Faculty Bibliography

Retrograde approach to chronic total occlusions (CTO) has been described via saphenous vein grafts, septal and epicardial collaterals. We report for the first time a successful retrograde approach to an ostial left anterior descending (LAD) artery CTO through a failed left internal mammary artery (LIMA) to LAD anastamosis. This case demonstrates the technical aspects of using a LIMA conduit as a retrograde approach to CTO. (c) 2015 Wiley Periodicals, Inc.

Patients hospitalized with sepsis may be predisposed to acute myocardial infarction (AMI). The incidence, treatment, and outcomes of AMI in sepsis have not been studied. We analyzed data from the National Inpatient Sample from 2002 to 2011 for patients with a diagnosis of sepsis. The incidence of AMI as a nonprimary diagnosis was evaluated. Propensity score matching was used to identify a cohort of patients with secondary AMI and sepsis with similar baseline characteristics who were managed invasively (defined as cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft [CABG] surgery) or conservatively. The primary outcome was in-hospital all-cause mortality. A total of 2,602,854 patients had a diagnosis of sepsis. AMI was diagnosed in 118,183 patients (4.5%), the majority with non-ST elevation AMI (71.4%). In-hospital mortality was higher in patients with AMI and sepsis than those with sepsis alone (35.8% vs 16.8%, p <0.0001; adjusted odds ratio 1.24, 95% CI 1.22 to 1.26). In patients with AMI, 11,899 patients (10.1%) underwent an invasive management strategy, in which 4,668 patients (39.2%) underwent revascularization. PCI was performed in 3,413 patients (73.1%), CABG in 1,165 (25.0%), and both CABG and PCI in 90 patients (1.9%). In a propensity-matched cohort of 23,708 patients with AMI, invasive management was associated with a lower mortality than conservative management (19.0% vs 33.4%, p <0.001; odds ratio 0.47, 95% CI 0.44 to 0.50). In subgroups that underwent revascularization, the odds of mortality were consistently lower than corresponding matched subjects from the conservative group. In conclusion, myocardial infarction not infrequently complicates sepsis and is associated with a significant increase in in-hospital mortality. Patients managed invasively had a lower mortality than those managed conservatively.

BACKGROUND: The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the treatment of blood cholesterol recommends moderate to high intensity statins for patients with atherosclerotic cardiovascular disease but departs from the traditional treat to target approach. Whether percentage low density lipoprotein cholesterol (LDL-C) reduction or attained LDL-C levels add incremental prognostic value to statin dose is not known. METHODS: Patients in the TNT, IDEAL and SPARCL trials (patient-level data) randomized to a statin arm (atorvastatin 80mg/10mg or simvastatin 20mg) were chosen. Patients were divided into groups based on attained LDL-C levels (70 mg/dl) and percent LDL-C reduction (>/=50% vs. <50%). Primary outcome was major cardiovascular event defined as death from coronary heart disease, nonfatal myocardial infarction, resuscitated cardiac arrest, or stroke. Incremental prognostic value was assessed by using a forward conditional Cox proportional hazards model. Two models were tested: Model 1: Step 1-statin dose; Step 2-add attained LDL-C levels (continuous variable); Step 3-add percent LDL-C reduction (continuous variable). Model 2: step 2 and 3 were reversed. RESULTS: Among 13,937 patients included in this study, percent LDL-C reduction added incremental prognostic value over both statin dose and attained LDL-C levels (Global chi2 increased from 3.64 to 26.1 to 47.5; P<0.0001). However, attained LDL-C level did not provide incremental prognostic value over statin dose and percent LDL-C reduction (Global chi2 increased from 3.64 to 47.5 to 47.5; P<0.0001 and 0.94 respectively). Among patients with attained LDL-C /=50%. CONCLUSIONS: In patients with atherosclerotic cardiovascular disease, percent LDL-C reduction provides incremental prognostic value over statin dose and attained LDL-C levels. However, the attained LDL-C level does not provide additional prognostic value over statin dose and percent LDL-C reduction.

