Cardiology

Huebinger, R., Jarvis, J., Schulz, K., Persse, D., Chan, H.K., Miramontes, D., Vithalani, V., Troutman, G., Greenberg, R., Al-Araji, R., Villa, N., Panczyk, M., Wang, H. and Bobrow, B. (2021). “Community Variations in Out-of-Hospital Cardiac Arrest Care and Outcomes in Texas.” Prehosp Emerg Care Mar 29;1-10. [Epub ahead of print]. 1-10.

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BackgroundLarge and unacceptable variation exists in cardiac resuscitation care and outcomes across communities. Texas is the second most populous state in the US with wide variation in community and emergency response infrastructure. We utilized the Texas-CARES registry to perform the first Texas state analysis of out-of-hospital cardiac arrest (OHCA) in Texas, evaluating for variations in incidence, care, and outcomes.MethodsWe analyzed the Texas-CARES registry, including all adult, non-traumatic OHCAs from 1/1/2014 through 12/31/2018. We analyzed the incidence and characteristics of OHCA care and outcome, overall and stratified by community. Utilizing mixed models accounting for clustering by community, we characterized variations in bystander CPR, bystander AED in public locations, and survival to hospital discharge across communities, adjusting for age, gender, race, location of arrest, and rate of witnessed arrest (bystander and 911 responder witnessed).ResultsThere were a total of 26,847 (5,369 per year) OHCAs from 13 communities; median 2,762 per community (IQR 444-2,767, min 136, max 9161). Texas care and outcome characteristics were: bystander CPR (43.3%), bystander AED use (9.1%), survival to discharge (9.1%), and survival with good neurological outcomes (4.0%). Bystander CPR rate ranged from 19.2% to 55.0%, and there were five communities above and five below the adjusted 95% confidence interval. Bystander AED use ranged from 0% to 19.5%, and there was one community below the adjusted 95% confidence interval. Survival to hospital discharge ranged from 6.7% to 14.0%, and there were three communities above and two below the adjusted 95% confidence interval.ConclusionWhile overall OHCA care and outcomes were similar in Texas compared to national averages, bystander CPR, bystander AED use, and survival varied widely across communities in Texas. These variations signal opportunities to improve OHCA care and outcomes in Texas.

Gertz, Z.M., Herrmann, H.C., Lim, D.S., Kar, S., Kapadia, S.R., Reed, G.W., Puri, R., Krishnaswamy, A., Gersh, B.J., Weissman, N.J., Asch, F.M., Grayburn, P.A., Kosmidou, I., Redfors, B., Zhang, Z., Abraham, W.T., Lindenfeld, J., Stone, G.W. and Mack, M.J. (2021). “Implications of Atrial Fibrillation on the Mechanisms of Mitral Regurgitation and Response to MitraClip in the COAPT Trial.” Circ Cardiovasc Interv Mar 15;CIRCINTERVENTIONS120010300. [Epub ahead of print]. Circinterventions120010300.

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BACKGROUND: Atrial fibrillation (AF), mitral regurgitation (MR), and left ventricular (LV) ejection fraction have a complex interplay. We evaluated the role of AF in patients with heart failure and moderate-to-severe or severe secondary MR enrolled in the randomized COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) and its impact on mechanisms and outcomes with the MitraClip. METHODS: Patients in the COAPT trial were stratified by the presence (n=327) or absence (n=287) of a history of AF and by assignment to treatment group. Clinical, echocardiographic, and outcome measures were assessed. The primary outcome was the composite rate of death or heart failure hospitalization at 24 months. RESULTS: Patients with history of AF were older and more often male. They had a higher LV ejection fraction, larger left atrial volumes and mitral valve orifice areas, smaller LV volumes, and similar MR severity. Patients with AF compared with those without a history of AF had a higher unadjusted (hazard ratio [HR], 1.32 [95% CI, 1.06-1.64], P=0.01) and adjusted (HR, 1.30 [1.03-1.64], P=0.03) 2-year rate of the primary outcome. Treatment with the MitraClip compared with guideline-directed medical therapy alone reduced death or heart failure hospitalization in both those with (HR, 0.61 [0.46-0.82]) and without (HR, 0.46 [0.33-0.66]) a history of AF (P(int)=0.18). Treatment with the MitraClip was associated with a lower risk of stroke in patients with a history of AF (HR, 0.18 [0.04-0.86]) but not in those without a history of AF (HR, 1.64 [0.58-4.62]; P(int)=0.02). CONCLUSIONS: In the COAPT trial, patients with a history of AF had larger left atrial and mitral valve orifice areas with higher LV ejection fraction and smaller LV volumes, suggesting an atrial mechanism contribution to functional MR. Despite the worse prognosis of heart failure patients with a history of AF, MR reduction with the MitraClip still afforded substantial clinical benefits. Treatment with MitraClip was associated with a lower risk of stroke in patients with a history of AF. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

Ferreira, J.P., Zannad, F., Pocock, S.J., Anker, S.D., Butler, J., Filippatos, G., Brueckmann, M., Jamal, W., Steubl, D., Schueler, E. and Packer, M. (2021). “Interplay of Mineralocorticoid Receptor Antagonists and Empagliflozin in Heart Failure: EMPEROR-Reduced.” J Am Coll Cardiol 77(11): 1397-1407.

