Umesh N. Khot

Background: The association between Coronavirus Disease-2019 (COVID-19) and new-onset cardiomyopathy (NOC) is unclear. Objectives: We aim to assess the incidence of NOC in hospitalized COVID-19 patients and its impact on short- and long-term survival. Methods: We retrospectively studied 2219 COVID-19 patients hospitalized between March 2020 and February 2022 who underwent an in-hospital echocardiogram. NOC was defined as a left-ventricular ejection fraction (LVEF) reduction of >10%, resulting in an LVEF of p = 0.001) and have chronic kidney disease (51.4% vs. 60.3%, p = 0.018). They had a higher 30-day mortality rate (29.1% vs. 32%, p = 0.033), but the 1-year survival rate was similar between the patients without and with NOC (36.9% vs. 41.6%, p = 0.12). Multivariable regression revealed that advanced age, admission to intensive care unit, mechanical ventilation, treatment with glucocorticoids, and treatment with vasopressors were associated with higher odds of 30-day mortality in NOC patients. Only 74 (35.4%) NOC patients had follow-up echocardiograms after discharge, of which 47 showed persistent cardiomyopathy. Conclusions: NOC can affect around 1 out of 10 hospitalized COVID-19 patients undergoing echocardiography. While NOC was associated with worse short-term survival, it did not impact the long-term mortality of these patients. Persistent LVEF deficits in some patients emphasize the need for improved outpatient follow-up to identify at-risk individuals and optimize treatment.

Background: Most US patients with ST‐segment–elevation myocardial infarction (STEMI) transferred for percutaneous coronary intervention (PCI) do not achieve the goal door‐to‐balloon time (D2BT) of ≤120 minutes. We evaluated the impact of a comprehensive STEMI protocol (CSP) implemented in our health care system on STEMI process metrics in patients transferred for PCI. Methods AND RESULTS: The CSP is a 4‐step protocol including (1) emergency department (ED) cardiac catheterization laboratory activation; (2) a STEMI Safe Handoff Checklist; (3) immediate transfer to an available cardiac catheterization laboratory; and (4) radial‐first approach to PCI. We compared the use of guideline‐directed medical therapy before angiography, radial‐first access, and D2BT in 1274 consecutive patients with STEMI transferred to our hospital for PCI before (pre‐CSP group; January 1, 2011, to July 14, 2014) and after (CSP group; July 15, 2014, to July 15, 2019) CSP implementation. The study population included 499 patients in the pre‐CSP group and 775 patients in the CSP group. After CSP implementation, guideline‐directed medical therapy before angiography (84.6% versus 93.9%, P P P P P =0.04) and an absolute risk reduction of 0.7%. Conclusions: In patients with STEMI transferred for PCI, a standardized protocol for STEMI care was associated in improvements in key process metrics (guideline‐directed medical therapy, radial access, and D2BT) with associated reduction in the 30‐day mortality rate.

Introduction Immune-mediated inflammatory disease (IMID) is a subset of autoimmune diseases including systemic lupus erythematosus, rheumatoid arthritis, and psoriasis that is emerging as a risk factor for many cardiovascular diseases including valvular disease. Objectives To determine whether IMID is associated with frequent and early development of bioprosthetic valve failure (BVF) after surgical aortic valve replacement (SAVR) and transcatheter valve replacement (TAVR). Methods Serial echocardiograms for patients who underwent SAVR and TAVR at Cleveland Clinic between 2000 and 2022 were assessed for time to development of BVF after procedure. ICD10 codes were used to stratify to those with and without IMID. Kaplan-Meier curve and cox proportional hazard regression analysis were used to assess for differences in development of BVF after TAVR and SAVR. Results 351 TAVR patients (52 IMID and 299 controls) and 1961 SAVR patients (300 IMID and 1661 controls) were included. BVF after TAVR occurred in 12 (23.1%) IMID and 21 (7.0%) control patients, respectively, yielding an adjusted hazard ratio of 4.02 (1.81 - 8.92). Time to 50% of patients developing BVF was earlier among IMID, occurring at 6.6 years IMID and not reached in controls (p < 0.001). There were no significant differences in prevalence and time to development of BVF in IMID vs controls after SAVR. Conclusion After TAVR, BVF occurred earlier and more frequently in patients with IMID than controls. This risk should be included during shared decision making among IMID patients considered for TAVR, and may warrant more frequent monitoring post procedure. These differences in BVF were not seen after SAVR.