Hydrochlorthiazide (HCTZ) is one of the most commonly prescribed antihypertensive drugs worldwide. More than 97% of all HCTZ prescriptions are for 12.5 to 25 mg per day. The purpose of this study was to evaluate the antihypertensive efficacy ofHCTZby clinic blood pressure (BP) and ambulatory BP (ABP) monitoring when compared to other anti-hypertensives. A systematic review was performed using Medline, Cochrane, Scopus and Embase databases for all randomized trials that assessed both clinic and 24-h ABP with HCTZ in comparison with other antihypertensive drugs. In addition, trials were selected only if they studiedHCTZas monotherapy and have trial duration of at least 4 weeks. Eleven studies (16 comparisons) with 918 patients fulfilled the inclusion criteria. All the studies used HCTZ dose 12.5 to 25 mg/day except one study that used a dose of 25-50 mg/day. The decrease in clinic BP with HCTZ was systolic 12.1mmHg (95% confidence interval [CI]: 6.0 to 18.3mmHg) and diastolic 6.3mmHg (95% CI: 2.8 to 9.9 mm Hg). The reduction in 24-h ABP with HCTZ was systolic 6.4 mm Hg (95% CI: 5.0 to 7.7 mm Hg) and diastolic 3.3 mm Hg (95% CI: 1.8 to 4.9 mm Hg). In head-to-head comparisons with other antihypertensive drug classes, compared to HCTZ, ACE inhibitors/ARBs resulted in significant greater reduction in systolic clinic andABPby 4.5/2.3mmHg, beta-blockers by 8.1/6.2 mm Hg, calcium antagonists by 3.2/2.5 mm Hg and thiazide-type diuretics by 7.8/5.3 mm Hg. Similarly, other anti-hypertensive drug classes resulted in significantly greater reduction of diastolic ABP and clinic

Background: In the United States, 40% of African Americans are disproportionately affected by hypertension leading to severe comorbidity and eventual mortality. Ethnic differences in hypertension among the various African American groups are not well documented. We evaluated the blood pressure control rates of Caribbean and West African born African Americans compared to US born African Americans attending New York City Health and Hospitals Corporation (NYC HHC) facilities. Methods: Data from NYC HHC clinical data warehouse were extracted for hypertensive patients seen between January 2004 and December 2009. Ethnic origin was based on self-reported country of birth (United States, the Caribbean, and West Africa). Blood pressure (BP) was scored by taking the average of 3 or more blood pressure measurements over the course of 3 months of HHC data. All BP measurements were made in the clinical setting and uncontrolled hypertension was defined as BP >140/90 mm Hg. All BPs were measured at least 4 months after hypertension diagnosis. We also extracted information regarding comorbid diagnoses, number of prescribed antihypertensive classes, number of medical visits, age, sex, BMI and mortality. We compared the groups using cox proportional hazard regression models. Results: The sample was composed of 25,142 African Americans of whom 13,778 (54.8%) were US born, 10,032 (39.9%) were Caribbean born, and 1,332 (5.3%) were West African born. The mean sample age was 51 (14.2) years, the mean BMI was 32.4 (11.0) and the sample was 61.4% (N=15,449) female. Compared to US born African Americans, Caribbean and West African born African Americans had higher levels of systolic blood pressure (3.8mmHg; p<.001 and 2.4mmHg; p<.001 respectively) and were more likely to have uncontrolled BP (OR=1.40;p<.001 and OR=1.21;p=.002, respectively). These differences were found in unadjusted models and after adjustment for age, sex, BMI, number of classes of antihypertensive medications prescribed, comorbidity, number of BP measurements, and length of HTN diagnosis. However, US born African Americans had higher rates of mortality (11.6%) compared to Caribbean born (6.0%) and West African born (2.5%) African Americans, which was confirmed by unadjusted and fully adjusted cox proportional hazards regression models. Conclusion: Ethnic differences in cardiovascular outcomes and mortality exist among hypertensive African Americans served by NYC HHC. US born African Americans have a lower survival rate despite lower BP and better BP control than Caribbean and West African born African Americans. Future studies on African Americans should take ethnic variations within these populations into account

