Geographical and socioeconomic disparities in post-transcatheter aortic valve replacement pacemaker placement

INTRODUCTION

Pacemaker (PPM) implantation is indicated for conduction abnormalities which can develop post-transcatheter aortic valve replacement (TAVR). However, whether post-TAVR PPM risk is associated with the geographical location of the hospital and socioeconomic status of the patient is not well established. Our goal was to explore geographical and socioeconomic disparities in post-TAVR PPM implantation.

METHODS

A retrospective cohort analysis was conducted using the National Inpatient Sample 2016-2020 with respective ICD-10 codes for TAVR and PPM implantation. A weighted multivariate logistic regression model was used to analyze prognostic outcomes.

RESULTS

The number of patients hospitalized for undergoing TAVR was 296,740, out of which 28,265 patients had PPM implantation (prevalence 9.5 %). Patients' demographics including sex, ethnicity, household income, and insurance were not associated with risk of post-TAVR PPM except age (OR 1.01, CI 1.07-12.5, p < 0.001). Compared to rural hospitals, urban non-teaching hospitals were associated with a higher risk of post-TAVR PPM (OR 2.09, 1.3-3.43, p = 0.003). Compared to New England hospitals (ME, NH, VT, MA, RI, CT), middle Atlantic hospitals (NY, NJ, PA) were associated with highest post-TAVR PPM risk (OR 1.54, CI 1.2-1.98, p < 0.001), followed by Pacific (AK, WA, OR, CA, HI), mountain (ID, MT, WY, NV, UT, CO, AZ, NM) and east north central US.

CONCLUSION

Patients' demographics including sex, ethnicity, household income, and insurance were not associated with the risk of post-TAVR PPM except for age. Compared to New England hospitals, Middle Atlantic hospitals were associated with the highest post-TAVR PPM risk followed by Pacific, Mountain, and East North Central US. Prospective studies with data on TAVR wait times, expertise of the interventional staff, and post-TAVR management and discharge planning are required to further explore the observed regional distribution of TAVR outcomes.

Spontaneous coronary artery dissection (SCAD) and takotsubo cardiomyopathy (TCM) - A potential association

Background

Spontaneous coronary artery dissection and takotsubo cardiomyopathy are increasingly recognized in the last two decades. Case reports have shown both entities can present concomitantly - however, little is known about their association.

Methods

In this retrospective study we aimed to explore a potential association between SCAD and TCM using the Nationwide Inpatient Sample. The odds of having TCM among patients with SCAD compared with those who did not have SCAD were calculated as an odds ratio. Conversely, the odds of having SCAD among patients with TCM compared with those who did not have TCM were also calculated. The primary outcome was the odds of TCM among patients with a primary diagnosis of SCAD and vice versa. The secondary endpoint was the odds of in-hospital mortality among patients with SCAD, and/or TCM.

Results

Hospitalized patients who had SCAD were 7.12 (95 % CI: 6.28-8.08) times more likely to also have TCM than those who did not have SCAD (p < 0.0001).), while patients with TCM were 6.91 (95 % CI: 6.07-7.85) times more likely to have SCAD compared to those who didn't have TCM adjusted for age, gender, race, hypertension, hyperlipidemia, and diabetes mellitus (p < 0.0001).

Conclusion

This data indicate that patients with either SCAD or TCM are seven times more likely to be diagnosed concomitantly with both, compared to the patients without either diagnosis [after adjusting for age, gender, race, hypertension, hyperlipidemia, and diabetes mellitus]. Our data are consistent with the growing body of evidence supporting an association between SCAD and TCM and raise the question of a common pathophysiologic mechanism.

