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**Abstract:**



AMA Research Challenge 2023

Primary Care Intervention Improves Hypertension Outcomes in Urban Indian Slums

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Nocturia, defined as waking to void during the hours of intended sleep, is a prevalent urologic complaint associated with non-urological conditions in both sexes. Hypertension (HTN) is among the most common associated condition in adults. Accordingly, nocturia has been proposed as a useful method to screen for HTN. Although nocturia is common in children, the relationship between blood pressure (BP) and nocturia has not been studied in the pediatric population. The objectives of this study were to determine the relation between HTN and nocturia in adolescents and to compare self-reported frequency to nocturnal voiding-diary frequencies. 100 patients aged 10-18 years were recruited. Demographic data and conventional BPs were measured. BP elevation and HTN stages were determined according to American Academy of Pediatrics height and sex-based tables. Urine collection containers were provided along with standardized nocturnal voiding diary that include times and volumes of urination voids. Voiding-diary data were collected via follow-up phone-call. Nocturia was predefined as >1 voids recorded by voiding diary. Univariate analyses and logistic regression were used to predict the dichotomous variable of nocturia and the dichotomous variable of BP elevation. Thirty-four study participants had HTN. In patients with nocturia, 17 (37.8%) had normal BP and 28 (62.2%) had elevated BP. While 37% patients self-reported waking up to urinate, voiding diaries showed 45% had >1 voids. Self-report and voiding frequencies were significantly correlated (r=.84, p<.05). On univariate analysis, patients with BP elevation were more likely to have nocturia by voiding diary (OR 13.5, 95% CI: 4.8, 38.1) and by self-report (OR 7.1, 95% CI: 3.2, 16.0). On multivariate analysis after adjusting for sex and obesity, the ORs increased (OR 26.2, 95% CI: 6.5, 106.0). Patient with nocturia were more likely to have BP elevation by voiding diary (OR 13.3, CI 4.8, 13.1) and by self-report (OR 11.3, 95% CI: 2.8, 45.4). On multivariate analysis, the likelihood of having BP elevation increased by voiding diary (OR 26.3, 6.5, 106.4) after adjusting for sex and obesity, whereas it was unchanged for nocturia by self-report (OR 8.1,95% CI: 3.2, 20.5). Our data suggest nocturia is common and is strongly related to BP elevation in adolescents. Since there is much lower prevalence of comorbid conditions such as diabetes, urological conditions, and congestive heart failure that are known to cause nocturia in adolescents as compared to adults, fewer confounding variables would strengthen the magnitude of the BP and nocturia link. Self-reported and voiding frequencies were also found to be significantly correlated. The prevalence of nocturia may also be underestimated in the pediatric population. Study findings suggest that history of nocturia can be an inexpensive and simple method of identifying adolescents at higher risk of having HTN.

Relation Between Nocturia and Blood Pressure Elevation in Adolescents

Background: While abnormalities in cardiac, respiratory, and autonomic function are each associated with seizures and sudden death, there is a great need for the development of a robust recording system to capture the concordance between these multi-system changes. Rare episodic health events are often not captured during inpatient hospital stays and require geographic and financial access. This barrier can result in inconclusive or delayed diagnosis and inappropriate treatments. The Equivital Eq02+ Life Monitor vest includes 2 ECG leads, strain gauge for respiratory amplitude/frequency monitoring, 3-axis accelerometry, temperature, and SpO2 plethysmography. It provides a potential out-of-hospital tool to capture rare health events and simultaneous multi-system parameters. We aimed to develop a protocol that optimized the comfort and signal quality of the vest and a Bluetooth SpO2 watch. 
Methods: Comfort levels of the vest were determined through a survey prior to the start of the study and upon completion of the study. Battery life, (re-) wetting the electrodes, fitting of the vest, and Bluetooth connectivity were all parameters that were tested to determine optimal signal quality and a protocol for fitting of the vest. 
Results: We tested the feasibility and comfort while wearing the Equivital vest in healthy adults (n=20). 80% of the subjects said they would be willing to wear the vest again, and 67% said they would be willing to wear it for ≥3 days if medically necessary. We tested the signal quality during specific physiological states and across multiple days. At each state, almost all QRS complexes were surrounded by a detected P and T wave. This enabled us to quantify standard ECG metrics of cardiac conduction and repolarization. There were no differences in signal quality when the person wore a vest that fit comfortably vs optimal fit according to the protocol. Additionally, there were no differences in signal quality when the person dampened the electrodes multiple times a day vs at the start of the study.
Conclusions: Feasibility studies indicate that the Equivital vest is comfortable and yields multi-system recordings of high signal quality. This vest may provide a future recording tool to improve access to health care and improve diagnostics.


