Faculty Bibliography

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.

Introduction: In patients presenting to non-PCI capable hospital with STEMI, the management options include transfer for primary PCI (PPCI) or administration of thrombolytics and transfer for PCI (lytics + PCI), a decision largely driven by the estimated door to device time. The 2013 AHA/ACC STEMI guidelines increased the door to device time for STEMI transfer patients from < 90 minutes to < 120 minutes. Whether this change has impacted management is not known.
Method(s): Patients in the New York (NY) State PCI Registry who underwent PCI (PPCI or lytics + PCI) for STEMI after being transferred from a non-PCI capable hospital in 2012 and 2014 were included in this study. Primary outcome was a change in the proportion of patients who underwent PPCI in relation to lytics + PCI in 2014 as compared with year 2012. Secondary outcomes were changes in transfer time (non-PCI capable transfer hospital door to PCI hospital door time), PCI hospital door to device time, transfer hospital door to device time in PPCI patients, and in-hospital mortality for all STEMI transfer patients who underwent PCI.
Result(s): There were 2019 and 1799 patients who underwent PCI (PCI or lytics +PCI) for a STEMI after presenting to a non-PCI capable hospital in NY State in 2012 and 2014 respectively. There was an increase in the proportion of patients receiving PPCI (vs lytics+ PCI) from 2012 to 2014 (74.15% to 78.32%, p = 0.0025). Moreover, in patients receiving PPCI, there was also a decrease in transfer time [median: 102 min (Q1:73, Q3162) to 97 min (Q1: 70, Q3:147),p = 0.005], PCI hospital door to device time [35 min (25,53) to 34 min (24, 51), p = 0.07), and transfer hospital door to device time [143 min (105, 220) to 134 min (102, 200), p = 0.005]. However, there was no change in mortality from 2012 to 2014 in all STEMI transfer patients who underwent PCI (2.13% vs 2.95%, p = 0.11).
Conclusion(s): Data from NY State indicates a significant increase in referral for PPCI in patients presenting with a STEMI to a non-PCI capable hospital with the change in guidelines increasing the door to device times for transfer patients. Whether such a strategy improves outcomes should be tested in further studies

Introduction: There are scant data on the use of P2Y12 antagonist therapy upstream of diagnostic angiography (DA), especially when administered in the ED for NSTEMI. We host a multicenter US registry to describe patterns of upstream P2Y12therapy and outcomes.
Method(s): UPSTREAM (NCT02271022) is an ongoing prospective, observational registry of consecutive NSTEMI patients, evaluated in an ED, who at the treating clinician's discretion are given a loading dose (LD) of ticagrelor, clopidogrel, or prasugrel 4 or more hrs prior to DA, which in turn is performed no more than 72 hrs after ED arrival. Data are collected on all patients through hospital discharge. Those patients receiving ticagrelor throughout the index hospitalization and at discharge are followed 30-40 days for vital status, rehospitalization, bleeding complications, and P2Y12 compliance. We report the in-hospital outcomes of the first 2512 NSTEMI patients studied at 54 hospitals.
Result(s): In this cohort over 3.5 years' enrollment, the P2Y12 upstream LD was clopidogrel in 53%, ticagrelor in 46%, and prasugrel in 1%, although agent switching during hospitalization and at discharge occurs. Overall, 1355 (54%) received at least one dose of ticagrelor? 697 (27.7%) were maintained on ticagrelor consistently and had 30-day follow-up completed. Patients had a mean age of 63 y? 19% are older than 75 y. Approximately 21% of patients had a documented prior MI, 26% had a prior stent, 15% had prior CABG, and 12% had documented CKD. The median (SD) time from ED arrival to LD was 6.4 (6.7) h, and time from LD to DA was 11.3 (9.5) h. DA was performed via femoral access in 57% of patients and radially in 43%. Post-DA management was 58% stent, 34% medical management, and 8% CABG. In-hospital CV events, including mortality, were infrequent (0.6%). Only 53 patients (31 [1.2%] CABG-related and 22 [0.9%] non-CABG) required RBC transfusion, while 23 (19 CABG-related) required a platelet transfusion. Six stent thrombosis events were recorded.
Conclusion(s): Upstream P2Y12therapy in NSTEMI patients undergoing an invasive strategy is associated with good clinical outcomes and minimal risk of bleeding. The most commonly used

