Faculty Bibliography

This retrospective cohort study compared blood pressure (BP) control (BP <140/90 mm Hg) and all-cause mortality between US- and foreign-born blacks. We used data from a clinical data warehouse of 41 868 patients with hypertension who received care in a New York City public healthcare system between 2004 and 2009, defining BP control as the last recorded BP measurement and mean BP control. Poisson regression demonstrated that Caribbean-born blacks had lower BP control for the last BP measurement compared with US- and West African-born blacks, respectively (49% vs 54% and 57%; P<.001). This pattern was similar for mean BP control. Caribbean- and West African-born blacks showed reduced hazard ratios of mortality (0.46 [95% CI, 0.42-0.50] and 0.28 [95% CI, 0.18-0.41], respectively) compared with US-born blacks, even after adjustment for BP. BP control rates and mortality were heterogeneous in this sample. Caribbean-born blacks showed worse control than US-born blacks. However, US-born blacks experienced increased hazard of mortality. This suggests the need to account for the variations within blacks in hypertension management.

BACKGROUND: The recent AHA/ACC guidelines on duration of dual anti-platelet therapy (DAPT) recommend DAPT for 1 year in patients presenting with an acute coronary syndrome, with a Class IIb recommendation for continuation. We aim to assess the evidence for these recommendations using a meta-analytic approach. METHODS: We searched electronic databases for randomized trials comparing short-term (12 months) DAPT in patients with an acute coronary syndrome undergoing percutaneous coronary intervention. We evaluated all-cause mortality, cardiovascular mortality, myocardial infarction, stent thrombosis and major bleeding. A random effects model was used to calculate pooled relative risk (RR) and 95% confidence intervals (CI). RESULTS: We included 8 trials comprising of 12,917 patients with an acute coronry syndrome; 5 trials compared short-term vs 12 months/extended DAPT, whereas 3 trials compared 12 months vs extended DAPT. There was no significant difference in cardiovascular mortality (RR: 1.04, 95% CI: 0.67-1.60), MI (RR: 1.08, 95% CI: 0.79-1.47) or major bleeding (RR: 0.91, 95% CI: 0.49-1.69) between short-term versus 12 months/extended DAPT. However, compared to extended DAPT, 12 months DAPT showed significantly higher risk of myocardial infarction (RR: 2.00, 95% CI: 1.47-2.73) but reduced risk of major bleeding (RR: 0.58, 95% CI: 0.34-0.98). All-cause mortality was found to be similar between 12 months vs extended DAPT. CONCLUSIONS: In acute coronary syndrome, short-term DAPT may be reasonable for some patients whereas extended DAPT may be appropriate in select others. An individualized approach is needed taking into account the competing risks of bleeding and ischemic events.

Background: Acute myocardial infarction (AMI) is a significant cardiovascular complication following non-cardiac surgery. We evaluated national trends in perioperative AMI, management, and outcomes using a large administrative database of United States hospital admissions. Methods: Patients who underwent non-cardiac surgery from 2005 to 2013 were identified using the National Inpatient Sample. Perioperative AMI was evaluated over time. Propensity score matching was used to compile cohorts of patients with perioperative AMI matched on their baseline characteristics who were managed invasively (defined as cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft surgery [CABG]) versus conservatively. The primary outcome was in-hospital all-cause mortality. Results: Among 9,566,277 hospitalizations for major non-cardiac surgery, perioperative AMI occurred in 84,093 (0.88%). Over time, the rate of perioperative AMI per 100,000 surgeries declined by 170 (95% CI 158 - 181), from 898 in 2005 to 729 in 2013 (p for trend <0.0001). Perioperative AMI occurred most frequently in patients undergoing vascular (2.0%), transplant (1.6%), and thoracic (1.5%) surgery. In-hospital mortality was higher in patients with perioperative AMI than those without AMI (18.0% vs. 1.5%, p<0.0001; adjusted OR 5.76, 95% CI 5.65 - 5.88). Mortality associated with perioperative AMI declined over time (adjusted OR 0.86, 95% CI 0.84 - 0.88). In a propensity-matched cohort of 34,650 patients with perioperative AMI, invasive management was associated with lower mortality than conservative management (8.9% vs. 18.1%, p<0.001; OR 0.44, 95% CI 0.41-0.47). Conclusion: Perioperative AMI occurs in 0.9% of patients undergoing major non-cardiac surgery and is strongly associated with in-hospital mortality. Invasive management of such patients may mitigate some of this excess risk

Background: The recent AHA/ACC guidelines on duration of dual anti-platelet therapy (DAPT) recommends DAPT for 1 year in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI), with a Class IIb recommendation for continuation. Methods: We searched electronic databases to identify randomized trials comparing short-term (<=6 months) vs 12 months vs extended (>12 months) DAPT in patients with ACS undergoing PCI. We evaluated allcause and cardiovascular mortality, myocardial infarction (MI), stent thrombosis and major bleeding. Random effects modeling was used to calculate pooled relative risk (RR) and 95% confidence intervals (CI). Results: We included 8 trials comprising of 12,917 ACS patients; 5 trials compared short-term vs 12 months or extended DAPT, whereas 3 trials compared 12 months vs extended DAPT. There were no significant differences in either ischemic or bleeding outcomes between short-term vs 12 months or extended DAPT. However compared to extended DAPT, 12 months DAPT showed significantly higher risk of MI (RR 2.00, 95% CI: 1.47 to 2.73, p<0.001) but reduced risk of major bleeding (RR 0.58, 95% CI: 0.34 to 0.98, p=0.04). All-cause mortality was similar between 12 months vs extended DAPT. The heterogeneity was low to moderate (I2 ranged from 17% to 39%). Conclusion: In ACS, DAPT beyond 1 year should be based on an individualized patient approach taking into account the competing risks of bleeding and ischemic complications. (Table Presented)

Von Willebrand disease (VWD) is an inherited bleeding disorder that often manifests clinically with hemorrhage after invasive procedures. We investigated the association between a diagnosis of VWD and bleeding and thrombotic outcomes following major non-cardiac surgery in a large national database from the United States. Patients age >/=45 years requiring major non-cardiac surgery were identified from Healthcare Cost and Utilization Project's National Inpatient Sample data. Von Willebrand disease, perioperative major adverse cardiovascular events (MACE), thrombotic events, and hemorrhage were defined by ICD9 diagnosis codes. From 2004 to 2013, a total of 10,581,621 hospitalizations for major non-cardiac surgery met study inclusion criteria and VWD was identified in 3765 (0.036%). In adjusted analyses, patients with VWD were significantly more likely to develop post-operative hemorrhage than patients without VWD (5.5 vs. 1.9%, p < 0.001; adjusted OR 3.49, 95% CI 3.03-4.03), but had similar odds of perioperative MACE and thrombotic events. Thus, a diagnosis of VWD was associated with increased risks of bleeding with non-cardiac surgery, without a corresponding reduction in perioperative thrombosis in comparison to patients without VWD. Perioperative management of patients with hereditary bleeding disorders and mitigation of thrombotic risks requires further study.