tbuckley/cabot-search huggingface dataset:
Abstract 15831: Characterization of Patient-Specific Care Pathways in Cardiogenic Shock
Authors: Amit Saha, Hadi Beaini, Sarah Godfrey, Eric J Hall, Lauren K Truby, Nicholas S Hendren, Jennifer T Thibodeau, Elizabeth A Hardin, Faris G Araj, Hurst M Hall, Justin L Grodin, Mark H Drazner, Maryjane A Farr
Journal: Circulation (2023)

Background: Heterogeneity in patient characteristics and clinical severity may affect treatment goals and associated management in cardiogenic shock (CS). We sought to better describe the development over time of specific care pathways and the associated patient phenotypes informing such decisions in CS. Methods: We consented and prospectively enrolled 60 patients presenting with CS from November 2022 to May 2023. Provider notes were reviewed for language describing 3 distinct care pathways: Advanced Group (AG): urgent evaluation for left ventricular assist device and/or heart transplantation; Recovery Group (RG): eligible for native myocardial recovery only; and Palliation Group (PG): unlikely to recover. Remaining patients were classified as No Decision (ND). Pathway decisions were assessed at days 3 and 7. Results: Median cohort age was 59 years (IQR 42-66), and 67% (n = 40) were men. Initial SCAI stages D and E comprised 63% (n = 38) of cases. By hospital days 3 and 7, care pathways were defined in 11 (18%) and 36 (60%) patients, respectively ( Figure ). There were no ND deaths before day 7. Patient characteristics were similar regardless of whether a pathway was specified by day 7. Across care pathways, recovery options decreased with increased age (AG 45, RG 53, PG 66 years; p = 0.037) and new dialysis requirement (AG 0%, RG 36% [n = 5], PG 56% [n = 5]; p = 0.007). Initial SCAI stage, CS etiology (AMI 20% [n = 12], HF 58% [n = 35]), rate of shock team activation (15% [n = 9]), and mechanical circulatory support use (43% [n = 26]) were numerically similar. Palliative care was involved in 78% (n = 47) of cases overall and in all PG cases. In-hospital mortality was 29% (n = 16) and was highest in PG (88.9% [n = 8], p &lt;0.0001). Conclusion: Even after 7 days in an intensive care unit at an academic medical center, 40% of patients with CS did not have a care pathway defined. These data suggest that structured interventions to expedite such decision-making should be tested to improve care in patients with CS.
Abstract 14814: Predictors and Outcomes of Extracorporeal Membrane Oxygenation in COVID-19 Patients With Acute Respiratory Distress Syndrome: A Propensity-Matched National Analysis
Authors: Shafaqat Ali, Lalitsiri Atti, Saliha Erdem, Bilal Hussain, Sanchit Duhan, Neel N Patel, Amro Taha, Faryal Farooq, Karthik Gonuguntla, Fnu Raheela, yasar sattar, M Chadi C Alraies
Journal: Circulation (2023)

Background: The current data is limited for understanding extracorporeal membrane oxygenation (ECMO) indicators and outcomes in COVID-19 patients with acute respiratory distress syndrome (ARDS). Methods: The National In-patient Sample (NIS) database from 2020 was queried to identify COVID-19 patients with ARDS who received endotracheal intubation and further divided into ECMO and Non-ECMO subgroups. Multivariate regression analysis and propensity score matching (PSM) were done to compare outcomes among both cohorts. Results: Among 1,666,960 patients (weighted) admitted with COVID-19, 99,785 (5.98%) patients developed acute respiratory distress syndrome (ARDS), and 60,114 (60.2%) were