Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission

Peer reviewedPostprin

Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting

Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography

Remote Patient Monitoring for Patients with Heart Failure: Sex- and Race-based Disparities and Opportunities

Remote patient monitoring (RPM), within the larger context of telehealth expansion, has been established as an effective and safe means of care for patients with heart failure (HF) during the recent pandemic. Of the demographic groups, female patients and black patients are under-enrolled relative to disease distribution in clinical trials and are under-referred for RPM, including remote haemodynamic monitoring, cardiac implantable electronic devices (CIEDs), wearables and telehealth interventions. The sex- and race-based disparities are multifactorial: stringent clinical trial inclusion criteria, distrust of the medical establishment, poor access to healthcare, socioeconomic inequities, and lack of diversity in clinical trial leadership. Notwithstanding addressing the above factors, RPM has the unique potential to reduce disparities through a combination of implicit bias mitigation and earlier detection and intervention for HF disease progression in disadvantaged groups. This review describes the uptake of remote haemodynamic monitoring, CIEDs and telehealth in female patients and black patients with HF, and discusses aetiologies that may contribute to inequities and strategies to promote health equity

Remnant cholesterol and risk of premature mortality: An analysis from a nationwide prospective cohort study

AIMS: To explore the relationship between remnant cholesterol (RC) and risk of premature mortality as well as life expectancy in the general population.METHODS: We included a total of 428,804 participants from the UK Biobank for analyses. Equivalent population percentiles approach based on the low-density lipoprotein cholesterol (LDL-C) cut-off points was performed to categorize participants into three RC groups: low (with a mean RC of 0.34 mmol/L), moderate (0.53 mmol/L), and high (1.02 mmol/L). We used multivariable Cox proportional hazards models to evaluate the relationship between RC groups and risk of premature mortality (defined as death before age 75 years). Life table methods were used to estimate life expectancy by RC groups.RESULTS: During a median follow-up of 12.1 years (Q1 - Q3: 11.0 - 13.0), there were 23,693 all-cause premature deaths documented with an incidence of 4.83 events per 1,000 person-years (95% confidence interval [CI]: 4.77 - 4.89). Compared with low RC group, the moderate RC group was associated with a 9% increased risk of all-cause premature mortality (hazard ratio [HR] = 1.09, 95% CI: 1.05 - 1.14), while the high RC group had an 11% higher risk (HR = 1.11, 95% CI: 1.07 - 1.16). At the age of 50 years, high RC group was associated with an average 2.2 lower years of life expectancy for females, and an average 0.1 lower years of life expectancy for males when compared to their counterparts in low RC group.CONCLUSIONS: Elevated RC was significantly related to increased risk of premature mortality and reduced life expectancy. Premature death in the general population would benefit from measurement to aid risk stratification and proactive management of RC to improved cardiovascular risk prevention efforts.</p

Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction:a nationwide cohort study

BACKGROUND: Little is known about ethnic disparities in care and clinical outcomes of patients admitted with non-ST-segment elevation myocardial infarction (NSTEMI) in national cohorts from universal healthcare systems derived from Europe. METHODS & RESULTS: We identified 280,588 admissions with NSTEMI in the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP), 2010-2017, including White patients (n = 258,364) and Black, Asian and Minority Ethnic (BAME) patients (n = 22,194). BAME patients were younger (66 years vs. 73 years, P < 0.001) and more frequently had hypertension (66% vs 54%, P < 0.001), hypercholesterolemia (49% vs 34%, P < 0.001) and diabetes (48% vs 24%, P < 0.001). BAME patients more frequently received invasive coronary angiography (80% vs 68%, P < 0.001), percutaneous coronary intervention (PCI) (52% vs 43%, P < 0.001) and coronary artery bypass graft surgery (9% vs 7%, P < 0.001). Following propensity score matching, BAME compared with White patients had similar in-hospital all-cause mortality (OR:0.91, CI: 0.76-1.06, P = 0.23), major bleeding (OR: 0.99, CI: 0.75 - 1.25, P = 0.95), reinfarction (OR: 1.15, CI: 0.84 - 1.46, P = 0.34) and major adverse cardiovascular events (MACE) (OR:0.94, CI: 0.80-1.07, P = 0.35). CONCLUSION: BAME patients with NSTEMI had higher cardiometabolic risk profiles and were more likely to undergo invasive angiography and revascularization, with similar clinical outcomes as those of their White counterparts. Among the quality indicators assessed, there is no evidence of care disparities among BAME patients presenting with NSTEMI

The need for increased pragmatism in cardiovascular clinical trials.

The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these 'explanatory' trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of 'pragmatism' in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the 'real-world' effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs

Distinct pathophysiological pathways in women and men with heart failure

Aims: Clinical differences between women and men have been described in heart failure (HF). However, less is known about the underlying pathophysiological mechanisms. In this study, we compared multiple circulating biomarkers to gain better insights into differential HF pathophysiology between women and men. Methods and results: In 537 women and 1485 men with HF, we compared differential expression of a panel of 363 biomarkers. Then, we performed a pathway over-representation analysis to identify differential biological pathways in women and men. Findings were validated in an independent HF cohort (575 women, 1123 men). In both cohorts, women were older and had higher left ventricular ejection fraction (LVEF). In the index and validation cohorts respectively, we found 14/363 and 12/363 biomarkers that were relatively up-regulated in women, while 21/363 and 14/363 were up-regulated in men. In both cohorts, the strongest up-regulated biomarkers in women were leptin and fatty acid binding protein-4, compared to matrix metalloproteinase-3 in men. Similar findings were replicated in a subset of patients from both cohorts matched by age and LVEF. Pathway over-representation analysis revealed increased activity of pathways associated with lipid metabolism in women, and neuro-inflammatory response in men (all p < 0.0001). Conclusion: In two independent cohorts of HF patients, biomarkers associated with lipid metabolic pathways were observed in women, while biomarkers associated with neuro-inflammatory response were more active in men. Differences in inflammatory and metabolic pathways may contribute to sex differences in clinical phenotype observed in HF, and provide useful insights towards development of tailored HF therapies