BACKGROUND:Some studies have shown that body weight variability is a risk factor for cardiovascular events, but this has not been studied in subjects with diabetes mellitus. METHODS AND RESULTS/RESULTS:We measured intraindividual variations in body weight from baseline and follow-up visits in 6408 subjects with type 2 diabetes mellitus from 3 clinical trials. The primary end point, any coronary event, was a composite of coronary heart disease death, myocardial infarction, resuscitated cardiac arrest, coronary revascularization, and unstable or new-onset angina. After adjustment for risk factors, baseline lipid levels, mean body weight, and weight change, each increase of 1 SD in body weight variability, measured as average successive variability and used as a time-dependent covariate, was associated with an increase in the risk of any coronary event (hazard ratio, 1.08; 95% CI, 1.01-1.14; P=0.017), major coronary event (hazard ratio, 1.12; 95% CI, 1.04-1.20; P=0.002), any cardiovascular event (hazard ratio, 1.08; 95% CI, 1.03-1.14; P=0.0015), and death (hazard ratio, 1.16; 95% CI, 1.10-1.22; P<0.0001). Among patients in the quintile with the highest variation in body weight compared with the lowest, the risk of any coronary event was 59% higher; the risk of a major coronary event, 82% higher; any cardiovascular event, 75% higher; death, 82% higher; myocardial infarction, 99% higher; and stroke, 92% higher in adjusted models. The results were consistent in a number of sensitivity analyses. CONCLUSIONS:Among subjects with type 2 diabetes mellitus, fluctuation in body weight was associated with higher mortality and a higher rate of cardiovascular events, independent of traditional cardiovascular risk factors. CLINICAL TRIAL REGISTRATION/BACKGROUND:URL: http://www.clinicaltrials.gov . Unique identifier: NCT00327691 and NCT00327418.

BACKGROUND:Myocardial infarction (MI) is a multifactorial disease with complex pathogenesis, mainly the result of the interplay of genetic and environmental risk factors. The regulation of thrombosis, inflammation and cholesterol and lipid metabolism are the main factors that have been proposed thus far to be involved in the pathogenesis of MI. Traditional risk-estimation tools depend largely on conventional risk factors but there is a need for identification of novel biochemical and genetic markers. The aim of the study is to identify differentially expressed genes that are consistently associated with the incidence myocardial infarction (MI), which could be potentially incorporated into the traditional cardiovascular diseases risk factors models. METHODS:The biomedical literature and gene expression databases, PubMed and GEO, respectively, were searched following the PRISMA guidelines. The key inclusion criteria were gene expression data derived from case-control studies on MI patients from blood samples. Gene expression datasets regarding the effect of medicinal drugs on MI were excluded. The t-test was applied to gene expression data from case-control studies in MI patients. RESULTS:A total of 162 articles and 174 gene expression datasets were retrieved. Of those a total of 4 gene expression datasets met the inclusion criteria, which contained data on 31,180 loci in 93 MI patients and 89 healthy individuals. Collectively, 626 differentially expressed genes were detected in MI patients as compared to non-affected individuals at an FDR q-value = 0.01. Of those, 88 genes/gene products were interconnected in an interaction network. Totally, 15 genes were identified as hubs of the network. CONCLUSIONS:Functional enrichment analyses revealed that the DEGs and that they are mainly involved in inflammatory/wound healing, RNA processing/transport mechanisms and a yet not fully characterized pathway implicated in RNA transport and nuclear pore proteins. The overlap between the DEGs identified in this study and the genes identified through genetic-association studies is minimal. These data could be useful in future studies on the molecular mechanisms of MI as well as diagnostic and prognostic markers.

