Kevin J. Graham

Epidemiology of Hypertrophic Cardiomyopathy–Related Death Revisited in a Large Non–Referral-Based Patient Population

BACKGROUND Death resulting from hypertrophic cardiomyopathy (HCM), particularly when sudden, has been reported to be largely confined to young persons. These data emanated from tertiary HCM centers with highly selected referral patterns skewed toward high-risk patients. METHODS AND RESULTS The present analysis was undertaken in an international population of 744 consecutively enrolled and largely unselected patients more representative of the overall HCM spectrum. HCM-related death occurred in 86 patients (12%) over 8+/-7 years (mean+/-SD). Three distinctive modes of death were as follows: (1) sudden and unexpected (51%; age, 45+/-20 years); (2) progressive heart failure (36%; age, 56+/-19 years); and (3) HCM-related stroke associated with atrial fibrillation (13%; age, 73+/-14 years). Sudden death was most common in young patients, whereas heart failure- and stroke-related deaths occurred more frequently in midlife and beyond. However, neither sudden nor heart failure-related death showed a statistically significant, disproportionate age distribution (P=0.06 and 0.5, respectively). Stroke-related deaths did occur disproportionately in older patients (P=0.002). Of the 45 patients who died suddenly, most (71%) had no or mild symptoms, and 7 (16%) participated in moderate to severe physical activities at the time of death. CONCLUSIONS HCM-related cardiovascular death occurred suddenly, or as a result of heart failure or stroke, largely during different phases of life in a prospectively assembled, regionally based, and predominantly unselected patient cohort. Although most sudden deaths occurred in adolescents and young adults, such catastrophes were not confined to patients of these ages and extended to later phases of life. This revised clinical profile suggests that generally held epidemiological tenants for HCM have been influenced considerably by skewed reporting from highly selected populations. These data are likely to importantly affect risk stratification and treatment strategies importantly for the prevention of sudden death in HCM.

A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Background— Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior to fibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. Methods and Results— We developed a standardized PCI-based treatment system for STEMI patients from 30 hospitals up to 210 miles from a PCI center. From March 2003 to November 2006, 1345 consecutive STEMI patients were treated, including 1048 patients transferred from non-PCI hospitals. The median first door-to-balloon time for patients <60 miles (zone 1) and 60 to 210 miles (zone 2) from the PCI center was 95 minutes (25th and 75th percentiles, 82 and 116 minutes) and 120 minutes (25th and 75th percentiles, 100 and 145 minutes), respectively. Despite the high-risk unselected patient population (cardiogenic shock, 12.3%; cardiac arrest, 10.8%; and elderly [≥80 years of age], 14.6%), in-hospital mortality was 4.2%, and median length of stay was 3 days. Conclusions— Rapid transfer of STEMI patients from community hospitals up to 210 miles from a PCI center is safe and feasible using a standardized protocol with an integrated transfer system.

Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest Evaluation of a Regional System to Increase Access to Cooling

Background— Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results— The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non–ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non–ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions— A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA.Background— Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results— The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non–ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non–ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions— A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA. # Clinical Perspective {#article-title-40}

Multidisciplinary Standardized Care for Acute Aortic Dissection Design and Initial Outcomes of a Regional Care Model

> “No physician can diagnose a condition he never thinks about.” > > — Michael DeBakey Patients with acute aortic dissection (AAD) have an in-hospital mortality of 26%, and for those patients with type A AAD, the mortality risk is 1% to 2% per hour until emergency surgical repair is performed.1,2 It is therefore critical that AAD be recognized promptly and that surgical care be provided expeditiously. Data from the International Registry of Acute Aortic Dissection (IRAD) indicate that the median time from emergency department (ED) presentation to definitive diagnosis of AAD is 4.3 hours, with an additional 4 hours between diagnosis and surgical intervention for type A patients.2,3 A portion of the delay to surgery is often the result of the patients presenting to smaller community hospitals underequipped to manage emergent AAD. Transfer to high-volume aortic care centers with highly specialized facilities and expertise is routine, but even at such centers, current surgical mortality is 25%.4 In an effort to address factors that delay AAD recognition and optimal management, a standardized, quality-improvement protocol for the regional treatment of AAD was developed and implemented with the goal of providing consistent, integrated, and coordinated care for patients with AAD throughout all phases of care. Modeled, in part, after a successful regional program for ST-segment elevation myocardial infarction,5, the specific aims of the program were to decrease the time from hospital arrival to diagnosis and treatment and to improve clinical outcomes for patients with AAD. A collaborative team designed program elements directed at (1) increasing awareness and knowledge of AAD among emergency care providers, (2) standardizing optimal care for AAD through the use of a formal protocol, (3) improving care coordination and communication across disciplines, and (4) providing …

Radiation following percutaneous balloon aortic valvuloplasty to prevent restenosis (RADAR pilot trial)

