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Patterns and outcomes of invasive management of type 2 myocardial infarction in the United States

Smilowitz, Nathaniel R; Shah, Binita; Lorin, Jeffrey; Berger, Jeffrey S
BACKGROUND:Type 2 myocardial infarction (MI) occurs due to a mismatch in myocardial oxygen supply and demand without unstable coronary artery disease. We sought to identify patterns, predictors and outcomes of invasive management of type 2 MI in the USA. METHODS:Adults aged ≥18 years hospitalized with type 2 MI were identified in a cross-sectional study from the 2018 National Inpatient Sample. Invasive management was defined as invasive coronary angiography or revascularization. Patient, hospital and geographic characteristics associated with invasive management were identified by multivariable logistic regression. Propensity-matched cohorts were generated to evaluate associations between invasive vs. conservative management and mortality. RESULTS:We identified 268 850 admissions with type 2 MI in 2018. Type 2 MI patients had a high burden of comorbidities and were commonly admitted with diagnoses of circulatory (39.7%), infectious (23.1%) or respiratory (10.8%) illness. Only 11.2% of type 2 MI were managed invasively, of which 17.9% underwent coronary revascularization. Odds of invasive management were higher with commercial insurance [adjusted OR (aOR) 1.39; 95% confidence interval (CI), 1.27-1.52] and lower with Medicaid (aOR 0.86; 95% CI, 0.76-0.96) vs. Medicare. Significant heterogeneity in invasive management of type 2 MI was observed by geographic region (range 7.2-13.8%), independent of patient and hospital factors. Invasive management was associated with lower in-hospital mortality than conservative management overall (3.9 vs. 9.1%; P < 0.001) and in propensity-matched analyses (OR, 0.70; 95% CI, 0.59-0.84). CONCLUSION/CONCLUSIONS:Invasive management of type 2 MI varies by insurance status and geography, highlighting uncertainty regarding optimal management and potential disparities in clinical care.
PMID: 35044332
ISSN: 1473-5830
CID: 5131562

Chasing the storm: Recruiting non-hospitalized patients for a multi-site randomized controlled trial in the United States during the COVID-19 pandemic

Hu, Kelly; Tardif, Jean-Claude; Huber, Melanie; Daly, Maria; Langford, Aisha T; Kirby, Ruth; Rosenberg, Yves; Hochman, Judith; Joshi, Avni; Bassevitch, Zohar; Pillinger, Michael H; Shah, Binita
Randomized controlled trials (RCTs) remain the gold standard to evaluate clinical interventions, producing the highest level of evidence while minimizing potential bias. Inadequate recruitment is a commonly encountered problem that undermines the completion and generalizability of RCTs-and is even more challenging when enrolling amidst a pandemic. Here, we reflect on our experiences with virtual recruitment of non-hospitalized patients in the United States for ColCorona, an international, multicenter, randomized, placebo-controlled coronavirus disease 2019 (COVID-19) drug trial. Recruitment challenges during a pandemic include constraints created by shelter-in-place policies and targeting enrollment according to national and local fluctuations in infection rate. Presenting a study to potential participants who are sick with COVID-19 and may be frightened, overwhelmed, or mistrusting of clinical research remains a challenge. Strategies previously reported to improve recruitment include transparency, patient and site education, financial incentives, and person-to-person outreach. Active measures taken during ColCorona to optimize United States recruitment involved rapid expansion of sites, adjustment of recruitment scripts, assessing telephone calls versus text messages for initial contact with participants, institutional review board-approved financial compensation, creating an infrastructure to systematically identify potentially eligible patients, partnering with testing sites, appealing to both self-interest and altruism, and large-scale media efforts with varying degrees of success.
PMID: 34953032
ISSN: 1752-8062
CID: 5100052

Long-term dietary and weight changes following a short-term dietary intervention study: EVADE-CAD trial follow-up

Dogra, Siddhant; Woolf, Kathleen; Xia, Yuhe; Getz, Alec; Newman, Jonathan D; Slater, James; Shah, Binita
PMID: 34010190
ISSN: 1473-5830
CID: 4908372

Characteristics and Outcomes of Type 1 versus Type 2 Perioperative Myocardial Infarction After Noncardiac Surgery