Development of a Protocol for Multi-System Recordings Using Wearable Technology

Uncovering Subclinical Atherosclerosis: Assessing a Novel Biomarker in Low-Risk Groups

Background: Management of ventricular tachycardia (VT) in cardiac sarcoidosis (CS) can be challenging. The role of ventricular tachycardia ablation (VTA) in cardiac sarcoidosis (CS) has been investigated in small, single-center, and few large observational studies, but the evidence remains scarce.
Objective: This study aimed to investigate the clinical outcomes of VTA in CS patients admitted with a diagnosis of VT.
Methods: A retrospective analysis was conducted using the National Inpatient Sample (NIS) database from 2010 to 2020. The primary outcome was the presence of major adverse cardiovascular and cerebrovascular events (MACCE), including in-hospital mortality, acute myocardial infarction, cardiac arrest, cardiogenic shock, pericardial effusion, vascular complications, hemorrhage requiring transfusion, and ischemic stroke. Propensity score matching was used to minimize confounding effects.
Results: Out of 3,999,906 patients diagnosed with VT, 86,537 (2.2%) underwent VTA, with 1,504 (0.6%) having a secondary diagnosis of CS. In unmatched cohorts, MACCE rates were significantly lower in VTA with CS patients (14.1%) compared to VTA without CS patients (35.0%). The lower MACCE rates in CS patients were attributed to a reduced incidence of in-hospital mortality, acute myocardial infarction, and hemorrhage requiring transfusion. In the propensity-matched analysis, MACCE rates remained significantly lower for VTA in CS patients (14.1% versus 30.8% in matched cohorts).
Conclusion: VTA in CS patients presents unique management challenges. However, catheter ablation appears to be a safer adjunctive treatment modality to antiarrhythmic drugs and immunosuppressive agents in this population. 


Ventricular Tachycardia Ablation in Cardiac Sarcoidosis

Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. It is characterized by several key features, including endothelial dysfunction, the proliferation of atherosclerotic plaques, and alterations in systemic immune responses. In this pseudo-immunocompromised state, relatively ubiquitous latent bacteria and viruses may be reactivated. Up to one-third of the world’s population carries latent tuberculosis (TB), though only 10% of individuals with latent TB progress to active TB disease. Despite the substantial global burden of CVD and TB, there remains a significant research gap, as few population-based studies have systematically investigated the intricate relationship between the two.

Methods: The National Inpatient Sample (NIS) database was queried from 2012 to 2020 to identify adult TB patients. The primary outcome of this study was to determine the prevalence of CVD among patients with TB. Secondary outcomes were to determine predictors of CVD and mortality among TB patients and the incidence of the need for mechanical ventilation (MV), vasopressor use, acute kidney injury (AKI), sepsis, urinary tract infection (UTI), and transfusion.

Results: TB patients with CVD were older (65.3±0.5 VS 45.3±0.3, P<0.001), with 47.7% of these patients aged >70 years (p<0.001). There was a slightly higher percentage of male TB patients with CVD (21.67% versus 20.62%, p=0.0045). Arrhythmias (9.28%) and ischemic heart disease (8.17%) were the prevalent cardiovascular manifestations in TB patients (p<0.001). Chronic dialysis (aOR=2.16, 95%CI 1.437–3.250, p<0.001), chronic lung disease (aOR=1.77, 95%CI 1.519-2.068, p<0.001), and dyslipidemia (aOR=1.77, 95%CI 1.531-2.049, p<0.001) were the leading predictors of CVD in TB patients. Fluid and electrolyte imbalance (aOR=3.27, 95%CI 2.373-4.517, p<0.001) and coagulopathy (aOR=3.05, 95%CI 1.897-4.893, p<0.001) were the leading predictors of mortality in TB patients. CVD patients with TB had a higher risk for mortality than CVD patients without TB (aOR=6.17, 95% CI 4.255-8.949, p<0.001). CVD patients with TB also generally had a higher likelihood for in-hospital clinical outcomes such as the need for MCS, vasopressor use, sepsis, UTI, and transfusion than CVD patients without TB.

