Faculty Bibliography

In addition to aggressive lifestyle and nonlipid risk factor modification, statin therapy improves cardiovascular disease outcomes following acute coronary syndromes. Despite established benefits of treatment, contemporary registries reveal substantial underutilization of and nonadherence to statin therapy for secondary prevention. In randomized controlled trials investigating statin therapy, including moderate-intensity statin plus ezetimibe therapy, rates of nonadherence are reported in up to 40% of subjects. Durable strategies to address gaps in lipid lowering for secondary prevention are essential to maximize reduction in cardiovascular disease risk.

Myocardial necrosis in the perioperative period of noncardiac surgery is associated with short-term mortality, but long-term outcomes have not been characterized. We investigated the association between perioperative troponin elevation and long-term mortality in a retrospective study of consecutive subjects who underwent hip, knee, and spine surgery. Perioperative myocardial necrosis and International Classification of Disease, Ninth Revision-coded myocardial infarction (MI) were recorded. Long-term survival was assessed using the Social Security Death Index database. Logistic regression models were used to identify independent predictors of long-term mortality. A total of 3,050 subjects underwent surgery. Mean age was 60.8 years, and 59% were women. Postoperative troponin was measured in 1,055 subjects (34.6%). Myocardial necrosis occurred in 179 cases (5.9%), and MI was coded in 20 (0.7%). Over 9,015 patient-years of follow-up, 111 deaths (3.6%) occurred. Long-term mortality was 16.8% in subjects with myocardial necrosis and 5.8% with a troponin in the normal range. Perioperative troponin elevation (hazard ratio 2.33, 95% confidence interval 1.33 to 4.10) and coded postoperative MI (adjusted hazard ratio 3.51, 95% confidence interval 1.44 to 8.53) were significantly associated with long-term mortality after multivariable adjustment. After excluding patients with coronary artery disease and renal dysfunction, myocardial necrosis remained associated with long-term mortality. In conclusion, postoperative myocardial necrosis is common after orthopedic surgery. Myocardial necrosis is independently associated with long-term mortality at 3 years and may be used to identify patients at higher risk for events who may benefit from aggressive management of cardiovascular risk factors.

BACKGROUND: Over the past decade, ischemic heart disease (IHD) mortality trends have been less favorable among adults age 25-54 than age >/=55 years. HYPOTHESIS: Disorders associated with IHD such as diabetes, chronic inflammatory and infectious diseases, and cocaine use are important contributors to premature IHD mortality. METHODS: Multiple-cause-of-death analysis was performed using the New York City (NYC) Vital Statistics database. Frequencies of selected contributing causes on death records with IHD as the underlying cause for decedents age >/=25 were assessed (n = 418,151; 1990-2008). Concurrent Telephone risk-factor surveys (NYC Community Health Survey, Centers for Disease Control Behavioral Risk Factor Survey in New York State) were analyzed. RESULTS: In sum, a prespecified contributing cause was identified on 13.6% of death certificates for IHD decedents age 25-54. Diabetes was reported more frequently for younger IHD decedents (15% of females and 10% of males age 25-54 vs 6% of both sexes age >/= 55). In contrast, concurrent diabetes prevalence in New York State was 3.4% for those age 25-54 and 13.6% for those age >55 (P < 0.0001). Systemic lupus erythematosus, human immunodeficiency virus, and cocaine were also more likely to contribute to IHD death among younger than older people. CONCLUSIONS: Diabetes may be a potent risk factor for IHD death in young people, particularly young women, in whom it was reported on IHD death records at a rate 5x higher than local prevalence. The high frequency of reporting of studied contributing causes in younger IHD decedents may provide a focus for further IHD mortality-reduction efforts in younger adults.

Type 2 myocardial infarction (type 2 MI) is defined as myocardial necrosis that results from an imbalance of myocardial oxygen supply and demand. Although type 2 MI is highly prevalent and strongly associated with mortality, the pathophysiology remains poorly understood. Discrepancies in definitions, frequency of screening, diagnostic approaches, and methods of adjudication lead to confusion and misclassification. To date, there is no consensus on the diagnostic criteria for type 2 MI. No guidelines exist for the optimal management of this condition, and further investigation is urgently needed. This review explores the existing evidence on the pathophysiology, diagnosis, prognosis, and management of type 2 MI.

