Javier Valle

Current Endovascular Management of Acute Limb Ischemia

Acute limb ischemia is a vascular emergency, threatening the viability of the affected limb and requiring immediate recognition and treatment. Even with revascularization of the affected extremity, acute limb ischemia is associated with significant morbidity and mortality resulting in up to a 15% risk of amputation during the initial hospitalization and a 1 in 5 risk of mortality within 1xa0year of the index event. This review summarizes the current management of acute limb ischemia. Understanding the diagnosis and therapeutic options will aid clinicians in treating these critically ill patients.

Guideline Recommended Medical Therapy for Cardiovascular Diseases in the Obese: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program

Background Stigma against the obese is well described in health care and may contribute to disparities in medical decision‐making. It is unknown whether similar disparity exists for obese patients in cardiovascular care. We evaluated the association between body mass index (BMI) and prescription of guideline‐recommended medications in patients undergoing elective percutaneous coronary intervention. Methods and Results Using data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program, we identified patients undergoing elective percutaneous coronary intervention from 2007 to 2012, stratifying them by category of BMI. We described rates of prescription for class I guideline recommended medications for each BMI category (normal, overweight, and obese). Multivariable logistic regression assessed the association between BMI category and medication prescription. Seventeen thousand thirty‐seven patients were identified, with 35.3% having overweight BMI, and 50.8% obese BMI. Obese patients were more likely than normal BMI patients to be prescribed β‐blockers (OR 1.34), statins (OR 1.39), or ACE/ARB (odds ratio [OR] 1.52; all significant) when indicated. Overweight patients were more likely than normal BMI patients to be prescribed statins (OR 1.29) and angiotensin‐converting enzymes/angiotensin II receptor blockers (OR 1.41) when indicated. There was no association between BMI category and prescription of anticoagulants. Conclusions Over 85% of patients undergoing elective percutaneous coronary intervention in the Veterans Affairs are overweight or obese. Rates of guideline‐indicated medication prescription were <70% among all patients, and across BMI categories, with an association between increased BMI and greater use of guideline‐recommended medications. Our findings offer a possible contribution to the obesity paradox seen in many cardiovascular conditions.

Variation in practice regarding pretreatment with dual antiplatelet therapy for patients with non–ST elevation myocardial infarction

Background Despite guideline recommendations, a significant number of patients with non–ST elevation myocardial infarction (NSTEMI) do not receive dual antiplatelet therapy (DAPT) before angiography “pretreatment.” While there may be valid clinical reasons to not pretreat, such as concern for bleeding or multivessel disease warranting coronary artery bypass graft surgery, the degree of variability and factors associated with DAPT pretreatment are unknown. Methods and Results From the multicenter TRIUMPH registry, 1632 NSTEMI patients were not taking DAPT on admission and were included in the study cohort. Among the study patients, only 22% patients received DAPT pretreatment. A multivariable logistic regression model showed that race other than white or black (odds ratio [OR] 0.41, 95% CI 0.21–0.83), hemoglobin level (OR 1.18, 95% CI 1.08–1.29), patients’ bleeding risk (assessed with NCDR CathPCI Bleeding Risk Score) (OR 0.85, 95% CI 0.74–0.99), and severe left ventricular dysfunction (OR 0.3, 95% CI 0.13–0.65) were the main predictors of pretreatment with DAPT, whereas likelihood of needing coronary artery bypass graft surgery (GRACE prediction model) was not (OR 1.09, 95% CI 0.88–1.35). Median ORs were calculated to assess variability of receiving DAPT pretreatment across sites after adjustment for patient characteristics. Receiving DAPT pretreatment varied substantially across sites (range 0–100%, mean OR 3.94, P<0.0001). Conclusions While deviating from guideline‐recommended DAPT pretreatment in patients with NSTEMI was associated with patient factors (eg, bleeding risk), marked variation was present across sites after accounting for patient‐level characteristics. This suggests that site‐level interventions are needed to improve concordance with current guidelines.

Medication Adherence in Secondary Prevention Post-Myocardial Infarction

Opinion statementNonadherence to cardiovascular medications is common and has been associated with adverse outcomes. Patient adherence to medications is complex, with multiple factors contributing to the development of nonadherence, and these factors likely evolve over time. Significant efforts have gone into identifying factors that impact patient adherence, including patient, physician, and social/environmental factors. To date, various efforts to improve medication adherence have demonstrated modest results. The most successful interventions have addressed multiple potential reasons for nonadherence, suggesting that an adaptive approach with interventions that are flexible and can address patient-specific needs is important. Future research should be aimed at the development of an adaptive set of tools to identify and address evolving patient barriers to adherence.