INTRODUCTION:The extent and associated reasons or characteristics related to patients presenting to hospital prior with ST-elevation myocardial infarction (STEMI) are unknown. METHODS:This retrospective cohort study analyzed the Nationwide Readmission Database from 2018 to 2020 to evaluate hospitalizations within 30 days preceding a hospitalization with the diagnosis of STEMI in order to determine how often this occurs and what are the causes and factors associated with the recent admission. RESULTS:There were 1,355,765 hospital admissions with a diagnosis of STEMI and 54,545 (4.0 %) were hospitalized within 30-days prior to STEMI event. The most common causes of preceding hospitalization were sepsis, chronic ischemic heart disease, hypertensive disease with chronic kidney disease, complications of cardiac or vascular prosthetic devices, and implants/grafts, hypertensive heart disease with heart failure, and cerebral infarction. Independent factors associated with hospitalization within 30-days preceding STEMI, were cancer (OR 3.44 95 %CI 3.23-3.67, p < 0.001), elective admission (OR 2.76 95 %CI 2.59-2.95, p < 0.001), chronic kidney disease (OR 1.93 95 %CI 1.84-2.02, p < 0.001), chronic lung disease (OR 1.65 95 %CI 1.58-1.73, p < 0.001), previous stroke (OR 1.46 95 %CI 1.38-1.73, p < 0.001), and previous myocardial infarction (OR 1.45 95 %CI 1.37-1.53, p < 0.001). CONCLUSIONS:Among the 4.0 % of patients were admitted to hospital within 30-days prior to a later admission for STEMI, predictors of such admissions were sepsis, chronic ischemic heart disease and hypertension and cancer. This raises potential opportunities to prevent future admissions with STEMI once such patients are hospitalized.

INTRODUCTION:The objective of this study is to determine if cardiac damage based on hospital discharge codes is associated with in-hospital outcomes in patients with aortic stenosis (AS). METHODS:We conducted a retrospective cohort study of hospital admissions between 2016 and 2021 with a diagnosis of AS in the National Inpatient Sample (NIS). The cardiac damage stages 0-4 were determined based on hospital discharge codes. Logistic and linear regressions were used to determine the association between cardiac stage and in-hospital mortality, length of stay (LoS) and cost. RESULTS:A total of 2,980,150 hospital admissions were included in the analysis (82.5% conservative management, 11.2% transcatheter aortic valve replacement [TAVR], 6.3% surgical aortic valve replacement [SAVR]). The association between cardiac damage stage and in-hospital outcome was most significant for patients who had SAVR treatment (stage 4 vs. stage 0: mortality OR 27.70 95% CI 17.35-35.17, LoS 7.34 95% CI 6.34-8.35, cost 70,710 95% CI 65,110-76,310) compared to TAVR treatment (stage 4 vs. stage 0: mortality OR 9.15 95% CI 5.52-15.15, LoS 6.27 95% CI 5.63-6.90, cost 28,384 25,084 to 31,684) and conservative treatment (stage 4 vs. stage 0: mortality OR 3.55 95% CI 3.13-4.04, LoS 2.09 95% CI 1.87 to 2.31, cost 6362 95% CI 5642-7083). CONCLUSIONS:Cardiac damage can be evaluated using diagnostic codes in patients with AS and it is associated with in-hospital mortality, LoS and cost, and has more impact on these outcomes in patients treated with SAVR versus those treated with TAVR.

