Carlos D. Davila

Infective endocarditis epidemiology over five decades: a systematic review.

Aims To Assess changes in infective endocarditis (IE) epidemiology over the last 5 decades. Methods and Results We searched the published literature using PubMed, MEDLINE, and EMBASE from inception until December 2011. Data From Einstein Medical Center, Philadelphia, PA were also included. Criteria for inclusion in this systematic review included studies with reported IE microbiology, IE definition, description of population studied, and time frame. Two authors independently extracted data and assessed manuscript quality. One hundred sixty studies (27,083 patients) met inclusion criteria. Among hospital-based studies (n=142; 23,606 patients) staphylococcal IE percentage increased over time, with coagulase-negative staphylococcus (CNS) increasing over each of the last 5 decades (p<0.001) and Staphylococcus aureus (SA) in the last decade (21% to 30%; p<0.05). Streptococcus viridans (SV) and culture negative (CN) IE frequency decreased over time (p<0.001), while enterococcal IE increased in the last decade (p<0.01). Patient age and male predominance increased over time as well. In subgroup analysis, SA frequency increased in North America, but not the rest of the world. This was due, in part, to an increase in intravenous drug abuse IE in North America (p<0.001). Among population-based studies (n=18; 3,477 patients) no significant changes were found. Conclusion Important changes occurred in IE epidemiology over the last half-century, especially in the last decade. Staphylococcal and enterococcal IE percentage increased while SV and CN IE decreased. Moreover, mean age at diagnosis increased together with male:female ratio. These changes should be considered at the time of decision-making in treatment of and prophylaxis for IE.

Marital status and living condition as predictors of mortality and readmissions among African Americans with heart failure

UNLABELLED Socioeconomic factors, including social support, may partially explain why African Americans (AA) have the highest prevalence of heart failure and with worse outcomes compared to other races. AA are more likely to be hospitalized and readmitted for heart failure and have higher mortality. The purpose of this study is to determine whether the social factors of marital status and living condition affect readmission rates and all-cause mortality following hospitalization for acute decompensated heart failure (ADHF) in AA patients. METHODS Medical records from 611 AA admitted to Einstein Medical Center Philadelphia from January, 2011 to February, 2013 for ADHF were reviewed. Patient demographics including living condition (nursing home residents, living with family or living alone) and marital status (married or non-married -including single, divorced, separated and widowed) were correlated with all-cause mortality and readmission rates. RESULTS In this cohort (53% male, mean age 65±15, mean ejection fraction 32±16%) 25% (n=152) of subjects were unmarried. Unmarried patients had significantly higher 30-day readmission rates (16% vs. 6% p=0.0002) and higher 1-year mortality (17% vs. 11% p=0.047) compared with married patients. Fifty percent (n=303) of subjects were living with family members, while 40% (n=242) and 11% (n=66) were living alone or in a nursing facility, respectively. Patients living with family members had significantly lower 30-day readmission rates when compared with those living alone or in a nursing facility (7% vs 21% vs. 18% p=<0.0001). Furthermore, they had the lowest 1-year mortality (14% vs 32% for nursing facility patients and 17% for those living alone (p=0.0007). After controlling for traditional risk factors (age, gender, body mass index, peak troponin I, left ventricular ejection fraction, B-type natriuretic peptide, hypertension, diabetes mellitus, hyperlipidemia, and coronary artery disease), being married was an indpendent predictor of 1-year mortality (OR 0.50 p=0.019) and living alone for 30-day readmission (OR 2.86 p=<0.001). CONCLUSION The socioeconomic factors of marital status and living condition significantly correlated with mortality and 30-day readmission rate in AA heart failure patients. Specifically, being married and living with family independently predict lower mortality and fewer readmissions. Surprisingly, living in a nursing facility was associated with significantly higher mortality than living alone or with family.

Psychiatric conditions as predictors of rehospitalization among African American patients hospitalized with heart failure

African Americans (AAs) have the highest risk of developing heart failure (HF) among all ethnicities in the United States and are associated with higher rates of readmissions and mortality. This study aims to determine the prevalence and relationship of common psychiatric conditions to outcomes of patients hospitalized with HF.

Dipstick proteinuria is an independent predictor of high on treatment platelet reactivity in patients on clopidogrel, but not aspirin, admitted for major adverse cardiovascular events

Abstract The effectiveness of aspirin and clopidogrel in patients with chronic kidney disease (CKD) suffering from acute cardiovascular events is unclear. High on treatment platelet reactivity (HTPR) has been associated with worse outcomes. Here, we assessed the association of dipstick proteinuria (DP) and renal function on HTPR and clinical outcomes. Retrospective cohort analysis of 261 consecutive, non-dialysis patients admitted for Major Adverse Cardiovascular Events (MACE) that had VerifyNow P2Y12 and VerifyNow Aspirin assays performed. HTPR was defined as P2Y12 reactivity unit (PRU) > 208 for clopidogrel and aspirin reaction units (ARU) > 550 for aspirin. Renal function was classified based on the estimated glomerular filtration rate (eGFR), and dipstick proteinuria was defined as ≥30 mg/dl of albumin detected on a spot analysis. All cause mortality, readmissions, and cardiac catheterizations were reviewed over 520 days. In patients on clopidogrel (n = 106), DP was associated with HTPR, independent of eGFR, diabetes mellitus, smoking or use of proton pump inhibitor (AOR = 4.76, p = 0.03). In patients with acute coronary syndromes, HTPR was associated with more cardiac catheterizations (p = 0.009) and readmissions (p = 0.032), but no differences in in-stent thrombosis or re-stenosis were noted in this cohort. In patients on aspirin (n = 155), no associations were seen between DP and HTPR. However, all cause mortality was significantly higher with HTPR in this group (p = 0.038). In this cohort, DP is an independent predictor of HTPR in patients on clopidogrel, but not aspirin, admitted to the hospital for MACE.

Integrating Interventional Cardiology and Heart Failure Management for Cardiogenic Shock

Cardiogenic shock remains one of the most common causes of in-hospital death. Recent data have identified an overall increase in patient complexity, with cardiogenic shock in the setting of acute myocardial infarction. The use of percutaneous acute mechanical circulatory support (AMCS) has steadily grown in the past decade. Guidelines and consensus statements addressing proper patient selection, timing of AMCS implantation, device choice, and postimplantation protocol are appearing. The emerging role of interventional heart failure specialists within the heart team includes integration and understanding of advanced hemodynamic and cathether-based therapies, with the goal of improving outcomes.

Safety, efficacy, and clinical utility of macitentan in the treatment of pulmonary arterial hypertension

Pulmonary arterial hypertension is a progressive, debilitating disease caused by a dysregulation of the pulmonary vascular tone that inevitably leads to right heart failure and death without treatment. Until relatively recently, the treatment options for those afflicted by pulmonary arterial hypertension were limited; today, a greater understanding of the pathophysiology behind this disease has led to several evidence-based therapies that can improve pulmonary function and quality of life for these patients. One of the primary mediators of pulmonary vascular tone is endothelin-1, which is a potent and long-lasting vasoconstrictor. Macitentan is a second-generation endothelin receptor antagonist that acts selectively as a pulmonary vasodilator without the significant side effects noted with previous endothelin receptor antagonists. This review focuses on the mechanism of action and pharmacokinetics of macitentan, as well as the adverse effects, efficacy, and clinical uses of macitentan in the clinical trials to date. In addition, the authors briefly review clinical trials currently underway to illustrate possible future directions for the use of macitentan.