Journal of the American Heart Association最新文献

Background: Limited knowledge exists about prophylactic anticoagulation patterns in patients hospitalized for COVID-19.

Methods and results: We conducted a retrospective cohort study using American Heart Association COVID-19 Cardiovascular Disease Registry data from May 2020 to March 2022. We included patients without preexisting indications for or contraindications to anticoagulation, excluding those with missing anticoagulation data. Patients were categorized by the highest anticoagulation dose received. Multilevel logistic regression was used to assess the relationship between anticoagulation use/dose, patient demographics, clinical presentation, in-hospital course, institutional characteristics, and admission date, accounting for hospital clustering. Among 26 775 patients, 4157 (16%) received no anticoagulation, 15 617 (58%) low-dose, 3071 (11%) intermediate-dose, and 3930 (15%) full-dose anticoagulation. Significant hospital-level variability occurred for any anticoagulation use (range, 0%-98%; P<0.0001) and by dose (full anticoagulation range, 0%-85%; P<0.0001). Controlling for hospital variability, older age, male sex, non-White race, higher body mass index, higher platelets, corticosteroid use, and intensive care unit admission were positively associated with any anticoagulation use. Older age, male sex, higher body mass index, higher platelets, corticosteroid use, intensive care unit admission, mechanical ventilation, and admission before October 2020 were associated with higher anticoagulation dose (full versus low dose). Rates of no anticoagulation significantly increased in both intensive care unit and non-intensive care unit strata over time (P trend=0.01 and <0.0001, respectively).

Conclusions: In this large real-world analysis, nearly 1 in 6 patients hospitalized for COVID-19 received no prophylactic anticoagulation. Patient and disease characteristics associated with thrombotic risk and COVID-19 severity correlated with anticoagulation strategy. Importantly, substantial institutional differences emerged, highlighting gaps between clinical practice and guideline recommendations.

Background: Thoracic endovascular aortic repair (TEVAR) and complex endovascular aneurysm repair (EVAR) are complex procedures that carry a significant risk of complications. While risk prediction tools can aid in clinical decision making, they remain limited. We developed machine learning algorithms to predict outcomes following TEVAR and complex EVAR.

Methods: The Vascular Quality Initiative database was used to identify patients who underwent elective TEVAR and complex EVAR for noninfrarenal aortic aneurysms between 2012 and 2023. We extracted 172 features from the index hospitalization, including 93 preoperative (demographic/clinical), 46 intraoperative (procedural), and 33 postoperative (in-hospital course/complications) variables. The primary outcome was 1-year thoracoabdominal aortic aneurysm life-altering event, defined as new permanent dialysis, new permanent paralysis, stroke, or death. The data were split into training (70%) and test (30%) sets. We trained 6 machine learning models using preoperative features with 10-fold cross-validation. Model robustness was evaluated using calibration plots and Brier scores.

Results: Overall, 10 738 patients underwent TEVAR or complex EVAR, with 1485 (13.8%) experiencing 1-year thoracoabdominal aortic aneurysm life-altering event. Extreme Gradient Boosting was the best preoperative prediction model, achieving an area under the receiver operating characteristic curve of 0.96 (95% CI, 0.95-0.97), compared with 0.70 (95% CI, 0.68-0.72) for logistic regression. The Extreme Gradient Boosting model maintained excellent performance at the intra- and postoperative stages, with areas under the receiver operating characteristic curves of 0.97 (95% CI, 0.96-0.98) and 0.98 (95% CI, 0.97-0.99), respectively. Calibration plots indicated good agreement between predicted/observed event probabilities, with Brier scores of 0.09 (preoperative), 0.08 (intraoperative), and 0.05 (postoperative).

Conclusions: Machine learning models can accurately predict 1-year outcomes following TEVAR and complex EVAR, performing better than logistic regression.

Background: Psychosocial stressors such as childhood trauma have been associated with an increased risk of hypertension. The impact of childhood trauma on vascular dysfunction in Black adults remains less clear. We examined the association between childhood trauma and vascular function in Black adults.

Methods and results: Childhood trauma exposure and vascular function were assessed in a cohort of healthy Black participants without known cardiovascular disease (n=404) from a large metropolitan city. Childhood trauma was assessed using the Early Trauma Inventory Short Form with higher scores indicative of higher traumatic life events assessed before age 18 years. Outcomes of central augmentation index (CAIx) and carotid femoral pulse wave velocity were measured as indices of wave reflections and arterial stiffness using applanation tonometry (Sphygmocor Inc.), and central pulse pressure (CPP) was calculated as the difference between the central aortic systolic and diastolic blood pressures. Relationships between Early Trauma Inventory Short Form and outcomes were assessed using multivariate-adjusted and sex-stratified linear regression models. The mean age of the cohort was 53 (SD=10.3), 61% women. Cumulative childhood trauma was not associated with CAIx, central pulse pressure, or carotid femoral pulse wave velocity in the minimal or fully adjusted models for sociodemographic, sex, clinical factors, medical history, health behaviors, and depression. Significant trauma × sex interactions were identified for CAIx (P=0.003) and central pulse pressure (P=0.025). Childhood trauma was associated with lower CAIx (β=-0.55% [95% CI, -1.07 to -0.03] in men, but higher CAIx (β=0.35% [95% CI, 0.08-0.63]) and central pulse pressure (β=0.23 mm Hg [95% CI, 0.01-0.43]) in women.