Conclusion: Overall, older age and male sex were linked with a higher prevalence of CVD among TB patients. Chronic dialysis and fluid and electrolyte imbalances were the leading predictors of CVD and mortality among TB patients, respectively. TB was linked with higher mortality risks among CVD patients and a higher likelihood of in-hospital clinical outcomes.

Tuberculosis and Cardiovascular Disease Perspectives from the National Inpatient Sample

Increased left ventricular mass has been associated with adverse cardiovascular outcomes including incident cardiomyopathy and atrial fibrillation. Such associations have been studied in relation to total left ventricular hypertrophy, although the regional distribution of myocardial hypertrophy is extremely variable and may impact clinical outcomes. The clinical significant and genetic associations of this variability require further study. Here, we use deep learning derived phenotypes of disproportionate patterns of hypertrophy, such as apical hypertrophy and septal hypertrophy, to study genome-wide and clinical associations in addition to and independent from total left ventricular mass within 35,268 UK Biobank participants. Adjusting for total left ventricular mass, apical hypertrophy is associated with elevated risk for cardiomyopathy and atrial fibrillation, and the risk for cardiomyopathy was increased for subjects with increased apical or septal mass even in the absence of global hypertrophy. We identified three unique associations with increased apical mass and three additional unique associations with increased septal mass.

Deep-learning enabled investigation of asymmetric left ventricular mass

Introduction: Left ventricular assist devices (LVADs) are a therapy for the management of end-stage heart failure. LVADs are typically managed with long-term therapeutic anticoagulation with warfarin to prevent thrombotic complications. Direct oral anticoagulants (DOACs) are easier to manage than warfarin for other medical conditions requiring therapeutic anticoagulation. There is limited data regarding DOAC safety in patients with LVADs.
Hypothesis: There is no significant difference in outcomes for patients with LVAD when on DOAC compared to warfarin.
Methods: In a single-center retrospective analysis from February 2019 to May 2023, patients with LVAD who were switched to the DOAC apixaban (due to warfarin complications or compliance problems) were compared to patients who remained on warfarin. Overall survival, number of hospitalizations, bleeding, and thrombotic complications were compared within/between groups.
Results: 72 patients were included. DOAC group vs warfarin group: n=12 vs 60, mean age = 52.5 vs 54.2 years; Male 75% vs 81.7%; black 66.7%; vs58.3%. For DOAC group, 10 out of 12 were on warfarin prior to DOAC. Of these 10, incidence rates for bleeding-related admissions were 4.2 per 1000 days on initial warfarin and 0.76 per 1000 days after switching to DOAC. Relative risk reduction of bleeding-related admissions decreased by 81.9%. In the DOAC group, thrombosis-related admissions on initial warfarin were 0, compared to 1 after switching to DOAC. When comparing DOAC and warfarin groups, there were no statistically significant differences in bleeding or thrombotic complications (HR = 0.61; 95%CI= 0.21 to 1.46; HR= 0.74;95%CI= 0.02 to 6.08, respectively) or mortality (HR = 0.44; 95%CI: 0.01 to 3.12). Incidence rates for bleeding-related admissions were 0.98 per 1000 days and 1.59 per 1000 days, for DOAC and Warfarin, respectively. Incidence rates for thrombotic-related admissions were 0.16 per 1000 days and 0.22 per 1000 days, for DOAC and Warfarin, respectively.
Conclusions: There was no statistically significant difference in bleeding, thrombotic events, or mortality in LVAD patients receiving DOAC compared to Warfarin. Switching to DOAC improved bleeding rates in LVAD patients who suffered bleeding complications with Warfarin.

Apixaban versus Warfarin for LVAD Anticoagulation

Introduction: Potentially inappropriate medications (PIMs) are defined as medications with greater potential risk than benefit in older adults. The prevalence of cardiovascular disease (CVD) is over 75% in the elderly- these patients have a host of comorbidities and are especially susceptible to polypharmacy and subsequent long-term PIM use. This study aims to examine PIM prescription in a particularly vulnerable population, older adults with CVD.

