National Cardiovascular Data Registry (NCDR) AKI risk model to provide contemporary estimates of AKI risk after PCI to further improve care. MethodsUsing the NCDR CathPCI Registry, we identified all 2020 PCIs, excluding those on dialysis or lacking postprocedural creatinine. The cohort was randomly split into a 70% derivation cohort and a 30% validation cohort, and logistic regression models were built to predict AKI (an absolute increase of 0.3 mg/dL in creatinine or a 50% increase from preprocedure baseline) and AKI requiring dialysis. Bedside risk scores were created to facilitate prospective use in clinical care, along with threshold contrast doses to reduce AKI. We tested model calibration and discrimination in the validation cohort. ResultsAmong 455,806 PCI procedures, the median age was 67 years (IQR: 58.0-75.0 years), 68.8% were men, and 86.8% were White. The incidence of AKI and new dialysis was 7.2% and 0.7%, respectively. Baseline renal function and variables associated with clinical instability were the strongest predictors of AKI. The final AKI model included 13 variables, with a C-statistic of 0.798 and excellent calibration (intercept = −0.03 and slope = 0.97) in the validation cohort. ConclusionsThe updated NCDR AKI risk model further refines AKI prediction after PCI, facilitating enhanced clinical care, benchmarking, and quality improvement.

Implications of a Race Term in GFR Estimates Used to Predict AKI After Coronary Intervention

BackgroundThe prediction of mortality, bleeding, and acute kidney injury (AKI) after percutaneous coronary intervention (PCI) traditionally relied on race-based estimates of the glomerular filtration rate (GFR). Recently, race agnostic equations were developed to advance equity. ObjectivesThe authors aimed to compare the accuracy and implications of various GFR equations when used to predict AKI after PCI. MethodsUsing the National Cardiovascular Data Registry (NCDR) CathPCI data set, we identified patients undergoing PCI in 2020 and calculated their AKI risk using the 2014 NCDR AKI risk model. We created 4 AKI models per patient for each estimate of baseline renal function: the traditional GFR equation with a race term, 2 GFR equations without a race term, and serum creatinine alone. We then compared each model’s performance predicting AKI. ResultsAmong 455,806 PCI encounters, the median age was 67 years, 32.2% were women, and 8.5% were Black. In Black patients, risk models without a race term were better calibrated than models incorporating an equation with a race term (intercept: −0.01 vs 0.15). Race-agnostic models reclassified 6% of Black patients into higher-risk categories, potentially prompting appropriate mitigation efforts. However, even with a race-agnostic model, AKI occurred in Black patients 18% more often than expected, which was not explained by captured patient or procedural characteristics. ConclusionsIncorporating a GFR estimate without a Black race term into the NCDR AKI risk prediction model yielded more accurate prediction of AKI risk for Black patients, which has important implications for reducing disparities and benchmarking.

Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST-elevation myocardial infarction.

ST-elevation myocardial infarction (STEMI) guidelines recommend an emergency medical services (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 min. The primary objective of this study was to evaluate the association between FMC to PCI time and mortality in rural STEMI patients. We conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in-hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals (CIs). A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death. Among 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean ± SD age of 62.5 ± 12.7 years. PCI was performed within the 90-min time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90-minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p = 0.03). Meeting the 90-min time goal yielded a 98.6% (95% CI 96.1%-99.7%) NPV for index death. A 78-min FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95% CI 96.1%-100%). Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 min.

Utilization and Outcomes of Primary Prevention Implantable Cardioverter-Defibrillators in Patients With Hypertrophic Cardiomyopathy.

