Background: During the first months of the COVID-19 outbreak, an increase was observed in atrial fibrillation (AF)-related mortality in the United States (U.S). We aimed to investigate AF-related mortality trends in the U.S. before, during, and after the COVID-19 pandemic peak, stratified by sociodemographic factors. Methods: using the Wide-Ranging Online Data for Epidemiologic Research database of the Centers for Disease Control and Prevention, we compared the AF-related age-adjusted mortality rate (AAMR) among different subgroups in the two years preceding, during, and following the pandemic peak (2018–2019, 2020–2021, 2022–2023). Result: By analyzing a total of 1,267,758 AF-related death cases, a significant increase of 24.8% was observed in AF-related mortality during the pandemic outbreak, followed by a modest significant decrease of 1.4% during the decline phase of the pandemic. The most prominent increase in AF-related mortality was observed among males, among individuals younger than 65 years, and among individuals of African American and Hispanic descent, while males, African American individuals, and multiracial individuals experienced a non-statistically significant decrease in AF-related mortality during the pandemic decline period. Conclusions: Our findings suggest that in future healthcare crises, targeted healthcare policies and interventions to identify AF, given its impact on patients’ outcomes, should be developed while addressing disparities among different patient populations.

IntroductionPatients with mental disorders are at increased risk of cardiovascular events. We aimed to assess the cardiovascular mortality trends over the last two decades among patients with mental and behavioral co-morbidities in the US.MethodsWe performed a retrospective, observational study using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death dataset. We determined national trends in age-standardized mortality rates attributed to cardiovascular diseases in patients with and without mental and behavioral disorders, from 1999 to 2020, stratified by mental and behavioral disorders subtype [ICD10 codes F], age, gender, race, and place of residence.ResultsAmong more than 18.7 million cardiovascular deaths in the United States (US), 13.5% [2.53 million] were patients with a concomitant mental and behavioral disorder. During the study period, among patients with mental and behavioral disorders, the age-adjusted mortality rate increased by 113.9% Vs a 44.8% decline in patients with no mental disorder (both p<0.05). In patients with mental and behavioral disorders, the age-adjusted mortality rate increased more significantly among patients whose mental and behavioral disorder was secondary to substance abuse (+532.6%, p<0.05) than among those with organic mental disorders, such as dementia or delirium (+6.2%, P− nonsignificant). Male patients (+163.6%) and residents of more rural areas (+128–162%) experienced a more prominent increase in age-adjusted cardiovascular mortality.DiscussionWhile there was an overall reduction in cardiovascular mortality in the US in the past two decades, we demonstrated an overall increase in cardiovascular mortality among patients with mental disorders.

ABSTRACTBackgroundInformation regarding the prevalence and etiologies of complete atrioventricular block (CAVB) in younger patients is scarce. We aimed to investigate the potential causes for non-iatrogenic CAVB, the prevalence of CAVB without an identified etiology, the utilization of guidelines-recommended advanced imaging modalities in adults presenting with an early-onset CAVB of unidentified etiology, as well as to identify the predictors for cardiac implantable electronic device (CIED) insertion.MethodsUsing the National Inpatient Sample (NIS) database, we identified patients aged 18-60 hospitalized with non-iatrogenic CAVB in the US between 2015 (last quarter)-2019. Baseline demographics, clinical characteristics, potential etiologies for CAVB, advanced imaging utilization as well as outcomes including the need for temporary cardiac pacing (TCP) and CIED implantation were analyzed. Multivariable logistic regression models were used to identify predictors of CIED implantation.ResultsAn estimated total of 14,495 patients aged 18-60 with non-iatrogenic CAVB were identified. The mean age was 51 years, 60% were males and 3,050 (21%) had documentation of a prior conduction disorder. Eleven percent of the patients had a diagnosis of syncope and 6% suffered from a cardiac arrest. Two third of the patients (9,735, 67%) had no identified etiology for CAVB, of whom 8,205 (84%) were implanted with a permanent pacemaker (PPM), 180 patients (2%) with an implantable cardioverter-defibrillator (ICD), and 295 patients (3%) with a cardiac resynchronization therapy device. Only 40 patients (0.3%) underwent advanced imaging during their hospitalization. In multivariate analyses, older age [adjusted OR 1.046 (1.04-1.05), p<0.001] and the need for TCP [adjusted OR 1.543 (1.29-1.84), p<0.001], emerged as predictors for PPM implantation. Cardiac arrest [adjusted OR 2.786 (1.69-4.58), p<0.001] and younger age [adjusted OR 0.98 (0.96-0.99), p=0.02], were associated with ICD implantation. 185 patients (1.3%) died during their hospitalization.ConclusionThe majority of patients, hospitalized in the US for non-iatrogenic early-onset CAVB, had no identified etiology for their conduction disease. Despite the current US and European guidelines recommendation, advanced imaging prior to CIED implantation was under-utilized in this patient population.