Prevalence and Prognostic Implications of Amyloidosis in Valvular Heart Disease

There has been less emphasis on the prognostic impact of amyloidosis in patients with valvular heart disease (VHD). We aimed to determine the prevalence of amyloidosis in VHD and its clinical implications in terms of mortality. Patients hospitalized for VHD were identified using National Inpatient Sample 2016-2020 which were divided into 2 cohorts: with and without amyloidosis. Among 5,728,873 patients hospitalized with VHD, 11,715 patients had amyloidosis in which mitral valve disease has the highest prevalence (7.6%) followed by aortic (3.6%), and tricuspid valve disease (1%). Underlying amyloidosis is associated with higher mortality in VHD (OR 1.45, CI 1.2-1.7, P<0.001), mainly mitral valve disease (OR 1.44, CI 1.1-1.9, P<0.01). Patients with amyloidosis have higher adjusted mortality rates (5-6% vs 2.6%, P<0.01), longer mean length of stay (7.1 vs 5.7 days, P<0.001), but they have lower valvular intervention rates. In hospitalized VHD patients, underlying amyloidosis is associated with higher in-hospital mortality.

Advancements in the Management of Endocrine System Disorders and Arrhythmias: A Comprehensive Narrative Review

In recent years, notable advancements have been made in managing endocrine system disorders and arrhythmias. These advancements have brought about significant changes in healthcare providers' approach towards these complex medical conditions. Endocrine system disorders encompass a diverse range of conditions, including but not limited to diabetes mellitus, thyroid dysfunction, and adrenal disorders. Significant advancements in comprehending the molecular underpinnings of these disorders have laid the foundation for implementing personalized medicine. Advancements in genomic profiling and biomarker identification have facilitated achieving more accurate diagnoses and developing customized treatment plans. Furthermore, the utilization of cutting-edge pharmaceuticals and advanced delivery systems presents a significant advancement in achieving enhanced glycemic control and minimizing adverse effects for individuals afflicted with endocrine disorders. Arrhythmias, characterized by irregular heart rhythms, present a substantial risk to cardiovascular well-being. Innovative strategies for managing arrhythmia encompass catheter-based ablation techniques, wearable cardiac monitoring devices, and predictive algorithms powered by artificial intelligence. These advancements facilitate the early detection, stratification of risks, and implementation of targeted interventions, ultimately leading to improved patient outcomes. Incorporating technology and telemedicine has been instrumental in enhancing the accessibility and continuity of care for individuals diagnosed with endocrine disorders and arrhythmias. The utilization of remote patient monitoring and telehealth consultations enables prompt modifications to treatment regimens and alleviates the need for frequent visits to the clinic. This is particularly significant in light of the current global health crisis. This review highlights the interdisciplinary nature of managing endocrine disorders and arrhythmias, underscoring the significance of collaboration among endocrinologists, cardiologists, electrophysiologists, and other healthcare professionals. Multidisciplinary care teams have enhanced their capabilities to effectively address the intricate relationship between the endocrine and cardiovascular systems. In summary, endocrine system disorders and arrhythmias management have undergone significant advancements due to groundbreaking research, technological advancements, and collaborative healthcare approaches. This narrative review provides a comprehensive overview of the advancements, showcasing their potential to enhance patient care, improve quality of life, and decrease healthcare expenses. Healthcare providers must comprehend and integrate these advancements into their clinical practice to enhance outcomes for individuals with endocrine system disorders and arrhythmias.

Precision Medicine Approaches to Diabetic Kidney Disease: Personalized Interventions on the Horizon

Diabetic kidney disease (DKD) is a significant complication of diabetes that requires innovative interventions to address its increasing impact. Precision medicine is a rapidly emerging paradigm that shows excellent promise in tailoring therapeutic strategies to the unique profiles of individual patients. This abstract examines the potential of precision medicine in managing DKD. It explores the genetic and molecular foundations, identifies biomarkers for risk assessment, provides insights into pharmacogenomics, and discusses targeted therapies. Integrating omics data and data analytics provides a comprehensive landscape for making informed decisions. The abstract highlights the difficulties encountered during the clinical implementation process, the ethical factors to be considered, and the importance of involving patients. In addition, it showcases case studies that demonstrate the effectiveness of precision-based interventions. As the field progresses, the abstract anticipates a future characterized by the integration of artificial intelligence in diagnostics and treatment. It highlights the significant impact that precision medicine can have in revolutionizing the provision of care for DKD.