Background There is uncertainty about the appropriate use of primary prevention implantable cardioverter-defibrillators (ICDs) among older patients with hypertrophic cardiomyopathy. Methods and Results Patients with hypertrophic cardiomyopathy who received a primary prevention ICD between 2010 and 2016 were identified using the National Cardiovascular Data Registry ICD Registry. Trends in ICD utilization and patient characteristics were assessed over time. Using linked Centers for Medicare and Medicaid Service claims data, Cox proportional hazard models assessed factors associated with mortality and postdischarge hospitalization for cardiac arrest/ventricular arrhythmia. Of 5571 patients with hypertrophic cardiomyopathy, 1511 (27.1%) were ≥65 years old. ICD utilization increased over time in all age groups. There were no changes in the prevalence of risk factors for sudden cardiac death over time. The variables most strongly associated with postdischarge mortality were older age (adjusted hazard ratio (aHR) 1.80 [95% CI, 1.47-2.21]), New York Heart Association class (III/IV versus I/II aHR 2.17 [95% CI, 1.57-2.98]), and left ventricular ejection fraction (left ventricular ejection fraction ≤35% versus >50% aHR 2.34 [95% CI, 1.58-3.48]; left ventricular ejection fraction 36%-50% versus >50% aHR 2.98 [95% CI, 2.02-4.40]), while history of nonsustained ventricular tachycardia (aHR 2.38 [95% CI, 1.62-3.51]) and New York Heart Association class (III/IV versus I/II aHR 1.84 [95% CI, 1.22-2.78]) were strongly associated with hospitalization for ventricular arrhythmia/cardiac arrest. Conclusions Primary prevention ICD utilization in patients with hypertrophic cardiomyopathy increased over time, including among those ≥65 years old. Among older patients, the strongest risk factors for hospitalization for ventricular arrhythmia/cardiac arrest following ICD implantation were history of nonsustained ventricular tachycardia and New York Heart Association class.

Percutaneous Closure of the Patent Ductus Arteriosus in Infants ≤2 kg: IMPACT Registry Insights.

Percutaneous patent ductus arteriosus (PDA) closure is becoming the standard of care for definitive closure in progressively smaller and younger neonates. The objective of this study was to assess safety and feasibility of percutaneous PDA closure in patients ≤2 kg. This was a cohort study using the IMPACT Registry (Improving Pediatric and Adult Congenital Treatments) from the American College of Cardiology Foundation's National Cardiovascular Data Registry. Patients who were ≤2 kg at the time of percutaneous PDA closure were included. The primary outcome was the composite of technical failure and/or major adverse event. A total of 1587 attempted PDA closures were included, with a 3% incidence of technical failure and 5.5% incidence of the composite outcome. Major adverse events were observed in 3.8% of the patients; the most common events were device embolization requiring retrieval and unplanned cardiac or vascular surgery in 1.3% and 1.3% of cases, respectively. The incidence of the composite outcome was associated with the need for arterial access (P < .001) as well as annual hospital volume of percutaneous PDA closures in infants ≤2 kg (P = .001). The incidence of the composite outcome has decreased overtime, whereas median weight at the time of procedure has also diminished. Percutaneous PDA closure appears to be safe and feasible procedures in infants ≤2 kg. The incidence of major adverse events has continued to decline over the years and seems to have a strong correlation with individual center case volumes and expertise.

Outcomes of same-day discharge following percutaneous coronary intervention in a rural population.

Same-day discharge (SDD) following percutaneous coronary intervention (PCI) is safe, yet the nationwide rate of SDD remains low. The impact that residing in a rural area has on the safety of SDD is unknown. To investigate the safety of SDD compared to next-day discharge (NDD) among PCI patients living in a largely rural area. There were 3502 outpatient elective PCIs at a tertiary care center between January 1, 2011 and December 31, 2017. Data from the National Cardiovascular Data Registry CathPCI Registry® and the electronic medical records were obtained for patient demographics, procedural characteristics, and procedural outcomes. Data from the initial PCI in each 365-day period were included in the analysis for each patient. Rural-Urban Commuting Areacodes 4-10 were used to define rural status. A total of 2099 (59.9%) PCIs met the inclusion criteria (63% rural). The overall rate of SDD increased over time (4.7% in 2011 to 39.6% in 2017) as radial access increased (14.2% in 2011 to 59.9% in 2017). In this population, a total of 329 PCIs had SDD (15.7%; median (interquartile range) age 66.0 (14.0) years, 20.1% female, 52.3% rural status). Compared to NDD, SDD patients had less hyperlipidemia, atrial fibrillation, congestive heart failure, history of coronary artery bypass graft, and more radial access. SDD was noninferior to NDD for 30-day readmission but had a decreased 1-year (adjusted odds ratio [aOR]: 0.20, 95% confidence interval [CI]: 0.05-0.81, p = 0.024) and 5-year (aOR: 0.43, 95% CI: 0.28-0.66, p < 0.001) all-cause mortality compared to NDD. Rural status did not predict outcomes. SDD in patients in rural areas does not have a significantly higher rate of 30-day readmission. SDD patients had lower odds of 1- and 5-year mortality when compared to NDD. Future studies prospectively evaluating the safety of SDD in this population are warranted.