Objectives: We wished to determine the feasibility and early safety of external beam radiation therapy (EBRT) used following balloon aortic valvuloplasty (BAV) to prevent restenosis. Background: BAV for calcific aortic stenosis (AS) has been largely abandoned because of high restenosis rates, i.e., > 80% at 1 year. Radiation therapy is useful in preventing restenosis following vascular interventions and treating other benign noncardiovascular disorders. Methods: We conducted a 20‐patient, pilot study evaluating EBRT to prevent restenosis following BAV in elderly patients with calcific AS. Total doses ranging from 12–18 Gy were delivered in fractions over a 3–5 day post‐op period to the aortic valve. Echocardiography was performed pre and 2 days post‐op, 1, 6, and 12 months following BAV. Results: One‐year follow‐up is completed (age 89 ± 4). There were no complications related to EBRT. Eight patients died prior to 1 year; 5 of 10 (50%) in the low‐dose (12 Gy) group and 3 of 10 (30%) in the high‐dose (15–18 Gy) group. None of these 8 patients had restenosis, i.e., > 50% loss of the initial AVA gain, and only three deaths were cardiac in origin. One patient underwent aortic valve replacement and none repeated BAV. By 1 year, 3 of the initial 10 (30%) in the low‐dose group and 1 of 9 (11%) in the high‐dose group demonstrated restenosis (21% overall). Conclusions: EBRT following BAV in elderly patients with AS is feasible, free of early complications, and holds promise in reducing the 1 year restenosis rate in a dose‐dependent fashion.

Feasibility of transcatheter intervention for severe aortic stenosis in patients ≥90 years of age: Aortic valvuloplasty revisited

The goals of this study were to determine the feasibility, safety, and early outcomes of balloon aortic valvuloplasty (BAV) for severe aortic stenosis in a nonagenarian population.

The heart of new ulm: a vision for the future.

Coronary artery disease (CAD) continues to be a leading cause of death in the USA and throughout the world. Allina Health System, with the Minneapolis Heart Institute at Abbott Northwestern, recently announced a long-term study in the city of New Ulm, MN, to reduce risk factors for myocardial infarction and, ultimately, reduce myocardial infarction incidence. To achieve this goal, the focus will be on health promotion interventions and primary and secondary prevention strategies for CAD that are innovative, community-wide, and able to impact individuals at home, at work, in their community, and in their health care settings. Factors considered in selecting this city included the identification of health as a priority by the community, readiness and willingness of the community to change, the ability to provide and deliver systematic care, and partnerships established across multiple disciplines and sectors centered on improved health. The following stakeholders will be engaged: the community, employers, public health, health care, and health plans. Unique aspects of the intervention include centralized healthcare, including an automated medical record; genetic testing; integrated behavioral interventions; social environmental change and social circumstances; health promotion, primary prevention and secondary prevention interventions; advanced diagnostics and imaging; and state-of-the-art therapy.

Has the Time Come for a National Cardiovascular Emergency Care System

In 2007, there were ≈4 million visits to emergency departments in the United States with a primary diagnosis of cardiovascular disease.1 Current forecasts estimate that the direct medical costs for cardiovascular disease in the United States will triple by 2030 to

The Heart of New Ulm Project: Using Community-Based Cardiometabolic Risk Factor Screenings in a Rural Population Health Improvement Initiative

800 billion dollars.2 Acute cardiovascular emergencies, including ST-segment–elevation myocardial infarction (STEMI), non-STEMI/unstable angina, out-of-hospital cardiac arrest (OHCA), acute aortic dissection (AAD), abdominal aortic aneurysm (AAA), stroke, and acute decompensated heart failure/cardiogenic shock, require rapid, complex, and resource-intensive care and confer a high risk of mortality. Regionalized systems of care enable patients with complex and urgent medical needs to be systematically directed to hospitals that can provide the highest level of clinical expertise and resources (ie, designated centers). Historically, trauma systems have used this paradigm with improved outcomes. There is a growing focus on regionalized medical care as a strategy to leverage limited resources, to manage cost, and to improve outcomes for other medical emergencies. National cardiovascular organizations have already published recommendations for the establishment of centers and regional systems of care for STEMI,3–6 cardiac arrest,7–9 and stroke.10,11 The purpose of this article is to propose the concept of a cardiovascular emergency system, ie, a comprehensive regional system of care for cardiovascular emergencies led by a designated cardiovascular emergency receiving center. Over the past decade, the Minneapolis Heart Institute at Abbott Northwestern Hospital (MHI-ANW) has implemented regional systems of care for STEMI,12 OHCA,13 AAD,14 non-STEMI, and AAA. These initiatives provide a demonstration of the clinical programs and supportive network that reflect the burgeoning framework of a cardiovascular emergency system. Informed by this work, we discuss the historical perspective of, rationale for, and proposed principal elements of a cardiovascular emergency system. Trauma systems are the prototype for …

Underuse of cardiovascular preventive pharmacotherapy in patients presenting with ST-elevation myocardial infarction

Awareness of cardiovascular disease and diabetes risk factors can improve the health of individuals and populations. Community-based risk factor screening programs may be particularly useful for quantifying the burden of cardiometabolic risk in a given population, particularly in underserved areas. This study provided a description of a screening platform and how it has been used to monitor the cardiometabolic risk profile within the broader Heart of New Ulm Project, which is based in a rural Minnesota community. A cross-sectional, descriptive examination of baseline screening data indicated that 45% of the target population participated in the program over 8 months. Overall, 13% of the sample reported a personal history of diabetes or cardiovascular disease. Among the subset without active cardiometabolic disease, 35% were found to be at high risk for developing cardiovascular disease or type 2 diabetes over the next 8-10 years. A high prevalence of metabolic syndrome, high low-density lipoprotein cholesterol, obesity, and low fruit/vegetable consumption were of particular concern in this community. This article describes the use of screening results to inform the design of intervention programs that target these risk factors at both the community and individual levels. In addition, design considerations for future community-based cardiometabolic risk factor screening programs are discussed, with a focus on balancing program objectives related to health surveillance, research, and the delivery of preventive health care services.