Background: Type 2 myocardial infarction (MI) is defined as myocardial necrosis due to an imbalance in supply and demand. Clinical characteristics predisposing to Type 2 MI and medical therapy use remain uncertain. Methods: Charts of patients admitted to NYU Langone Medical Center in 2013 with a diagnosis of secondary myocardial ischemia (ICD9 411.89) or non-primary diagnosis of non-ST-elevation MI (ICD9 410.71) were retrospectively reviewed, following hospital standardization of acute MI ICD9 coding. Cases with suspected/confirmed Type 1 MI or without rise and fall of troponin were excluded. Results: Charts of 104 inpatients with Type 2 MI have been reviewed to date, with evaluation of additional cases ongoing. Conditions associated with and possibly provoking Type 2 MI included sepsis (defined as SIRS with an infectious source, 39%), surgery (37%), anemia (Hgb < 7 mg/dL), bleeding, or transfusion >1 PRBCs (34%), respiratory failure (28%), tachyarrhythmia (21%), hypotension (17%), hypertensive crisis (8%), and bradycardia (2%). Multiple provoking conditions were identified in 74% of cases. See Table for risk factors, procedure use and results and in-hospital outcomes. Inpatient mortality was 3%. Among 92 patients discharged alive and not to hospice, medical regimens included aspirin (65%), statin (66%), ACE inhibition (ACEi) (38%), and beta blocker (65%). Patients with a peak troponin >1.0 ng/mL (35%) were more likely to be discharged on aspirin (p=0.004) and beta-blocker (p=0.027), but not statin or ACEi. Conclusions: Type 2 MI occurs most frequently in the setting of sepsis, surgery, and/or anemia in patients with cardiovascular risk factors, but mechanisms of Type 2 MI remain poorly understood. Rates of outpatient antiplatelet and statin prescription are low at hospital discharge, reflecting physician uncertainty about the role of secondary prevention. Further research into mechanisms is needed to inform management of patients with Type 2 MI

Remote-controlled robotic-enhanced percutaneous coronary intervention (PCI) was developed to improve procedural outcomes, reduce operator radiation exposure, and improve ergonomics. Critics questioned whether protection of the operator might result in increased radiation exposure to the patient and increase contrast media use. We studied this in a single-center comparison of robotic-enhanced versus traditional PCIs. A total of 40 patients who enrolled in the PRECISE study and had PCI with the CorPath 200 robotic system (Corindus Vascular Robotics) were compared to 80 consecutive patients who underwent conventional PCI. All patients had obstructive coronary artery disease, evidence of myocardial ischemia, and clinical indications for single-vessel PCI. Baseline demographics of the 40 robotic and 80 traditional PCIs were similar. Only 2 robotic-assisted cases required conversion to manual PCI. All patients had a final residual stenosis <30%. Robotic-enhanced PCI was associated with trends toward lower duration of fluoroscopy (10.1 +/- 4.7 min vs 12.3 +/- 7.6 min; P=.05), radiation dose (1389 +/- 599 mGy vs 1665 +/- 1026 mGy; P=.07), and contrast volume (121 +/- 47 mL vs 137 +/- 62 mL; P=.11). In conclusion, the initial experience with robotic-enhanced PCI was not associated with increased fluoroscopy duration, radiation, or contrast media exposure to patients, and compared favorably to the traditional approach.

OBJECTIVES: The PRECISE multi-center study demonstrated the safety and feasibility of robotic-enhanced coronary intervention (PCI). We studied the learning curve associated with the robotic PCI approach. METHODS: The CorPath 200 robotic system was used to perform clinically indicated PCI. The first 3 cases performed by each interventional cardiologist were considered early-experience cases and subsequent procedures were regarded as advanced-experience cases. We compared procedure efficiency, patient radiation exposure, and clinical outcomes in early and advanced-experience cases. RESULTS: A total of 164 robotic-enhanced PCI procedures were performed, with 60 early-experience cases. Advanced-experience cases were associated with shorter procedure duration (51.3 +/- 25.5 min vs. 42.2 +/- 16.4 min, P = 0.008) and fluoroscopy time (12.9 +/- 7.8 min vs. 10.1 +/- 4.8 min, 0.009) as compared to early-experience cases. CONCLUSIONS: After performing 3 cases, interventionalists were able to complete robotic-enhanced PCI faster, with reduced radiation, and without compromising safety. The steep learning curve highlights the easy adoption of remote-control robotic technology for PCI.

A remote-controlled, robotic system was developed to address procedural challenges and occupational hazards associated with traditional percutaneous coronary intervention (PCI). The PRECISE (Percutaneous Robotically Enhanced Coronary Intervention) Study demonstrated the safety and feasibility of the robotic system. We report four cases of complex coronary interventions demonstrating the capabilities of robotic-enhanced PCI to treat multilesion, multivessel coronary disease, saphenous venous graft disease, and an ST-elevation myocardial infarction. The robotic system offers enhanced visibility, precise measurement, accurate stent positioning, improved ergonomics, and superior operator protection from radiation.