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Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are at higher risk of aortic stenosis. Data regarding transcatheter aortic valve implantation (TAVI) in these patients are limited. Herein, we aim to investigate TAVI outcomes in patients with ESKD and CKD. We analyzed clinical data of patients with ESKD and CKD who underwent TAVI from 2008 to 2018 in a large urban healthcare system. Patients' demographics were compared, and significant morbidity and mortality outcomes were noted. Multivariable analyses were used to adjust for potential baseline variables. A total of 643 patients with CKD underwent TAVI with an overall in-hospital mortality of 5.1%, whereas 84 patients with ESKD underwent TAVI with an overall mortality rate of 11.9%. The most frequently observed comorbidities in patients with CKD were heart failure, atrial fibrillation (AF), mitral stenosis (MS), pulmonary hypertension, and chronic lung disease. After multivariable analysis, MS (adjusted odds ratio (OR) 3.92; 95% confidence interval (CI) 1.09 to 11.1, p <0.05) and AF (adjusted OR 2.42; 95% CI 1.3 to 4.4 p <0.05) were independently associated with mortality in patients with CKD. The most common comorbidities observed in patients with ESKD undergoing TAVI were heart failure, chronic lung disease, AF, MS, and pulmonary hypertension. An association between MS and increased mortality was observed (adjusted OR 2.01; 95 CI 0.93 to 2.02, p = 0.09) in patients with ESKD, but was not statistically significant. In conclusion, in patients with CKD undergoing TAVI, AF and MS were independently associated with increased mortality.

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There have been inconsistent reports regarding the clinical features and characteristics of patients diagnosed with spontaneous coronary artery dissection (SCAD). In addition, predictors of mortality in SCAD patients are unknown. We evaluated the prevalence, clinical characteristics, medical management, and predictors of in-hospital mortality of SCAD-related hospitalizations using data from a single health care system from January 1, 2008, to December 31, 2018. Among 30,425 patients who presented with an acute coronary syndrome, 375 (1.2%) patients were diagnosed with SCAD. Of these, the mean age was 52.2 ± 12.8 years, 64.3% were women, and 44% were white. SCAD was significantly associated with emotional stress, fibromuscular dysplasia (FMD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), peripheral artery disease (PAD), and carotid artery disease compared with non-SCAD acute coronary syndrome (all p-values < 0.05). Multivariable analysis showed that atrial fibrillation (OR 2.56; 95% CI 1.01-6.23; p = 0.04), steroid use (OR 7.11; 95% CI 1.31-31.2; p = 0.01), ventricular arrhythmias (OR 4.53; 95% CI 1.58-12.3; p = 0.003), and cardiac arrest (OR 16.82; 95% CI 5.14-56.5; p < 0.001) were independent predictors of in-hospital mortality in SCAD patients. In conclusion, SCAD is an uncommon diagnosis that should be considered across all ages and both sexes and in patients with FMD, carotid artery disease, or PAD. Cardiac arrest, ventricular arrhythmia, steroid use, and atrial fibrillation were independently associated with in-hospital mortality in patients with SCAD.

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AIM: We investigated the feasibility and safety of intra-arterial bivalirudin bolus during primary angioplasty. BACKGROUND: Bivalirudin has been shown to be an effective and safe anticoagulant during angioplasty. However, in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial, the bivalirudin group experienced higher acute stent thrombosis rate compared with the heparin and glycoprotein IIb/IIIa inhibitor group. One possible explanation is suboptimal systemic administration. METHODS: To prevent this possibility and to potentially prevent acute stent thrombosis, we administered intra-arterial bivalirudin bolus during primary angioplasty in 100 consecutive patients. RESULTS: Our observational study suggests safety with no bleeding episode and no observed acute stent thrombosis. CONCLUSION: We conclude that intra-arterial bivalirudin bolus during primary angioplasty is safe and could ensure effective systemic delivery of bivalirudin.

