Faculty Bibliography

BACKGROUND:Studies have demonstrated the value of transthoracic echocardiogram (TTE) diastolic parameters in predicting left atrial appendage (LAA) thrombus; however, these studies have been small. We aim to clarify the relationship between TTE diastolic parameters, in particular average e', and LAA thrombus or sludge. METHODS:A case-control review was conducted of subjects with non-valvular atrial fibrillation (n = 2263) who had undergone TEE (transesophageal echocardiogram) and had a TTE within 1 year of TEE. Cases of LAA sludge or thrombus were matched to controls by age, sex, left ventricular ejection fraction (LVEF), and anticoagulation status. RESULTS:Forty-three subjects (mean age 73 ± 12, 65% male, LVEF 47%, 44% on anticoagulation) with LAA sludge or thrombus were identified. Compared to matched controls, average TTE e' (7.3 ± 2.1 cm/s vs 8.7 ± 2.1 cm/s, P < 0.001) and the E:e' ratio (15 ± 7 cm/s vs 12 ± 5 cm/s; P = 0.005) were significant predictors of LAA sludge or thrombus. Average TTE e' value of >11 cm/s had 100% sensitivity for ruling out LAA sludge or thrombus. CONCLUSION/CONCLUSIONS:In individuals with atrial fibrillation, average e' >11 cm/s on TTE is a promising independent predictor of the absence of LAA sludge or thrombus on TEE.

OBJECTIVES/OBJECTIVE:The aim of this study was to determine whether frailty is associated with increased bleeding risk in the setting of acute myocardial infarction (AMI). BACKGROUND:Frailty is a common syndrome in older adults. METHODS:Frailty was examined among AMI patients ≥65 years of age treated at 775 U.S. hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. Frailty was classified on the basis of impairments in 3 domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of 3 categories was then created: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding. RESULTS:Among 129,330 AMI patients, 16.4% had any frailty. Frail patients were older, more often female, and were less likely to undergo cardiac catheterization. Major bleeding increased across categories of frailty (fit/well 6.5%; vulnerable/mild frailty 9.4%; moderate-to-severe frailty 9.9%; p < 0.001). Among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the non-frail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.23 to 1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24 to 1.58). Among patients managed conservatively, there was no association of frailty with bleeding (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86 to 1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81 to 1.14). CONCLUSIONS:Frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) than nonfrail patients, making attention to clinical strategies to avoid bleeding imperative in this population.

More than 13 million persons in the United States aged 65 and older have cardiovascular disease (CVD), and this population is expected to increase exponentially over the next several decades. In the absence of clinical studies that would inform how best to manage this population, there is an urgent need for collaborative, thoughtful approaches to their care. Although cardiologists are traditionally regarded as leaders in the care of older adults with CVD, these individuals have multiple comorbidities, physiological differences, and distinct goals of care than younger patients that require a specialized geriatric lens. Thus, collaboration is needed between geriatricians, cardiologists, and other specialists to address the unique needs of this growing population. Accordingly, clinicians at New York University Langone Health and School of Medicine established a monthly Geriatric Cardiology Conference to foster an integrative approach to the care of older adults with CVD by uniting specialists across disciplines to collaborate on treatment strategies. At each conference, an active case is discussed and analyzed in detail, and a consensus is reached among participants regarding optimal treatment strategies. The conference attracts faculty and trainees at multiple levels from geriatrics, cardiology, and cardiothoracic surgery. The model may serve as a paradigm for other institutions moving towards geriatric-informed care of older adults with CVD.

