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**Abstract:**



2023 AMA Research Challenge

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

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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.

IVUS: A Predicted Method to Improve Outcomes for Patients with Multivessel Disease

Association between Height and Change in Blood Pressure over time in the ALLHAT Trial

Background
Metabolic syndrome (MS) has gained attention as a newly discovered risk factor for coronary artery disease (CAD). Studies have demonstrated that individuals with MS have a higher risk for coronary artery disease (CAD), more commonly in females compared to males. ST-elevation myocardial infarction (STEMI) is a significant complication in patients with MS and should be screened as a tactic for secondary prevention. In our study, we aim to compare the clinical outcome of STEMI in those patients with and without MS.
Methods
A total of 132 consecutive patients with acute STEMI admitted to Mamata Medical College and General Hospital, Khammam, a tertiary care hospital, in India, were analyzed. Ethics board approval from the ethical committee of Mamata Medical College and informed consent from each individual patient were obtained. Individuals were then grouped into patients with or without MS based on the criteria from the “International Diabetes Federation 2005.” Among these patients, a diagnosis of STEMI was made based on ECG findings and cardiac biomarkers. The results of the observational study were analyzed using SPSS (IBM Corp., Armonk, NY).
Results
A total of 100 patients were included in the study. The frequency of Metabolic syndrome in patients with STEMI was 46%. The frequency was greater in females (53.2%) than in males (43.2%). Patients who had MS had poor clinical outcomes when compared to patients without MS. Mortality due to STEMI in patients with MS was 15.2% whereas in patients without MS was just 2% (p < 0.05).
Conclusion
Metabolic Syndrome is an important risk factor that should be taken into account for secondary prevention of coronary artery disease. It has the potential to be used as a predictor of the severity and short-term outcomes of STEMI. Further, longitudinal studies with larger sample sizes would help improve existing literature by increasing the external validity of this hypothesis. In conclusion, MS should be an independent screening criterion to decrease cardiovascular mortality and morbidity.

Impact of Metabolic Syndrome on Clinical Profile and Outcomes in Patients with Acute​ ST-Elevation Myocardial Infarction: A Cross-Sectional Study​

Background
Pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF; PH-HFpEF) is a relatively newly recognized condition that poses a leading healthcare burden. The development of PH is the strongest predictor of adverse outcomes in HFpEF patients, with a staggering 60% 5-year mortality rate. Incomplete understanding of pathophysiology, ineffective therapies, and limited non-invasive diagnostic methods contribute to this growing epidemic. HFpEF patients initially develop reversible isolated postcapillary PH (ipc-PH) from passively transmitted backward pressures. If not diagnosed promptly, ipc-PH can transform into pre- and postcapillary PH (cpc-PH), characterized by irreversible pulmonary vascular remodeling. Progression to cpc-PH is not explained by traditional risk factors alone, suggesting the need to examine novel regulatory mechanisms. 
Polyunsaturated Fatty Acid (PUFA) metabolites have emerged as pivotal players in cardiovascular health by regulating balance between anti-inflammatory, pro-inflammatory, and pro-resolutory lipid mediators. Previous research has revealed that an imbalance of these lipids leads to metabolic syndrome, an established risk factor of PH-HFpEF. We aimed to identify PUFA-derived lipid mediators that can predict PH in HFpEF patients.
Methods
A single center prospective cohort study was conducted on 88 enrolled patients with a new diagnosis of HFpEF who were grouped into PH subtypes post-diagnostic right heart catheterization: HFpEF without PH (control, n=40), HFpEF with ipc-PH (ipc-PH-HFpEF, n=30), and HFpEF with cpc-PH (cpc-PH-HFpEF, n=18). Venous samples were collected during catheterization. Levels of 143 PUFA metabolites were analyzed using mass spectroscopy with Multiple Reaction Monitoring. Regression models assessed which PUFA metabolites predicted the PH subtypes. Statistics: p<0.05.
Results
Clinical demographics were similar among all groups. Ipc-PH-HFpEF was characterized by low pro-resolutory 7(S)-Maresin1 (p=0.0003), low anti-inflammatory 11(12)-EpETrE (p=0.02), and low anti-inflammatory 8(S)-HETrE (p=0.02) compared to control. These metabolites collectively predicted ipc-PH-HFpEF with 69% diagnostic accuracy. Cpc-PH-HFpEF was distinguishable from control by low pro-resolutory 7(S)-Maresin1 (p=0.004), high pro-inflammatory 5,6-DiHETrE (p=0.001), and high pro-inflammatory tetranor prostaglandin E2 (p=0.007). Collectively, these metabolites predicted cpc-PH-HFpEF with 83% diagnostic accuracy. High pro-resolutory 12(13)-EpOME (p=0.013) distinguished cpc-PH-HFpEF from ipc-PH-HFpEF, with a 75% predictive value. Interestingly, low pro-resolutory 7(S)-Maresin1 yielded the greatest predictive value of 67% in predicting cpc-PH-HFpEF compared to all groups. 
Conclusion
Our findings demonstrate that distinct PUFA inflammatory mediators are associated with PH pathogenesis in HFpEF. This novel lipidomics framework introduces new non-invasive biomarkers to predict PH and facilitates further experimental study of innovative therapeutic molecular targets.

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

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Ventricular Tachycardia Ablation in Cardiac Sarcoidosis

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