BACKGROUND: While strong associations are seen between serum uric acid levels and gout and cardiovascular disease (CVD), few studies have assessed differences between gout patients (pts) with and without CVD.
OBJECTIVE(S): To compare disease and comorbidity characteristics among gout pts with and without CVD, identifying differences in treatment patterns and healthcare utilization in a real-world cohort.
METHOD(S): Data were assessed from a survey of U.S. physicians and in-depth patient chart audits. Severity of gout was measured by physician global assessment, flares, organ/joint damage, and tophi. Type/dose of xanthine oxidase inhibitor, length of current treatment, sociodemographic factors, and physician type were identified. Multivariate and descriptive statistics described differences among pts with and without CVD and assessed urate-lowering therapy (ULT) use and gout disease control.
RESULT(S): 1159 patient charts were abstracted (738, CVD; 421, no CVD; 81% male; 38% >= 61 y; 71% white). Pts with CVD had longer duration of gout (52 vs. 34 mo; P < 0.001) and were more likely to have clinician-reported tophi (28% vs. 15%; P < 0.001), organ/joint damage (19% vs. 9%; P < 0.001), severe gout (19% vs. 11%; P < 0.001), and more flares in the past 12 mo. (2.1% vs. 1.8%; P = 0.017). Time from gout diagnosis to start of ULT was delayed for those with CVD (24 vs. 16 mo.; P = 0.02), but these pts were more likely to be on ULT (83% vs. 59%; P < 0.001). Gout pts with CVD were more likely to have obesity (28% vs. 18%; P < 0.001), diabetes (26% vs. 12%; P < 0.001), osteoarthritis (25% vs. 11%; P < 0.001), chronic kidney disease (17% vs. 5%; P < 0.001), and prostate disease (males, n = 933; 10% vs. 2%; P < 0.001). Gout pts with CVD were more likely to have an emergency department visit for gout in the past 12 mo. (12% vs. 7%; P = 0.003). Overall, ULT use was associated with better gout control. In a backward, stepwise logistic model in pts with CVD, those more likely be treated with ULT had organ/joint damage (odds ratio [OR] = 13.3), severe gout (OR = 1.5), or prostate disease (OR = 4.2), but these were not significant predictors for pts without CVD.
CONCLUSION(S): In this study, pts treated with ULT were more likely to have better gout control. Gout pts with CVD were more likely to be on ULT, despite delayed initiation of therapy. Given that gout pts with CVD were more likely to have additional comorbidities and more severe gout, the delay in treatment may be associated with the severity of disease in these pts. These data suggest that gout pts with CVD constitute a less healthy group in need of earlier, more aggressive therapy

OBJECTIVES: The purpose of this study was to examine the temporal trends in demographics, clinical characteristics, management strategies, and in-hospital outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS-AMI) who underwent percutaneous coronary intervention (PCI) from the Cath-PCI Registry (2005 to 2013). BACKGROUND: The authors examined contemporary use and outcomes of PCI in patients with CS-AMI. METHODS: The authors used the Cath-PCI Registry to evaluate 56,497 patients (January 2005 to December 2013) undergoing PCI for CS-AMI. Temporal trends in clinical variables and outcomes were assessed. RESULTS: Compared with cases performed from 2005 to 2006, CS-AMI patients receiving PCI from 2011 to 2013 were more likely to have diabetes, hypertension, dyslipidemia, previous PCI, dialysis, but less likely to have chronic lung disease, peripheral vascular disease, or heart failure within 2 weeks (p < 0.01). Between 2005 and 2006 to 2011 and 2013, intra-aortic balloon pump use decreased (49.5% to 44.9%; p < 0.01), drug-eluting stent use declined (65% to 46%; p < 0.01), and the use of bivalirudin increased (12.6% to 45.6%). Adjusted in-hospital mortality; increased (27.6% in 2005 to 2006 vs. 30.6% in 2011 to 2013, adjusted odds ratio: 1.09, 95% confidence interval: 1.005 to .173; p = 0.04) for patients who were managed with an early invasive strategy (<24 h from symptoms). CONCLUSIONS: Our study shows that despite the evolution of medical technology and use of contemporary therapeutic measures, in-hospital mortality in CS-AMI patients who are managed invasively continues to rise. Additional research and targeted efforts are indicated to improve outcomes in this high-risk cohort.