The prevalence of thrombophilia among patients who are hospitalized with acute coronary syndrome (ACS) and whether the condition affects outcomes is unknown. We conducted a retrospective cohort study of patients hospitalized with ACS by analyzing data from the United State National Inpatient Sample (NIS) between 2016 and 2021. Multiple logistic and linear regressions were used to determine the association between thrombophilia and in-hospital mortality, length of stay and cost. There were a total of 5,627,065 hospital admissions with ACS and 43,040 had thrombophilia (0.76

How frequent and whether outcomes are worse for patients with atypical presentation in acute coronary syndrome (ACS) across the literature is not known. We conducted a systematic review of the literature on patients with ACS or acute myocardial infarction who reported whether their symptoms were atypical or typical. We determined the proportion of patients with atypical or no chest pain and used meta-analysis to evaluate predictors of atypical presentation and mortality associated with atypical presentation. A total of 43 studies were included with 1 691 401 patients (mean age: 65.4 years, 63.8% male). The proportion of patients with atypical presentation ranged from 4.6 to 74.2% while for those with no chest pain it ranged from 1.4 to 35.5%. Atypical presentation occurred in 11.6% of patients (28 studies) and no chest pain occurred in 33.6% of patients (16 studies). The three strongest factors associated with increased odds of atypical presentation or no chest pain presentation were non-ST-elevation myocardial infarction [odds ratio (OR): 2.38, 95% confidence interval (CI): 1.55-3.64], greater Killip class (OR: 2.22, 95% CI: 1.84-2.67), and prior heart failure (OR: 1.79, 95% CI: 1.76-1.82). There is a two-fold increase in odds of mortality with atypical or no chest pain presentation in ACS compared with the typical presentation (OR: 2.07, 95% CI: 1.71-2.50, I2  = 99%). Atypical presentation occurs in approximately 1 in 10 patients with ACS but can be as high as 1 in 3 in some populations. Patients who present atypically are at two-fold increased risk of mortality.

Background Smoking cessation is an effective secondary prevention measure after acute coronary syndrome (ACS). We conducted a systematic review with the aim to better understand which patients have a greater propensity to quit smoking and the risk factors for continued smoking after ACS. Methods We searched MEDLINE and EMBASE for studies that evaluated smoking cessation after ACS. The pooled rate of smoking cessation across included studies was performed. Random effects meta-analysis for different variables and their association with smoking cessation was conducted. Results A total of 39 studies with 11 228 patients were included in this review. The pooled rate of smoking cessation following ACS across 38 studies was 45.0%. Factors associated with greater likelihood of smoking cessation were attendance at cardiac rehabilitation (OR 1.90 95% CI 1.44-2.51), married/not alone (OR 1.68 95% CI 1.32-2.13), intention/attempt to quit smoking (OR 1.27 95% CI 1.11-1.46), diabetes mellitus (OR 1.24 95% CI 1.03-1.51) and hospitalised duration (OR 1.09 95% CI 1.02-1.15). Variables associated with a lower likelihood of smoking cessation were depression (OR 0.57 95% CI 0.43-0.75), chronic obstructive pulmonary disease/lung disease (OR 0.73 95% CI 0.57-0.93), previous admission with acute myocardial infarction/cardiac admission (OR 0.61 95% CI 0.47-0.80), cerebrovascular disease/transient ischaemic attack (OR 0.42 95% CI 0.30-0.58) and unemployment (OR 0.37 95% CI 0.17-0.80). Conclusions The majority of smokers with an ACS continue to smoke after admission. Patients attending cardiac rehabilitation show increased odds of quitting while people who are depressed and those with chronic lung disease were less likely to quit smoking and should be targeted for intensive smoking cessation interventions.

