Han Tun

African-American patients are less likely to receive drug-eluting stents during percutaneous coronary intervention.

BACKGROUND Previous research has shown that African-Americans, patients without insurance, and those with government-sponsored insurance are less likely to be referred for invasive cardiovascular procedures. We therefore sought to compare the impact of race and insurance type upon the use of drug-eluting stents (DES). METHODS Patients undergoing percutaneous coronary intervention (PCI) with stenting from January 2008 to December 2012 at Los Angeles County Hospital and Keck Hospital of USC were retrospectively analyzed. Race was categorized as African-American, Hispanic, or non-African-American/non-Hispanic. Insurance was categorized as private, Medicare, Medicaid, incarcerated, or uninsured. Multivariable logistic regression was performed, with receipt of ≥1 DES the outcome variable of interest. RESULTS Among 2763 patients undergoing PCI, 62.8% received ≥1 DES, 45.4% were Hispanic, 6.7% were African-American, 33.2% were uninsured, 28.5% had Medicaid, 22.5% had Medicare, 14.1% had private insurance, and 1.7% were incarcerated. Following multivariable adjustment, African-Americans, in comparison to non-African-American/non-Hispanic patients, were less likely to receive ≥1 DES (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.40-0.82, p=0.002). Hispanic patients, however, were not less likely to receive DES. Uninsured patients (OR 1.51, 95% CI 1.13-2.03, p=0.006) and those with Medicaid (OR 1.49, 95% CI 1.11-2.00, p=0.008) were more likely to receive DES than patients with private insurance, whereas those with Medicare were less likely to receive DES (OR 0.71, 95% CI 0.52-0.95, p=0.02). CONCLUSIONS African-American race continues to have a significant impact upon the decision to use DES. Future research should focus upon patient and provider perceptions at the time of PCI. SUMMARY This study is a retrospective analysis of the impact of race and insurance status upon the utilization of drug-eluting stents. Multivariable logistic regression showed that African-American race was associated with less utilization of drug-eluting stents.

Prevalence of High On-Treatment (Aspirin and Clopidogrel) Platelet Reactivity in Patients with Critical Limb Ischemia ☆

OBJECTIVES The goal of this study is to establish the prevalence of high on-treatment platelet reactivity to aspirin (HPRA) and clopidogrel (HPRC) in patients with critical limb ischemia (CLI). BACKGROUND CLI is associated with an increased risk of death and cardiovascular events. Unlike other patient populations with atherosclerotic cardiovascular disease, previous studies failed to demonstrate a benefit of antiplatelet therapy in patients with CLI. METHODS From June 2014 to November 2016, we performed platelet reactivity studies for P2Y12 and thromboxane A2 (TXA2) inhibition in 100 CLI patients receiving daily treatment with aspirin and clopidogrel. P2Y12 inhibition was measured by two assays: vasodilator-stimulated phosphoprotein (VASP) and VerifyNow P2Y12 assays. HPRC was defined as VerifyNow P2Y12 reactive units (PRU) >208 and VASP-platelet reactivity index (VASP-PRI) >50%. TXA2 inhibition was measured with the VerifyNow aspirin test and HPRA was defined as aspirin reaction units (ARU) >550. RESULTS Mean age was 67±11 years, 50% were male, 80% had diabetes mellitus, and 26% had chronic renal insufficiency. Thirty-three percent of patients had a PRU >208 and 46% a VASP-PRI >50%. HPRC was present in 26% of patients based on the criteria of both a PRU >208 and VASP-PRI >50%. HPRA was present in 25% of patients. The overall prevalence of HPR to ASA or clopidogrel was 35% and HPR to both drugs was present in 8% of patients. Clinical characteristics were similar between groups. CONCLUSIONS HPR to aspirin or clopidogrel is highly prevalent in patients with CLI. Nearly one in ten patients with CLI is a hyporesponder to both aspirin and clopidogrel.

Same-day discharge after coronary stenting and femoral artery device closure: A randomized study in stable and low-risk acute coronary syndrome patients ☆

OBJECTIVE To compare same-day (SD) vs. delayed hospital discharge (DD) after single and multivessel coronary stenting facilitated by femoral closure device in patients with stable angina and low-risk acute coronary syndrome (ACS). METHODS University of Southern California patients were screened and coronary stenting was performed in 2480 patients. Four hundred ninety-three patients met screening criteria and consented. Four hours after percutaneous coronary intervention, 100 were randomized to SD (n=50) or DD (n=50). Patients were followed for one year; outcomes-, patient satisfaction-, and cost analyses were performed. RESULTS Groups were well distributed, with similar baseline demographic and angiographic characteristics. Mean age was 58.1±8.8years and 86% were male. Non-ST-elevation myocardial infarction and unstable angina were the clinical presentations in 30% and 44% of the SD and DD groups, respectively (p=0.2). Multivessel stenting was performed in 36% and 30% of SD and DD groups, respectively (p=0.14). At one year, two patients from each group (4%) required unplanned revascularization and one patient in the SD group had a gastrointestinal bleed that required a blood transfusion. Six SD and four DD patients required repeat hospitalization (p=0.74). There were no femoral artery vascular complications in either group. Patient satisfaction scores were equivalent. SD discharge was associated with

Association of elevated triglycerides and acute myocardial infarction in young Hispanics

1200 savings per patient. CONCLUSIONS SD discharge after uncomplicated single and multivessel coronary stenting of patients with stable, low-risk ACS, via the femoral approach facilitated by a closure device, is associated with similar clinical outcomes, patient satisfaction, and cost savings compared to overnight (DD) hospital stay.