Background/Introduction: The 2016 ESC Guideline on the Diagnosis and Treatment of Acute and Chronic Heart Failure endorsed sacubitril/valsartan (S/V) as class I-B treatment for heart failure with reduced ejection fraction(HFrEF) based on the PARADIGM-HF trial. Data on characteristics of S/V initiators and S/V adherence among renin-angiotensin aldosterone system inhibitor (RAASi)-nai ve patients treated in the community are limited. Purpose: Determine associated baseline patient and healthcare facility characteristics and medication adherence of S/V vs angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in RAASi-naive HFrEF patients. Methods: Retrospective cohort study of U.S. Veterans Affairs (VA) data including HFrEF ( = 1 record of left ventricular ejection fraction (LVEF) = 40%) patients with = 1 in/outpatient visit for HF within 1-year pre-index (baseline period) treated with S/V, ACEI, or ARB from July 2015-June 2017. The index date was first S/V pharmacy fill and if none, first ACEI or ARB fill. RAASi-naive defined as no S/V, ACEI, or ARB fills during the baseline period. Poisson regression models with robust errors were used to compare baseline characteristics and 4-month medication adherence (i.e. follow-up fills, proportion of days covered [PDC], and discontinuation) for S/V vs ACEI or ARB. Medication adherence comparisons were adjusted for baseline characteristics using matching weights. Results: Among RAASi-naive HFrEF Veterans (N = 10,743),most (97.5%)weremale and 371 (3.5%) had an S/V pharmacy fill and 10,372 (96.5%) had an ACEI or ARB fill on the index date. Mean (standard deviation) baseline age, estimated glomerular filtration rate, and LVEF in S/V vs ACEI or ARB initiators were 73.6 (10.7) vs 70.3 (11.4) years, 61.3 (19.1) vs 66.4 (25.2) mL/min/1.73 m2, and 27.9% (8.3%) vs 34.4% (12.0%), respectively. History of ischemic cardiomyopathy was associated with S/V vs ACEI or ARB initiation. Veterans with lower systolic blood pressure, history of stroke, hypertension, myocardial infarction, or a visit with a Cardiologist on the index date were less likely to initiate S/V. In Veterans with a 30 day-supply index fill (N = 251 S/V and N = 3,101 ACEI or ARB) the adjusted risk ratio for 4-month PDC >80% was 0.78, 95% (confidence interval: 0.66-0.93) for S/V vs ACEI or ARB. Follow-up fills and discontinuation were similar for S/V vs ACEI or ARB. Adherence was similar for S/V vs ACEI or ARB among Veterans with a 90 day-supply. Conclusions: In a large, integrated healthcare system, 3.5% RAASi-naive HFrEF patients initiated S/V during the first 2-years post U.S. FDA approval. Overall, our findings suggest that S/V adherence is similar to ACEI or ARB in community-treated RAASi-naive HFrEF patients. The low numbers of S/V initiation may reflect a lag in formulary availability; S/V was added to the VA Formulary in October 2016. The reasons for lack of guideline-directed S/V initiation needs further elucidation

BACKGROUND: Frailty is a syndrome of decreased physiologic reserve that results from compromise of multiple physiologic systems including cardiovascular. We aimed to determine the association between the frail phenotype and cardiac abnormalities in liver transplant (LT) candidates through evaluation of transthoracic echocardiography (TTE) indices. METHODS: Included were consecutive outpatients listed for LT who underwent a frailty assessment from 1/1/14-6/30/16 (using the Liver Frailty Index) and a 2-dimensional/doppler TTE exam. Patients were categorized as robust, intermediate frail, or frail by the Liver Frailty Index based on scores of <3.2, between 3.2-4.5 or >/=4.5. Linear regression assessed associations between the Liver Frailty Index and TTE indices. RESULTS: Of 335 patients, 19% were robust, 65% intermediate frail, and 16% frail. TTE indices of left atrial (LA) dilatation differed significantly by frailty status: median LA dimension (p=0.03), LA volume index (LAVIcc/m; p<0.001) and %LAVI>34cc/m (p= 0.001). In linear regression adjusted for age, sex, hypertension and diabetes, the Liver Frailty Index was positively associated with LA dimension (coeff 0.20, 95%CI 0.07-0.34), LAVIcc/m (coeff 0.01, 95%CI 0.005-0.02), ejection fraction (coeff 1.59, 95%CI 0.32-2.85) and pulmonary artery systolic pressure (coeff 0.01, 95%CI 0.003-0.02) and negatively associated with LV hypertrophy (coeff -0.22, 95%CI -0.37, -0.06). CONCLUSION: In LT candidates, frailty is associated with cardiac structural and functional changes, independent of known risk factors. Our study provides evidence to support that measures of frailty in cirrhotic patients encompass abnormalities of the cardiovascular system and may inform assessments of cardiovascular reserve in this population.

BACKGROUND:Heart failure (HF) is associated with cognitive impairment. However, we know little about the time course of cognitive change after HF diagnosis, the importance of comorbid atrial fibrillation, or the role of ejection fraction. We sought to determine the associations of incident HF with rates of cognitive decline and whether these differed by atrial fibrillation status or reduced versus preserved ejection fraction. METHODS AND RESULTS/RESULTS:=0.734). CONCLUSIONS:Decline in global cognitive ability tends to be faster after HF diagnosis than without HF. Clinical and public health implications of this finding warrant further attention.