The Determining Risk of Vascular Events by Apnea Monitoring (DREAM) Study: Design, Rationale and Methods

Purpose The goal of the Determining Risk of Vascular Events by Apnea Monitoring (DREAM) study is to develop a prognostic model for cardiovascular outcomes, based on physiologic variables—related to breathing, sleep architecture, and oxygenation—measured during polysomnography in US veterans. Methods The DREAM study is a multi-site, retrospective observational cohort study conducted at three Veterans Affairs (VA) centers (West Haven, CT; Indianapolis, IN; Cleveland, OH). Veterans undergoing polysomnography between January 1, 2000 and December 31, 2004 were included based on referral for evaluation of sleep-disordered breathing, documented history and physical prior to sleep testing, and ≥2-h sleep monitoring. Demographic, anthropomorphic, medical, medication, and social history factors were recorded. Measures to determine sleep apnea, sleep architecture, and oxygenation were recorded from polysomnography. VA Patient Treatment File, VA–Medicare Data, Vista Computerized Patient Record System, and VA Vital Status File were reviewed on dates subsequent to polysomnography, ranging from 0.06 to 8.8 years (5.5 ± 1.3 years; mean ± SD). Results The study population includes 1840 predominantly male, middle-aged veterans. As designed, the main primary outcome is the composite endpoint of acute coronary syndrome, stroke, transient ischemic attack, or death. Secondary outcomes include incidents of neoplasm, congestive heart failure, cardiac arrhythmia, diabetes, depression, and post-traumatic stress disorder. Laboratory outcomes include measures of glycemic control, cholesterol, and kidney function. (Actual results are pending.) Conclusions This manuscript provides the rationale for the inclusion of veterans in a study to determine the association between physiologic sleep measures and cardiovascular outcomes and specifically the development of a corresponding outcome-based prognostic model

Time and event-specific deep learning for personalized risk assessment after cardiac perfusion imaging

Standard clinical interpretation of myocardial perfusion imaging (MPI) has proven prognostic value for predicting major adverse cardiovascular events (MACE). However, personalizing predictions to a specific event type and time interval is more challenging. We demonstrate an explainable deep learning model that predicts the time-specific risk separately for all-cause death, acute coronary syndrome (ACS), and revascularization directly from MPI and 15 clinical features. We train and test the model internally using 10-fold hold-out cross-validation (n = 20,418) and externally validate it in three separate sites (n = 13,988) with MACE follow-ups for a median of 3.1 years (interquartile range [IQR]: 1.6, 3.6). We evaluate the model using the cumulative dynamic area under receiver operating curve (cAUC). The best model performance in the external cohort is observed for short-term prediction - in the first six months after the scan, mean cAUC for ACS and all-cause death reaches 0.76 (95% confidence interval [CI]: 0.75, 0.77) and 0.78 (95% CI: 0.78, 0.79), respectively. The model outperforms conventional perfusion abnormality measures at all time points for the prediction of death in both internal and external validations, with improvement increasing gradually over time. Individualized patient explanations are visualized using waterfall plots, which highlight the contribution degree and direction for each feature. This approach allows the derivation of individual event probability as a function of time as well as patient- and event-specific risk explanations that may help draw attention to modifiable risk factors. Such a method could help present post-scan risk assessments to the patient and foster shared decision-making

Periprocedural prognostic factors in coronary interventions – retrospective studies