OBJECTIVE:To evaluate the outcomes with use of renin angiotensin system (RAS) blockers compared with other antihypertensive agents in people with diabetes. DESIGN/METHODS:Meta-analysis. DATA SOURCES AND STUDY SELECTION/METHODS:PubMed, Embase, and the Cochrane central register of controlled trials databases for randomized trials of RAS blockers versus other antihypertensive agents in people with diabetes mellitus. Outcomes were death, cardiovascular death, myocardial infarction, angina, stroke, heart failure, revascularization, and end stage renal disease. RESULTS:The search yielded 19 randomized controlled trials that enrolled 25,414 participants with diabetes for a total of 95,910 patient years of follow-up. When compared with other antihypertensive agents, RAS blockers were associated with a similar risk of death (relative risk 0.99, 95% confidence interval 0.93 to 1.05), cardiovascular death (1.02, 0.83 to 1.24), myocardial infarction (0.87, 0.64 to 1.18), angina pectoris (0.80, 0.58 to 1.11), stroke (1.04, 0.92 to 1.17), heart failure (0.90, 0.76 to 1.07), and revascularization (0.97, 0.77 to 1.22). There was also no difference in the hard renal outcome of end stage renal disease (0.99, 0.78 to 1.28) (power of 94% to show a 23% reduction in end stage renal disease). CONCLUSIONS:In people with diabetes, RAS blockers are not superior to other antihypertensive drug classes such as thiazides, calcium channel blockers, and β blockers at reducing the risk of hard cardiovascular and renal endpoints. These findings support the recommendations of the guidelines of the European Society of Cardiology/European Society of Hypertension and eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure to also use other antihypertensive agents in people with diabetes but without kidney disease.

OBJECTIVES: To compare the efficacy and safety of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) in patients without heart failure. PATIENTS AND METHODS: Meta-analysis of randomized trials identified using PubMed, Embase, and Cochrane Central Register of Controlled Trials searches from January 1, 1980, through April 13, 2015, of ACEis and ARBs compared with placebo or active controls and corroborated with head-to-head trials of ARBs vs ACEis. Outcomes were all-cause mortality, cardiovascular death, myocardial infarction (MI), angina, stroke, heart failure, revascularization, and new-onset diabetes. RESULTS: Our search yielded 106 randomized trials that enrolled 254,301 patients. Compared with placebo, ACEis but not ARBs reduced the outcomes of all-cause mortality (ACEis vs placebo: relative risk [RR], 0.89; 95% CI, 0.80-1.00; ARBs vs placebo: RR, 1.01; 95% CI, 0.96-1.06; Pinteraction=.04), cardiovascular death (RR, 0.83; 95% CI, 0.70-0.99 and RR, 1.02; 95% CI, 0.92-1.14; Pinteraction=.05), and MI (RR, 0.83; 95% CI, 0.78-0.90 and RR, 0.93; 95% CI, 0.85-1.03; Pinteraction=.06). The meta-regression analysis revealed that the difference between ACEis and ARBs compared with placebo was due to a higher placebo event rate in the ACEis trials (most of these trials were conducted a decade earlier than the ARB trials) for the outcome of all-cause mortality (P=.001), cardiovascular death (P<.001), and MI (P=.02). Sensitivity analyses restricted to trials published after 2000 revealed similar outcomes with ACEis vs placebo and ARBs vs placebo (Pinteraction>.05). Head-to-head comparison trials of ARBs vs ACEis exhibited no difference in outcomes except for a lower risk of drug withdrawal due to adverse effects with ARBs (RR, 0.72; 95% CI, 0.65-0.81). CONCLUSION: In patients without heart failure, evidence from placebo-controlled trials (restricted to trials after 2000), active controlled trials, and head-to-head randomized trials all suggest ARBs to be as efficacious and safe as ACEis, with the added advantage of better tolerability.