Fabio V. Lima

National Trends and In-Hospital Outcomes in Pregnant Women With Heart Disease in the United States

Investigation of trends and outcomes in heart disease (HD) and pregnancy has been limited. We chose to identify the prevalence, trends, and outcomes of pregnant women with different forms of HD in the United States. Healthcare Cost and Utilization Projects National Inpatient Sample was screened for hospital admissions for delivery in pregnant women with HD from 2003 to 2012. Maternal clinical characteristics and outcomes were identified in women with and without HD, and in HD subtypes: congenital (CHD), valvular HD, cardiomyopathy, and pulmonary hypertension (PH). Primary outcomes of interest were prevalence, trends, and major adverse cardiac events (MACEs), a composite of in-hospital death, acute myocardial infarction, heart failure, arrhythmia, cerebrovascular event, embolic events, or cardiac complications of anesthesia. We studied 81,295 patients with HD and 39,894,032 without. CHD was the most frequent type (41.8%, 33,982 of 81,295 patients), followed by valvular HD (30.9%, 25,138 of 81,295 patients), cardiomyopathy (20.8%, 16,926 of 81,295 patients), and PH (6.5%, 5,250 of 81,295 patients). MACE was highest among women with cardiomyopathy and lowest among women with CHD (44.0%, 7,449 of 16,926 vs 6.2%, 2,102 of 33,982; p <0.0001). PH patients had the highest in-hospital death, followed by cardiomyopathy patients (1.0%, 51 of 5,250 and 0.7%, 124 of 16,926, respectively). Pregnant women with HD significantly increased by 24.7%, related to increases in cardiomyopathy, CHD, and PH from 2003 to 2012. MACE significantly increased by 18.8%. In conclusion, pregnancy in women with HD is increasing, particularly for high risk conditions such as cardiomyopathy and PH. There is a significant and gradual increase in MACE for women with HD.

The impact of unfractionated heparin or bivalirudin on patients with stable coronary artery disease undergoing percutaneous coronary intervention

OBJECTIVES To compare bleeding and clinical events of patients with stable angina or silent ischemia undergoing percutaneous coronary intervention (PCI) treated with unfractionated heparin (UFH) or bivalirudin. BACKGROUND Few direct comparisons between UFH monotherapy versus bivalirudin exist for patients with stable ischemic heart disease undergoing PCI. METHODS A prospective, investigator-initiated, single-center, single-blinded, randomized trial of UFH versus bivalirudin was conducted. The primary endpoint was all bleeding (major and minor) from index-hospitalization to 30 days post discharge. Secondary endpoints included major adverse cerebral and cardiovascular events (MACCE) and net adverse clinical events (NACE). RESULTS Two-hundred-sixty patients were randomized for treatment with either UFH (n = 123) (47%) or bivalirudin (n = 137) (53%) There were no significant differences in baseline clinical and angiographic characteristics between the two groups. Primary endpoint was similar in both groups (10.9% with bivalirudin vs 7.3% with UFH [P = 0.31]). Major bleeding rates were 5.8% and 2.4%, respectively (P = 0.17). There was a higher MACCE (3.5% vs 0%, P = 0.03) and NACE (8.8% vs 2.4%, P = 0.03) rate with bivalirudin compared to UFH, respectively. Bivalirudin had increased odds of NACE (OR = 3.65, 95% CI: 1.00-13.3.6). Death and stent thrombosis rates were low and similar in both groups. Radial access was associated with fewer bleeding events compared to femoral access but not statistically significant (P = 0.29). CONCLUSIONS Among patients with stable angina or silent ischemia, there was no difference between UFH and bivalirudin in bleeding rates up to 30-days post-PCI. MACCE and NACE were higher among the bivalirudin group. Radial access was associated with a numerically lower rate of bleeding compared with femoral access.

Peripartum cardiomyopathy-diagnosis, management, and long term implications

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-associated disease that typically arises in the peripartum period. While the disease is relatively uncommon, its incidence is rising. It is a form of idiopathic dilated cardiomyopathy, defined as pregnancy-related left ventricular dysfunction, diagnosed either towards the end of pregnancy or in the months following delivery, in women without any other identifiable cause. The clinical presentation, diagnostic assessment and treatment usually mirror that of other forms of cardiomyopathy. Timing of delivery and management require a multidisciplinary approach and individualization. Subsequent pregnancies generally carry risk, but individualization is required depending on the pre-pregnancy left ventricular function. Recovery occurs in most women on standard medical therapy for heart failure with reduced ejection fraction, more frequently than in other forms of nonischemic cardiomyopathy. The purpose of this review is to summarize the current state of knowledge with regard to diagnosis, treatment and management, with a focus on long term implications.