Background: Approximately 11,000 revascularization procedures, either percutaneous coronary interventions (PCI) or coronary artery bypass grafting surgery (CABG), are performed yearly in Finland for coronary artery disease. Periprocedural risk factors for mortality and morbidity as well as long-term outcome have been extensively studied in general populations undergoing revascularization. Treatment choice between PCI and CABG in many high risk groups and risk-stratification, however, needs clarification and there is still room for improvement in periprocedural outcomes. Materials and methods: Cohorts of patients from Finnish hospitals revascularized between 2001 and 2011 were retrospectively analyzed. Patient records were reviewed for baseline variables and postprocedural outcomes (stroke, myocardial infarction, quality of life measured by the EQ-5D –questionnaire, repeat revascularization, bleeding episodes). Data on date and mode of death was acquired from Statistics Finland. Statistical analysis was performed to identify predictors of adverse events and compare procedures. Results: Postoperative administration of blood products (red blood cells, fresh frozen plasma, platelets) after isolated CABG independently and dose-dependently increases the risk of stroke. Patients 80 years or older who underwent CABG had better survival at 5 years compared to those who underwent PCI. After adjusting for baseline differences survival was similar. Patients on oral anticoagulation (OAC) for atrial fibrillation (AF) treated with CABG had better survival and overall outcome at 3 years compared to PCI patients. There was no difference in incidence of stroke or bleeding episodes. Differences in outcome remained significant after adjusting for propensity score. Lower health-related quality of life (HRQOL) scores as measured by the visual analogue scale (VAS) of the EQ-5D questionnaire at 6 months after CABG predicted later major adverse cardiac and cerebrovascular events (MACCE). Deteriorating function and VAS scores between 0 and 6 months on the EQ-5D also independently predicted later MACCE. Conclusions: Administration of blood products can increase the risk of stroke after CABG and liberal use of transfusions should be avoided. In the frail subpopulations of patients on OAC and octogenarians CABG appears to offer superior long-term outcome as compared to PCI. Deteriorating HRQOL scores predict later adverse events after CABG. Keywords: percutaneous coronary intervention, coronary artery bypass grafting, age over 80, transfusion, anticoagulants, coronary artery disease, health-related quality of life, outcome.Sepelvaltimotoimenpiteiden ennusteelliset tekijät – retrospektiivisiä tutkimuksia Tausta: Suomessa tehdään vuosittain yli 10 000 sepelvaltimoiden pallolaajennusta (PCI) ja ohitusleikkausta (CABG). Toimenpiteeseen liittyviä riskitekijöitä ja pitkäaikaisennustetta on tutkittu laajalti tavanomaisissa potilasaineistoissa. Toimenpidevalintaa ohjaavaa tietoa riskiryhmistä sekä riskinarviointikeinoja kuitenkin tarvitaan yhä ja välittömiä toimenpiteen jälkeisiä tuloksia voi edelleenkin parantaa. Aineisto ja menetelmät: Vuosien 2001 ja 2011 välillä suomalaisissa sairaaloissa sepelvaltimoihin kohdistuvin toimenpitein hoidettuja potilaskohortteja tutkittiin taannehtivasti. Potilasasiakirjoista etsittiin toimenpidettä edeltävät sairastavuustiedot, toimenpidejakson tiedot sekä toimenpiteen jälkeisen ajan tiedot (aivo- ja sydäninfarktit, uusintatoimenpiteet, verenvuodot ja EQ-5D –lomakkeella mitattu elämänlaatu). Kuolintiedot haettiin Tilastokeskuksen rekistereistä. Tilastomatemaattisin keinoin selvitettiin myöhäissairastavuutta ja -kuolleisuutta ennakoivat tekijät ja toimenpideryhmien väliset erot. Tulokset: Leikkauksen jälkeinen verituotteiden (punasolut, jääplasma, verihiutaleet) annostelu lisää annosriippuvaisesti ja itsenäisesti toimenpiteen jälkeisen aivoinfarktin riskiä. Yli 80-vuotiaat sepelvaltimotoimenpitein hoidetut potilaat ovat todennäköisemmin elossa ohitusleikkauksen kuin pallolaajennuksen jälkeen 5 vuoden seuranta-aikana. Lähtötilanteen muuttujien samankaltaistamisen jälkeen ei tullut esille eroa ryhmien välillä. Eteisvärinän vuoksi antikoaguloitujen potilaiden elossaolo ja haittatapahtuman todennäköisyys ovat paremmat ohitusleikkauksen jälkeen. Aivoinfarkteissa tai verenvuodoissa ei ollut eroa ryhmien välillä. Tulos säilyy propensity score -korjauksen jälkeen. Huonompi visual analogue scale (VAS) -arvo EQ-5D -lomakkeella mitattuna 6 kk CABG:n jälkeen ennakoi haittatapahtumia. Huononeva VAS ja toimintakyky EQ-5D -lomakkeella mitattuna ennakoivat myöhempiä haittatapahtumia. Johtopäätökset: Verituotteiden anto ohitusleikkauksen jälkeen lisää aivoinfarktin riskiä ja sitä tulisi pyrkiä välttämään. Tutkituissa suuren riskin potilasryhmissä (yli 80-vuotiaat ja eteisvärinän vuoksi antikoaguloidut) ennuste vaikutti paremmalta sepelvaltimoiden ohitusleikkauksen kuin pallolaajennuksen jälkeen. Huononeva elämänlaatu EQ-5D -mittarilla arvioituna ennustaa ohitusleikkauksen jälkeisiä haittatapahtumia.Siirretty Doriast