Patent foramen ovale and neurologic events in patients undergoing liver transplantation

BACKGROUND Previous studies have demonstrated that acute myocardial infarction (AMI) in young patients (age <45years) is associated with a high prevalence of smoking, obesity, hyperlipidemia and single vessel coronary artery disease (CAD). Hispanics represent the largest growing ethnic minority in the United States, yet features of AMI in young Hispanics have not been described. METHODS Patients undergoing percutaneous coronary intervention for AMI at Los Angeles County + University of Southern California Medical Center and Keck Medical Center were studied. We compared young Hispanics (age<45, n=47) with older patients (Hispanics and non-Hispanics age ≥45, n=888) to identify unique features of AMI in young Hispanics. We also compared young Hispanics with young non-Hispanics (n=33) and older Hispanics (n=447) in regards to traditional CAD risk factors, laboratory values and in-hospital outcomes. Multivariable logistic regression was performed to identify variables independently associated with in-hospital mortality. RESULTS Young Hispanics had higher triglyceride levels than young non-Hispanics and older patients (234.5±221.0mg/dL vs. 145.3±67.4mg/dL vs. 156±118.2mg/dL, p<0.0004); and higher triglyceride than older Hispanics (234.5±221.0 vs. 147.0±98.9mg/dL, p<0.02). Body mass index was independently associated with the logarithm (base10) of triglyceride levels (p<0.0001). Hispanic ethnicity and age<45years, however, were not independently associated with in-hospital mortality. CONCLUSIONS Young Hispanics with AMI have higher triglyceride levels than young non-Hispanics and older Hispanics. The elevated triglyceride levels may be related to lifestyle changes experienced by a young immigrant population transitioning to life in the United States.

Switch To Ticagrelor in Critical Limb Ischemia Antiplatelet Study (STT-CLIPS)☆

BACKGROUND Patent foramen ovale (PFO) is present in approximately 20% of individuals. During liver transplantation (LT), intra-operative transesophageal echocardiography can observe transient intra-cardiac shunting of atheromatous debris via a PFO. Closure of PFOs prior to LT has thus been suggested as a potential treatment to reduce peri-operative cerebral vascular accident (CVA). The objective of this study was to assess if the presence of PFO is associated with CVA in patients undergoing LT. METHODS Three hundred fifty-eight patients undergoing LT at a single academic institution were included. All patients underwent standardized cardiac evaluation including a detailed cardiovascular history and physical examination, electrocardiogram and transthoracic echocardiogram. Five patients were excluded because of poor transthoracic echocardiographic image quality, and three patients were excluded because of PFO closure prior to LT, yielding a study population of 350 patients. Medical records were reviewed to determine demographics, echocardiographic findings and outcome following LT. Major adverse cardiovascular events, myocardial infarction, CVA and death were collected. RESULTS Mean age was 53.4 ± 10.2 years; 61% male and 5% of patients had a prior history of CVA. Alcohol and hepatitis C were the most common etiologies for liver disease. Forty-six patients (13.1%) were diagnosed with PFO prior to LT. In-hospital CVA occurred in 6 patients (1.7%). The prevalence of a CVA was not significantly higher in patients with PFO compared to patients without PFO, 2.2% vs 1.6%, p = 0.57. In-hospital mortality was similar in patients with PFO compared to patients without PFO, 4.4% and 5.3%, p = 1.0. CONCLUSIONS The presence of a PFO in patients undergoing LT is not associated with postoperative CVA. Prophylactic closure of PFOs, in the absence of other indications, does not appear to be warranted in patients undergoing LT.

Utility of fluoroscopy in teaching trainees groin puncture technique.

OBJECTIVE To investigate platelet reactivity in patients with critical limb ischemia (CLI) after switching from clopidogrel to ticagrelor. BACKGROUND High on-treatment platelet reactivity (HPR) is highly prevalent in patients with CLI treated with clopidogrel. The effect of ticagrelor in patients with CLI is not known, however. METHODS We performed P2Y12 platelet receptor inhibition studies (VASP and VerifyNow) in 50 patients with CLI. Tests were performed before and 6±1h after daily 75mg clopidogrel dose. Patients were then switched to ticagrelor 90mg twice daily for two weeks and platelet assays repeated. Patients were divided based on VerifyNow P2Y12 reaction units (PRU). Group 1: HPR defined as PRU ≥208 and Group 2: Appropriate platelet inhibition (API), PRU <208. RESULTS After two weeks of uninterrupted antiplatelet therapy, mean PRU results were 173 PRU and 71 PRU at baseline (p<0.0001) and 140 PRU and 63 PRU after 6h (p<0.0001) for clopidogrel and ticagrelor, respectively. Before daily clopidogrel dose, 36% of patients (n=18) demonstrated HPR and after 6h, 30% (n=15). One patient (2%) had HPR on ticagrelor. Ninety-four percent of patients with HPR on clopidogrel demonstrated appropriate platelet inhibition after switching to ticagrelor and all patients with API on clopidogrel remained with API after switching to ticagrelor. Six hours after daily dosing, VASP-PRI >50% was found in 42% of clopidogrel and 2% of ticagrelor treated patients. CONCLUSIONS Among patients with CLI, ticagrelor achieved greater platelet inhibition than clopidogrel during maintenance treatment and at 6h after daily dosing. High on-treatment platelet reactivity to clopidogrel in patients with CLI can be overcome by switching to ticagrelor.