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BACKGROUND: Mineralocorticoid receptor antagonists (MRAs) and sodium glucose co-transporter 2 inhibitors favorably influence the clinical course of patients with heart failure and reduced ejection fraction. OBJECTIVES: This study sought to study the mutual influence of empagliflozin and MRAs in EMPEROR-Reduced (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Reduced Ejection Fraction). METHODS: Secondary analysis that compared the effects of empagliflozin versus placebo in 3,730 patients with heart failure and a reduced ejection fraction, of whom 71% used MRAs at randomization. RESULTS: The effects of empagliflozin on the primary endpoint, on most efficacy endpoints, and on safety were similar in patients receiving or not receiving an MRA (interaction p > 0.20). For cardiovascular death, the hazard ratios for the effect of empagliflozin versus placebo were 0.82 (95% confidence interval [CI]: 0.65 to 1.05) in MRA users and 1.19 (95% CI: 0.82 to 1.71) in MRA nonusers (interaction p = 0.10); a similar pattern was seen for all-cause mortality (interaction p = 0.098). Among MRA nonusers at baseline, patients in the empagliflozin group were 35% less likely than those in the placebo group to initiate treatment with an MRA following randomization (hazard ratio: 0.65; 95% CI: 0.49 to 0.85). Among MRA users at baseline, patients in the empagliflozin group were 22% less likely than those in the placebo group to discontinue treatment with an MRA following randomization (hazard ratio: 0.78; 95% CI: 0.64 to 0.96). Severe hyperkalemia was less common in the empagliflozin group. CONCLUSIONS: In EMPEROR-Reduced, the use of MRAs did not influence the effect of empagliflozin to reduce adverse heart failure and renal outcomes. Treatment with empagliflozin was associated with less discontinuation of MRAs. (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Reduced Ejection Fraction [EMPEROR-Reduced]; NCT03057977).

Davis, A.P., Wilson, G.M., Erwin, J.P., 3rd, Michel, J.B., Banchs, J., Saeed, A. and Widmer, R.J. (2021). “Use of Web-Based Patient Portals in Patients With Atrial Fibrillation Is Associated With Higher Readmissions.” Ochsner J 21(1): 25-29.

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Background: The impact of web-based patient portals on patient outcomes-specifically hospital readmissions in patients with atrial fibrillation (AF)-remains understudied. Methods: This single-center retrospective cohort study investigated the use of an online portal system (MyChart) by patients hospitalized from January 1, 2014 to June 30, 2017 for AF. During the study period, 11,334 unique AF admissions were identified; 50.3% were MyChart users and 49.7% were non-MyChart users. Patients who experienced inpatient mortality were excluded. The study groups were analyzed for demographic variables, comorbidities, readmission rates, and the frequency of MyChart use during the 3.5-year time frame. Results: MyChart users were younger (median age, 74 years, interquartile range [IQR] 66-82 vs 77 years, IQR 68-85; P<0.0001) and more likely to be white (91.9% vs 84.6%; P<0.0001), but the sex distribution was similar between groups, with 51.8% males in the MyChart group vs 53.2% in the non-MyChart group. MyChart users had a significantly higher rate of readmission compared to non-MyChart users at 1 year (43.0% vs 32.0%, respectively; P<0.0001). MyChart users who were readmitted had a higher median number of logins to MyChart (121 [IQR 32-270.5]) than MyChart users who were not readmitted (91 [IQR 26-205]; P<0.0001). Multivariable regression analysis demonstrated that MyChart use was associated with readmission (odds ratio 1.57, 95% CI 1.49-1.70; P<0.0001). Conclusion: Among patients with AF, MyChart use was associated with higher readmissions in this single-center cohort. Use and benefit of bespoke portals require further study.

Davidson, C.J., Abramson, S., Smith, R.L., Kodali, S.K., Kipperman, R.M., Eleid, M.F., Reisman, M., Whisenant, B.K., Puthumana, J., Fowler, D., Grayburn, P.A., Hahn, R.T., Koulogiannis, K., Pislaru, S.V., Zwink, T., Minder, M., Deuschl, F., Feldman, T., Gray, W.A. and Lim, D.S. (2021). “Transcatheter Tricuspid Repair With the Use of 4-Dimensional Intracardiac Echocardiography.” JACC Cardiovasc Imaging Mar 10;S1936-878X(21)00153-4. [Epub ahead of print].

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We report the systematic use of 4-dimensional intracardiac echocardiography (4D-ICE) as an intraprocedural imaging modality in transcatheter annular repair therapies. Twenty-six patients enrolled in the U.S. Food and Drug Administration–approved early feasibility study were analyzed to compare 4D-ICE and TEE. Results showed that 4D-ICE was predominantly used in the lateral annulus (Figures 2 and 3) and improved visualization compared with TEE. [No abstract; excerpt from article].