Background Routine addition of an atrial lead during an implantable cardioverter‐defibrillator (ICD) implantation for primary prevention of sudden cardiac death, in patients without pacing indications, was not shown beneficial in contemporary studies. We aimed to investigate the use and safety of single‐ versus dual‐chamber ICD implantations in these patients. Methods and Results Using the National Inpatient Sample database, we identified patients with no pacing indications who underwent primary‐prevention ICD implantation in the United States between 2015 and 2019. Sociodemographic and clinical characteristics, as well as in‐hospital complications, were analyzed. Multivariable logistic regression was used to identify predictors of in‐hospital complications. An estimated total of 15 940 patients, underwent ICD implantation for primary prevention of sudden cardiac death during the study period, 8860 (55.6%) received a dual‐chamber ICD. The mean age was 64 years, and 66% were men. In‐hospital complication rates in the dual‐chamber ICD and single‐chamber ICD group were 12.8% and 10.7%, respectively ( P <0.001), driven by increased rates of pneumothorax/hemothorax (4.6% versus 3.4%; P <0.001) and lead dislodgement (3.6% versus 2.3%; P <0.001) in the dual‐chamber ICD group. Multivariable analyses confirmed atrial lead addition as an independent predictor for “any complications” (odds ratio [OR], 1.1 [95% CI, 1.0–1.2]), for pneumo/hemothorax (odds ratio, 1.1 [95% CI, 1.0–1.4]), and for lead dislodgement (odds ratio, 1.3 [95% CI, 1.1–1.6]). Conclusions Despite lack of evidence for clinical benefit, dual‐chamber ICDs are implanted for primary prevention of sudden cardiac death in a majority of patients who do not have pacing indication. This practice is associated with increased risk of periprocedural complications. Avoidance of routine implantation of atrial leads will likely improve safety outcomes.

Introduction: In the United States the impact of the COVID-19 pandemic on atrial fibrillation (AF) related mortality has not been described. Methods: AF related mortality data were extracted for the years 2018-2020 from the Centers for Disease Control and Prevention (CDC), the Wide-ranging Online Data for Epidemiologic Research (WONDER) database. We compared main causes of AF related mortality and age adjusted mortality rate (AAMR) among different subgroups in the years 2018-2019 vs 2020 to reveal patterns of increased mortality. Results: Compared to 2018-2019, we observed a 18% increase in AF related age adjusted mortality in 2020 (52.2 vs 44.25 per 100,000 vs population). In 2020, COVID-19 was the third most common main cause of death among people with AF (8% of deaths, AAMR of 4.9 per 100,000). Examination of the relative increase in AF related mortality among different subgroups revealed a more prominent increase among males (21% increase vs 14.5% among females) those younger than 65 years old (30% increase, vs. 16% among those younger than 65 years old), and among racial and ethnic minorities. Conclusion: There was a sharp rise in AF related mortality during the first pandemic year. Males, those from younger age groups, and ethnic minority groups showed the largest increases in mortality. Targeted health policies could help address the disparities observed in this analysis.

BACKGROUND:The treatment of myopericarditis is different than that of acute myocardial infarction (AMI). However, since their clinical presentation is frequently similar it may be difficult to distinguish between these entities despite a disparate underlying pathogenesis. Myopericarditis is primarily an inflammatory disease associated with high C-reactive protein (CRP) and relatively low elevated troponin concentrations, while AMI is characterized by the opposite. We hypothesized that evaluation of the CRP/troponin ratio on presentation to the emergency department could improve the differentiation between these two related clinical entities whose therapy is different. Such differentiation should facilitate triage to appropriate and expeditious therapy. METHODS:We evaluated the CRP/troponin ratio on presentation among patients consecutively included in a large single center registry that included 1898 consecutive patients comprising 1025 ST-elevation myocardial infarction (STEMI) patients, 518 Non-STEMI (NSTEMI) patients, and 355 patients diagnosed on discharge as myopericarditis. CRP and troponin were sampled on admission in all patients and their ratio was assessed against discharge diagnosis. ROC analysis of the CRP/troponin ratios evaluated the diagnostic accuracy of myopericarditis against all AMI, STEMI, and NSTEMI patients. RESULTS:Median admission CRP/troponin ratios were 84, 65, and 436 mg×ml/liter×ng in STEMI, NSTEMI and myopericarditis groups, respectively (p<0.001) demonstrating good differentiating capability. The Receiver-operator-curve of admission CRP/troponin ratio for diagnosis of myopericarditis against all AMI, STEMI, and NSTEMI patients yielded an area-under-the curve of 0.74, 0.73, and 0.765, respectively. CRP/troponin ratio>500 resulted in specificity exceeding 85%, and for a ratio>1000, specificity>92%. CONCLUSION:The CRP/troponin ratio can serve as an effective tool to differentiate between myopericarditis and AMI. In the appropriate clinical context, the CRP/troponin ratio may preclude further evaluation.

The mortality of women with ST-elevation myocardial infarction (STEMI) exceeds that of men, supposedly the result of older age and co-morbidities. Patients with STEMI can be transported directly to the catherization lab by the emergency medical service (EMS) or to the emergency department (ED) by the EMS, a regular ambulance, or independently. This raises the question whether gender disparity in the transport of patients with STEMI may affect time to therapy and consequently explain the disparate outcome in men and women with STEMI. We analyzed a large nationwide registry of prospectively-recorded patients with acute coronary syndromes in order to determine if there is a survival gap between men and women with STEMI, and to assess the gender-related effect of admission pathway on time intervals and 5-year mortality. Study population included 2,740 patients with STEMI who underwent primary percutaneous coronary interventions, comprising 464 women (17%, median-70 years) and 2,276 men (83%, median-58 years). The unadjusted 5-year mortality of women was higher compared with men (26.4% vs 15.6%, p = 0.001) but adjustment abrogated this survival difference. Regardless of adjustment, the 5-year mortality of patients with STEMI admitted directly to the catherization lab or to the ED by EMS was similar for men and women but significantly lower in the directly admitted patients (p <0.028). In contrast, admission to the ED by non-EMS was associated with markedly worse survival among women. These results indicate that women suspected of STEMI benefit from transportation by the EMS and should use this pathway exclusively to reach the hospital.