Faculty Bibliography

BACKGROUND:Intravascular imaging with intravascular ultrasound (IVUS) and optical coherence tomography (OCT) is an important adjunct to invasive coronary angiography. OBJECTIVES/OBJECTIVE:The primary objective was to examine the frequency of intravascular coronary imaging, trends in imaging use, and outcomes of patients undergoing angiography and/or percutaneous coronary intervention (PCI) in the United States. METHODS:Adult patients ≥18 years of age undergoing in-hospital cardiac catheterization from January 2004 to December 2014 were identified from the National Inpatient Sample (NIS). International Classification of Diseases, Ninth Revision (ICD-9) diagnosis and procedure codes were used to identify IVUS and OCT use during diagnostic angiography and PCI. RESULTS:Among 3,211,872 hospitalizations with coronary angiography, intracoronary imaging was performed in 88,775 cases (4.8% of PCI and 1.0% of diagnostic procedures), with IVUS in 98.9% and OCT in 1.1% of cases. Among patients undergoing PCI, the rate of intravascular coronary imaging increased from 2.1% in 2004-2005 to 6.6% in 2013-2014 (P < 0.001 for trend). Use of intravascular coronary imaging was associated with lower in-hospital mortality in patients undergoing PCI (adjusted OR 0.77; 95% CI 0.71-0.83). There was marked variability in intravascular imaging by hospital, with 63% and 13% of facilities using intravascular imaging in <5% and >15% of PCIs, respectively. CONCLUSIONS:In a large administrative database from the United States, intravascular imaging use was low, increased over time, and imaging was associated with reduced in-hospital mortality. Substantial variation in the frequency of intravascular imaging by hospital was observed. Additional investigation to determine clinical benefits of IVUS and OCT are warranted.

Venous thromboembolism (VTE), comprised of deep vein thrombosis and pulmonary embolism, is a common health problem both in the United States and worldwide, with significant associated morbidity and mortality. Despite multiple known genetic and situational risk factors, an estimated 30% of all events remain classified as idiopathic, demonstrating a significant knowledge gap in the pathophysiology VTE. While platelets are well established as an essential contributor to thrombus formation and there has been recent interest in the role of neutrophil extracellular traps, specific cell types and pathways involved in the pathogenesis of VTE remain uncertain. In this study, our primary aims were to define a unique transcriptional signature for VTE and to identify the types of cells and specific pathways involved in development of VTE. Whole blood was collected in PAX gene tubes and RNA sequencing for coding mRNA was performed in an unbiased manner in 201 patients with prevalent VTE as well as 43 healthy controls. We used a bioinformatics approach to develop a unique signature for VTE by identifying differentially expressed genes, developing cell-type modules, and ascertaining pathways driving differentially expressed transcripts. We performed additional analyses on subgroups of patients with idiopathic VTE, patients with incident VTE, and VTE patients matched to healthy controls by age and sex. We went on to use machine learning methods to learn models that best differentiate VTE patients from healthy controls and validated it on a left out test set within our VTE population. Genes specific to neutrophils, erythrocytes, and platelets, in that order, were most significantly upregulated in patients with VTE compared to healthy controls. Genes related to T-cells were downregulated. Pathway analysis revealed upregulated neutrophil activation and degranulation, erythrocyte differentiation and homeostasis, and platelet degranulation. A gene signature of 217 transcripts was outstanding at differentiating patients with VTE versus healthy controls (AUC 0.94). Following adjustment for age, sex, and race/ethnicity our genetic signature remained significantly robust at differentiating patients with VTE versus controls (AUC 0.83). Our expression signature remained stable across patients with idiopathic VTE (AUC 0.93), and in patients who went on to develop future VTE events (AUC 0.95). In summary, we have demonstrated a whole blood transcriptional signature for prevalent and incident VTE. Genes related to neutrophils, erythrocytes, and platelets are upregulated in patients with VTE and genes related to T-cells were downregulated. These findings suggest an active role of cell types once thought to be passively entrapped within thrombus and provide new areas of study to establish the pathophysiology of VTE

Introduction: Thrombocytopenia is a common laboratory abnormality among patients presenting with acute myocardial infarction (AMI). We sought to evaluate associations between thrombocytopenia, in-hospital management and cardiovascular outcomes in patients hospitalized for AMI in the United States.
Method(s): Patients hospitalized from 2004 to 2014 with a primary diagnosis of AMI were identified from the National Inpatient Sample (NIS). Thrombocytopenia was identified based on ICD-9 codes. Multivariable logistic regression models were used to estimate odds of in-hospital adverse events stratified by thrombocytopenia and adjusted for demographics, cardiovascular risk factors, comorbidities, and treatment.
Result(s): A total of 6,717,769 patients were hospitalized with a primary diagnosis of AMI and thrombocytopenia was reported in 219,351 (3.3%). Patients with thrombocytopenia were older, more likely to have medical comorbidities, were more likely to undergo coronary artery bypass grafting [CABG] (28.8% vs. 8.2%, p<0.001), and were less likely to receive a drug eluting stent [DES] (15.5% vs. 29.5%, p<0.001). After multivariable adjustment, thrombocytopenia remained an independent predictor of in-hospital mortality, ischemic stroke, cardiogenic shock, cardiac arrest and bleeding complications (Table).
Conclusion(s): This is the largest analysis of AMI outcomes for patients with and without thrombocytopenia. AMI patients with thrombocytopenia have a significantly greater risk of adverse outcomes, are more likely to undergo CABG and less likely receive a DES during hospitalization compared to other AMI patients. Thrombocytopenia may identify AMI patients at high risk for in-hospital morbidity and mortality. Future investigations to mitigate the poor prognosis of patients with AMI and thrombocytopenia are warranted