Background: Readmissions after PCI are a burden to patients and health services that are not well understood. Methods: A systematic review was performed to identify studies of readmission after PCI. Readmission rates and causes of readmission were examined and factors associated with 30-day readmissions were combined using meta-analyses. Results: A total of 39 studies evaluated readmissions after PCI (6,569,690 patients, 31 studies). The 30-day read-mission rate varied from 3.3%-15.8%. Beyond 30-days, the readmission rate was 6% at 2 months, 31.5% at 6 months, 18.6-50.4% at 12 months and 26.3-71% beyond 48 months. The pooled proportion of patients with car-diac cause for readmissions ranged from 4.6%-75.3%. The range of rates of 30-day readmissions for reinfarction/ stent thrombosis, heart failure, chest pain and bleeding were 2.5%-9.5%, 5.9%-12%, 6.7-38.1% and 0.7-7.5%, re-spectively. Meta-analysis suggests that female gender (RR 1.25(1.20-1.30), I-2 = 65.2%), diabetes (RR 1.22 (1.20-1.25), I-2 = 0%), heart failure (RR 1.43(CI 1.28-1.60), I-2 = 92.8%), renal failure (RR 1.50(1.45-1.55), I-2 = 0%), chronic lung disease (RR 1.34(1.26-1.44), I-2 = 87.5%), peripheral artery disease (RR 1.20(1.15-1.25), I-2 = 46.5%) and cancer (RR 1.35(1.15-1.58), I-2 = 72.8%) were associated with 30-day readmissions. The average cost of unplanned and all 30-day readmissions has been reported to be $12,636 and $17,576, respectively. Conclusions: We estimate that 1 in 7 patients who undergo PCI are readmitted within 30-days and the rate can rise to up to 3 in 4 patients beyond 3 years. Interventions should be considered to reduce readmissions such as discharge checklists, evaluation of medication compliance at follow-up and prompt management when patients re-present to emergency department. (c) 2019 Elsevier Inc. All rights reserved.

OBJECTIVES:The aims of this study were to examine the relationship between body mass index (BMI) and clinical outcomes following percutaneous coronary intervention (PCI) and to determine the relevance of different clinical presentations requiring PCI to this relationship. BACKGROUND:Obesity is a growing problem, and studies have reported a protective effect from obesity compared with normal BMI for adverse outcomes after PCI. METHODS:Between 2005 and 2013, 345,192 participants were included. Data were obtained from the British Cardiovascular Intervention Society registry, and mortality data were obtained through the U.K. Office of National Statistics. Multiple logistic regression was performed to determine the association between BMI group (<18.5, 18.5 to 24.9, 25 to 30 and >30 kg/m2) and adverse in-hospital outcomes and mortality. RESULTS:At 30 days post-PCI, significantly lower mortality was seen in patients with elevated BMIs (odds ratio [OR]: 0.86 [95% confidence interval (CI): 0.80 to 0.93] 0.90 [95% CI: 0.82 to 0.98] for BMI 25 to 30 and >30 kg/m2, respectively). At 1 year post-PCI, and up to 5 years post-PCI, elevated BMI (either overweight or obese) was an independent predictor of greater survival compared with normal weight (OR: 0.70 [95% CI: 0.67 to 0.73] and 0.73 [95% CI: 0.69 to 0.77], respectively, for 1 year; OR: 0.78 [95% CI: 0.75 to 0.81] and 0.88 [95% CI: 0.84 to 0.92], respectively, for 5 years). Similar reductions in mortality were observed for the analysis according to clinical presentation (stable angina, unstable angina or non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction). CONCLUSIONS:A paradox regarding the independent association of elevated BMI with reduced mortality after PCI is still evident in contemporary U.K. practice. This is seen in both stable and more acute clinical settings.

BACKGROUND:Percutaneous coronary intervention (PCI) is the most common modality of revascularization in patients with coronary artery disease. Understanding the readmission rates and reasons for readmission after PCI is important because readmissions are a quality of care indicator, in addition to being a burden to patients and healthcare services. METHODS:A literature review was performed. Relevant studies are described by narrative synthesis with the use of tables to summarize study results. RESULTS:Data suggests that 30-day readmissions are not uncommon. The rate of readmission after PCI is highly influenced by the cohort and the healthcare system studied, with 30-day readmission rates reported to be between 4.7-% and 15.6%. Studies consistently report that a majority of readmissions within 30days are due to a cardiac-related disorders or complication-related disorders. Female sex, peripheral vascular disease, diabetes mellitus, renal failure and non-elective PCI are predictive of readmission. Studies also suggest that there is greater risk of mortality among patients who are readmitted compared to those who are not readmitted. CONCLUSION:Readmission after PCI is common and its rate is highly influenced by the type of cohort studied. There is clear evidence that majority of readmissions within 30days are cardiac related. While there are many predictors of readmission following PCI, it is not known whether targeting patients with modifiable predictors could prevent or reduce the rates of readmission.

