Improving Safety of Direct Oral Anticoagulant (DOAC) Dosing in Patients with Severe Chronic and End-Stage Renal Disease

The significance of this study is to determine the degree of inconsistency in dosing practice of DOACs at a quaternary care institution such as Thomas Jefferson University Hospital. What is the primary indication for anticoagulation in out population? What percentage is dosed correctly? Are patients primarily over or underdosed

Cardiogenic Shock Due to Atrial Arrhythmia as the Initial Presentation of Transthyretin Cardiac Amyloidosis

Atrial arrhythmias are common in transthyretin cardiac amyloidosis (ATTR-CA), with a prevalence of ≤80%. They are often not well tolerated. We describe 3 patients with decompensated heart failure and cardiogenic shock precipitated by atrial arrhythmias who ultimately received diagnoses of ATTR-CA. (Level of Difficulty: Intermediate.

Adverse Outcomes of Atrial Fibrillation Ablation in Heart Failure Patients With and Without Cardiac Amyloidosis: A Nationwide Readmissions Database Analysis (2015-2019)

AIMS: Atrial fibrillation (AF) in patients with cardiac amyloidosis (CA) has been linked with a worse prognosis. The current study aimed to determine the outcomes of AF catheter ablation in patients with CA. METHODS AND RESULTS: The Nationwide Readmissions Database (2015-2019) was used to identify patients with AF and concomitant heart failure. Among these, patients who underwent catheter ablation were classified into two groups, patients with and without CA. The adjusted odds ratio (aOR) of index admission and 30-day readmission outcomes was calculated using a propensity score matching (PSM) analysis. A total of 148 134 patients with AF undergoing catheter ablation were identified on crude analysis. Using PSM analysis, 616 patients (293 CA-AF, 323 non-CA-AF) were selected based on a balanced distribution of baseline comorbidities. At index admission, AF ablation in patients with CA was associated with significantly higher adjusted odds of net adverse clinical events (NACE) [adjusted odds ratio (aOR) 4.21, 95% CI 1.7-5.20], in-hospital mortality (aOR 9.03, 95% CI 1.12-72.70), and pericardial effusion (aOR 3.30, 95% CI 1.57-6.93) compared with non-CA-AF. There was no significant difference in the odds of stroke, cardiac tamponade, and major bleeding between the two groups. At 30-day readmission, the incidence of NACE and mortality remained high in patients undergoing AF ablation in CA. CONCLUSION: Compared with non-CA, AF ablation in CA patients is associated with relatively higher in-hospital all-cause mortality and net adverse events both at index admission and up to 30-day follow-up

Outcomes After Transcatheter Aortic Valve Implantation in Patients Excluded From Clinical Trials

Background: The use of transcatheter aortic valve implantation (TAVI) in patients with aortic valve disease excluded from clinical trials has increased with no large-scale data on its safety. Objectives: The purpose of this study was to assess the trend of utilization and adjusted outcomes of TAVI in clinical trials excluded (CTE) vs clinical trials included TAVI (CTI-TAVI) patients. Methods: We used the National Readmission Database (2015-2019) to identify 15 CTE-TAVI conditions. A propensity score-matched analysis was used to calculate the adjusted odds ratio (aOR) of net adverse clinical events (composite of mortality, stroke, and major bleeding) in patients undergoing CTE-TAVI vs CTI-TAVI. Results: Among the 223,238 patients undergoing TAVI, CTE-TAVI was used in 41,408 patients (18.5%). The yearly trend showed a steep increase in CTE-TAVI utilization (P = 0.026). At index admission, the adjusted odds of net adverse clinical events (aOR: 1.83, 95% CI: 1.73-1.95) and its components, including mortality (aOR: 2.94, 95% CI: 2.66-3.24), stroke (aOR: 1.20, 95% CI: 1.07-1.34), and major bleeding (aOR: 1.49, 95% CI: 1.36-1.63) were significantly higher in CTE-TAVI compared with CTI-TAVI. Among the individual contraindications to clinical trial enrollment in the CTE-TAVI, patients with bicuspid aortic valve, leukopenia, and peptic ulcer disease appeared to have similar outcomes compared with CTI-TAVI, while patients with end-stage renal disease, bioprosthetic aortic valves, and coagulopathy had a higher readmission rate at 30 and 180 days. Conclusions: CTE-TAVI utilization has increased significantly over the 4-year study period. Patients undergoing CTE-TAVI have a higher likelihood of mortality, stroke, and bleeding than those undergoing CTI-TAVI