Methods: We conducted a retrospective cross-sectional study of older adults (≥65 years) admitted to a tertiary teaching hospital’s Cardiac Intensive Care Unit (CCU) and Cardiac Intermediate Care Unit (CIMU) from January 2019- April 2020. A McNemar’s chi-square test was used to assess PIM prevalence at home vs. at discharge, and a multivariable logistic regression model was used to identify demographic and clinical predictors of PIM use.

Results: We included 1296 patients from the CIMU (n=765) and CCU (n=515). The PIM use rate was 44% at home (prior to admission) and 42% on discharge (p-value =0.324). Of the administered PIMs, pantoprazole was the most prevalent both at home and on discharge, with proton pump inhibitors (PPIs) making up the largest fraction of PIMs (49% for home meds, 55% for discharge meds). Nifedipine, another highly prescribed PIM, had a 43% increase in prescription rate at discharge vs. at admission. A multivariate logistic regression of demographic factors showed that women were much more likely than men to be prescribed PIMs both at home (odds ratio (OR) 1.31, p-value =0.041) and upon discharge (OR 1.35, p-value =0.025). The comorbidities rheumatic disease (OR 2.37, p-value =0.002), peptic ulcer disease (OR 6.24, p-value =0.001), and chronic diabetes (OR 1.64, p-value =0.005) were positive predictors of PIM use on discharge. Additionally, Asian race was a strong positive predictor of PIM prescription on discharge (OR 3.57, p-value =0.011), but not on admission. Interestingly, geriatric consultation was not associated with lower PIM rates on discharge (OR 1.128, p-value =0.706).

Conclusion: Older adults admitted to the acute cardiac care unit had a high prevalence of PIM use upon both admission and discharge. Our results highlight certain patient demographics (gender, race, comorbidities) associated with disproportionately high rates of PIM use. Targeting interventions to these populations and increasing awareness of highly prescribed PIM drug classes has the potential to reduce PIM-associated adverse events. 


Prevalence of Potentially Inappropriate Medications in an Acute Cardiac Care Setting


Introduction: CAD occurs when atherosclerotic plaque formation creates variable degrees of stenosis in the coronary arteries. When this occlusion occurs, adequate blood flow will decrease to the heart muscle. If the stenosis is severe or sudden, myocardial injury or infarction can result. The primary goal of interventional treatment is to restore adequate blood flow to myocardial tissue. Two invasive methods are currently available, percutaneous coronary intervention (PCI) and coronary artery bypass (CABG).1 PCI can now be accompanied by intravascular ultrasound (IVUS), which aims to increase physicians' understanding of vessel characteristics to optimize stent implantation.2 It is currently unknown if PCI with IVUS technology will improve one-year outcomes when compared to PCI standard of care and CABG in patients with multivessel disease. Methods: Our team completed a meta-analysis of selected clinical trials studying one year outcomes of patients with multivessel CAD who received PCI, PCI with IVUS, or CABG. These three procedural groups composed our study arms. Three trials were selected based on study arm criteria: FAME 3, BEST, and Syntax II. From these studies, one primary endpoint, Death from any cause, MI, stroke, or repeat revascularization (MACE) and two secondary endpoints, death from any cause and repeat revascularization, were compared between each arms. Results: PCI with IVUS had significantly reduced repeat revascularization (OR 0.623, CI95 0.409-0.950, p=0.028), reduced MACE outcomes (OR .736, CI95 0.539-1.005, p=0.054) and reduced deaths (OR 0.760, CI95 0.483-1.196, p=.236) when compared to CABG. PCI with IVUS had significantly reduced MACE outcomes (OR 0.524, CI95 0.380-0.721, p<0.001), reduced deaths (OR 0.656, CI95 0.363-1.184, p=0.162) and reduced repeat revascularization (OR 0.664, CI95 0.431-1.021, p=0.062) when compared to PCI without IVUS.

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Primary Care Intervention Improves Hypertension Outcomes in Urban Indian Slums

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Relation Between Nocturia and Blood Pressure Elevation in Adolescents

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