Smilowitz, Nathaniel R; Shah, Binita; Ruetzler, Kurt; Garcia, Santiago; Berger, Jeffrey S
BACKGROUND:Perioperative myocardial infarction is frequently attributed to type 2 myocardial infarction, a mismatch in myocardial oxygen supply-demand without unstable coronary artery disease. Our aim was to identify characteristics, management, and outcomes of perioperative type 1 versus type 2 myocardial infarction among surgical inpatients. METHODS:Adults age ≥45 years hospitalized for noncardiac surgery were identified in the United States. Perioperative myocardial infarction were identified using International Classification of Diseases, 10th revision (ICD-10) codes. Clinical characteristics, invasive myocardial infarction management, mortality, and readmissions were assessed by myocardial infarction subtype. RESULTS:Among 4,755,382 surgical hospitalizations, we identified 38,975 perioperative myocardial infarctions (0.82%), with type 2 infarction in 42%. Patients with type 2 myocardial infarction were older, more likely to be women, and less likely to have cardiovascular comorbidities compared with type 1 myocardial infarction. Fewer patients with type 2 myocardial infarction underwent invasive management than type 1 myocardial infarction (6.7% vs 28.8%, P < .001). Type 2 myocardial infarction mortality was lower than type 1 myocardial infarction mortality (12.1% vs 17.4%, P < .001; adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] 0.45-0.59). Invasive management of perioperative myocardial infarction was associated with lower mortality in type 1 (aOR 0.56, 95% CI 0.49-0.74) but not type 2 (aOR 1.19, 95% CI 0.77-1.85) myocardial infarction. Among survivors, there was no difference in 90-day hospital readmission between type 2 and type 1 perioperative myocardial infarction (36.5% vs 36.1%, P = .72). CONCLUSIONS:Type 2 myocardial infarctions account for approximately 40% of perioperative myocardial infarctions. Patients with type 2 perioperative myocardial infarction are less likely to undergo invasive management and have lower mortality compared with those with type 1 perioperative myocardial infarction.
PMID: 34560032
ISSN: 1555-7162
CID: 5085532

Colchicine in Cardiovascular Disease: In-Depth Review

Deftereos, Spyridon G; Beerkens, Frans J; Shah, Binita; Giannopoulos, George; Vrachatis, Dimitrios A; Giotaki, Sotiria G; Siasos, Gerasimos; Nicolas, Johny; Arnott, Clare; Patel, Sanjay; Parsons, Mark; Tardif, Jean-Claude; Kovacic, Jason C; Dangas, George D
Inflammation plays a prominent role in the development of atherosclerosis and other cardiovascular diseases, and anti-inflammatory agents may improve cardiovascular outcomes. For years, colchicine has been used as a safe and well-tolerated agent in diseases such as gout and familial Mediterranean fever. The widely available therapeutic has several anti-inflammatory effects, however, that have proven effective in a broad spectrum of cardiovascular diseases as well. It is considered standard-of-care therapy for pericarditis, and several clinical trials have evaluated its role in postoperative and postablation atrial fibrillation, postpericardiotomy syndrome, coronary artery disease, percutaneous coronary interventions, and cerebrovascular disease. We aim to summarize colchicine's pharmacodynamics and the mechanism behind its anti-inflammatory effect, outline thus far accumulated evidence on treatment with colchicine in cardiovascular disease, and present ongoing randomized clinical trials. We also emphasize real-world clinical implications that should be considered on the basis of the merits and limitations of completed trials. Altogether, colchicine's simplicity, low cost, and effectiveness may provide an important addition to other standard cardiovascular therapies. Ongoing studies will address complementary questions pertaining to the use of low-dose colchicine for the treatment of cardiovascular disease.
PMID: 34965168
ISSN: 1524-4539
CID: 5108232

Consensus Statement Regarding the Efficacy and Safety of Long-Term Low-Dose Colchicine in Gout and Cardiovascular Disease

Robinson, Philip C; Terkeltaub, Robert; Pillinger, Michael H; Shah, Binita; Karalis, Vangelis; Karatza, Eleni; Liew, David; Imazio, Massimo; Cornel, Jan H; Thompson, Peter L; Nidorf, Mark
Over the last decade, evidence has demonstrated that long-term, low-dose colchicine (0.5 mg daily) is effective for preventing gout flare and cardiovascular (CV) events in a wide range of patients. Given the potentially expanding use of colchicine in CV disease, we here review and update the biologic effects and safety of colchicine based on recent data gathered from bench and pharmacodynamic studies, clinical reports, controlled clinical trials, and meta-analyses, integrated with important studies over the last 50 years, to offer a consensus perspective by experts from multiple specialties familiar with colchicine's long-term use. We conclude that the clinical benefits of colchicine in gout and CV disease achieved at low dose do not sustain serum levels above the upper limit of safety when used in patients without advanced renal or liver disease or when used concomitantly with most medications. Further, data accrued over the last 50 years strongly suggest that the biologic effects of long-term colchicine do not increase the risk of cancer, sepsis, cytopenia, or myotoxicity.
PMID: 34416165
ISSN: 1555-7162
CID: 5011012