Left ventricular end diastolic pressure and contrast-induced acute kidney injury in patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND Left ventricular end-diastolic pressure (LVEDP) reflects ventricular performance and volume status. We sought to analyze the relationship between LVEDP and the incidence of contrast-induced acute kidney injury (AKI) in patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI). METHODS Between January 2006 and December 2008, a total of 254 patients presenting with an acute coronary syndrome had the LVEDP assessed prior to the intervention. Contrast-induced AKI was defined as an increase in serum creatinine ≥25% from baseline or an absolute increase of >0.5 mg/dL from baseline. Patients were divided into three groups according to baseline LVEDP (<12 mmHg, 12-20 mmHg and > 20 mmHg). Baseline clinical, angiographic and procedural characteristics, as well as serum creatinine and estimated glomerular filtration rate (eGFR) at baseline and at 24, 48 and 72 h were retrospectively collected. RESULTS Baseline clinical characteristics were similar in all three groups with the exception of lower left ventricular ejection fraction in patients with elevated LVEDP (p = 0.02). Among the 17 patients with an LVEDP < 12 mmHg, only one (5.9%) developed AKI; among the 82 patients with an LVEDP = 12-20 mmHg, 15 (18.3%) developed AKI; and among the 155 patients with an LVEDP > 20 mmHg, only 22 developed AKI (13.6%). There was no correlation between LVEDP and the change in GFR at 24 h and at 48 h. Further comparison between the group of patients that developed contrast induced AKI versus those that did not, showed a that there was a significantly lower baseline left ventricular ejection fraction (LVEF) among patients that developed contrast induced AKI compared to those that did not (41.4% vs. 48.3%, p = 0.045, respectively). CONCLUSIONS In patients with acute coronary syndrome undergoing PCI, baseline LVEDP was not associated with contrast-induced AKI. However patients with reduced ejection fraction seemed to be at a higher risk of developing AKI. More studies are needed to assess the relationship between LVEDP, LVEF and the risk of developing contrast induced AKI.

Impact of atrial fibrillation in patients with chronic kidney disease undergoing transcatheter aortic valve replacement: Insights of the Healthcare Cost and Utilization Project's National Inpatient Sample

BACKGROUND Limited data exists exploring the relationship between varying degrees of chronic kidney disease (CKD) and atrial fibrillation (AF) in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS Records were selected from the 2011 to 2012 Healthcare Cost and Utilization Projects National Inpatient Sample for TAVR patients with pre-existing AF and CKD. Demographics, clinical characteristics, and TAVR-related in-hospital adverse events were identified and compared between patients with and without AF and moderate CKD (CKD stage 3-4), and between patients with and without AF and severe CKD (CKD stage 5 or end stage renal disease [ESRD]). Evaluated outcomes included major adverse cardiac and cerebrovascular events (MACCE). RESULTS We identified a total of 293 patients with moderate CKD (stage 3 and higher) that underwent TAVR at selected U.S. hospitals between 2011 and 2012. Among these patients, 112 had a diagnosis of AF and 181 did not have AF. MACCE rates were similar among CKD 3-4 patients with and without AF (10.3% and 9.0% respectively, p=0.74). MACCE rates were similar among CKD 5/ESRD patients with and without AF (20.0% and 16.2% respectively, p=0.74). However, MACCE rates were higher in patients with CKD 5/ESRD compared with CKD 3-4 patients. Multivariate logistic regression analysis did not show that AF was an independent predictor of in-hospital MACCE. CONCLUSIONS In a large retrospective analysis of CKD stage 3-4 or CKD 5/ESRD patients undergoing TAVR at selected U.S. hospitals, the presence of AF did not seem to be associated with increased adverse in-hospital events or length of stay.

Pregnant women with heart disease: Placental characteristics and their association with fetal adverse events

ABSTRACT Background: Pregnant women with heart disease (HD) have higher rates of adverse fetal outcomes. We describe placental pathologic characteristics and their association with fetal events. Methods: In pregnant women, known HD were categorized into: (1) cardiomyopathy (CM) or (2) other HD (congenital, coronary, arrhythmia, or valvular). Outcomes were maternal major adverse cardiac events (MACE), fetal adverse clinical events (FACE), a composite of infant death, prematurity, underweight status, intracranial hemorrhage, and respiratory distress. Only pathologically reported placental analyses were included. Results: We studied 86 pregnancies in women with CM and HD, with pathologic analyses on 35 CM and 52 HD placentas. CM placentas, compared with those with HD, were more likely to have ischemic changes (65.7% vs. 37%, p 0.008), demonstrate immaturity (62.90% vs. 10%, p < 0.001), and have a lower weight (p < 0.001), despite similar gestational age. CM was independently associated with increased risk for MACE (OR 7.38, 95%CI 2.20–24.76). Ischemic placental changes were associated with increased odds of FACE (OR 24.78, 95%CI 2.37–259.03). Conclusions: Women with CM were more likely to have ischemic placentas, with lower placental and fetal weights, and evidence of immaturity compared with those with other forms of HD, and an increased odds of MACE.