Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Lipid management: Considerations in acute coronary syndrome

Managing dyslipidemia is an important part of the primary and secondary prevention of coronary heart disease. Low-density lipoprotein cholesterol reduction remains the primary lipid goal. Patients who have experienced an acute coronary syndrome (ACS) are at very high risk of recurrent adverse cardiovascular events. A growing body of literature supports the concept that early and intensive treatment with statins after an ACS event decreases recurrent adverse cardiovascular events. We review available evidence pertaining to lipid alterations in ACS

Novel markers of inflammation in atherosclerosis

Inflammation plays a key role in the pathogenesis of atherosclerosis. Understanding the process of inflammation as it pertains to atherosclerosis has provided researchers with multiple opportunities to identify novel markers for use in cardiovascular disease management. This article discusses the inflammatory cascade as it pertains to atherosclerosis and some of the well-studied markers of inflammation. It also discusses the limitations of current risk stratification models and characteristics of a good biomarker

Lipid management: Considerations in acute coronary syndrome

Managing dyslipidemia is an important part of the primary and secondary prevention of coronary heart disease. Low-density lipoprotein cholesterol reduction remains the primary lipid goal. Patients who have experienced an acute coronary syndrome (ACS) are at very high risk of recurrent adverse cardiovascular events. A growing body of literature supports the concept that early and intensive treatment with statins after an ACS event decreases recurrent adverse cardiovascular events. We review available evidence pertaining to lipid alterations in ACS

Efficacy and tolerability of multidrug therapy for hypertriglyceridemia

Background: Although there is clinical evidence for the safety and efficacy of single-drug therapy and some two-drug combinations for the treatment of hypertriglyceridemia, information is limited on the use of more than 2 drugs.Objective: We evaluated the efficacy and safety of multidrug regimens (≥3 agents) in the management of hypertriglyceridemia.Methods: The study included 40 individuals in an academic lipid referral clinic with mean follow-up of 1.98 years and an average use of 3.5 medications.Results: During the study, mean body mass index decreased significantly (P=.0127), from 29.2kg/m(2) to 28.7kg/m(2), and mean hemoglobin A1C showed a trend towards decreasing (P=.06), from 7.9% to 7.2% in patients with diabetes (n=17). All lipid parameters decreased significantly: total cholesterol level decreased significantly from (mean±SD) 334.3±282.9mg/dL to 183.8±54.8mg/dL (P=.001, mean reduction of 45%), mean (± SD) triglyceride level decreased significantly from 1900.9±4576.8mg/dL to 300.7±372.2mg/dL (P=.02), median (range) triglyceride level decreased from 599 (242-28,550) mg/dL to 301 (40-1960) mg/dL (P \u3c .001, mean reduction of 50%), and mean (± SD) non-high-density lipoprotein cholesterol decreased significantly from 189.9±131.6mg/dL to 138.4±49.1mg/dL (P=.014, mean reduction of 27%). There were no serious adverse effects (rhabdomyolysis or increased liver function tests \u3e3 times upper limit of normal).Conclusion: In a 2-year follow-up of 40 individuals on multidrug therapy (average of 3.5 drugs) for severe hypertriglyceridemia, combination therapy was efficacious and well tolerated

Non-high-density lipoprotein cholesterol calculation and goal awareness among physicians-in-training

Background: Non-high density lipoprotein cholesterol (non-HDL-C) goal attainment per Adult Treatment Panel III (ATP III) guidelines remains low.Objective: To understand gaps in knowledge and practices of physicians-in-training (internal medicine, family medicine, cardiology, endocrinology) towards non-HDL-C.Methods: A survey based on a conceptual model to assess the trainee\u27s knowledge, attitudes, and practice regarding non-HDL-C was developed and administered to physicians-in-training (n = 655) at 26 training programs in the United States. Responses of those in internal medicine and family medicine (residents-in-training; n = 418) were compared with those in cardiology and endocrinology (fellows-in-training; n = 124).Results: Response rate was 83.7%. Fifty-three percent of residents and 31% of fellows-in-training had not read the ATP III guidelines (P \u3c .001). Thirty-three percent of the residents and 35% fellows-in-training could not calculate non-HDL-C from a standard lipid panel (P = .7). Sixty-seven percent of the residents and 52% of fellows were not aware of treatment goals for non-HDL-C (P = .004 for comparison between residents and fellows). Both residents and fellows reported infrequent calculation of non-HDL-C levels in patients with elevated triglycerides (≥200 mg/dL; 32.5% vs 35.4%, respectively, P = .6). Lack of familiarity with ATP III guidelines, lack of knowledge regarding importance of non-HDL-C, lack of institutional mandate to calculate non-HDL-C, and lack of emphasis on non-HDL-C by teaching staff were reported as barriers to non-HDL-C use in routine clinical practice.Conclusions: At least one-third of physicians-in-training could not calculate non-HDL-C from a standard lipid panel, and a large number were not aware of ATP III treatment goals pertaining to non-HDL-C. This area represents one for improvement if non-HDL-C is to be retained as a treatment target in the forthcoming ATP-IV guidelines

Preoperative statin therapy decreases risk of postoperative renal insufficiency

Introduction: Although current guidelines recommend withholding statins in perioperative patients, little information is available on whether perioperative statin use increases risk for postoperative renal failure.Aims: We examined the relation between preoperative statin therapy and postoperative risk for renal insufficiency in patients undergoing cardiac surgery.Methods: Retrospective cohort review from the Texas Heart Institute research database was performed. Patients were divided into two groups: those who received preoperative statins and those who did not. Primary outcome was the development of postoperative renal insufficiency (requiring dialysis or not). Outcomes were assessed in the entire cohort and in subgroups undergoing isolated coronary artery bypass grafting (CABG), isolated valve surgery, or combined CABG and valve surgery.Results: Of 3001 patients, 56% received preoperative statins. In multivariate logistic regression analysis, preoperative statins were associated with significant reductions in risk for postoperative renal insufficiency in the entire cohort (odds ratio [OR]= 0.60, 95% confidence interval [CI] 0.38-0.95) and in patients undergoing isolated CABG (OR = 0.34, 95% CI 0.17-0.68). In patients undergoing isolated valve surgery (OR = 1.35, 95% CI 0.61-2.96) or combined CABG and valve surgery (OR = 1.39, 95% CI 0.48-3.99), preoperative statins were not associated with decreased incidence of postoperative renal insufficiency. Age \u3e65 years, preoperative renal insufficiency, history of congestive heart failure, preoperative intra-aortic balloon pump insertion, and total cardiopulmonary bypass time \u3e80 min were also independent predictors associated with increased risk for postoperative renal insufficiency.Conclusions: Preoperative statin therapy was associated with decreased incidence of postoperative renal insufficiency in patients undergoing cardiac surgeries, particularly in patients undergoing isolated CABG