placed on mechanical ventilation. Of these mechanically ventilated COVID-ARDS, 2580 patients (4.3%) were placed on ECMO. Patients with ECMO intervention had higher adjusted odds of blood loss anemia (aOR 9.1, 95% CI: 6.16 - 13.5, PSM 42% vs. 5.4%, P&lt;0.001), major bleeding (aOR 3.79, 95% CI: 2.5 - 5.6, PSM 19.9% vs. 5.9%, P&lt;0.001) and acute liver injury (aOR 1.7, 95% CI: 1.14 - 2.6 PSM 14% vs. 6%, P = 0.009) compared to patients without ECMO intervention. However, in-hospital mortality, acute kidney injury, and cardiac arrest were insignificant. Patients on ECMO had longer hospital stays and higher total costs of hospitalization. Patients placed on venoarterial-ECMO had higher odds of cardiogenic shock (aOR 13.4, CI 3.95 to 46, P&lt;0.001), cardiac arrest (aOR 3.5, CI 1.45 to 8.47, P = 0.005), acute heart failure (aOR 4.18, CI 1.05 to 16.5, P = 0.042) and lower odds of major bleeding (aOR 0.26, CI 0.07 to 0.92) than venovenous-ECMO. Conclusion: Mechanically intubated COVID-19 ARDS patients placed on ECMO had no significant difference in mortality. Despite being younger, they had higher rates of in-patient blood loss anemia, major bleeding, and acute liver injury. Resources utilization was significantly higher for the ECMO subgroup. ECMO.
Abstract 13611: Right Ventricular Perforation and Subsequent Tamponade Due to Fractured Inferior Vena Cava Filter Strut
Authors: Andrei Minciunescu, Raghav Gattani, Joseph M kiernan, Ibrahim Saeed, Tariq M Haddad, Liam Ryan, Edward Howard
Journal: Circulation (2023)

Description of Case: A 39-year-old woman with a remote history of unprovoked pulmonary embolism (PE) treated with a retrievable inferior vena cava (IVC) filter presented with chest pain and syncope. Initial vital signs and examination were unremarkable. ECG showed diffuse ST elevations with PR depression consistent with acute pericarditis (Figure 1A). Given her history, CT angiogram (CTA) was performed and revealed complex pericardial effusion without PE. Echocardiogram confirmed large pericardial effusion with evidence of right ventricular diastolic collapse, raising concern for impending cardiac tamponade (Figure 1B). Urgent pericardiocentesis yielded 500 mL of sanguineous fluid, with resolution of effusion. A pericardial drain was left in place. Overnight she became hypotensive, tachycardic, diaphoretic, with muffled heart sounds on exam. Rapid re-accumulation of blood was noted from the drain, confirmed by repeat echo showing enlargement of the pericardial effusion. She was diagnosed with recurrent hemorrhagic pericardial effusion (HPE) of unclear etiology and was emergently taken for mediastinal exploration, where a metal shard measuring 2.2 cm was seen protruding though the RV (Figure 1C), confirmed on intraoperative TEE (Figure 1D). It was determined that a fractured IVC filter strut had migrated into the RV causing perforation and recurrent HPE. The strut was removed and RV defect patched. The patient did well post-operatively without effusion recurrence. Follow up CTA confirmed fractured IVC filter strut, with another filter strut also seen extending through the IVC wall (Figure E). Discussion: Rapid reaccumulation of a hemorrhagic, hemodynamically significant pericardial effusion without clear etiology, as in this case, should prompt consideration of surgical exploration to assess for bleeding source. As strut fractures are a known complication of retrievable IVC filters, these filters should be removed when no longer indicated.
