Faculty Bibliography

AIMS/OBJECTIVE:The influence of community acute kidney injury on patients with myocardial infarction has not been explored. The Veterans Affair electronic health system was analyzed to test the hypothesis that patients who have myocardial infarction complicated by community acute kidney injury have higher short- and long-term mortality and cardiovascular outcomes than those who do not suffer acute kidney injury. MATERIALS AND METHODS/METHODS:Odd ratios were calculated for in-hospital mortality. Cox proportional hazard model was used to assess hazard ratios for long-term mortality comparing patients with and without community acute kidney injury. Secondary outcomes included recurrent cardiovascular events including hospitalization for congestive heart failure, stroke, or repeat myocardial infarction. RESULTS:10,689 patients were available for evaluation, 679 had community acute kidney injury and 10,010 with no acute kidney injury. Community acute kidney injury resulted in higher odds for inpatient mortality (odds ratio 5.87, p < 0.001), and adjusted hazard ratio for mortality at 5 years as compared to no acute kidney injury (hazard ratio 1.67, p < 0.001). No differences in cardiovascular outcomes were identified in Cox proportional hazard analysis. CONCLUSION/CONCLUSIONS:In patients with myocardial infarction, community acute kidney injury is associated with delays in or not receiving appropriate myocardial infarction related process of care measures. In addition it is an independent predictor of short- and long-term mortality.
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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.

BACKGROUND:Patients with chronic kidney disease (CKD) and stable ischemic heart disease are at markedly increased risk of cardiovascular events. Prior trials comparing a strategy of optimal medical therapy (OMT) with or without revascularization have largely excluded patients with advanced CKD. Whether a routine invasive approach when compared with a conservative strategy is beneficial in such patients is unknown. METHODS:or on dialysis) and moderate or severe ischemia on stress testing. Participants were randomized in a 1:1 fashion to the invasive or a conservative strategy. The primary end point is a composite of death or nonfatal myocardial infarction. Major secondary endpoints are a composite of death, nonfatal myocardial infarction, hospitalization for unstable angina, hospitalization for heart failure, or resuscitated cardiac arrest; angina control; and disease-specific quality of life. Safety outcomes such as initiation of maintenance dialysis and a composite of initiation of maintenance dialysis or death will be reported. The trial is projected to have 80% power to detect a 22% to 24% reduction in the primary composite end point with the invasive strategy when compared with the conservative strategy. CONCLUSIONS:ISCHEMIA-CKD will determine whether an initial invasive management strategy improves clinical outcomes when added to OMT in patients with advanced CKD and stable ischemic heart disease.

There are no dedicated data to guide drug eluting stent (DES) versus bare metal stent (BMS) selection in patients with end stage renal disease undergoing dialysis (ESRD-D). It is unclear whether long-term benefits of a specific stent-type outweigh risks in this population at high risk for both bleeding and ischemic events. We performed a meta-analysis of non-randomized studies extracted from PubMed, Scopus, and EMBASE; assessing the safety and effectiveness of DES versus BMS in ESRD-D patients. Odds ratios (OR) and 95% confidence intervals (CI) were computed with the Mantel-Haenszel method. Random-effects model was used for all analyses. A total of 17 non-randomized studies (N=63,157; 41,621 DES and 21,536 BMS) met the inclusion criteria and were included for the final quantitative analysis; median follow-up of 1 year (range: 9 months - 6 years). The use of DES in ESRD-D patients was associated with lower all-cause mortality (OR 0.75, 95%CI 0.64-0.89, P<0.001) compared with BMS. The use of DES was also associated with lower rates of cardiovascular mortality (OR 0.75, 95%CI 0.60-0.99, P=0.047) and target lesion/vessel revascularization (TLR/TVR) (OR 0.78, 95%CI 0.64-0.94, P=0.01). However, there were no differences in non-cardiovascular mortality, myocardial infarction, stent thrombosis, stroke or major bleeding in DES versus BMS. In this largest meta-analysis of long-term outcomes following percutaneous coronary intervention in ESRD-D patients, DES was associated with lower rates of all-cause mortality, TLR/TVR, and cardiovascular death.

BACKGROUND:Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality among patients with chronic kidney disease (CKD) with a glomerular filtration rate of < 60 mL/min/1.73 m2 body surface area. The availability of high-quality randomized controlled trial data to guide management for the population with CKD and ASCVD is limited. Understanding current practice patterns among providers caring for individuals with CKD and CVD is important in guiding future trial questions. METHODS:A qualitative survey study was performed. An electronic survey regarding the diagnosis and management of CVD in patients with CKD was conducted using a convenience sample of 450 practicing nephrology and cardiology providers. The survey was administered using Qualtrics® (https://www.qualtrics.com). RESULTS:There were a total of 113 responses, 81 of which were complete responses. More than 90% of the respondents acknowledged the importance of CVD as a cause of morbidity and mortality in patients with CKD. Outside the kidney transplant evaluation setting, 5% of the respondents would screen an asymptomatic patient with advanced CKD for ASCVD. Outside the kidney transplant evaluation scenario, the respondents did not opt for invasive management strategies in advanced CKD. CONCLUSIONS:The survey results reveal a lack of consensus among providers caring for patients with advanced CKD about the management of ASCVD in this setting. Future randomized controlled trials will be needed to better inform the clinical management of ASCVD in these patients. The limitations of the study include its small sample size and the relatively low response rate among the respondents.

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.