Biomarkers Predict In-Hospital Major Adverse Cardiac Events in COVID-19 Patients: A Multicenter International Study

COVID-19; Biomarkers; CreatinineCOVID-19; Biomarcadores; CreatininaCOVID-19; Biomarcadors; CreatininaBackground: The COVID-19 pandemic carries a high burden of morbidity and mortality worldwide. We aimed to identify possible predictors of in-hospital major cardiovascular (CV) events in COVID-19. Methods: We retrospectively included patients hospitalized for COVID-19 from 10 centers. Clinical, biochemical, electrocardiographic, and imaging data at admission and medications were collected. Primary endpoint was a composite of in-hospital CV death, acute heart failure (AHF), acute myocarditis, arrhythmias, acute coronary syndromes (ACS), cardiocirculatory arrest, and pulmonary embolism (PE). Results: Of the 748 patients included, 141(19%) reached the set endpoint: 49 (7%) CV death, 15 (2%) acute myocarditis, 32 (4%) sustained-supraventricular or ventricular arrhythmias, 14 (2%) cardiocirculatory arrest, 8 (1%) ACS, 41 (5%) AHF, and 39 (5%) PE. Patients with CV events had higher age, body temperature, creatinine, high-sensitivity troponin, white blood cells, and platelet counts at admission and were more likely to have systemic hypertension, renal failure (creatinine ≥ 1.25 mg/dL), chronic obstructive pulmonary disease, atrial fibrillation, and cardiomyopathy. On univariate and multivariate analysis, troponin and renal failure were associated with the composite endpoint. Kaplan–Meier analysis showed a clear divergence of in-hospital composite event-free survival stratified according to median troponin value and the presence of renal failure (Log rank p < 0.001). Conclusions: Our findings, derived from a multicenter data collection study, suggest the routine use of biomarkers, such as cardiac troponin and serum creatinine, for in-hospital prediction of CV events in patients with COVID-19

The assessment, serial evaluation, and subsequent sequelae of acute kidney injury (ASSESS-AKI) study: design and methods

<p>Abstract</p> <p>Background</p> <p>The incidence of acute kidney injury (AKI) has been increasing over time and is associated with a high risk of short-term death. Previous studies on hospital-acquired AKI have important methodological limitations, especially their retrospective study designs and limited ability to control for potential confounding factors.</p> <p>Methods</p> <p>The Assessment, Serial Evaluation, and Subsequent Sequelae of Acute Kidney Injury (ASSESS-AKI) Study was established to examine how a hospitalized episode of AKI independently affects the risk of chronic kidney disease development and progression, cardiovascular events, death, and other important patient-centered outcomes. This prospective study will enroll a cohort of 1100 adult participants with a broad range of AKI and matched hospitalized participants without AKI at three Clinical Research Centers, as well as 100 children undergoing cardiac surgery at three Clinical Research Centers. Participants will be followed for up to four years, and will undergo serial evaluation during the index hospitalization, at three months post-hospitalization, and at annual clinic visits, with telephone interviews occurring during the intervening six-month intervals. Biospecimens will be collected at each visit, along with information on lifestyle behaviors, quality of life and functional status, cognitive function, receipt of therapies, interim renal and cardiovascular events, electrocardiography and urinalysis.</p> <p>Conclusions</p> <p>ASSESS-AKI will characterize the short-term and long-term natural history of AKI, evaluate the incremental utility of novel blood and urine biomarkers to refine the diagnosis and prognosis of AKI, and identify a subset of high-risk patients who could be targeted for future clinical trials to improve outcomes after AKI.</p