Abstract 17755: Post-Cardiac Injury Syndrome From Robotic Atrial Septal Defect Closure: A Case of Recurrent Pericarditis
Authors: Zachary S Yaker, Alveena B Syed, Aqieda Bayat, Ushasi Saraswati, Ambreen F Ali, Tiffany Dong, Vineet Tornekar, Allan L Klein
Journal: Circulation (2023)

Case Presentation: A 23-year-old female rugby player presented for recurrent chest pain. She has a history of atrial septal defect (ASD) repaired with robotic ASD closure. She developed acute pericarditis postoperatively and was treated with naproxen and colchicine inpatient. Her subsequent recurrences occurred with playing rugby and were treated with ibuprofen, colchicine, and prednisone. Electrocardiogram showed sinus bradycardia at 59 beats per minute but without ST segment changes. Cardiac magnetic resonance (CMR) imaging showed mild-to-moderate circumferential pericardial late gadolinium enhancement (LGE) without signal hyperintensity on T2 STIR imaging. She was diagnosed with chronic recurrent pericarditis secondary to post-cardiac injury syndrome (PCIS) and was started on rilonacept. On follow-up after 1 year, the patient remained symptom-free. She gradually increased her activity level to walking 3 miles per day and weaned down to rilonacept monotherapy. Repeat CMR showed mild pericardial LGE that was improved from before. Discussion: PCIS is a known cause of pericarditis due to local and systemic inflammatory responses to cardiothoracic surgery. Robotic ASD closure is a minimally invasive endoscopic procedure that has a favorable safety profile; PCIS is not a previously documented complication. Treatment of pericarditis secondary to PCIS includes NSAIDs plus 3 months of colchicine for acute pericarditis, NSAIDs plus 6 months of colchicine for a first recurrence, with corticosteroids or interleukin-1 inhibitors added for further recurrences. Incomplete treatment of acute pericarditis, as in this patient's case, is a risk factor for recurrent pericarditis. The risk of recurrences with physical activity is debated and current guidelines recommend restriction from physical activity until there is no evidence of active disease, though the data is not robust. In clinical practice, a gradual return-to-play program is frequently utilized.
Abstract 12764: Reduced EF With Mavacamten Initiation in a Patient With Atrial Fibrillation: A Case Report
Authors: Nidhi Patel, B Robinson Williams
Journal: Circulation (2023)

Description of Case: A 55-year-old male with a history of paroxysmal atrial fibrillation (AF) and hypertrophic cardiomyopathy (HCM) diagnosed three years prior at an outside institution presented to clinic with exertional dyspnea. Baseline TTE confirmed HCM demonstrating an EF of 69%, mitral systolic anterior motion (SAM), left ventricular outflow tract (LVOT) obstruction, and a peak gradient exceeding 100 mmHg. Initiation of mavacamten 5mg resulted in symptom improvement and a one-month follow-up TTE demonstrating a reduced peak gradient of 74 mmHg and normal EF. However, two months after initiation the patient returned with AF with rapid ventricular response (RVR) and TTE showed a newly reduced EF of 21%. Mavacamten was stopped while home metoprolol XL was increased from 100 to 150 mg daily for rate optimization. Holter monitoring showed a 100% Afib burden with an average heart rate of 108 beats per minute. Stopping mavacamten for four weeks resulted in worsening exertional dyspnea but restoration of EF to 52% on TTE. Mavacamten was reinstated at a lower dose of 2.5 mg, resulting in symptom improvement. Monthly TTE exams over four months consistently demonstrated a normal EF without LVOT obstruction at rest. Discussion: Mavacamten, a promising drug used to treat obstructive HCM, modulates myosin to reduce myosin-actin cross-bridging. Reduction in contractility improves mitral SAM, LVOT obstruction, and symptoms. However, because mavacamten is a negative inotrope it can also precipitate reductions in EF. Generally, patients have a mild drop in EF (~5 points) after initiation. However, our patient had a significant EF drop of over 25 points likely due to both mavacamten initiation and new AF with RVR reducing systolic function. Discontinuation of mavacamten for four weeks and rate optimization likely restored EF. Dose reduced re-initiation of mavacamten resulted in long-term normal EF and improvement in symptoms. This case highlights the need for close monitoring and individualized mavacamten treatment plans. Further research is warranted to understand the interplay and long term outcomes of tachyarrhythmias and mavacamten use.
