Fath, Ayman R

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been demonstrated to improve outcomes in congestive heart failure (HF). However, their effect in hypertrophic cardiomyopathy (HCM) is unknown. Research Question: Can SGLT2i improve clinical outcomes in HCM patients? Methods: Using TriNetX Global Research Network from March 2013 to February 2021, patients diagnosed with HCM (ICD-10 codes I42.1, I42.2) were identified and categorized into 2 groups: those on SGLT2i vs. those who are not. To avoid inclusion of other causes of left ventricular hypertrophy, patients with aortic stenosis or systemic hypertension were excluded. Propensity score matching (PSM) was used to limit confounders. Primary outcome was all-cause mortality and secondary outcomes were HF exacerbation, all-cause hospitalization, and documented cardiovascular symptoms (chest pain, dyspnea, palpitations, or leg edema) over a 2-year follow-up period. Results: A total of 27,561 HCM patients were identified; 408 (1.5%) on SGLT2i and 27,153 (98.5%) were not. Patients on SGLT2i were older (55 ± 15 vs. 48 ± 19, p<0.01) and had more comorbidities, including a nearly 6-fold higher prevalence of diabetes mellitus (44% vs. 7%, p<0.01) and congestive HF (65% vs. 10%, p<0.01). After PSM, each group consisted of 355 patients. HCM patients on SGLT2i had lower rates of all-cause mortality (OR 0.22 [95% CI: 0.12, 0.39]; p<0.01), hospitalizations (OR 0.72 [95% CI: 0.53, 0.98]; p=0.04), and cardiovascular symptoms (OR 0.71 [95% CI: 0.52, 0.97]; p=0.029) when compared to patients not on SGLT2i. There was no statistical difference in the rate of HF exacerbation (OR 0.82 [95% CI: 0.54, 1.24]; p=0.3). Conclusion: In this large dataset, SGLT2i use in a select subset of HCM patients was associated with improved survival, less hospitalizations, and fewer cardiovascular symptoms. These data support future randomized trials to evaluate the efficacy and safety of SGLT2i in more diverse HCM patient populations.

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been proven to improve clinical outcomes in heart failure (HF). However, there remains a paucity of data on the potential cardioprotective impact of SGLT2i in cancer patients receiving anthracyclines. Aim: To evaluate if SGLT2i use is associated with improved outcomes in anthracycline-treated cancer patients. Methods: Using TriNetX Global Research Network from 2013 to 2021, patients diagnosed with cancer and receiving anthracycline therapy were identified and categorized into those who were taking SGLT2i versus those who were not. A 1:1 propensity score matching was used to control for baseline characteristics between the two groups. Patients were followed for 2 years. The primary endpoint was all-cause mortality and secondary endpoints were new-onset HF, acute HF exacerbation, myocardial infarction, new-onset atrial fibrillation/flutter, and all-cause hospitalization. Results: A total of 82,369 anthracycline-treated cancer patients were identified. After propensity score matching application, 1,412 patients were included in our analysis (706 patients in each group). Patients on SGLT2i had lower rates of all-cause mortality (OR: 0.7 [95% CI: 0.56, 0.88]; P=0.002), acute HF exacerbation (OR: 0.64 [95% CI: 0.41-1]; P=0.048), and new-onset atrial fibrillation/flutter (OR: 0.52 [95% CI: 0.33, 0.8]; P=0.003) compared to those not on SGLT2i. The incidence of myocardial infarction, new-onset HF, and all-cause hospitalization were similar between the two groups (Figure). Conclusion: Among cancer patients receiving anthracyclines, SGLT2i were associated with lower rates of mortality, acute HF exacerbations, and new-onset atrial fibrillation/flutter and similar rates of myocardial infarction, new-onset HF, and hospitalization.

Background: Choosing either a mechanical or a bioprosthetic valve during surgical aortic valve replacement (AVR) in middle-aged patients is still controversial, especially with contemporary advancements in valve technology. Aims: To evaluate long-term survival and major morbidity in patients aged 50-70 years undergoing AVR using contemporary mechanical and bioprosthetic valves. Methods: A retrospective study was performed using the TriNetX global database to identify patients aged 50 to 70 years who had primary isolated surgical AVR from 2014 to 2020. Patients who had transcatheter AVR, concomitant, or prior cardiac surgery were excluded. Patients were stratified into 2 groups: mechanical and bioprosthetic. A 1:1 propensity-score matching was performed to control for baseline differences between the two cohorts. The primary endpoint was all-cause mortality and secondary endpoints were stroke, major bleeding, and reoperation over a follow-up period of 8 years. Results: A total of 1,138 propensity-matched patients were included in each group. There was no significant difference in survival, stroke, or reoperation rates between the two groups. Survival probability at the end of the follow-up period was 76.6% in the mechanical group and 80.1% in the bioprosthetic group (HR, 0.946 [95% CI, 0.702, 1.276]) (Figure 1). A total of 137(12%) vs 119 (10.4%) patients had stroke in the mechanical vs the bioprosthetic group, respectively (HR, 1.08 [95% CI, 0.851-1.392]). A total of 19 (1.7%) vs 17 (1.5%) patients had reoperation in the mechanical, and the bioprosthetic valve group, respectively (HR, 1.01 [95% CI, 0.526, 1.951]). There were higher major bleeding events in the mechanical group, 266 (23.4%) vs 163 (14.3%) in the bioprosthetic group, (HR, 1.64 [95% CI, 1.353, 1.999]). Conclusion: Contemporary bioprosthetic valves could be a reasonable option for AVR in patients aged 50 to 70 years with less major bleeding risk and similar survival, stroke, and reoperation rates.

