Slusser, Joshua P.

Abstract Aims Diagnosing myocardial infarction (MI) in patients with chronic kidney disease (CKD) is difficult as they often have increased high-sensitivity cardiac troponin T (hs-cTnT) concentrations. Methods and results Observational US cohort study of emergency department patients undergoing hs-cTnT measurement. Cases with ≥1 hs-cTnT increase > 99th percentile were adjudicated following the Fourth Universal Definition of MI. Diagnostic performance of baseline and serial 2 h hs-cTnT thresholds for ruling-in acute MI was compared between those without and with CKD (estimated glomerular filtration rate < 60 mL/min/1.73 m2). The study cohort included 1992 patients, amongst whom 501 (25%) had CKD. There were 75 (15%) and 350 (70%) patients with CKD and 80 (5%) and 351 (24%) without CKD who had acute MI and myocardial injury. In CKD patients with baseline hs-cTnT thresholds of ≥52, >100, >200, or >300 ng/L, positive predictive values (PPVs) for MI were 36% (95% CI 28–45), 53% (95% CI 39–67), 73% (95% CI 50–89), and 80% (95% CI 44–98), and in those without CKD, 61% (95% CI 47–73), 69% (95% CI 49–85), 59% (95% CI 33–82), and 54% (95% CI 25–81). In CKD patients with a 2 h hs-cTnT delta of ≥10, >20, or >30 ng/L, PPVs were 66% (95% CI 51–79), 86% (95% CI 68–96), and 88% (95% CI 68–97), and in those without CKD, 64% (95% CI 50–76), 73% (95% CI 57–86), and 75% (95% CI 58–88). Conclusion Diagnostic performance of standard baseline and serial 2 h hs-cTnT thresholds to rule-in MI is suboptimal in CKD patients. It significantly improves when using higher baseline thresholds and delta values.

Introduction: Among those hospitalized with heart failure, diabetes (DM) is a common comorbid condition and the population characteristics and natural history of those with preserved EF (HFpEF) versus those with reduced EF (HFrEF) remain undefined. Hypothesis: To determine the epidemiologic profile and natural history among those hospitalized with acute heart failure (AHF) with DM and compare outcomes of those with reduced versus preserved EF. Methods: A retrospective chart analysis of adults hospitalized with primary ICD diagnosis of AHF from Olmsted County hospitalized from 2005 - 2008, with follow up until 2013. Demographic, clinical and lab data were collected. Results: Of 912 subjects hospitalized with AHF, 381 (42%) had DM. Among subjects with AHF and DM, those with HFrEF were similar in age to those with HFpEF (76.3±11.7 years vs 78.3±11.2 years, p=0.12), but were more likely to be male (58% vs 37%, p<0.001). Those with DM and HFrEF compared to HFpEF had less hypertension (95% vs 99%, p=0.046), but more coronary artery disease (89% vs 75%, p<0.001), prior myocardial infarction (65% vs 33%, p<0.001), and higher BNP values (1155±906 pg/mL vs 676±568 pg/mL, p<0.001). E/e’ ratio was similar in those with DM and HFrEF versus HFpEF (22.6±10.4 vs 21.7±10.9, p=0.49), suggesting both groups had increased filling pressures. There was no difference in mortality between the HFrEF and HFpEF groups up to 5 years in either the DM group (p=0.46) or the non-DM group (p=0.11). However, those hospitalized with AHF and DM demonstrated a higher rate in those with HFrEF versus HFpEF groups in all cause rehospitalization (p=0.019) and heart failure rehospitalization (p=0.008). This was different from the non-DM group, where there was no difference between HFrEF and HFpEF in all cause hospitalization (p=0.31) or heart failure rehospitalization (p=0.19). Conclusions: In patients hospitalized for AHF with DM, those with HFrEF had increased all cause and heart failure hospitalization as compared to HFpEF. In contrast, subjects without DM had no differences in rehospitalization between the HFrEF and HFpEF groups. Further studies are warranted to define pathophysiological mechanism for this observation.