OBJECTIVE:To analyze trends in the incidence, in-hospital management, and outcomes of acute myocardial infarction (AMI) complicating pregnancy and the puerperium in the United States. PATIENTS AND METHODS/METHODS:Women 18 years or older hospitalized during pregnancy and the puerperium were identified from the National Inpatient Sample database from January 1, 2002, to December 31, 2014. International Classification of Diseases, Ninth Revision diagnosis and procedure codes were used to identify AMI during pregnancy-related admissions. RESULTS:Overall, 55,402,290 pregnancy-related hospitalizations were identified. A total of 4471 cases of AMI (8.1 [95% CI, 7.5-8.6] cases per 100,000 hospitalizations) occurred, with 922 AMI cases (20.6%) identified in the antepartum period, 1061 (23.7%) during labor and delivery, and 2390 (53.5%) in the postpartum period. ST-segment elevation myocardial infarction occurred in 1895 cases (42.4%), and non-ST-segment elevation myocardial infarction occurred in 2576 cases (57.6%). Among patients with pregnancy-related AMI, 2373 (53.1%) underwent invasive management and 1120 (25.1%) underwent coronary revascularization. In-hospital mortality was significantly higher in patients with AMI than in those without AMI during pregnancy (adjusted odds ratio, 39.9; 95% CI, 23.3-68.4; P<.001). The rate of AMI during pregnancy and the puerperium increased over time (adjusted odds ratio, 1.25 [for 2014 vs 2002]; 95% CI, 1.02-1.52). CONCLUSION/CONCLUSIONS:In patients hospitalized during pregnancy and the puerperium, AMI occurred in 1 of every 12,400 hospitalizations and rates of AMI increased over time. Maternal mortality rates were high. Additional research on the prevention and optimal management of AMI during pregnancy is necessary.

Standard clinical X-ray contrast agents are small iodine-containing molecules that are rapidly cleared by the kidneys and provide robust imaging for only a few seconds, thereby limiting more extensive vascular and tissue biodistribution imaging as well as optimal tumor uptake. They are also not generally useful for preclinical microCT imaging where longer scan times are required for high resolution image acquisition. We here describe a new iodine nanoparticle contrast agent that has a unique combination of properties: 20 nm hydrodynamic diameter, covalent PEG coating, 40 hour blood half-life, 50% liver clearance after six months, accumulation in tumors, and well-tolerated to at least 4 g iodine/kg body weight after intravenous administration in mice. These characteristics are unique among the other iodine nanoparticles that have been previously reported and provide extended-time high contrast vascular imaging and tumor loading. As such, it is useful for preclinical MicroCT animal studies. Potential human applications might include X-ray radiation dose enhancement for cancer therapy and vascular imaging for life-threatening situations where high levels of contrast are needed for extended periods of time.

Each year, more than 300 million patients worldwide undergo non-cardiac surgery. Perioperative myocardial infarction (MI) is a common cardiovascular complication of surgery; thus, we sought to determine coronary artery anatomy in patients referred for coronary angiography for the evaluation of perioperative MI after non-cardiac surgery.

OBJECTIVES/OBJECTIVE:Cardiovascular risk factors are prevalent in the population undergoing non-cardiac surgery. Changes in perioperative cardiovascular risk factor profiles over time are unknown. The objective of this study was to evaluate national trends in cardiovascular risk factors and atherosclerotic cardiovascular disease (ASCVD) among patients undergoing non-cardiac surgery. METHODS:Adults aged ≥45 years old who underwent non-cardiac surgery were identified using the US National Inpatient Sample from 2004 to 2013. The prevalence of traditional cardiovascular risk factors (hypertension, dyslipidaemia, diabetes mellitus, obesity and chronic kidney disease) and ASCVD (coronary artery disease, peripheral artery disease and prior stroke] were evaluated over time. RESULTS:A total of 10 581 621 hospitalisations for major non-cardiac surgery were identified. Between 2008 and 2013, ≥2 cardiovascular risk factors and ASCVD were present in 44.5% and 24.3% of cases, respectively. Over time, the prevalence of multiple (≥2) cardiovascular risk factors increased from 40.5% in 2008-2009 to 48.2% in 2012-2013, P<0.001. The proportion of patients with coronary artery disease (17.2% in 2004-2005 vs 18.2% in 2012-2013, P<0.001), peripheral artery disease (6.3% in 2004-2005 vs 7.4% in 2012-2013, P<0.001) and prior stroke (3.5% in 2008-2009 vs 4.7% 2012-2013, P<0.001) also increased over time. The proportion of patients with a modified Revised Cardiac Risk Index score ≥3 increased from 6.6% in 2008-2009 to 7.7% in 2012-2013 (P<0.001). CONCLUSIONS:Among patients undergoing major non-cardiac surgery, the burden of cardiovascular risk factors and the prevalence of ASCVD increased over time. Adverse trends in risk profiles require continued attention to improve perioperative cardiovascular outcomes.