Faculty Bibliography

Background/UNASSIGNED:Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction with symptoms and ECG changes mimicking acute myocardial infarction (AMI). The objective of the present study was to evaluate in-hospital death and hospital readmission in patients with TTS and to compare outcomes to patients with AMI. Methods/UNASSIGNED:Patients diagnosed with TTS and AMI were identified using the United States Nationwide Readmission Database from 2010-2014. In-hospital outcomes for the index admission, and rates and causes of 30-day readmissions were compared between TTS patients and AMI patients without TS. Results/UNASSIGNED:61,412 patients with TTS and 3,470,011 patients with AMI without TTS were identified. Patients with TTS were younger, more often women (89% vs. 41%), and less likely to have cardiovascular risk factors than AMI patients. Mortality during the index admission was lower in TTS compared to AMI (2.3% vs. 10.2%, p < 0.0001). Cardiogenic shock occurred at the same frequency (5.7%) with TTS or AMI. Among TTS survivors, 7,132 patients (11.9%) were readmitted within 30 days, and mortality associated with readmission was 3.5%. The most common reason for readmission after TTS was heart failure (10.6% of readmissions). Conclusions/UNASSIGNED:TTS is associated with substantial morbidity and mortality. Although outcomes are more favorable than AMI, ∼2% of patients died in-hospital and ∼12% of survivors were readmitted within 30-days; heart failure was the most frequent indication for re-hospitalization. Careful outpatient follow-up of TTS patients may be warranted to avoid readmissions. Condensed Abstract/UNASSIGNED:We evaluated in-hospital death and hospital readmission in patients with Takotsubo syndrome (TTS) and compared outcomes to those of patients after acute myocardial infarction (AMI) in the United States using the Nationwide Readmission Database from 2010-2014. Mortality during the index admission was lower with TTS than AMI (2.3% vs. 10.2%, p < 0.0001). Readmission within 30 days occurred in 11.9% of TTS survivors associated with 3.5% mortality during readmission. Readmission rates were lower after TTS than AMI (16.7%), p < 0.0001 vs. TTS. The most common reason for readmission was heart failure (10.6% of TTS survivors). TTS is associated with substantial morbidity and mortality.

BACKGROUND:Myocardial injury after non-cardiac surgery (MINS) is a common post-operative cardiovascular complication and is associated with short and long-term mortality. The objective of this study was to describe the contemporary management of patients with and without MINS after total joint and spine orthopedic surgery at a large urban health system in the United States. METHODS:Adults admitted for total joint and major spine surgery from January 2013 through December 2015 with ≥1 cardiac troponin (cTn) measurement during their hospitalization were identified. MINS was defined by a peak cTn above the 99th percentile of the upper reference limit. Demographics, medical comorbidities, and admission and discharge medications were reviewed for all patients. RESULTS:A total of 2561 patients underwent 2798 orthopedic surgeries, and 236 cases of MINS were identified. Patients with MINS were older (71.9 ± 10.9 vs. 67.0 ± 10.0, p < 0.001) and more likely to have cardiovascular risk factors, including hypertension, chronic kidney disease, prior stroke, coronary artery disease, prior MI, and a history of heart failure. Among patients with MINS, only 112 (47.5%) were discharged on a combination of aspirin and statin. Patients with MINS were more likely to be prescribed a statin (154 [65.3%] vs. 1463 [57.1%], p = 0.018), beta-blocker (147 [62.3%] vs. 1194 [46.6%], p < 0.001), and oral anticoagulation (65 [27.5%] vs. 436 [17.0%], p < 0.001) than patients without MINS. CONCLUSIONS:The proportion of patients with MINS who were prescribed medical therapy for atherosclerotic cardiovascular disease was low. Additional efforts to determine optimal management of MINS are warranted.

Background: Perioperative stroke is associated with significant morbidity and mortality. Conventional cardiovascular risk scores have not been validated to predict acute stroke after non-cardiac surgery. Method(s): Patients undergoing non-cardiac surgery between 2009-2011 were identified from the United States National Surgical Quality Improvement Program (n=540,717). Established cardiovascular and perioperative risk models (CHADS, CHADS2VASC, RCRI, MICA and NSQIP ACS Surgical Risk Calculator [ACS-SRC]) were assessed to predict perioperative stroke. Receiver operating characteristic curves and c-statistics (AUC) were compared using Delong's test and likelihood ratios. Result(s): Stroke occurred in the perioperative period of 1,474 non-cardiac surgeries (0.2%). Patients with stroke were older, more frequently male, had lower body mass index, and were more likely to have undergone vascular surgery (p<0.001 all comparisons). The MICA risk score had the most favorable test characteristics in predicting perioperative stroke (AUC 0.83; Figure), and outperformed the more complex ACS-SRC model (AUC 0.81, p for comparison <0.001). In the subgroup of patients undergoing vascular surgery, the AUCs ranged from 0.59-0.67. Conclusion(s): The MICA surgical risk score provides excellent risk prediction for perioperative stroke in non-cardiac surgery. Stroke prediction in vascular surgery is suboptimal. Efforts to prevent perioperative stroke in high risk surgical patients are necessary. [Figure presented]2019 American College of Cardiology Foundation. All rights reserved