MANAGEMENT OF LDL-C IN HIGH RISK FEMALE PATIENTS WITH ASCVD- A CROSS-SECTIONAL STUDY

Therapeutic Area: ASCD/CVD in Women Background: The 2018 ACC/AHA guidelines recommend an LDL-C of 70mg/dL as a threshold to initiate non-statin medications in patients with a history of a major ASCVD event. Analysis of the PINNACLE Registry and the TRANSFORM LDL-C Risk Initiative identified female patients as a high risk population with a low likelihood of achieving an LDL-C 70mg/dL despite having a history of a major ASCVD event, of which only 27% were on the max dose of a high intensity statin. Only 10.4% were noted to be on additional non-statin lipid lowering therapies, of which Ezetimibe was the most prescribed (76.9%) while PCSK9 inhibitors were the least prescribed (7.7%). CVA was the most common observed major ASCVD event (45.8%), while HTN and HLD were the most common associated comorbidities (85.9%, 83.4%). Conclusion: Although the 2018 ACC/AHA guidelines recommend initiating non-statin medications in patients with a major ASCVD event, clinical implementation of these guidelines has not yet become widespread. In this study, we identify female patients as a high risk population that does not meet these guidelines at our institution. Further studies will focus on implementing a quality initiative program to improve the prescribing practices of non-statin medications in this population

Risk of coronary artery disease in patients with gout on treatment with Colchicine: A systematic review and meta-analysis

Background: Colchicine has anti-inflammatory properties, but its utility in improving cardiovascular outcomes has been disputed. Here, we study the impact of colchicine on cardiovascular outcomes in patients with gout with and without coronary artery disease (CAD). Methods: Medline, Web of Science and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Primary outcomes included myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Secondary outcomes included stroke and all-cause mortality. Results: We included 4 observational studies comprising 10,026 patients with gout on treatment with colchicine. There was no significant difference in the risk of myocardial infarction (risk ratio [RR] 0.71; 95% confidence interval [CI], 0.36–1.39), need for PCI, or need for CABG, between patients on colchicine and those not receiving colchicine. Colchicine was associated with a significantly lower risk of all-cause mortality (RR 0.58; 95% CI 0.43–0.79). Conclusion: Non-randomized studies suggest that risk of MI, stroke and revascularization is not higher in gout patients treated with colchicine compared to gout patients without colchicine treatment

Outcomes After Transcatheter Aortic Valve Implantation in Patients Excluded from Clinical Trials

Background: The use of transcatheter aortic valve implantation (TAVI) in patients with aortic valve disease excluded from clinical trials has increased with no large-scale data on its safety. Objectives: The purpose of this study was to assess the trend of utilization and adjusted outcomes of TAVI in clinical trials excluded (CTE) vs clinical trials included TAVI (CTI-TAVI) patients. Methods: We used the National Readmission Database (2015-2019) to identify 15 CTE-TAVI conditions. A propensity score-matched analysis was used to calculate the adjusted odds ratio (aOR) of net adverse clinical events (composite of mortality, stroke, and major bleeding) in patients undergoing CTE-TAVI vs CTI-TAVI. Results: Among the 223,238 patients undergoing TAVI, CTE-TAVI was used in 41,408 patients (18.5%). The yearly trend showed a steep increase in CTE-TAVI utilization (P = 0.026). At index admission, the adjusted odds of net adverse clinical events (aOR: 1.83, 95% CI: 1.73-1.95) and its components, including mortality (aOR: 2.94, 95% CI: 2.66-3.24), stroke (aOR: 1.20, 95% CI: 1.07-1.34), and major bleeding (aOR: 1.49, 95% CI: 1.36-1.63) were significantly higher in CTE-TAVI compared with CTI-TAVI. Among the individual contraindications to clinical trial enrollment in the CTE-TAVI, patients with bicuspid aortic valve, leukopenia, and peptic ulcer disease appeared to have similar outcomes compared with CTI-TAVI, while patients with end-stage renal disease, bioprosthetic aortic valves, and coagulopathy had a higher readmission rate at 30 and 180 days. Conclusions: CTE-TAVI utilization has increased significantly over the 4-year study period. Patients undergoing CTE-TAVI have a higher likelihood of mortality, stroke, and bleeding than those undergoing CTI-TAVI. Keywords: CTE; clinical trials excluded; CTI; clinical trials included; TAVI; transcatheter aortic valve implantatio