Background: Guidelines are still unclear regarding whether mechanical or bioprosthetic valves should be selected for mitral valve replacement (MVR) in patients aged 50-70 years. Aims: To assess long-term outcomes in patients aged 50-70 years undergoing MVR using contemporary mechanical and bioprosthetic valves. Methods: We performed a retrospective study using the TriNetX global database to identify patients aged 50 to 70 years who had primary isolated surgical MVR from 2014 to 2020. Patients who had concomitant or prior cardiac surgeries were excluded. Patients were stratified into 2 groups: mechanical and bioprosthetic, and a 1:1 propensity-score matching to control for baseline differences between the two groups was performed. The primary endpoint was all-cause mortality and secondary endpoints were stroke, major bleeding, and reoperation over a follow-up period of 8 years. Results: Propensity-score matching yielded 1,130 patients in each group. There were significantly higher rates of all-cause mortality, stroke, and major bleeding events in the mechanical group compared to the bioprosthetic valve. There was no significant difference between the two groups regarding reoperation (Table 1 and Figure 1). Conclusion: At an 8-year follow-up, the use of contemporary bioprosthetic valves for MVR in patients aged 50-70 years shows favorable all-cause mortality and lower rates of strokes and major bleeding with similar reoperation rates compared to mechanical valves.

Background: We sought to investigate the outcomes of direct oral anticoagulants (DOACs) versus warfarin in patients with atrial fibrillation and bioprosthetic mitral valve replacement (bMVR) due to rheumatic heart disease. Methods: We performed a retrospective study using the TriNetX global database to identify patients with atrial fibrillation and bMVR due to rheumatic heart disease from 2010 to 2020. Patients who had mechanical mitral or aortic valve replacement were excluded. Patients were stratified into 2 groups: DOAC group and Warfarin group. 1:1 propensity-score matching to control for baseline differences between the two groups was performed. The primary endpoint was ischemic stroke and secondary endpoints were all-cause mortality, major bleeding, myocardial infarction, and all-cause hospitalization over a mean follow-up of 3 years. Results: A total of 2,011 patients were identified and 586 were included after propensity-score matching (293 patients in each group). Patients in the DOAC group, compared to the warfarin group aged 68.9 ± 11.2 vs 68.2 ± 11 years (P=0.41) and 63.4% vs 63.8% were females (P=0.93). There was no significant difference between the two groups in ischemic stroke, all-cause mortality, major bleeding, myocardial infarction, and all-cause hospitalization. (Table 1, figure 1). Conclusion: In patients with atrial fibrillation and bMVR due to rheumatic heart disease, DOACs use was associated with similar rates of ischemic stroke, mortality, major bleeding, myocardial infarction, or hospitalization compared to warfarin.

Introduction: The COVID-19 pandemic has had major impacts on all healthcare services, including cardiac imaging. In this study, we investigate annual changes in cardiac imaging procedural volume and reimbursement among Medicare Beneficiaries (MB) from 2018 to 2020. Methods: We used the Center of Medicare and Medicaid Services database to identify a 100% sample of MB who underwent cardiac imaging procedures from 2018 to 2020. Using the Current Procedural Terminology (CPT) codes, we identified transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), stress echocardiogram, and nuclear stress test procedures. We examined each procedure’s total, inpatient (facility), and outpatient (non-facility) annual volumes per 1,000 MB. We also examined the total annual Medicare reimbursement per imaging type during that period. We compared annual changes in volumes and total reimbursement between two-time intervals: 2018-2019 and 2019-2020. Results: All annual cardiac imaging procedural volumes decreased significantly in 2020 compared to 2019 ( P<0.001 ). The biggest change was observed in TEE, which decreased by 29.20%, followed by stress echocardiography (26.01%), nuclear stress test (22.96%), and TTE (10.68%). The decrease was more evident in the inpatient setting. Inpatient stress echocardiography decreased by 27.04% (vs 23.82% in the outpatient setting), nuclear stress test decreased by 24.82% (vs 20.66%), and TTE decreased by 11.03% (vs 9.58%). There was also a significant reduction in total annual reimbursement for all procedures in 2020 compared to 2019 ( P=0.0015 ). Stress echocardiogram, nuclear stress test, TEE, and TTE reimbursement decreased by 28.08%, 24.00%, 21.11%, and 15.79%, respectively. Conclusions: The COVID-19 pandemic was associated with a significant and abrupt reduction in annual cardiac imaging procedural volumes and total reimbursement among MB in both inpatient and outpatient settings.