Abstract 15592: Artificial Intelligence-Derived Left Ventricular Global Longitudinal Strain is Associated More Strongly With All-Cause Mortality Than is Speckle Tracking Echocardiography-Derived Strain in a Cohort of Cardio-Oncology Patients
Authors: Sojin Youn Wass, Herman Carneiro, Tabitha Lobo, Willington Amutuhaire, Nour Tashtish, Robert Okyere, Sadeer Al-Kindi, Brian Hoit
Journal: Circulation (2023)

Introduction: Myocardial strain, a marker of heart muscle deformation, is crucial for assessing cardiac function and prognosis in cardiovascular diseases. Speckle Tracking Echocardiography (STE) is the preferred non-invasive method for strain. However, STE's accuracy can vary due to image quality, vendor-dependence, and operator inconsistency. STE-derived Global Longitudinal Strain (manual GLS) changes are key in early detection of cancer treatment-related cardiotoxicity. Hypothesis: We hypothesized that AI-derived GLS would have a stronger correlation with all-cause mortality (ACM) than STE-derived GLS. Methods: We retrospectively analyzed 1,224 echocardiograms, from 762 patients, with STE GLS values from Harrington Heart and Vascular Institute Cardio-Oncology studies performed between Jan 2021 - Jun 2022. Images were analyzed using EchoGo Core (Ultromics Ltd), a cloud-based, AI-powered software employing convolutional neural networks. Pearson's correlation coefficients and Bland-Altman analysis compared STE and AI-derived GLS (R-Studio). Both methods were evaluated using Receiver Operating Characteristic (ROC) curves. Patients were divided into tertiles based on their GLS values to assess ACM hazard ratios (HR). Results: Out of 762 patients, a moderate correlation (r=0.63, p&lt;0.001) existed between STE and AI-derived GLS. The mean difference between the two was 2.37 and the limits of agreement were -3.65 to 8.39. The Area Under the Curve (AUC) was higher for AI (0.66) than STE GLS (0.59). Over an average follow-up of 215 days (± 169 days), 26 deaths occurred. When Tertile 3 was compared to Tertile 1, AI-derived GLS showed an HR of 4.46 (p=0.023), whereas the STE GLS HR was not statistically significant (HR=2.4). Conclusions: The study showed moderate agreement between AI and manual GLS measurements. The HR for ACM was statistically significant only in AI-derived GLS in patients undergoing cardiotoxic chemotherapy.
Abstract 14547: Genetically Predicted Inhibition of HMG-CoA Reductase Reduces Risk of <i>DNMT3A</i> Clonal Hematopoiesis
Authors: Paul R Carter, Malgorzata Gozdecka, Pedro Quirós, Samuel M Lockhart, Victoria Gray, George Richenberg, Carina Owen, Joop Jansen, Maaike van Bergen, Susanna Larsson, Brian Huntly, Peter Libby, Murray C Clarke, George Vassiliou, Stephen Burgess, Siddhartha Kar
Journal: Circulation (2023)

Introduction: Clonal hematopoiesis (CH) is associated with increased morbidity and mortality from cancer and cardiovascular diseases including heart failure and ischemic heart disease. At present no medications are known to protect from CH. However, leukemia cells with equivalent mutations show sensitivity to statin-induced cell death. Aims: To evaluate the association of LDL-C lowering genetic variants at HMGCR (the target of statins) with CH risk using two-sample Mendelian randomization. Methods: We investigated whether lower LDL-C genetically predicted by 6 variants at HMGCR associates with CH risk. Secondary exposures included a polygenic instrument of 74 LDL-C-lowering genome-wide variants. Genetic associations for LDL-C derived from a genome-wide association study (GWAS) meta-analysis of circulating LDL-C