The American journal of cardiology
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Isolated low high-density lipoprotein cholesterol (HDL-C) is associated with lower fitness and increased mortality. Whether the association between isolated low HDL-C and mortality differs by fitness is uncertain. Patients in the Henry Ford ExercIse Testing Project (FIT Project) completed a physician-referred treadmill stress test and those prescribed lipid-lowering medications or with known cardiovascular disease were excluded. ⋯ Compared to individuals with optimal lipids, those with isolated low HDL-C who achieved <6 METs had a lower survival (p = 0.02), whereas there was no mortality difference for those who achieved 6 to 10 METs (p = 0.13) or ≥10 METs (p = 0.66). In adjusted Cox models, the mortality hazard for those with isolated low HDL-C compared with optimal lipids was 1.73 (95% confidence interval [CI] 1.18 to 2.54), 1.90 (95% CI 1.19 to 3.04), and 0.97 (95% CI 0.53 to 1.78) for the METS categories of <6, 6 to 10, and ≥10. In conclusion, individuals with isolated low HDL-C fitness significantly improved risk stratification and only those with lower fitness had an increased totality mortality risk.
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Multicenter Study
Trends in Readmission and Costs After Transcatheter Implantation Versus Surgical Aortic Valve Replacement in Patients With Renal Dysfunction.
Patients with renal dysfunction are at increased risk for developing aortic valve pathology. In the present era of value-based healthcare delivery, a comparison of transcatheter and surgical aortic valve replacement (SAVR) readmission performance in this population is warranted. All adult patients who underwent transcatheter or SAVR from 2011 to 2014 were identified using the Nationwide Readmissions Database, containing data for nearly 50% of US hospitalizations. ⋯ Transcatheter aortic valve replacement in chronic kidney disease stage 1 to 3 patients had a higher rate of readmission due to heart failure and pacemaker placement than SAVR. Transcatheter aortic valve replacement was associated with increased costs compared with SAVR for all renal failure patients. In conclusion, in this national cohort of chronic and end-stage renal disease patients, transcatheter aortic valve implantation was associated with increased mortality, readmissions for chronic kidney disease stages1 to 3, and index hospitalization costs.
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We investigated the association of perioperative antiplatelet therapy (APT) and outcomes in patients with drug-eluting stent (DES) placement for noncardiac surgery (NCS). In consecutive 23,358 patients who underwent percutaneous coronary interventions between 2005 and 2016, total of 2,179 patients that required 2,179 elective NCS after DES placement were retrospectively analyzed. A net adverse clinical event (NACE), composite of death, myocardial infarction, stent thrombosis, and major bleeding, was assessed at 30 days. ⋯ Our findings persisted (adjusted HR 1.26, 95% CI 0.51 to 3.10, p = 0.618) when those who continued dual-APT were excluded from the continuation of APT group due to a higher tendency of NACE compared with those who continued single-APT (adjusted HR 2.26, 95% CI 0.98 to 5.21, p = 0.055). However, the patients who discontinued APT for >7 days had a significantly higher NACE than those who discontinued for ≤7 days (adjusted HR 6.93, 95% CI 2.16 to 22.24, p = 0.001). In conclusion, discontinuation of APT may not be associated with higher NACEs 30 days postsurgery compared with continuation of APT, when APT was discontinued for ≤7 days in patients undergoing elective NCS after DES implantation.
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In a population with atherosclerotic cardiovascular disease, previous research indicated that approximately 86% can achieve low-density lipoprotein cholesterol (LDL-C) of <70 mg/dL with oral lipid-lowering therapies (LLT) only, whereas 14% would require a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. We aim to estimate these values accounting for varying levels of statin intolerance. A simulation model described previously was used to estimate the utilization of LLT needed to achieve LDL-C <70 mg/dL via an intensification algorithm which maximized statins before adding ezetimibe or a PCSK9 inhibitor. ⋯ With treatment intensification and 10% of patients having partial statin intolerance, the use of ezetimibe (± statin ± PCSK9 inhibitor) increased from 32.7% to 34.9%, and the need for a PCSK9 inhibitor (+ ezetimibe ± statin) increased from 14.0% to 15.5%. If, instead, 10% were fully statin intolerant, the use of ezetimibe (± statin ± PCSK9 inhibitor) increased from 32.7% to 38.5%, and the use of a PCSK9 inhibitor (+ ezetimibe ± statin) increased from 14.0% to 19.7%. In conclusion, in our simulation-based study, partial statin intolerance increased the need for nonstatins only modestly (by an absolute 2.2%), whereas having 10% of patients with full statin intolerance increased the need for PCSK9 inhibitors from 14% overall to approximately 20%.
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Implantable cardioverter defibrillators (ICDs) have been a relative contraindication to cardiovascular magnetic resonance imaging. Although cardiovascular magnetic resonance provides valuable information regarding scar in patients with ventricular arrhythmias or cardiomyopathy, ICDs in these patients frequently cause artifacts hindering accurate interpretation of both cine and late gadolinium enhancement (LGE) images. We sought to quantify the frequency and severity of artifact on LGE images and assess whether a modified wideband LGE protocol could improve the diagnostic yield of scar identification in agreement with invasive electroanatomic mapping (EAM). ⋯ Wideband LGE imaging resulted in an increase from 48% to 94% diagnostic-quality slices, with a significant reduction in artifact score, and correlated with EAM in 21 of 27 patients (78%). In conclusion, assessment of standard LGE is markedly limited by artifact in patients with ICD. The use of wideband LGE significantly improves image quality and can accurately localize myocardial scar before VT ablation.