Invasive Management of Acute Myocardial Infarctions During the Initial Wave of the COVID-19 Pandemic

Talmor, Nina; Ramachandran, Abhinay; Brosnahan, Shari B; Shah, Binita; Bangalore, Sripal; Razzouk, Louai; Attubato, Michael; Feit, Frederick; Thompson, Craig; Smilowitz, Nathaniel R
BACKGROUND:The initial wave of the coronavirus disease 2019 (COVID-19) pandemic resulted in an influx of patients with acute viral illness and profound changes in healthcare delivery in New York City. The impact of this pandemic on the presentation and invasive management of acute myocardial infarction (MI) is not well described. METHODS:This single-center retrospective study compared patients with MI who underwent invasive coronary angiography at New York University from March-April 2020, during the peak of the first wave of the pandemic, with those presenting in March-April 2019. RESULTS:Only 35 patients with MI underwent angiography during the study period in 2020 vs 109 patients in 2019. No differences in comorbidities or baseline medications were identified. The proportion of patients with ST-segment elevation MI (STEMI) was higher in 2020 than in 2019 (48.6% vs 24.8%, respectively; P=.01). Median peak troponin concentration was higher (14.5 ng/mL vs 2.9 ng/mL; P<.01) and left ventricular ejection fraction was lower (43.34% vs 51.1%; P=.02) during the pandemic. Among patients with non-STEMI, time from symptom onset to presentation was delayed in 2020 compared with 2019 (median, 24 hours vs 10 hours; P=.04). CONCLUSION/CONCLUSIONS:There was a dramatic decrease in the number of patients with MI undergoing coronary angiography during the first wave of the COVID-19 pandemic. Of those who presented, patients tended to seek care later after symptom onset and had excess myocardial injury. These data indicate a need for improved patient education to ensure timely cardiovascular care during public health emergencies.
PMID: 34866048
ISSN: 1557-2501
CID: 5085552

Hot topics in interventional cardiology: Proceedings from the society for cardiovascular angiography and interventions (SCAI) 2021 think tank

Naidu, Srihari S; Baron, Suzanne J; Eng, Marvin H; Sathanandam, Shyam K; Zidar, David A; Feldman, Dmitriy N; Ing, Frank F; Latif, Faisal; Lim, Michael J; Henry, Timothy D; Rao, Sunil V; Dangas, George D; Hermiller, James B; Daggubati, Ramesh; Shah, Binita; Ang, Lawrence; Aronow, Herbert D; Banerjee, Subhash; Box, Lyndon C; Caputo, Ronald P; Cohen, Mauricio G; Coylewright, Megan; Duffy, Peter L; Goldsweig, Andrew M; Hagler, Donald J; Hawkins, Beau M; Hijazi, Ziyad M; Jayasuriya, Sasanka; Justino, Henri; Klein, Andrew J; Kliger, Chad; Li, Jun; Mahmud, Ehtisham; Messenger, John C; Morray, Brian H; Parikh, Sahil A; Reilly, John; Secemsky, Eric; Shishehbor, Mehdi H; Szerlip, Molly; Yakubov, Steven J; Grines, Cindy L; Alvarez-Breckenridge, Jennifer; Baird, Colleen; Baker, David; Berry, Charles; Bhattacharya, Manisha; Bilazarian, Seth; Bowen, Rosanne; Brounstein, Kevin; Cameron, Cole; Cavalcante, Rafael; Culbertson, Casey; Diaz, Pedro; Emanuele, Susan; Evans, Erin; Fletcher, Rob; Fortune, Tina; Gaiha, Priya; Govender, Devi; Gutfinger, Dan; Haggstrom, Kurt; Herzog, Andrea; Hite, Denise; Kalich, Bethany; Kirkland, Ann; Kohler, Toni; Laurisden, Holly; Livolsi, Kevin; Lombardi, Lois; Lowe, Sarah; Marhenke, Kevin; Meikle, Joie; Moat, Neil; Mueller, Megan; Patarca, Roberto; Popma, Jeff; Rangwala, Novena; Simonton, Chuck; Stokes, Jerry; Taber, Margaret; Tieche, Christopher; Venditto, John; West, Nick E J; Zinn, Laurie
The Society for Cardiovascular Angiography and Interventions (SCAI) Think Tank is a collaborative venture that brings together interventional cardiologists, administrative partners, and select members of the cardiovascular industry community annually for high-level field-wide discussions. The 2021 Think Tank was organized into four parallel sessions reflective of the field of interventional cardiology: (a) coronary intervention, (b) endovascular medicine, (c) structural heart disease, and (d) congenital heart disease. Each session was moderated by a senior content expert and co-moderated by a member of SCAI's Emerging Leader Mentorship program. This document presents the proceedings to the wider cardiovascular community in order to enhance participation in this discussion, create additional dialog from a broader base, and thereby aid SCAI, the industry community and external stakeholders in developing specific action items to move these areas forward.
PMID: 34398509
ISSN: 1522-726x
CID: 5052742

