Prasad, Abhiram

Aim Angina pectoris in the absence of obstructive coronary artery disease (CAD) is common and is associated with poor quality of life (QOL). Coronary microvascular endothelial dysfunction is associated with myocardial ischaemia and is a common cause of angina. We hypothesise that evaluation of coronary endothelial function, its diagnosis and treatment will favourably impact QOL in patients with angina symptoms and non-obstructive CAD. Methods and results Follow-up was done on 457 patients with chest pain and non-obstructive coronary arteries who had undergone coronary vascular reactivity evaluation by administration of intracoronary acetylcholine at the time of diagnostic study. After a mean follow-up of 8.4±4.7 years, QOL was assessed by administration of the SF-36 QOL survey. Patients diagnosed and treated for microvascular endothelial dysfunction had a higher (better) overall mental composite score (44.8 vs 40.9, p=0.036) and mental health score (44.2 vs 40.7, p=0.047), and a trend towards higher vitality scores (39.1 vs 35.9, p=0.053) and role emotional scores (43.6 vs 40.4, p=0.073), compared with patients with normal endothelial function. Conclusion Among patients with chest pain and normal coronaries, diagnosis and treatment of coronary microvascular endothelial dysfunction in those with angina pectoris and non-obstructive CAD are associated with better QOL compared with patients with normal endothelial function.

Background There are limited data on the role of temporary mechanical circulatory support ( MCS ) devices for cardiogenic shock before left ventricular assist device ( LVAD ) surgery. This study sought to evaluate the trends of use and outcomes of MCS in cardiogenic shock before LVAD surgery. Methods and Results This was a retrospective cohort study from 2005 to 2014 using the National Inpatient Sample (20% stratified sample of US hospitals). This study identified admissions undergoing LVAD surgery with preoperative cardiogenic shock. Admissions for other cardiac surgery and heart transplant were excluded. Temporary MCS was identified using administrative codes. The primary outcome was hospital mortality and secondary outcomes were hospital costs and lengths of stay in admissions with and without MCS use. In this 10‐year period, 9753 admissions were identified with 40.6% requiring pre‐ LVAD MCS . There was a temporal increase in the frequency of cardiogenic shock associated with an increase in non–intra‐aortic balloon pump MCS devices. The cohort receiving MCS had greater in‐hospital myocardial infarction, ventricular arrhythmias, and use of coronary angiography. On multivariable analysis, older age, myocardial infarction, and need for MCS devices were independently predictive of higher in‐hospital mortality. In 696 propensity‐matched pairs, use of MCS was predictive of higher in‐hospital mortality (odds ratio 1.4 [95% confidence interval 1.1–1.6]; P =0.02) and higher hospital costs, but similar lengths of stay. Conclusions In patients with cardiogenic shock bridged to LVAD therapy, there was a steady increase in preoperative MCS use. Use of MCS identified patients at higher risk for in‐hospital mortality and greater resource utilization.

Apical ballooning syndrome (ABS) is an under recognised clinical entity characterised by acute reversible left ventricular systolic dysfunction that mimics acute myocardial infarction in the absence of obstructive coronary artery disease; typically occurring in the setting of profound stress.1 ABS disproportionately affects older women and recurrences are infrequent. We, hereby, describe a rare phenomenon of recurrent ABS in an elderly male patient, 10 years apart, presenting with the same left ventricular morphological appearance following non-cardiac surgeries. The case illustrates the importance of considering ABS in the differential diagnosis of perioperative acute myocardial infarction in older men undergoing major surgery.

Background There are limited data on the presentation of Takotsubo cardiomyopathy ( TTC ) in severe sepsis. Methods and Results This was a retrospective cohort study using the National Inpatient Sample database (2007–2013) of all adults with severe sepsis. TTC was identified in patients with severe sepsis using previously validated administrative codes. The primary outcome was in‐hospital mortality, and secondary outcomes included resource utilization and discharge disposition. Regression analysis was performed for the entire cohort and a propensity‐matched sample. An exploratory analysis was performed for predictors of TTC incidence and mortality in TTC . During this 7‐year period, in 7.1‐million hospitalizations for severe sepsis, TTC was diagnosed in 10 746 (0.15%) admissions. TTC was noted more commonly in whites, females, and among 65‐ to 79‐year‐old individuals. TTC was independently associated with lower in‐hospital mortality in severe sepsis (odds ratio, 0.58; 95% confidence interval, 0.51–0.65). This association was more prominent in females (odds ratio, 0.51; 95% confidence interval, 0.44–0.59]) compared with males (odds ratio, 0.69; 95% confidence interval, 0.55–0.85]). Presentation in later years of the study period, middle‐age, female sex, and white race were independent predictors for the diagnosis of TTC . Age ≥80 years, black race, greater comorbidity, and multiorgan dysfunction were independently associated with higher in‐hospital mortality among TTC admissions. Conclusions TTC is observed with increasing frequency in severe sepsis and was associated with a significantly lower in‐hospital mortality compared with patients without TTC . Presentation in later years of the study period, middle age, female sex, and white race were independent predictors for the diagnosis of TTC in severe sepsis.