Background Religiosity/spirituality is a major coping mechanism for African Americans, but no prior studies have analyzed its association with the American Heart Association Life's Simple 7 (LS7) indicators in this group. Methods and Results This cross‐sectional study using Jackson Heart Study (JHS) data examined relationships between religiosity (religious attendance, private prayer, religious coping) and spirituality (theistic, nontheistic, total) with LS7 individual components (eg, physical activity, diet, smoking, blood pressure) and composite score among African Americans. Multivariable logistic regression assessed the odds of achieving intermediate/ideal (versus poor) LS7 levels adjusted for sociodemographic, behavioral, and biomedical factors. Among the 2967 participants (mean [SD] age=54.0 [12.3] years; 65.7% women), higher religious attendance was associated with increased likelihood (reported as odds ratio [95% CI]) of achieving intermediate/ideal levels of physical activity (1.16 [1.06–1.26]), diet (1.10 [1.01–1.20]), smoking (1.50 [1.34–1.68]), blood pressure (1.12 [1.01–1.24]), and LS7 composite score (1.15 [1.06–1.26]). Private prayer was associated with increased odds of achieving intermediate/ideal levels for diet (1.12 [1.03–1.22]) and smoking (1.24 [1.12–1.39]). Religious coping was associated with increased odds of achieving intermediate/ideal levels of physical activity (1.18 [1.08–1.28]), diet (1.10 [1.01–1.20]), smoking (1.32 [1.18–1.48]), and LS7 composite score (1.14 [1.04–1.24]). Total spirituality was associated with increased odds of achieving intermediate/ideal levels of physical activity (1.11 [1.02–1.21]) and smoking (1.36 [1.21–1.53]). Conclusions Higher levels of religiosity/spirituality were associated with intermediate/ideal cardiovascular health across multiple LS7 indicators. Reinforcement of religiosity/spirituality in lifestyle interventions may decrease overall cardiovascular disease risk among African Americans.

BACKGROUND. Nearly half of strokes in non-valvular atrial fibrillation (NVAF) are due to non-cardioembolic mechanisms including carotid disease, lacune, watershed, venous sinus thrombosis, or hemorrhage. Tools capable of identifying those AF patients most likely to suffer a cardioembolic complication of AF would be very helpful for deciding which patients to treat with anticoagulants compared to aspirin. CHA 2 DS 2 -VASc has been advocated as an improved stroke risk assessment tool for NVAF patients. METHODS. CHA 2 DS 2 -VASc was compared to CHADS 2 for the prediction of left atrial appendage thrombus (LAAT), and association (Spearman correlation) with spontaneous echo contrast (SEC), left atrium appendage emptying velocity (LAAEV), left atrium volume index (LAVI) in consecutive NVAF patients undergoing echocardiographic study (10/1/2007 - 9/30/2009). RESULTS. 525 NVAF patients (age 62±13 years; 25% women; 28% persistent AF and 17% permanent AF) were parsed by extent of atrial blood stasis/LAAT ( Table ). CHA 2 DS 2 -VASc and CHADS 2 were similar for the prediction of LAAT (Figure). Measures of SEC intensity (0.416 vs 0.414;), LAAEV (-0.393 vs -0.344), and LAVI (0.322 vs 0.303) carried similarly associations with CHA 2 DS 2 -VASc and CHADS 2 scores. CONCLUSION. The challenge of stroke prevention in NVAF is balancing the risk and benefit of anticoagulant therapy. CHA 2 DS 2 -VASc does not improve the identification of patients with LAAT or low atrial mechanical function compared to CHADS 2 . Moreover CHA 2 DS 2 -VASc appears to overestimate the score of low risk patients for whom antiplatelet therapy would be sufficient and is more cumbersome compared to the original CHADS 2 .

Introduction: The risk of stroke or transient ischemic attack (TIA) remains increased after transcatheter aortic valve replacement (TAVR), especially in the first 30 days. Limited data is available regarding the impact of procedural characteristics on risk of stroke/TIA. Hypothesis: Post deployment balloon dilatation (PD) and total number of balloon dilatations (pre, valve and post insertion) may be associated with increased risk of stroke/TIA in patients undergoing TAVR. Methods: We included consecutive patients who underwent balloon-expandable TAVR until June 2014 at Mayo Clinic, Rochester. Patients who died in the operating room, converted to open surgery, or had valve-in-valve, or underwent self-expanding TAVR were excluded. Primary end-point was stroke or TIA at 30 days. Results: Mean age was 80.9±8 y, mean STS score was 8.3±5 and 50% underwent transfemoral access. The overall incidence of PD was 14% (n=53). Total number of dilations ranged from 2-7, with 5% (n=19) getting ≥ 4 total dilatations. Out of the 370 patients, 13 patients (3.5%) suffered stroke/TIA (9.4% in PD group vs. 2.2% in non-PD group) in the first 30 days after TAVR. Cox-proportional hazards regression analysis indicated that PD during TAVR was associated with a significantly increased risk of 30-day stroke/TIA (HR, 3.8; 95% CI, 1.2-11.6; p=0.02). There was a trend towards increased stroke/TIA with total number of dilations (HR, 1.5; 95% CI, 0.87-2.6; p=0.14), longer procedural time (HR per 30 minutes, 1.3; 95% CI, 0.96-1.7; p=0.09) and severity of atherosclerosis (moderate-severe - HR, 1.9; 95% CI 0.95- 3.8; p=0.07). PD was not significantly associated with the risk of 30 day death (HR, 1.1; 95% CI, 0.24-4.85; p=0.93). Conclusions: In patients undergoing PD after balloon-expandable TAVR, 9.4% suffered a stroke or TIA in the first 30 days. PD was associated with a four-fold increase in 30 day risk of stroke or TIA.