levels by the Global Lipid Genetics Consortium (N≤188,578 individuals of European ancestry). Outcome associations for CH were from a GWAS in 368,526 European individuals in UK Biobank. Results: Genetically predicted reduction in HMG-CoA reductase activity equivalent to a 38.7mg/dL lower circulating LDL-C level was associated with reduced odds of overall CH (OR 0.75, 95% CI 0.58-0.97, P = 0.027) or DNMT3A CH (OR 0.64, 95% CI 0.48-0.86, P = 0.003) but not TET2 CH (OR 1.12, 95% CI 0.63-2.00, P = 0.70). Associations were consistent across all 6 HMGCR variants in sensitivity analyses. Co-localization plots showed evidence of co-localization of LDL-C with DNMT3A CH and overall CH at the HMGCR locus. Associations were stronger for CH with variant allele fraction ≥10%, and, statins suppressed colony formation of mutant DNMT3A cells in vitro , suggesting statins may limit clonal expansion. In a secondary analysis to explore LDL-C dependence, LDL-C lowering predicted by the polygenic instrument did not associate with overall or DNMT3A CH but associated with increased odds of TET2 CH (OR 1.13, 95% CI 1.01-1.27, P = 0.03). Findings were replicated in a non-European cohort. Conclusions: Genetically predicted lifelong reduction of HMG-CoA reductase activity was associated with reduced risk of overall and DNMT3A -mutant CH, likely by LDL-C-independent mechanisms. This provides a strong rationale for clinical trials testing the effects of statins in CH.
Abstract 19203: Predictors of Mortality Among Patients Admitted With Both Acute Myocardial Infarction and Non-Alcoholic Fatty Liver Disease
Authors: CYRUS MUNGUTI, Umar Hayat, Abhiram Challa, Stephen Wanjala, Ahmad Mahdi, Tariq Ali Ahmad
Journal: Circulation (2023)

Introduction: Non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular disease (CVD). Indeed, cardiovascular disease is the most common cause of death among NAFLD patients We aimed to assess the association between NAFLD and mortality due to acute myocardial infarction and the predictors of in-hospital mortality among patients with both diagnosis in the USA. Methods: Hospitalizations with AMI with a concurrent diagnosis of NAFLD were identified in the National Inpatient Sample (2016-2019) using ICD-10 codes. The prevalence and trends over four years were calculated among different sociodemographic groups. Regression model was used to determine mortality outcomes due to AMI among NAFLD patients by age, race, and gender. A multivariable regression analysis was done to determine NAFLD as an independent predictor of mortality. Results: A total of 5450 patients were hospitalized with concurrent diagnosis of AMI and NAFLD during the study period. Among them, 5.11% (279) died in the hospital. Males were more likely to die compared to the females [OR 1.58, 95% CI 1.25-1.91]. Also, patients &gt; 50 had higher odds of dying due to AMI if they had NAFLD compared to those &lt;50 [OR 4.29, 95% CI 2.94-6.27]. Compared with the white population, Blacks [OR 0.79, 95% CI 0.54-1.15, p &lt;0.001] Hispanics [OR 1.21, 95% CI 0.85-1.74, p &lt;0.001], Asian and Pacific Islanders [OR 0.95, 95% CI 0.45-2.03, p &lt;0.001], and Native Americans [OR 0.58, 95% CI 0.08-4.17, p &lt;0.001] are less likely to die due to AMI if they have NAFLD. The NAFLD patients had higher odds of dying if they were admitted to the hospital with AMI [OR 1.96, 95% CI 1.74-2.21, p &lt;0.001]. Conclusion: Elderly white males with NAFLD are more likely to die if they are admitted to the hospital due to AMI. NAFLD was found to be an independent predictor of death among patients who had AMI.