Exploring the Cardiovascular Benefits of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors: Expanding Horizons Beyond Diabetes Management

Globally, cardiovascular disease (CVD) continues to be the primary cause of morbidity and mortality. The risk of cardiovascular disease is markedly increased in individuals with type 2 diabetes mellitus (T2DM), making managing cardiovascular health a top priority. Initially developed for their glucose-lowering properties, sodium-glucose cotransporter 2 (SGLT2) inhibitors have emerged as a transformative class of pharmaceuticals with profound cardiovascular benefits that extend far beyond glycemic control. One of the most striking findings is the substantial reduction in major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and cardiovascular mortality, observed in clinical trials evaluating SGLT2 inhibitors. These extraordinary cardioprotective effects are demonstrated by landmark trials such as EMPA-REG OUTCOME, CANVAS, and DECLARE-TIMI 58, which are discussed in detail. In addition, SGLT2 inhibitors have demonstrated positive outcomes in heart failure (HF) with reduced ejection fraction, which has led to their incorporation into HF treatment guidelines. SGLT2 inhibitors offer renoprotection by delaying the progression of diabetic kidney disease, reducing albuminuria, preserving glomerular filtration rates, and their immediate cardiovascular benefits. We investigate the potential mechanisms underlying these renal benefits, focusing on the role of hemodynamic alterations and intraglomerular pressure reduction. In addition, SGLT2 inhibitors have a distinct diuretic effect that can contribute to volume reduction and symptom alleviation in patients with heart failure (HF). This diuretic action, distinct from conventional diuretics, warrants additional research to optimize their use in T2DM and HF patients. The risk of euglycemic diabetic ketoacidosis, genital mycobacterial infections, and bone fractures are also discussed. Understanding these issues is essential for making educated clinical decisions. In conclusion, SGLT2 inhibitors have transcended their initial function as anti-diabetic agents to become essential components of cardiovascular and renal protection strategies in T2DM patients. Their diverse benefits, which include cardioprotection, renoprotection, and the potential for HF management, highlight their potential to transform cardiovascular medicine. Optimizing the use of SGLT2 inhibitors in clinical practice bears the promise of improved cardiovascular outcomes for patients with T2DM and beyond as we navigate this changing landscape.

Adverse events following COVID‐19 mRNA vaccines: A systematic review of cardiovascular complication, thrombosis, and thrombocytopenia

Background and Objectives

Since publishing successful clinical trial results of mRNA coronavirus disease 2019 (COVID‐19) vaccines in December 2020, multiple reports have arisen about cardiovascular complications following the mRNA vaccination. This study provides an in‐depth account of various cardiovascular adverse events reported after the mRNA vaccines' first or second dose including pericarditis/myopericarditis, myocarditis, hypotension, hypertension, arrhythmia, cardiogenic shock, stroke, myocardial infarction/STEMI, intracranial hemorrhage, thrombosis (deep vein thrombosis, cerebral venous thrombosis, arterial or venous thrombotic events, portal vein thrombosis, coronary thrombosis, microvascular small bowel thrombosis), and pulmonary embolism.

Methods

A systematic review of original studies reporting confirmed cardiovascular manifestations post‐mRNA COVID‐19 vaccination was performed. Following the PRISMA guidelines, electronic databases (PubMed, PMC NCBI, and Cochrane Library) were searched until January 2022. Baseline characteristics of patients and disease outcomes were extracted from relevant studies.