Conclusions: Childhood trauma is independently associated with impaired arterial compliance in Black women.

Background: The economic burden of atrial fibrillation (AF) continues to increase. AF treatment pathways have been shown to reduce avoidable admissions, but the effects on health care costs are not understood. This study sought to assess the impact of an AF treatment pathway on health service charges and emergency department (ED) discharge rates.

Methods: An AF treatment pathway was implemented at 7 hospital EDs in North Carolina between 2017 and 2020. Thirty-day health service charges were calculated for ED visits, hospitalizations, and outpatient clinic appointments. A quasi-experimental design was used to assess changes in health service charges and ED discharge rates following implementation of the AF treatment pathway. Adjusted quantile and negative binomial regressions were used to analyze changes in median 30-day health service charges and discharge rates from the ED, respectively.

Results: Among 12 504 patients that met eligibility for study inclusion (preperiod: n=3893; postperiod: n=8611), implementation of the AF treatment pathway significantly reduced 30-day health service charges (preperiod: $11 922; postperiod: $9219; P<0.001). In adjusted models, implementation of the AF treatment pathway was associated with an $834 decrease in median 30-day health service charges (95% CI, -$1630 to $-37; P=0.04). Additionally, the adjusted predicted probability of ED discharge increased from 65.3% to 70.0% after the AF treatment pathway implementation, a 4.7 percentage point increase (95% CI, 1.4-8.0; P<0.001).

Conclusions: The implementation of an AF treatment pathway in the ED was associated with a decrease in median 30-day health service charges and an increase in ED discharge rate for patients presenting with AF.

Background: The efficacy of icosapent ethyl among patients with very well-controlled baseline low-density lipoprotein cholesterol (LDL-C) is unknown.

Methods: In this post hoc analysis of the REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial) randomized clinical trial, statin-treated patients with high cardiovascular risk, elevated triglycerides (135-499 mg/dL), and baseline LDL-C of 41 to 100 mg/dL were included. Patients were randomized to icosapent ethyl (2 g twice daily) or placebo and then post hoc stratified by baseline LDL-C (<55 mg/dL versus ≥55 mg/dL). The primary composite end point included cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina.

Results: Among 8175 patients with baseline LDL-C data, 7117 (87.1%) had LDL-C ≥55 mg/dL and 1058 (12.9%) had LDL-C <55 mg/dL. In patients with LDL-C <55 mg/dL, the rate of the primary composite end point was lower in the icosapent ethyl group (16.2% versus 22.8%) than in the placebo group (hazard ratio [HR], 0.66 [95% CI, 0.50-0.87]; absolute risk reduction, 6.6%; P=0.003). Among patients with LDL-C ≥55 mg/dL, a primary composite end point event occurred in a lower proportion of patients in the icosapent ethyl group (17.4% versus 21.9%) than in the placebo group (HR, 0.76 [95% CI, 0.69-0.85]; absolute risk reduction, 4.5%; P<0.0001). No significant interaction was observed between baseline LDL-C and treatment group (P for interaction=0.40). Findings were consistent among secondary cardiovascular end points and in sensitivity analyses.

Conclusions: Among statin-treated patients with elevated triglycerides and high cardiovascular risk, icosapent ethyl reduced the rate of cardiovascular end points irrespective of baseline LDL-C, including among eligible patients with optimal LDL-C control.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01492361.

Background: MGP (matrix Gla protein) inhibits arterial calcification. Higher inactive MGP, in its dephosphorylated-uncarboxylated (dp-uc) form, is positively associated with vascular calcification, possibly portending adverse cardiovascular events. The objective of this study was to determine the association of dp-ucMGP with incident cardiovascular disease (CVD) events and mortality in MESA (Multi-Ethnic Study of Atherosclerosis).

Methods: MESA is a prospective cohort study of 45- to 84-year-old individuals enrolled between 2000 and 2002 with adjudicated outcomes through 2019. Dp-ucMGP was measured at baseline in n=2663 participants with cardiac computed tomography at Exams 1 (2000-2002) and 5 (2010-2012). Age-stratified Cox proportional hazard models were used to assess dp-ucMGP with risk of all CVD (mean follow-up 16±4 years), hard CVD (17±3 years), hard coronary heart disease (17±3 years), and all-cause mortality (18±2 years).