AbstractIntroductionAn algorithmic approach, termed the prolonged clot time profile (PROCT), consisting of initial screening with prothrombin time (PT) and activated partial thromboplastin time (aPTT), reflexive mixing studies if indicated, and follow‐up assays depending on initial testing results, offers an efficient approach to delineate the etiology of a prolonged PT/aPTT. Herein, we present the outcomes of the PROCT in the outpatient setting.MethodsIn this retrospective study, we reviewed medical records of consecutive outpatients who had prolonged PT and/or aPTT noted in the routine coagulation laboratory and who had PROCT ordered in our institutional Special Coagulation Laboratory between 2010 and 2017.ResultsOne hundred and six patients, median age 55 years (IQR 30‐67), met our study criteria. Twenty‐nine patients had normal PT/aPTT, while 77 had persistent abnormalities and underwent reflexive testing. A prolonged PT, aPTT, or PT and aPTT was noted in 27 (35%), 27 (35%), and 23 (30%) respectively. Forty‐nine (64%) had an acquired condition, 17 (22%) had a congenital condition, 7 (9%) had unclear etiology, and 4 (5%) were the result of laboratory artifact. The most common known cause of an isolated prolonged PT in our study was vitamin K deficiency in 8 (10%), the most common cause of an isolated prolonged aPTT was lupus anticoagulant in 4 (5%), and the most common cause of prolonged PT and aPTT was liver disease in 11 (14%).ConclusionProlonged PT/aPTT have a wide range of causes, including artifactual prolongation or abnormalities in secondary hemostasis due to both inherited and acquired conditions.

Introduction: Triple oral antithrombotic therapy (TOAT) (aspirin, clopidogrel, and warfarin) is associated with an increased risk of bleeding. Despite this, the optimal management of patients with indications for warfarin following percutaneous coronary intervention (PCI) has not been established. We sought to compare long-term clinical outcomes between patients receiving TOAT with those receiving dual antiplatelet therapy (DAPT) (aspirin and clopidogrel) after PCI. Hypothesis: Patients with clinical indications for warfarin have higher baseline risk which is largely responsible for the observed differences in outcomes between patients receiving TOAT vs. DAPT. Methods: Retrospective analysis of prospectively collected data from 9,009 patients. The primary outcome was a composite of all-cause mortality, ischemic or embolic events (myocardial infarction or stroke), or bleeding. Secondary outcomes were death plus ischemic or embolic events, death plus bleeding, death, MI, stroke, and bleeding. A 2:1 propensity matched analysis was also performed. Results: In 9,009 patients, 812 received TOAT and 8,197 received DAPT. Median follow-up was 61 months. The primary end point occurred in 2,749 patients. At 1 year, 22% of patients treated with TOAT had the primary endpoint versus 11% of DAPT patients (p<0.001). At 1 year, secondary end points of death or ischemic or embolic events (19% vs. 10%, p<0.001), and death or bleeding events (15% vs. 5%, p<0.001) also occurred with a higher frequency with TOAT. After propensity matched analysis the above differences were no longer significant with 1 year primary endpoint rates of 19% vs. 17% respectively (HR 1.95%, CI 0.88, 1.47; p = 0.33). Following propensity matching the only significant difference between TOAT and DAPT groups was minor bleeding (5% vs. 2%; HR 2.65, 95% CI 1.39, 5.03; p=0.003). Conclusions: In a large single center registry with comprehensive follow up, patients treated with TOAT had higher rates of ischemic and bleeding events. However, when baseline risks are accounted for event rates are similar, other than minor bleeding, indicating patient risk characteristics are largely responsible for the observed differences in outcomes.