Women and Coronary Artery Disease

Heart disease, including coronary artery disease, affects approximately 42 million women in the United States. Many of those affected are not aware they have the condition. Contributing to the problem is the fact that women are more likely than men to be misdiagnosed and undertreated for heart disease. Morbidity and mortality are high in women affected by heart disease, making the problem important to address. The purpose of this project was to understand the coronary artery or heart disease risk and the treatment for the condition provided for 31 participants at a cardiology service in the Northeast U.S. The project question focused on understanding how coronary artery disease manifest in women and the gender differences in treatment for men and women. A descriptive case design was used by gathering data from patient risk profiles and treatments. Participants were males and females aged between 30 and 80. Qualitative data were obtained through cardiology staff interviews and existing literature. The data were subjected to a content analysis to identify emergent themes. Findings indicated that the women experienced different cardiac symptoms to men, and these differences translated to misdiagnosis and resulting treatment ineffectiveness. This project contributes to social change through raising awareness of the gender differences in heart disease presentation so that providers can recognize and treat the condition effectively

IMPLEMENTATION OF AMERICAN COLLEGE OF CARDIOLOGY / AMERICAN HEART ASSOCIATION CARDIOVASCULAR EVALUATION GUIDELINES FOR PATIENTS HAVING NON-CARDIAC SURGERY

Leeper, Robert S., Implementation of American College of Cardiology/American Hospital Association Cardiovascular Evaluation Guidelines for Patients having Non-cardiac Surgery. Unpublished Doctor of Nursing Practice Scholarly Project, University of Northern Colorado, (2020). Anesthesia outcomes in non-cardiac surgery are dependent upon recognition of cardiovascular disease, estimating functional capacity, the status of existing co-morbidities, and degree of end-organ disease. Anesthesia providers in a rural surgery center identified an increase in the number of patients coming to the surgery center with unstable cardiovascular conditions resulting in delayed start-times, postponements, and cancellations. The broader objective for this anesthesia quality improvement project was greater patient access, improved quality of life, and safer delivery of anesthesia service. Anesthesia provider’s cardiovascular evaluation methodology was updated by providing education for anesthesia staff including implementation of recommendations and step-wise algorithm in the current American College of Cardiology/American Heart (Fleisher et al., 2014) guidelines. According to the guidelines anesthesia providers can greatly reduce the number of surgical start-time delays or cancellations due to unstable cardiovascular conditions on the day of surgery. Following evidence-based guideline recommendations and cardiac assessment tools anesthesia providers are able to minimize the probability of major adverse cardiac events. Quality anesthesia care is enhanced by pre-operative identification of active cardiac disease, estimation of functional capacity using the Duke Activity Scale Index, and a cardiac risk calculator the Revised Cardiac Risk Index (Lee et al. 1999). The primary objective for this anesthesia quality improvement project was greater patient access, safer anesthesia delivery, and improved quality of life. Donabedian’s (1990) structure-process-outcome model provided the framework for this clinical practice improvement project

The association of hypertriglyceridemia with cardiovascular events and pancreatitis: a systematic review and meta-analysis

<p>Abstract</p> <p>Background</p> <p>Hypertriglyceridemia may be associated with important complications. The aim of this study is to estimate the magnitude of association and quality of supporting evidence linking hypertriglyceridemia to cardiovascular events and pancreatitis.</p> <p>Methods</p> <p>We conducted a systematic review of multiple electronic bibliographic databases and subsequent meta-analysis using a random effects model. Studies eligible for this review followed patients longitudinally and evaluated quantitatively the association of fasting hypertriglyceridemia with the outcomes of interest. Reviewers working independently and in duplicate reviewed studies and extracted data.</p> <p>Results</p> <p>35 studies provided data sufficient for meta-analysis. The quality of these observational studies was moderate to low with fair level of multivariable adjustments and adequate exposure and outcome ascertainment. Fasting hypertriglyceridemia was significantly associated with cardiovascular death (odds ratios (OR) 1.80; 95% confidence interval (CI) 1.31-2.49), cardiovascular events (OR, 1.37; 95% CI, 1.23-1.53), myocardial infarction (OR, 1.31; 95% CI, 1.15-1.49), and pancreatitis (OR, 3.96; 95% CI, 1.27-12.34, in one study only). The association with all-cause mortality was not statistically significant.</p> <p>Conclusions</p> <p>The current evidence suggests that fasting hypertriglyceridemia is associated with increased risk of cardiovascular death, MI, cardiovascular events, and possibly acute pancreatitis.</p> <p>Précis: hypertriglyceridemia is associated with increased risk of cardiovascular death, MI, cardiovascular events, and possibly acute pancreatitis</p