BACKGROUND: Adequacy of major depressive disorder (MDD) treatment among cardiovascular disease (CVD) patients has been linked with improved CVD outcomes. OBJECTIVE: The current study examined the association between MDD care adequacy and healthcare resource use (HCRU) and costs among patients with prior myocardial infarction (MI) or stroke. METHODS: This was a retrospective cohort study conducted using the Truven Health MarketScan Claims Database (2010-2015) among adults diagnosed with MDD following an initial MI or stroke. The date of the first MI/stroke diagnosis was defined as the index CVD date and the first date of a subsequent MDD diagnosis was the index MDD date. Adequacy of MDD care was assessed during the 90-day period post index MDD date using 2 measures: dosage adequacy (average fluoxetine equivalent dose of 20 mg/day for nonelderly and 10 mg/day for elderly patients) and duration adequacy (measured as the proportion of days covered of 80% or higher for all MDD drugs). Patients who did not meet either of these criteria were categorized as receiving inadequate MDD care. Multivariate logistic regression adjusted for baseline characteristics was used to calculate the propensity of receiving adequate MDD care. Propensity-score adjusted annual HCRU outcomes were estimated using generalized linear models (GLM) with Poisson distribution. Adjusted costs were estimated using two-part logit-GLMs. RESULTS: Of 1,568 CVD patients who were treated for MDD, 937 (59.8%) were categorized as receiving inadequate MDD care. Patients receiving inadequate MDD care had 14% higher (IRR: 1.14 [95% CI: 1.01-1.30]; P = 0.036) and 21% longer (IRR: 1.21 [95% CI: 1.15-1.27]; P < 0.001) all-cause hospitalizations,4% more all-cause outpatient visits (IRR: 1.04 [95% CI: 1.02-1.06]; P < 0.001), 24% longer CVDrelated hospitalizations (IRR: 1.24 [95% CI: 1.17-1.31]; P < 0.001), 17% more CVD-related outpatient visits (IRR: 1.17 [95% CI: 1.13-1.21]; P < 0.001), and 13% more CVD-related ER visits (IRR: 1.13 [95% CI: 1.03-1.24]; P = 0.006) compared to patients receiving adequate MDD care. Adjusted per patient CVD-related hospitalization costs ($21,485 vs. $17,756; P < 0.001), all-cause outpatient costs ($2,820 vs. $2,055; P < 0.001), and CVD-related ($520 vs. $434; P < 0.001) outpatient costs were significantly higher for CVD patients receiving inadequate MDD care versus those receiving adequate care. CONCLUSIONS: Among patients with newly diagnosed MI or stroke, inadequate MDD care was associated with a significantly higher economic burden. Hospitalization was the key driver of this increased burden

Background Standardization of evidence-based medical therapies has improved outcomes for patients with non- ST -segment-elevation myocardial infarction ( NSTEMI ). Although racial differences in NSTEMI management have previously been reported, it is uncertain whether these differences have been ameliorated over time. Methods and Results The ARIC (Atherosclerosis Risk in Communities) Community Surveillance study conducts hospital surveillance of acute myocardial infarction in 4 US communities. NSTEMI was classified by physician review, using a validated algorithm. From 2000 to 2014, 17 755 weighted hospitalizations for NSTEMI (patient race: 36% black, 64% white) were sampled by ARIC . Black patients were younger (aged 60 versus 66 years), more often female (45% versus 38%), and less likely to have medical insurance (88% versus 93%) but had more comorbidities. Black patients were less often administered aspirin (85% versus 92%), other antiplatelet therapy (45% versus 60%), β-blockers (85% versus 88%), and lipid-lowering medications (68% versus 76%). After adjustments, black patients had a 24% lower probability of receiving nonaspirin antiplatelets (relative risk: 0.76; 95% confidence interval, 0.71-0.81), a 29% lower probability of angiography (relative risk: 0.71; 95% confidence interval, 0.67-0.76), and a 45% lower probability of revascularization (relative risk: 0.55; 95% confidence interval, 0.50-0.60). No suggestion of a changing trend over time was observed for any NSTEMI therapy ( P values for interaction, all >0.20). Conclusions This longitudinal community surveillance of hospitalized NSTEMI patients suggests black patients have more comorbidities and less likelihood of receiving guideline-based NSTEMI therapies, and these findings persisted across the 15-year period. Focused efforts to reduce comorbidity burden and to more consistently implement guideline-directed treatments in this high-risk population are warranted.

AIMS/OBJECTIVE:To evaluate the safety and efficacy of BioMime™ sirolimus-eluting coronary stent (SES) compared to the XIENCE family everolimus-eluting coronary stent (EES) in the treatment of patients with de novo native coronary artery lesions. METHODS AND RESULTS/RESULTS:The meriT-V is a prospective, multicenter, randomized, open-label, active-controlled, and non-inferiority trial. A total of 256 patients with up to two de novo native coronary artery lesions were enrolled and randomly assigned (2:1) to BioMime SES or XIENCE EES. BioMime SES was non-inferior to XIENCE EES for the primary endpoint of in-stent late lumen loss (0.15±0.27 mm vs. 0.15±0.29 mm; difference: -0.006 mm; 95% confidence interval: -0.085 to 0.072; p=0.87; p for non-inferiority <0.0001) at 9-month follow-up. The major adverse cardiac event rate was numerically lower in BioMime SES group (2.98% vs. 7.14%; p=0.13), driven by a statistically significant lower risk of any myocardial infarction (0.60% vs. 4.76%; p=0.03), when compared with the XIENCE EES group. There was no difference in target vessel myocardial infarction (p=0.62) between the groups. There was no definite or probable stent thrombosis in either group. CONCLUSIONS:In the treatment of de novo native coronary artery lesions, the biodegradable polymer ultra-thin SES (BioMime) was non-inferior to durable polymer EES (XIENCE) at 9-month follow-up. Further studies powered for clinical endpoints are needed.