Results: The youngest age quartile (45- to 53-years-old) with higher dp-ucMGP levels (520-2934 pmol/L) had an increased risk of all CVD (hazard ratio [HR], 3.05 [95% CI, 1.58-5.90], P=0.001), hard CVD (HR, 2.85 [95% CI, 1.30-6.23], P=0.009), hard coronary heart disease (HR, 3.79 [95% CI, 1.31-10.95], P=0.014), and all-cause mortality (HR, 2.73 [95% CI, 1.19-6.30], P=0.018) compared with those with dp-ucMGP levels between 150 and 519 pmol/L in maximally adjusted models.

Conclusions: Younger individuals 45 to 53 years old with elevated dp-ucMGP levels (≥520 pmol/L) had an increased risk of incident CVD, coronary heart disease, and all-cause mortality. No association was seen in older adults. Additional studies are needed to better delineate the relationship of inactive MGP with incident CVD, coronary heart disease, and all-cause mortality.

Background: Out-of-hospital cardiac arrest (OHCA) with initial shockable rhythm generally has a favorable prognosis. However, the prognosis worsens when this rhythm transitions to nonshockable rhythm on hospital arrival. This study aimed to investigate the association between no-flow time (NFT), prehospital low-flow time (LFT), and the conversion to nonshockable rhythm on hospital arrival in patients with OHCA initially exhibiting shockable rhythm.

Methods: We analyzed adult patients with OHCA from the JAAM-OHCA (Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest) registry (June 2014-December 2020) with initial shockable rhythm. The primary outcome was rhythm conversion to nonshockable on hospital arrival. Adjusted odds ratios (aORs) with 95% CIs were calculated using a logistic model to examine the associations between NFT, prehospital LFT, and rhythm conversion.

Results: Of 68 110 patients, 3720 patients were included in our analysis. On hospital arrival, 27.9% patients achieved return of spontaneous circulation, 32.8% maintained shockable rhythm, and 39.3% transitioned to nonshockable rhythm (718 to pulseless electrical activity, 744 to asystole). Median NFT was 4 minutes (interquartile range [IQR], 1-9 minutes), and median prehospital LFT was 22 minutes (IQR, 14-31 minutes). Longer NFT and prehospital LFT were associated with higher aORs of rhythm conversion: NFT (5-9 minutes: aOR, 1.38 [95% CI, 1.14-1.67]; ≥10 minutes: aOR, 1.75 [95% CI, 1.44-2.14]); and prehospital LFT (15-19 minutes: aOR, 2.56 [95% CI, 2.00-3.27]; 20-29 minutes, aOR, 4.73 [95% CI, 3.83-5.85]; ≥30 minutes, aOR, 6.85 [95% CI, 5.49-8.56]).

Conclusions: Prolonged NFT and prehospital LFT were significantly associated with rhythm conversion to nonshockable on hospital arrival in patients with OHCA with initial shockable rhythm at the scene.

Background: Stent implantation poses challenges in small children due to their limited vessel size and rapid growth. This multicenter study evaluates in vivo efficacy of implanting Optimus-L stents in small patients using a low-profile approach.

Methods: We retrospectively reviewed data from children weighing ≤20 kg with congenital heart stenotic lesions who received Optimus-L stents manually mounted on small-sized balloon catheters (diameter ≤12 mm) using a hand-actuated compression tool and implanted through small-sized sheaths (≤8 Fr) at our institutions between May 2022 and January 2024. Stent performance was assessed.

Results: We identified 28 patients (67.8% male) with median age and weight of 3.4 years (interquartile range [IQR], 1.5-5.5) and 12.9 kg (IQR, 9.1-16.4). Six (21.4%) were infants, 11 (39.3%) ≤10 kg. Stenotic lesions included 16 branch pulmonary arteries, 9 aortic isthmus, 2 right ventricular outflow tracts, and 1 Glenn anastomosis. Percentage of stenosis was 50% (IQR, 36%-58%). All implantations were successful without complications. The procedures mostly used 7 Fr sheaths for stents on 6, 7, and 8 mm balloons and 8 Fr sheaths for 9, 10, 12 mm balloons. Median stent expansion percentage was 95% (IQR, 90%-96%). Median vessel diameters increased from 4.6 mm (IQR, 3.8-5.1) to 8.8 mm (IQR, 7.5-9.5) (P<0.001), with median stenosis expansion at 103% (IQR, 51%-146%). Median stent shortening was 1.9% (IQR, 0%-3.9%). Two patients required redo stent balloon dilation after 18 and 20 months. Median follow-up was 8 months (IQR, 3.2-13.2). Median last recorded Doppler velocity on implanted stents was 1.6 m/s (IQR, 1.2-2).

Conclusions: Optimus-L stents can safely treat arterial and venous stenosis in infants and small children via a low-profile approach with good outcomes.