Background Patients who experience in-hospital ST-segment elevation myocardial infarction (iSTEMI) represent a uniquely high-risk cohort owing to delays in diagnosis, prolonged time to reperfusion and increased mortality. Quality initiatives aimed at improving the care of this vulnerable, yet understudied population are needed. Methods This study included consecutive patients with iSTEMI treated with percutaneous coronary intervention (PCI) between 1 January 2011 and 15 July 2019 at a single, tertiary referral centre. A comprehensive iSTEMI protocol (CSP) was implemented on 15 July 2014, incorporating: (1) cardiology fellow activation of the catheterisation lab using standardised criteria, (2) nursing chest pain protocol, (3) improved electronic access to electrocardiographic studies, (4) checklist for initial triage and management, (5) 24/7/365 catheterisation lab readiness and (6) radial-first PCI approach. Key metrics and clinical outcomes were compared before and after CSP implementation. Results Among 125 total subjects, the post-CSP cohort (n=81) was younger, had more males and were more likely to be hospitalised for cardiac-related reasons relative to the pre-CSP cohort (n=44) who were more likely hospitalised for operative-related aetiologies. After CSP adoption, median ECG-to-first-device-activation time decreased from 113 min to 64 min (pConclusions The implementation of a CSP was associated with marked enhancements in key care metrics among patients with iSTEMI. Among a larger cohort, the use of a CSP yielded a significant reduction in ECG-to-first-device-activation time in a particularly vulnerable population at high risk of death.

OBJECTIVES: Guidewire retention after intravascular catheter insertion is considered a “never event.” Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. DESIGN: Pre-specified observational analysis as part of a quality improvement study of consecutive guidewire retention events across a multihospital health system from August 2007 to October 2015. SETTING: Ten hospitals within the Cleveland Clinic Health System in Ohio, United States. PATIENTS: Consecutive all-comers who experienced guidewire retention after vascular catheter insertion. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention, stratified into patient, operator, and procedural characteristics. A total of 24 events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m². A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, three (12%) were performed by first-year trainees, seven (29%) by residents, three (12%) by fellows, and four (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8 amto 5 pm). In total, 22 (92%) guidewires were inserted nonemergently, with two (8%) during a cardiac arrest. Ultrasound guidance was used in all but one case. CONCLUSIONS: Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.

Background: Compared with White Americans, Black Americans have a greater prevalence of cardiac events following percutaneous coronary intervention. We evaluated the association between race and neighborhood income on post–percutaneous coronary intervention cardiac events and assessed whether income modifies the effect of race on this relationship. Methods and Results: Consecutive patients (n=23 822) treated with percutaneous coronary intervention from January 1, 2000, to December 31, 2016, were included. All‐cause mortality and major adverse cardiac event were assessed at 3 years. Extended 10‐year follow‐up was performed for those residing locally (n=1285). Neighborhood income was derived using median adjusted annual gross household income reported within the patient's zip code. We compared differences in treatment and outcomes, adjusting for race, income, and their interaction. In total, 3173 (13.3%) patients self‐identified as Black Americans, and 20 649 (86.7%) self‐identified as White Americans. Black Americans had a worse baseline cardiac risk profile and lower neighborhood income compared with White Americans. Although risk profile improved with increasing income in White Americans, no difference was observed across incomes among Black Americans. Despite similar long‐term outpatient cardiology follow‐up and medication prescription, risk profiles among Black Americans remained worse. At 3 years, unadjusted all‐cause mortality (18.0% versus 15.2%; P P P P =0.005), Black race (HR, 1.77 [95% CI, 1.58–1.96]; P =0.006), and their interaction (HR, 0.98 [95% CI, 0.97–0.99]; P =0.003) were significant predictors. Similar findings were observed for cardiac death. Conclusions: Early 3‐year post–percutaneous coronary intervention outcomes were driven by worse risk factor profiles in both Black Americans and those with lower neighborhood income. However, late 10‐year outcomes showed an independent effect of race and income, with improving outcomes with greater income limited to White Americans. These findings illustrate the importance of developing novel care strategies that address both risk factor modification and social determinants of health to mitigate disparities in cardiac outcomes.