Abstract 14112: Reproductive Risk Factors and Pulmonary Arterial Hypertension in Women
Authors: Jessica Badlam, David Badesch, raymond Benza, Peter Callas, Wendy Chung, Greg Elliott, Hap Farber, Adaani Frost, Bill Nichols, Michael Pauciulo, Abby Poms, Renee Stapleton, Chang Yu, Eric D Austin
Journal: Circulation (2023)

Introduction: Pulmonary arterial hypertension (PAH) is a devastating disease that affects women more often than men. The female predominance has increased over time; recent U.S. cohorts demonstrate a female:male ratio of nearly 4:1. The role of women-specific risk, such as reproductive exposures, is poorly understood in the pathophysiology of PAH. Hypothesis/Goals: We hypothesize that reproductive exposures influence the development and/or severity of PAH in women. We sought to investigate the role of reproductive factors and contribution of exogenous estrogen exposures to PAH onset and severity. Methods: Using reproductive history/exposure questionnaires from 390 women with PAH, enrolled in both the PAH Biobank and United States Pulmonary Hypertension Scientific Registry, we conducted linear regression analyses to assess the association between individual disease severity variables, as well as REVEAL Lite 2.0 scores, and patient reported reproductive variables as the predictors (Table 1). We adjusted for potential confounders including age, race, BMI, and PAH sub-group (idiopathic, heritable, or associated). Results: We found that younger menopause age, less than or equal to 40 years old, associates with a lower cardiac index (CI) at diagnosis [β -0.57, p 0.02]. The association persisted when controlling for use of hormone replacement therapy (HRT). There was a trend toward lower CI in those with menopause age of 41 to 50 years old, but not statistically significant [p 0.10]. Ever use of HRT was associated with a higher pulmonary vascular resistance [β 1.6, p 0.05] and lower CI [β -0.28, p 0.01] at diagnosis. Conclusion: Premature menopause (age less than 40 years) and ever use of HRT associate with worse hemodynamics at diagnosis in women with PAH, including lower cardiac index. Further investigations into reproductive exposures may offer an opportunity for more comprehensive risk factor screening and modification by physicians treating PAH patients.
Abstract 18801: Impact of COVID-19 Pandemic on Cardiovascular Diseases Hospitalisation, Management and Mortality in Brazil
Authors: Antonio A Fagundes, Luiz Passaglia, Pedro Pinheiro, Bruno R Nascimento, Luisa C Brant, Antonio L Ribeiro
Journal: Circulation (2023)

Introduction: The COVID-19 pandemic led to a reduction in cardiovascular (CVD) hospital admissions in many countries. We aimed to assess the effect of the COVID-19 pandemic on CVD hospitalizations, management, and mortality in Brazil. Methods: Hospitalization data for the years 2020 and 2021 for Brazil and regions were analyzed using the Datasus hospital admission system. We analyzed the number of hospitalizations, the number and proportion of intensive care unit (ICU) utilization, and the number and proportion of in-hospital deaths. The observed data were compared to the average of the previous three years (2017 to 2019). Absolute differences and risk ratios (RR) were calculated, with the RR obtained by dividing the observed values by the expected ones for each period studied. Results: There was a reduction in CVD hospital admissions, with 184,727 (95% CI 157,579 to 211,876) fewer hospitalizations than expected, representing a decrease of 16.2% (RR 0.838; 95% CI 0.836-0.839). There were two valleys of reduction in CVD hospitalizations, the first before the first peak of Covid-19 hospitalizations and the second simultaneous to the second peak of Covid-19 hospitalizations in 2021. There was a 9% decrease in the absolute number of CVD admissions in the ICU (RR 0.910; 95% CI 0.907-0.912), associated with a 4.7% absolute decrease in the number of CVD admissions that resulted in in-hospital deaths (RR 0.953; 95% CI 0.949-0.957). However, there was an 8.6% increase in the proportion of ICU admissions due to CVD (RR 1.086; 95% CI 1.084-1.088) and a significant increase of 14.4% in the proportion of admissions due to CVD that resulted in in-hospital death. Conclusions: Brazil′s data reveal that the Covid-19 pandemic reduced the number of CVD hospitalizations, but with a higher proportion of ICU use and higher in-hospital mortality.