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AIMS: To evaluate the relationship between presenting heart rate (HR) and in-hospital events in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). METHODS AND RESULTS: We evaluated 139 194 patients with NSTE-ACS in the CRUSADE quality improvement initiative. The presenting HR was summarized as 10 beat increments. Patients with systolic BP < 90 mm Hg (4030 patients) were excluded to avoid the confounding effect of cardiogenic shock. An adjusted odds ratio (OR) was calculated using a reference OR = 1 for HR of 60-69 b.p.m. after controlling for baseline variables. Primary outcome was a composite of in-hospital events all-cause mortality, non-fatal re-infarction, and stroke. Secondary outcomes were each of these considered separately. From the cohort of 135 164 patients, 8819 (6.52%) patients had a primary outcome (death/re-infarction or stroke) of which 5271 (3.90%) patients died, 3578 (2.65%) patients had re-infarction, and 1038 (0.77%) patients had a stroke during hospitalization. The relationship between presenting HR and primary outcome, all-cause mortality, and stroke followed a 'J-shaped' curve with an increased event rate at very low and high HR even after controlling for baseline variables. However, there was no relationship between presenting HR and risk of re-infarction. CONCLUSION: In contrast to patients with stable CAD, in the acute setting, the relationship between presenting HR and in-hospital cardiovascular outcomes has a 'J-shaped' curve (higher event rates at very low and high HRs). These associations should be considered in ACS prognostic models.

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BACKGROUND: The relationship between systolic blood pressure (BP) and the risk of cardiovascular events is complex. In patients with chronic coronary artery disease, a J-shaped relationship has been shown, such that there is an increased risk of events both at high and low BP. The current coronary artery disease risk prediction models, however, considers a linear relationship between presenting BP and outcomes in patients presenting with acute coronary syndromes. METHODS: We evaluated 139,194 patients with non-ST-segment elevation acute coronary syndromes in the Can Rapid risk stratification of Unstable anigina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) quality improvement initiative. The presenting systolic BP was summarized as 10-unit increments. Primary outcome was a composite of in-hospital events all-cause mortality, reinfarction, and stroke. Secondary outcomes were each of these outcomes considered separately. RESULTS: From the cohort of 139,194 patients, 9,566 (6.87%) patients had a primary outcome (death/reinfarction or stroke) of which 5,910 (4.25%) patients died, 3,724 (2.68%) patients had reinfarction, and 1,079 (0.78%) patients had a stroke during hospitalization. There was an inverse association between presenting systolic BP and the risk of primary outcome, all-cause mortality, and reinfarction such that there was an exponential increase in the risk with lower presenting systolic BP even after controlling for baseline variables. However, there was no clear relationship between stroke and lower presenting systolic BP. CONCLUSIONS: In contrast to longitudinal impacts, there is a BP paradox on acute outcomes such that a lower presenting BP is associated with increased risk of in-hospital cardiovascular events. These associations should be considered in acute coronary syndrome prognostic models.

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BACKGROUND: Direct angioplasty (PTCA) and thrombolytic therapy are the chief therapies for treating an ST-segment elevation myocardial infarction (MI). OBJECTIVE: This study was designed to evaluate sex differences in the relative benefit of direct PTCA versus thrombolytic therapy among patients enrolled in the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B PTCA) Substudy. METHODS: Women and men presenting with an acute ST-segment elevation MI were randomized to receive either direct PTCA or accelerated tissue plasminogen activator (t-PA). Patients were then randomized to treatment with either heparin or bivalirudin. A gender analysis of outcome was performed. RESULTS: Women were older than men (68.6 +/- 11.5 vs 59.5 +/- 12.0 years, P <.001) and were more likely to have diabetes (22.5% vs 13.5%, P <.0001) and hypertension (53.3% vs 34.8%, P =.001). After adjusting for differences in baseline variables, the odds ratio (OR) for reaching a 30-day clinical end point (death, nonfatal infarction, or nonfatal disabling stroke) was similar for women and men (1.35, 95% CI 0.88-2.08). The OR for reaching a clinical end point at 30 days for the PTCA-treated women compared with the t-PA-treated women was 0.685 (95% CI 0.36-1.32) and similar to the OR in men, 0.565 (95% CI 0.35-0.91), P for interaction =.535. Because women had a higher event rate than men, the absolute number of major events prevented when treating women with direct PTCA was higher than men (56 events/1000 women treated with PTCA vs 42 events per 1000 men treated with PTCA). CONCLUSIONS: Although the relative benefit of direct PTCA to t-PA for the treatment of an acute MI appears to be similar in women and men, women may derive a larger absolute benefit from direct PTCA.

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