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Despite previously noted healthcare disparities, there are limited data on the management and outcomes of uninsured patients presenting with pulmonary embolism (PE). All adult (>18 years) nonelective admissions with a primary diagnosis of PE with either private or uninsured (self-pay or no charge) primary payor were identified using the National Inpatient Sample (2016-2022). We excluded admissions with Medicare and Medicaid payor status. The primary outcome was in-hospital mortality. Secondary outcomes included utilization rates of different interventions, hospital length of stay, hospitalization costs, and discharge disposition. During 01/01/2016 to 12/31/2022, 416,599 admissions were identified as uninsured (54,444) and privately insured (362,155). Compared to those privately insured, the uninsured cohort was on average younger, more frequently male, from a minority race/ethnicity, belonging to lower socioeconomic status, and residing in the southern United States (all p < 0.001). The rates of acute organ failure were largely comparable between the 2 groups. Use of catheter-directed therapies (3.7% vs 4.5%, p = 0.002) and mechanical thrombectomy (3.0% vs 3.5%, p = 0.005) was lower in the uninsured insurance subgroup, but systemic thrombolysis and surgical thrombectomy were similar. The uninsured cohort had comparable rates of in-hospital mortality (2.9% vs 2.3%, adjusted odds ratio 1.19; 95% confined interval 0.98-1.46; p = 0.07). The uninsured cohort also had longer hospitalization duration, higher hospitalization costs, and higher rates of leaving against medical advice (all p < 0.05). In conclusion, using over 7 years of retrospective data, we noted that despite comparable in-hospital mortality, there were significant socioeconomic differences between uninsured and privately insured admissions with PE.

The B-type or brain natriuretic peptides (BNP) and the amino-terminal probrain natriuretic peptide (NT-proBNP) are good markers of prognosis and diagnosis in chronic heart failure (HF). It is unclear, however, whether differences in their biological characteristics modify their clinical correlates and prognostic performance in HF. This work aimed to provide a direct comparison of the prognostic value of BNP and NT-proBNP in patients with chronic and stable HF. We measured BNP and NT-proBNP at baseline in 3916 patients enrolled in the Valsartan Heart Failure Trial. To identify the variables associated with both peptides, we conducted simple and multivariable linear regression analyses. We used Cox multivariable regression models to evaluate the independent prognostic value for all-cause mortality, mortality and morbidity, and hospitalization for HF. Prognostic performance was assessed by pairwise comparisons of the area under the curve of receiver-operator characteristic curves. NT-proBNP and BNP had similar relationships with age, left ventrical ejection fraction, and internal diameter and creatinine clearance. Either peptide ranked as the first independent predictor of outcome after adjustment for major confounding clinical characteristics. ROC curves were almost superimposable for all-cause mortality (area under the curve (SE): BNP 0.665 (0.011) vs NT-proBNP 0.679 (0.011); P=0.0734), but NT-proBNP was superior to BNP for predicting mortality and morbidity (P=0.032) or hospitalization for HF (P=0.0143). Overall sensitivity and specificity ranged from 0.590 to 0.696. The natriuretic peptides BNP and NT-proBNP showed subtle differences in their relation to clinical characteristics and prognostic performance in a large population of patients with chronic and stable HF. They were the most powerful independent markers of outcome in HF.