Cardiogenic shock occurs in up to 5% to 10% of acute myocardial infarctions(MI) and is associated with high short- and long-term mortality risk. Since its introduction into clinical practice >50 years ago, intra-aortic balloon counterpulsion has been used empirically to provide hemodynamic support in patients undergoing coronary revascularization in the setting of MI and cardiogenic shock. In the landmark SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial, conducted between 1993 and 1998, intra-aortic balloon pumps (IABP) were placed in 86% of participants, irrespective of the assigned management strategy.¹ Although expert opinion supported clinical benefit of IABP use in cardiogenic shock, the first large randomized, multi-center trial of IABP, published in 2012, upended this conventional wisdom. The IABP-SHOCK II(Intra-aortic Balloon Pump in Cardiogenic Shock II) trial randomly assigned 600 participants planned for early revascularization of acute MI complicated by cardiogenic shock to either IABP placement or no IABP placement.² The primary end point was 30-day all-cause mortality. At 30 days, all-cause mortality was 40%, with no difference between patients randomized to receive an IABP versus those who were not. There were no differences between treatment groups in secondary outcomes, including bleeding, ischemic complications, stroke, time to hemodynamic stabilization, intensive care unit length of stay, and the dose and duration of catecholamine therapy. A previous intermediate-term report of IABP-SHOCK II trial outcomes demonstrated no difference between treatment groups for allcause mortality at 12 months.³ In this issue of Circulation, Thiele et al⁴ report the 6-year results of the IABPSHOCK II randomized trial. At 6 years of follow-up, all-cause mortality was high and did not differ between the IABP and control groups (66.3% versus 67.0%) in intention-to-treat, per-protocol, and as-treated analyses. No signal for benefit associated with IABP use was observed in any prespecified or post hoc subgroups. There were no differences in the frequency of recurrent MI, repeat revascularization, stroke, or cardiovascular rehospitalization between the 2 groups. Quality of life, measured by the EuroQol 5D questionnaire and New York Heart Association classification, was favorable in survivors of cardiogenic shock. Four of 5 survivors had New York Heart Association Class I or II symptoms, with no difference between patients randomly assigned to IABP and no IABP therapy.

Background/UNASSIGNED:Perioperative cardiovascular outcomes of transplant surgery are not well defined. We evaluated the incidence of perioperative major cardiovascular and cerebrovascular events (MACCE) after non-cardiac transplant surgery from a large database of hospital admissions from the United States. Methods/UNASSIGNED:Patients ≥18 years of age undergoing non-cardiac solid organ transplant surgery from 2004 to 2014 were identified from the Healthcare Cost and Utilization Project's (HCUP) National Inpatient Sample (NIS). The primary outcome was perioperative MACCE, defined as in-hospital death, myocardial infarction (MI), or ischemic stroke. Results/UNASSIGNED:A total of 49,978 hospitalizations for transplant surgery were identified. Renal (67.3%), liver (21.6%), and lung (6.7%) transplantation were the most common surgeries. Perioperative MACCE occurred in 1,539 transplant surgeries (3.1%). Recipients of organ transplantation were more likely to have perioperative MACCE in comparison to non-transplant, non-cardiac surgery (3.1% vs. 2.0%, p < 0.001; adjusted OR [aOR] 1.29, 95% CI 1.22-1.36). MACCE after transplant surgery were driven by increased mortality (1.7% vs. 1.1%, p < 0.001; aOR 1.15, 95% CI 1.07-1.23) and MI (1.2% vs. 0.6%, p < 0.001; aOR 2.26, 95% CI 2.09-2.46) versus non-transplant surgery, with lower rates of stroke (0.3% vs. 0.5%, p < 0.001; aOR 0.56, 95% CI 0.47-0.65). Among patients hospitalized for renal, liver, and lung transplantation, MACCE occurred in 1.7%, 5.6%, and 7.5%, respectively, with no difference in the frequency of MI by surgery type. Conclusions/UNASSIGNED:Cardiovascular outcomes of transplant surgery vary by surgical subtype and are largely driven by increased perioperative death and MI. Efforts to reduce cardiovascular risks of non-cardiac organ transplant surgery are necessary.

BACKGROUND:Myocardial infarction (MI) presentations are more common during winter months and morning hours. However, it is unknown whether MI with obstructive coronary artery disease (MI-CAD) and non-obstructive CAD (MINOCA) display similar patterns. METHODS:We evaluated seasonal and circadian patterns of MI presentation by coronary artery disease (CAD) status and sex in patients with MI from 2007 to 2014 in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines. Adult patients who underwent coronary angiography for MI were included. Patients with missing age, sex, or angiographic data, cocaine use, thrombolytic therapy prior to catheterization, or prior revascularization were excluded. Baseline demographics and characteristics of symptom onset, including season and time of day of presentation, were compared by CAD status and sex. RESULTS:Among 322,523 patients, 112,547 were female (35%); 18,918 had MINOCA (5.9%). There was no seasonal pattern of MI overall. However, both men and women with MINOCA presented more often in the summer and fall while MI-CAD presentations were equally distributed across seasons. The most common time of presentation was 8 am-2 pm regardless of CAD status or sex. A secondary peak in women with MINOCA during late afternoon hours was also identified. CONCLUSIONS:Seasonal variation of MI differed between MINOCA and MI-CAD, with a small increase in MINOCA incidence in the summer and fall. MINOCA and MI-CAD most commonly occurred in the morning, with a secondary peak in late afternoon in women with MINOCA. These differences in presentation may relate to underlying MI pathophysiology.