Results

A total of 81 articles analyzed confirmed cardiovascular complications post‐COVID‐19 mRNA vaccines in 17,636 individuals and reported 284 deaths with any mRNA vaccine. Of 17,636 cardiovascular events with any mRNA vaccine, 17,192 were observed with the BNT162b2 (Pfizer−BioNTech) vaccine, 444 events with mRNA‐1273 (Moderna). Thrombosis was frequently reported with any mRNA vaccine (n = 13,936), followed by stroke (n = 758), myocarditis (n = 511), myocardial infarction (n = 377), pulmonary embolism (n = 301), and arrhythmia (n = 254). Stratifying the results by vaccine type showed that thrombosis (80.8%) was common in the BNT162b2 cohort, while stroke (39.9%) was common with mRNA‐1273 for any dose. The time between the vaccination dosage and the first symptom onset averaged 5.6 and 4.8 days with the mRNA‐1273 vaccine and BNT162b2, respectively. The mRNA‐1273 cohort reported 56 deaths compared to the 228 with BNT162b2, while the rest were discharged or transferred to the ICU.

Conclusion

Available literature includes more studies with the BNT162b2 vaccine than mRNA‐1273. Future studies must report mortality and adverse cardiovascular events by vaccine types.

Early Transcatheter or Surgical Aortic Valve Replacement Versus Conservative Management in Asymptomatic Patients With Severe Aortic Stenosis: A Systematic Review and Meta-analysis

The merits of conservative management vs early intervention in patients with asymptomatic severe aortic stenosis remains unknown. Digital databases (MEDLINE, Google Scholar, and Embase) were searched for all relevant studies from inception through September 2022. Studies comparing conservative management with early intervention were compared using a random-effects model to calculate risk ratios (RRs) with 95% confidence interval (CI). A total of 12 studies comprising 3624 asymptomatic aortic stenosis patients (1747 receiving surgery, and 1877 receiving conservative treatment) were included in the analysis. The average follow-up time was 4.45 (IQR 3.5-5) years. Early intervention was associated with a significantly reduced risk of cardiac (RR 0.42, 95% CI 0.25-0.72; P = 0.001; I² = 54%), non-cardiac (RR 0.46, 95% CI 0.32-0.68; P < 0.0001; I² = 0%), all-cause mortality (RR 0.40, 95% CI 0.32-0.51; P < 0.00001; I² = 58%), heart failure hospitalization (RR 0.21, 95% CI 0.13-0.36; P < 0.00001; I² = 0%), sudden cardiac death (RR 0.29, 95% CI 0.12-0.66; P = 0.004, I² = 24%), and MACE (RR 0.46, 95% CI; 0.28-0.75; P = 0.002; I² = 68%), compared with conservative management. There was no significant difference in the 30-day mortality (RR 0.63, 95% CI 0.19-2.04; P = 0.44; I² = 28%), myocardial infarction (RR 0.44, 95% CI 0.19-1.06; P = 0.07, I²=0%), and 90-day mortality (RR 0.68, 95% CI 0.20-2.37; P = 0.55; I² = 61%) between the 2 groups. This meta-analysis shows statistically significant reductions in the risk for all-cause mortality, cardiac specific mortality, non-cardiac mortality, heart failure hospitalization, MACE, and sudden cardiac death among asymptomatic aortic stenosis patients who underwent early intervention as opposed to conservative management.

Visual patterns of breast attenuation artifacts in women and men with an upright and supine cadmiun-zinc-telluride camera

BACKGROUND

Breast attenuation artifacts occurring with upright cadmium-zinc-telluride (CZT) cardiac imaging systems have not been well characterized.

METHODS

216 consecutive patients with Single Photon Emission Computerized Tomography myocardial perfusion imaging and no angiographically significant obstructive coronary artery disease were identified. All upright and supine SPECT images as well as coronary angiograms were reviewed and analyzed in blinded fashion.