Advances in anti-thrombotic and anti-platelet therapies have improved outcomes in patients undergoing percutaneous coronary interventions (PCIs) through a reduction in ischaemic events, at the expense of peri-procedural bleeding complications. These may occur through either the access site through which the PCI was performed or through non-access-related sites. There are currently over 10 definitions of major bleeding events consisting of clinical events, changes in laboratory parameters and clinical outcomes, where different definitions will differentially influence the reported incidence of major bleeding events. Use of different major bleeding definitions has been shown to change the reported outcome of a number of therapeutic strategies in randomised controlled trials but as yet a universal bleeding definition has not gained widespread adoption in assessing the efficacy of such therapeutic interventions. Major bleeding complications are independently associated with adverse mortality and major adverse cardiovascular event (MACE) outcomes, irrespective of the definition of major bleeding used, with the worst outcomes associate with non-access-site related bleeds. We consider the mechanisms through which bleeding complications may affect longer-term outcomes and discuss bleeding avoidance strategies, including access site choice, pharmacological considerations and formal bleeding risk assessment to minimise such bleeding events.

Primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) represents the current gold standard reperfusion therapy. Recent advances in antiplatelet and anticoagulant therapy have reduced the risk of ischemic complications and mortality in PPCI although this has been at the expense of major bleeding complications. Access site-related bleeding complications account for up to 50 % of major peri-procedural bleeding complications in PCI. Increasing adoption of the radial artery as the default access site has been shown to markedly reduce such major bleeding complications and mortality in selected patient cohorts. Recent data has suggested that adoption of the transradial access site in STEMI PCI procedures is associated with significant reductions in major bleeding complications and mortality in both national registry data and randomised controlled trials. We provide an overview of this data and discuss the remaining uncertainties around the synergy between access site and contemporary antithrombotic and antiplatelet therapy in such patients. Finally, whilst adoption of the radial artery as the default access site in PPCI has yielded a similar reduction in mortality as observed in the switch from thrombolysis to PPCI in the past, its adoption as a default access site is not universal. We discuss the remaining obstacles and challenges for more widespread adoption of the radial access site as the default access site in PPCI.

Percutaneous coronary intervention (PCI) is the commonest form of revascularization in patients with coronary heart disease. The benefit of early invasive treatment with PCI in patients presenting with acute coronary syndromes are well accepted. Traditionally, PCI has been performed via the femoral access with significant risks for the development of access site-related bleeding complications. Increased international adoption of the transradial access site for PCI procedures has been shown to reduce such major access site-related bleeding complications and mortality, especially in the high-risk patient groups. We provide a brief overview of the historical perspective on transradial approach and the evidence supporting its use. We then discuss the current data supporting transradial access in high-risk populations and factors that have limited its adoption.

Cardiac catheterization involves insertion of fine-bore tubes (catheters) into the heart through cannulae inserted into a peripheral artery or vein. Procedures are commonly performed via the femoral vessels, although the radial artery approach has the best safety record and is now the preferred access route for most UK operators. Left heart catheterization is used to diagnose or evaluate coronary artery disease and valvular heart disease. Left ventriculography, selective coronary angiography and measurement of pressure in the left ventricle (LV) are routinely performed. Aortography is performed in patients with aortic regurgitation or aortic root dilatation. Left ventriculography allows visual assessment of LV size/function as well as measurement of LV pressure and pressure gradients across diseased aortic valves. Coronary angiography provides information on coronary anatomy. Right heart catheterization allows measurement of haemodynamic data and oxygen saturations from the right heart chambers and pulmonary circulation. It provides information on right ventricular function, pulmonary artery pressure, right-sided and left-sided filling pressures, cardiac output and left-to-right shunts. Combined right and left heart catheterization is used in the comprehensive evaluation of patients with complex cardiac conditions, particularly those with valvular heart disease, intra-cardiac shunts or heart failure.