Faculty Bibliography

BACKGROUND:Few data exist regarding the implementation of high-sensitivity cardiac troponin (hs-cTn) assays in the United States since their approval. OBJECTIVES/OBJECTIVE:To explore trends in hs-cTn assay implementation over time and assess the association of their use with in-hospital cardiac testing and outcomes. METHODS:We examined trends in implementation of hs-cTn assays among participating hospitals in the NCDR® Chest Pain-MI Registry from 1/1/2019 through 9/30/2021. Associations between hs-cTn use, use of in-hospital diagnostic imaging, and patient outcomes were assessed using generalized estimating equation models with logistic or Gamma distributions. RESULTS:<0.001). hs-cTn use was associated with more echocardiography among persons with NSTE-ACS (82.4% vs. 75.0%; aOR: 1.43, 95% CI, 1.19-1.73) but not among low-risk chest pain individuals. hs-cTn use was associated with less invasive coronary angiography among low-risk patients (3.7% vs. 4.5%; aOR: 0.73, 95% CI, 0.58-0.92) but similar use for NSTE-ACS. There was no association between hs-cTn use and non-invasive stress/CTCA testing. Among NSTE-ACS individuals, hs-cTn use was not associated with revascularization or in-hospital mortality. Use of hs-cTn was associated with shorter length of stay (LOS; median 47.6 hours vs. 48.0 hours; ratio: 0.94, 95% CI, 0.90-0.98). CONCLUSIONS:Implementation of hs-cTn among U.S. hospitals is increasing but most U.S hospitals continue to use less-sensitive assays. hs-cTn use was associated with modestly shorter LOS, greater use of echocardiography for NSTE-ACS, and less use of invasive angiography among low-risk patients.

Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.

In the United States, the frequency of using percutaneous mechanical circulatory support devices for acute myocardial infarction complicated by cardiogenic shock is increasing. These devices require large-bore vascular access to provide left, right, or biventricular cardiac support, frequently under urgent/emergent circumstances. Significant technical and logistical variability exists in device insertion, care, and removal in the cardiac catheterization laboratory and in the cardiac intensive care unit. This variability in practice may contribute to adverse outcomes observed in centers that receive patients with cardiogenic shock, who are at higher risk for circulatory insufficiency, venous stasis, bleeding, and arterial hypoperfusion. In this position statement, we aim to: 1) describe the public health impact of bleeding and vascular complications in cardiogenic shock; 2) highlight knowledge gaps for vascular safety and provide a roadmap for a regulatory perspective necessary for advancing the field; 3) propose a minimum core set of process elements, or "vascular safety bundle"; and 4) develop a possible study design for a pragmatic trial platform to evaluate which structured approach to vascular access drives most benefit and prevents vascular and bleeding complications in practice.

Randomized clinical trials have not demonstrated a survival benefit with percutaneous coronary intervention in stable ischemic heart disease (SIHD). We evaluated the generalizability of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial findings to the broader population of veterans with SIHD. Veterans who underwent coronary angiography between 2005 and 2013 for SIHD were identified from the Veterans Affairs Clinical Assessment, Reporting and Tracking Program (VA CART). Patient-level comparisons were made between patients from VA CART who met the eligibility criteria for COURAGE and veterans enrolled in COURAGE between 1999 and 2004. All-cause mortality over long-term follow-up was assessed using Cox proportional hazards models. COURAGE-eligible patients from VA CART (n = 59,758) were older, had a higher body mass index, a greater prevalence of co-morbidities, but fewer diseased vessels on index coronary angiography, and were less likely to be on optimal medical therapy at baseline and on 1-year follow-up compared with VA COURAGE participants (n = 968). Patients from VA CART (median follow-up 6.5 years) had higher all-cause mortality (adjusted hazard ratio [aHR] 1.98 [1.61 to 2.43]) than participants from VA COURAGE (median follow-up: 4.6 years). Risks of mortality were greater in the 56.4% patients from CART who were medically managed (aHR 1.94 [1.49 to 2.53]) and in the 43.6% who underwent percutaneous coronary intervention (aHR 1.99 [1.45 to 2.74]), compared with their respective VA COURAGE arms. In conclusion, in this noncontemporaneous patient-level analysis, veterans in the randomized COURAGE trial had more favorable outcomes than the population of veterans with SIHD at large.

Aims/UNASSIGNED:We aimed to use optical coherence tomography (OCT) to identify differences in atherosclerotic culprit lesion morphology in women with myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) compared with MI with obstructive coronary artery disease (MI-CAD). Methods and results/UNASSIGNED:Women with an OCT-determined atherosclerotic aetiology of non-ST segment elevation (NSTE)-MINOCA (angiographic diameter stenosis <50%) who were enrolled in the multicentre Women's Heart Attack Research Program (HARP) study were compared with a consecutive series of women with NSTE-MI-CAD who underwent OCT prior to coronary intervention at a single institution. Atherosclerotic pathologies identified by OCT included plaque rupture, plaque erosion, intraplaque haemorrhage (IPH, a region of low signal intensity with minimum attenuation adjacent to a lipidic plaque without fibrous cap disruption), layered plaque (superficial layer with clear demarcation from the underlying plaque indicating early thrombus healing), or eruptive calcified nodule.We analysed 58 women with NSTE-MINOCA and 52 women with NSTE-MI-CAD. Optical coherence tomography features of underlying vulnerable plaque (thin-cap fibroatheroma) were less common in MINOCA (3 vs. 35%) than in MI-CAD. Intraplaque haemorrhage (47 vs. 2%) and layered plaque (31 vs. 12%) were more common in MINOCA than MI-CAD, whereas plaque rupture (14 vs. 67%), plaque erosion (8 vs. 14%), and calcified nodule (0 vs. 6%) were less common in MINOCA. The angle of ruptured cavity was smaller and thrombus burden was lower in MINOCA. Conclusion/UNASSIGNED:The prevalence of atherothrombotic culprit lesion subtype varied substantially between MINOCA and MI-CAD. A majority of culprit lesions in MINOCA had the appearance of IPH or layered plaque. Clinical Trial Registration Information/UNASSIGNED:

BACKGROUND:Clinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding. METHODS:Patients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 United States Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment. RESULTS:A total of 644,622 patients with gastrointestinal bleeding were identified, of which 7,523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to myocardial infarction patients without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, present with non-ST segment elevation MI, and were less likely to undergo invasive management of AMI (28% vs 63%, P<0.01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P<0.01). CONCLUSION/CONCLUSIONS:In the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.