RESULTS

In women imaged upright, more visual false positive defects were noted in the inferior wall compared to the anterior wall (26 vs. 10 at rest, p = 0.006, and 33 vs. 13 at stress, p < 0.001). Visual inferior wall defects were more common in the upright than supine position at stress (33 vs. 23, p = 0.018) and rest (26 vs. 14, p = 0.011), and most apparent in non-obese women (13 vs. 8, at stress, p = 0.059 and 11 vs. 5, at rest, p = 0.014).

CONCLUSIONS

With upright CZT myocardial perfusion imaging, women often have visible inferior wall attenuation artifact defects, likely from pendant breast tissue. These inferior wall attenuation artifacts may be seen in non-obese female patients.

Effects of gender and defect reversibility on detection of coronary disease with an upright and supine cadmium-zinc-telluride camera

BACKGROUND

Limited data address the roles of gender, perfusion defect reversibility, and imaging position in interpretation of images acquired on an upright/supine cadmium-zinc-telluride (CZT) cardiac imaging system.

METHODS AND RESULTS

From a consecutive cohort of patients imaged on an upright/supine CZT camera, 260 patients with coronary angiograms were studied. Multivariable models identified gender as a significant effect modifier for imaging variables of CAD. For males, a supine summed stress score (SSS) ≥ 3 provided high accuracy (sensitivity 70.7%, specificity 72.2%), and highest contribution to multivariable models. In females, supine SSS ≥ 2 provided the best cut-off for defect size and severity (sensitivity 90%, specificity 35.9%), but specificity was improved substantially to 53.3% with decrease in sensitivity to 80% by also requiring quantitative identification of perfusion defect reversibility in the supine position. Eight variables, accurate for predicting coronary disease, were more accurate with supine than upright imaging.

CONCLUSIONS

Perfusion defect reversibility improved specificity in female patients for detection of coronary disease compared to perfusion defect size and extent alone. Supine images provided superior accuracy for detection of coronary disease compared to upright images.

Cardiac autonomic innervation

The autonomic nervous system plays a key role in regulating changes in the cardiovascular system and its adaptation to various human body functions. The sympathetic arm of the autonomic nervous system is associated with the fight and flight response, while the parasympathetic division is responsible for the restorative effects on heart rate, blood pressure, and contractility. Disorders involving these two divisions can lead to, and are seen as, a manifestation of most common cardiovascular disorders. Over the last few decades, extensive research has been performed establishing imaging techniques to quantify the autonomic dysfunction associated with various cardiovascular disorders. Additionally, several techniques have been tested with variable success in modulating the cardiac autonomic nervous system as treatment for these disorders. In this review, we summarize basic anatomy, physiology, and pathophysiology of the cardiac autonomic nervous system including adrenergic receptors. We have also discussed several imaging modalities available to aid in diagnosis of cardiac autonomic dysfunction and autonomic modulation techniques, including pharmacologic and device-based therapies, that have been or are being tested currently.

Idiopathic Atrial Fibrillation and Coronary Arteriovenous Fistulae: Is There a Link?

Despite being one of the most prevalent cardiac arrhythmias, the cause of atrial fibrillation (AF) in a vast majority of patients remains unknown. There is growing evidence of associated AF in patients diagnosed with coronary arteriovenous fistula. In this discussion, we have included an example of a patient who presented with new-onset AF and was subsequently diagnosed with an anomalous fistula between the right coronary artery and the superior vena cava. Definitive treatment of the fistula resulted in permanent resolution of the AF. Based on this case and a similar case reported in the literature, it is proposed that further research will unmask this possibly underdiagnosed and very treatable cause of AF.