Sex-Based Differences in Outcomes With Percutaneous Transcatheter Repair of Mitral Regurgitation With the MitraClip System: Transcatheter Valve Therapy Registry From 2011 to 2017

Villablanca, Pedro A; Vemulapalli, Sreekanth; Stebbins, Amanda; Dai, Dadi; So, Chak-Yu; Eng, Marvin H; Wang, Dee Dee; Frisoli, Tiberio M; Lee, James C; Kang, Guson; Szerlip, Molly; Ibrahim, Homam; Staniloae, Cezar; Gaba, Prakriti; Lemor, Alejandro; Finn, Matthew; Ramakrishna, Harish; Williams, Mathew R; Leon, Martin B; O'Neill, William W; Shah, Binita
BACKGROUND:Women have a higher rate of adverse events after mitral valve surgery. We sought to evaluate whether outcomes after transcatheter edge-to-edge repair intervention by sex have similar trends to mitral valve surgery. METHODS:The primary outcome was 1-year major adverse events defined as a composite of all-cause mortality, stroke, and any bleeding in the overall study cohort. Patients who underwent transcatheter edge-to-edge repair for mitral regurgitation with the MitraClip system in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry were evaluated. Linked administrative claims from the Centers for Medicare and Medicaid Services were used to evaluate 1-year clinical outcomes. Associations between sex and outcomes were evaluated using a multivariable logistic regression model for in-hospital outcomes and Cox model for 1-year outcomes. RESULTS:<0.001) and had a lower adjusted odds ratio of device success (adjusted odds ratio, 0.78 [95% CI, 0.67-0.90]), driven by lower odds of residual mitral gradient <5 mm Hg (adjusted odds ratio, 0.54 [CI, 0.46-0.63]) when compared with males. At 1-year follow-up, the primary outcome did not differ by sex. Female sex was associated with lower adjusted 1-year risk of all-cause mortality (adjusted hazard ratio, 0.80 [CI, 0.68-0.94]), but the adjusted 1-year risk of stroke and any bleeding did not differ by sex. CONCLUSIONS:No difference in composite outcome of all-cause mortality, stroke, and any bleeding was observed between females and males. Adjusted 1-year all-cause mortality was lower in females compared with males.
PMID: 34784236
ISSN: 1941-7632
CID: 5049102

Impact of COVID-19 pandemic on STEMI care: An expanded analysis from the United States

Garcia, Santiago; Stanberry, Larissa; Schmidt, Christian; Sharkey, Scott; Megaly, Michael; Albaghdadi, Mazen S; Meraj, Perwaiz M; Garberich, Ross; Jaffer, Farouc A; Stefanescu Schmidt, Ada C; Dixon, Simon R; Rade, Jeffrey J; Smith, Timothy; Tannenbaum, Mark; Chambers, Jenny; Aguirre, Frank; Huang, Paul P; Kumbhani, Dharam J; Koshy, Thomas; Feldman, Dmitriy N; Giri, Jay; Kaul, Prashant; Thompson, Craig; Khalili, Houman; Maini, Brij; Nayak, Keshav R; Cohen, Mauricio G; Bangalore, Sripal; Shah, Binita; Henry, Timothy D
OBJECTIVE:To evaluate the impact of COVID-19 pandemic migitation measures on of ST-elevation myocardial infarction (STEMI) care. BACKGROUND:We previously reported a 38% decline in cardiac catheterization activations during the early phase of the COVID-19 pandemic mitigation measures. This study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data. METHODS:Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019-February 2020 and March-April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC. RESULTS:Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18-38, p < .001), number of activations leading to angiography (34%, 95% CI: 12-50, p = .005) and number of activations leading to PPCI (20%, 95% CI: 11-27, p < .001). A decline in STEMI activations drove the reductions in angiography and PPCI volumes. Relative to BC, the D2B times in the AC period increased on average by 20%, 95%CI (-0.2 to 44, p = .05). CONCLUSIONS:The COVID-19 Pandemic has adversely affected many aspects of STEMI care, including timely access to the cardiac catheterization laboratory for PPCI.
PMID: 32767652
ISSN: 1522-726x
CID: 4555742