Objectives We sought to assess and compare the diagnostic accuracy and prognostic value of dobutamine stress echocardiography (DSE), dobutamine SPECT, and adenosine SPECT myocardial perfusion imaging (MPI) in patients with end-stage renal disease (ESRD). Background The optimal stress imaging modality for patients with ESRD has not yet been determined. Methods Forty-nine patients with ESRD underwent DSE, dobutamine SPECT MPI, and adenosine SPECT MPI. The primary endpoint of the trial was concordance between stress tests with respect to the presence or absence of ischemia. Results Agreement on the presence or absence of ischemia between adenosine SPECT MPI and DSE was 69% (kappa = .25, P  = NS). Agreement on the presence or absence of ischemia between adenosine and dobutamine SPECT MPI was 77% (kappa = .37, P  = <.009). Summed stress scores for adenosine and dobutamine SPECT MPI studies were highly correlated ( r  = .9, P  = <.0001). DSE and SPECT MPI results provided incremental prognostic information when added to clinical variables. Conclusions There is moderate concordance between DSE and adenosine SPECT MPI in ESRD patients referred for stress testing. Interobserver agreement was higher for SPECT MPI compared to DSE. Based on these observations, the optimal approach for diagnosing severe coronary artery disease and assessing risk in patients with ESRD has yet to be determined, but appears to warrant further investigation.

Atrial fibrillation (Afib) is the most common abnormal heart rhythm in adults and has become a significant public health concern affecting 2% to 3% of the population in Europe and North America. Left atrial appendage (LAA) thrombi is the source of 90% of left-sided cardiac thrombi in patients with Afib, which can cause stroke and other systemic vascular events. Right atrial appendage (RAA) thrombi formation in Afib is much less common but complications include pulmonary embolism or paradoxical migration across patent foramen ovale with risk of systemic embolization. The prevalence and subsequent clinical complications of RAA thrombi formation in Afib patients is not well understood. Management of RAA thrombi should be similar to that of LAA thrombi which includes delaying cardioversion and anticoagulating with warfarin therapy to achieve international normalized ratio of 2 to 3.

The goals of treatment of cor pulmonale are 1) to reduce pulmonary arterial hypertension; 2) to optimize gas-exchange efficiency; and 3) to improve survival. These goals are achieved through long-term oxygen therapy, bronchodilator and vasodilator therapy, aggressive treatment of pulmonary infection, and anticoagulation. Selected patients may benefit from available surgical options.

Anthracycline chemotherapy remains an integral part of the care for curative intent chemotherapy in breast cancer and non-Hodgkin lymphoma patients. Better tools need to be identified to predict cardiac complications of anthracycline chemotherapy. We investigated the utility of high-sensitivity cardiac troponin T (hscTnT), N-terminal pro-B-type natriuretic peptide, cardiac troponin T and I, and creatine kinase (CK)-MB in cancer patients receiving anthracycline-based chemotherapy, in order to determine whether baseline levels or changes in these biomarkers may help predict the onset of congestive heart failure. Eighteen consecutive patients with a pathologic diagnosis of breast cancer or non-Hodgkin lymphoma were enrolled. The median dose of doxorubicin exposure was 240 mg/m(2) (range 240-400 mg/m(2)). After treatment with doxorubicin, the hscTnT increased to 19.1 pg/mL (P<0.001). CKMB and N-terminal pro-B-type natriuretic peptide levels increased to 1.1 ng/mL and 88.3 pg/mL, respectively (P=0.02). When subjects who had a decline in left ventricular ejection fraction (LVEF) by equilibrium radionuclide ventriculography were compared to those who did not have a change in LVEF, there was a suggestion that those subjects with an elevated baseline hscTnT were more likely to have a decline in LVEF (2.7 pg/mL and 0.1 pg/mL, respectively; P=0.07). Spearman correlation demonstrated that patients with higher baseline hscTnT and CKMB tended to have a greater decline in LVEF (Spearman correlation -0.54, 95% confidence interval -0.80 to -0.08 [P=0.02], and -0.49, 95% confidence interval -0.77 to -0.01 [P=0.04], respectively). Elevations in baseline hscTnT levels are suggestive of an oncology subgroup at high risk of developing cardiac complications from their chemotherapy. Early detection by oncologists with the use of baseline biomarkers may be clinically important in designing interventions to prevent serious anthracycline-based chemotherapy complications.

A 69-year-old woman with a history of myocardial infarction came to hospital after more than 24 h of intermittent chest pain, shortness of breath, and diaphoresis.