Cardiac Tamponade Physiology Secondary to Tense Ascites

Cardiac tamponade is a common and often life-threatening process, which is typically associated with a pericardial effusion or, in rare cases, with a large pleural effusion. Theoretically, as reported in only a single prior case, it can be caused by extrinsic compression from tense ascites. We present a case in which dynamic inferior wall collapse was secondary to increased abdominal pressure from tense ascites. This phenomenon may be more common than previously diagnosed, especially in patients with liver disease. These patients often develop frequent ascites and present with clinical signs and symptoms similar to cardiac tamponade (tachycardia, hypotension and dyspnea). Presently, no formal practice guidelines exist regarding cardiac imaging for these patients. A high index of suspicion is required for timely diagnosis and management.

Comprehensive evaluation of the association of APOE genetic variation with plasma lipoprotein traits in U.S. whites and African blacks

Although common APOE genetic variation has a major influence on plasma LDL-cholesterol, its role in affecting HDL-cholesterol and triglycerides is not well established. Recent genome-wide association studies suggest that APOE also affects plasma variation in HDL-cholesterol and triglycerides. It is thus important to resequence the APOE gene to identify both common and uncommon variants that affect plasma lipid profile. Here, we have sequenced the APOE gene in 190 subjects with extreme HDL-cholesterol levels selected from two well-defined epidemiological samples of U.S. non-Hispanic Whites (NHWs) and African Blacks followed by genotyping of identified variants in the entire datasets (623 NHWs, 788 African Blacks) and association analyses with major lipid traits. We identified a total of 40 sequence variants, of which 10 are novel. A total of 32 variants, including common tagSNPs (≥5% frequency) and all uncommon variants (<5% frequency) were successfully genotyped and considered for genotype-phenotype associations. Other than the established associations of APOE*2 and APOE*4 with LDL-cholesterol, we have identified additional independent associations with LDL-cholesterol. We have also identified multiple associations of uncommon and common APOE variants with HDL-cholesterol and triglycerides. Our comprehensive sequencing and genotype-phenotype analyses indicate that APOE genetic variation impacts HDL-cholesterol and triglycerides in addition to affecting LDL-cholesterol.

Survival of patients receiving fibrinolytic therapy for acute ST-segment elevation myocardial infarction in a developing country - patient characteristics and predictors of mortality

There is paucity of outcomes data on patients receiving fibrinolytic therapy (FT) for acute ST-elevation myocardial infarction (STEMI) in Indo-Asians. We conducted this study to determine survival as well as correlates of mortality in this population. Hospital charts of 230 patients receiving FT for acute STEMI between January 2002 and December 2004 were reviewed. Primary outcome variable was total mortality. Cox proportional hazards regression models were constructed. At a median follow-up of 717 days, 13.5% died, majority (23) during the in-hospital period. Multivariate predictors of mortality included (adjusted hazards ratio [HR], 95% confidence interval [CI]) age (HR 1.06, 95% CI 1.01-1.13), ejection fraction (HR 0.93, 95% CI 0.89-0.97), admission white cell count (HR 1.02, 95% CI 1.01-1.04) and change in ST-segment elevation (HR 0.96, 95% CI 0.92-0.99). We conclude that patients receiving FT for acute STEMI in Pakistan are a relatively high-risk group with a 10% in-hospital mortality and high frequency of recurrent events. Comparison data with primary angioplasty as an alternative strategy are needed.

Prevalence and management of ovarian tumours in Women and Children Hospital Abbottabad

BACKGROUND

The purpose of study was to compare world incidence of ovarian tumours whether benign or malignant with that of our unit. We have also discussed management of all these patients at our center.

RESULTS

In our unit out of total 1400 admissions in 24 months, 26 had ovarian tumours, out of these 6 were malignant. The over all malignancy in our unit was 23% as compared to 15% of over all world incidence, 24 of these patients, were admitted through the OPD with advanced size of tumours. None of them previously had any check up at proper Gynaecological Centers. All these 24 were admitted to the ward, investigated, operated and after receiving histopathology reports were further managed accordingly. Two patients had torsion of ovarian tumour and were admitted through emergency and operated as emergency cases. In our study group the majority, 77% had benign ovarian tumours in which simple salpingoophorectomies was performed.