Background Soluble urokinase plasminogen activator receptor (su PAR ) is a proinflammatory biomarker associated with immune activation and fibrinolysis inhibition. Plasminogen activator inhibitor ( PAI ‐1) is associated with excessive fibrin accumulation, thrombus formation, and atherosclerosis. The relationship between cross‐coronary su PAR and PAI ‐1 production and endothelial dysfunction remains unknown. Methods and Results Seventy‐nine patients (age 53±10 years, 75% women) with angina and normal coronary arteries or mild coronary artery disease (<40% stenosis) on angiogram underwent acetylcholine assessment of epicardial endothelial dysfunction (mid–left anterior descending coronary artery diameter decrease >20% after acetylcholine) and mircovascular endothelial dysfunction (coronary blood flow change <50% after acetylcholine). Simultaneous left main and coronary sinus su PAR and PAI ‐1 levels were measured in each patient before acetylcholine administration, and cross‐coronary su PAR and PAI ‐1 production rates were calculated. Patients’ characteristics, except for age (51±10 versus 57±9, P =0.02), and resting coronary hemodynamics were not significantly different between patients with (26%) versus without (74%) epicardial endothelial dysfunction. Patients’ characteristics and resting coronary hemodynamics were not significantly different between those with (62%) and those without (38%) mircovascular endothelial dysfunction. Patients with mircovascular endothelial dysfunction demonstrated local coronary su PAR production versus su PAR extraction in patients with normal microvascular function (median 25.8 [interquartile range 121.6, −23.7] versus −12.7 [52.0, −74.8] ng/min, P =0.03). Patients with epicardial endothelial dysfunction had higher median coronary PAI ‐1 production rates compared with those with normal epicardial endothelial function (1224.7 [12 940.7, −1915.4] versus −187.4 [4444.7, −4535.8] ng/min, P =0.03). Conclusions su PAR is released in coronary circulation of patients with mircovascular endothelial dysfunction and extracted in those with normal microvascular function. Cross‐coronary PAI ‐1 release is higher in humans with epicardial endothelial dysfunction.

Background— Women have higher rates of all-cause mortality after percutaneous coronary intervention. Whether this is because of greater age and comorbidity burden or a sex-specific factor remains unclear. Methods and Results— We retrospectively assessed cause-specific long-term mortality after index percutaneous coronary intervention over 3 time periods (1991–1997, 1998–2005, and 2006–2012). Cause of death was determined using telephone interviews, medical records, and death certificates. We performed competing risks analyses of cause-specific mortality. A total of 6847 women and 16 280 men survived index percutaneous coronary intervention hospitalization 1991 to 2012. Women were older (mean±SD: 69.4±12 versus 64.8±11.7 years; P <0.001) with more comorbidities (mean±SD: Charlson index 2.1±2.1 versus 1.9±2.1; P <0.001). Across the 3 time periods, both sexes exhibited a decline in cardiac deaths at 5 years (26% relative decrease in women, 17% in men, trend P <0.001 for each). Although women had higher all-cause mortality compared with men in all eras, the excess mortality was because of noncardiac deaths. In the contemporary era, only a minority of deaths were cardiac (33.8% in women, 38.0% in men). After adjustment, there was no evidence for a sex-specific excess of risk for cardiac or noncardiac mortality. The commonest causes of death were chronic diseases and heart failure in women (5-year cumulative mortality, 5.4% and 3.9%) but cancer and myocardial infarction/sudden death in men (5.4% and 4.3%). Conclusions— The higher mortality after percutaneous coronary intervention in women is because of death from noncardiac causes. This is accounted for by baseline age and comorbidities rather than an additional sex-specific factor. These findings have implications for sex-specific clinical care and trial design.

Background Participation in cardiac rehabilitation ( CR ) is an essential component of care for patients with coronary artery disease. However, little is known about its benefit on cardiovascular outcomes in patients with diabetes mellitus ( DM ) who have undergone percutaneous coronary intervention. The aim of our study was to evaluate the impact of CR in this high‐risk group of patients. Methods and Results We performed a retrospective analysis of all patients with DM who underwent percutaneous coronary intervention in Olmsted County (Minnesota) between 1994 and 2010, assessing the impact of CR participation on clinical outcomes. CR participation was significantly lower in patients with DM (38%, 263/700) compared with those who did not have DM (45%, 1071/2379; P =0.004). Using propensity score adjustment, we found that in patients with DM , CR participation was associated with significantly reduced all‐cause mortality (hazard ratio, 0.56; 95% confidence interval, 0.39–0.80; P =0.002) and composite end point of mortality, myocardial infarction, or revascularization (hazard ratio, 0.77; 95% confidence interval, 0.60–0.98; P =0.037), during a median follow‐up of 8.1 years. In patients without DM , CR participation was associated with a significant reduction in all‐cause mortality (hazard ratio, 0.67; 95% confidence interval, 0.55–0.82; P <0.001) and cardiac mortality (hazard ratio, 0.67; 95% confidence interval, 0.47–0.95; P =0.024). Conclusions CR participation after percutaneous coronary intervention is associated with lower all‐cause mortality rates in patients with DM , to a similar degree as for those without DM . However, CR participation was lower in patients with DM , suggesting the need to identify and correct the barriers to CR participation for this higher‐risk group of patients.