Adefisayo Oduwole

Gender differences and practice implications of risk factors for frequent hospitalization for heart failure in an urban center serving predominantly African-American patients

To identify the clinical correlates of recurrent heart failure hospitalization in a large urban hospital serving predominately African-American patients, and to provide further insight into modifiable risks for heart failure readmissions, a retrospective period prevalence review of the records of all adult patients admitted with a primary diagnosis of heart failure (International Classification of Diseases-9 code 428.0) between January and December 1995 was performed. The main outcome was the number of heart failure hospitalizations over 12 months. Twelve hundred patients were identified. Mean age was 64 +/- 16 years, 94% were black, 57% were women, and 40% were > or = 65 years old. Ninety-eight percent had a history of systemic hypertension and 55% had uncontrolled hypertension. Other comorbidities were left ventricular (LV) hypertrophy (64%), coronary artery disease (52%), and tobacco abuse (28%). Sixty-five percent of patients were on angiotensin-converting enzyme (ACE) inhibitors, 51% on calcium antagonists, and 8% on beta blockers. Most patients had suboptimal dosing of ACE inhibitors and there was inappropriate use of calcium antagonists in 56% of patients with moderate or severe systolic dysfunction. Diabetes mellitus and echocardiographic wall motion abnormality were independently associated with frequent admissions for women but not for men. Medication-related increase in heart failure hospitalization was seen for calcium antagonists in patients with severe LV dysfunction (odds ratio 2.24, 95% confidence intervals 1.0 to 5.03; p <0.03). Uncontrolled hypertension, underdosing of ACE inhibitors, and overuse of calcium antagonists in patients with significant LV dysfunction are potential targets for intervention.

Surgical Timing for Mitral Valve Regurgitation

Advances in diagnostic and surgical techniques in the management of mitral regurgitation have resulted in improved survival rates and clinical outcomes. Echocardiography is a valuable noninvasive diagnostic tool in the determination of the timing of surgical correction of mitral regurgitation. Improved surgical techniques, the growing role of mitral valve repair, low operative mortality rates, and improved long‐term survival rates are important considerations for earlier surgical intervention in symptomatic patients and in asymptomatic patients with echocardiographic criteria of left ventricular dilatation. Intraoperative transesophageal echocardiography is very useful in mitral valve repair and valve replacement with preservation of chordal structures.

The 894T allele of the endothelial nitric oxide synthase gene is related to left ventricular mass in African Americans with high-normal blood pressure

BACKGROUND AND OBJECTIVES The 894T allele in exon 7 of the endothelial nitric oxide synthase (eNOS) gene has been inconsistently associated with hypertension in different racial groups. Because high-normal blood pressure (BP) confers an increased risk for the development of hypertension and other cardiovascular disorders, including left ventricular hypertrophy (LVH), we tested the hypothesis that the allelic variation (894T) in the eNOS gene would directly correlate with alterations in LV mass (LVM) in individuals with high-normal BP. METHODS Genotype distribution of G894T was compared between 20 African Americans (10 females/10 males) with high-normal BP (systolic BP of 130-139 and/or diastolic BP of 85-89 mmHg) and 64 counterparts (37 females/27 males) with normal BP (<130/85 mmHg). Echocardiographic LVM was calculated (Devereux formula) and indexed to body surface area to define the presence of LVH (LVMI >134/110 g/m2 for men/women). RESULTS For the entire group, the 894T allelic frequencies (15, 48%) and G894T genotype distributions were consistent with the Hardy-Weinberg equilibrium expectations (estimated disequilibrium coefficient = 0.0118, P=0.40). LVMI was significantly higher in homozygous carriers (TT) of the rare 894T allele (n = 3 females/0 males) than in heterozygous GT (n = 13 females/7 males) and individuals bearing the GG (n=34 females/27 males) variant (124 +/- 70 vs. 82 +/- 24 and 82 +/- 19 g/m2, respectively, P < 0.05). The observed relationship between eNOS 894T allele and LVMI was restricted to individuals with high-normal BP (r = 0.94, P = 0.03) but not in those with normal BP (r = 0.39, P =0.64), by analysis of variance (ANOVA) after adjusting for age, gender, body mass index, smoking and systolic BP. CONCLUSION These findings, not previously described, provide important preliminary evidence to suggest an increased susceptibility to LVH in African Americans who carry the 894T variant of the eNOS gene and have high-normal blood pressure.

Long-term outcome of isolated coronary artery bypass surgery in blacks

Objective: There are conflicting data on the influence of race and gender on the outcome of patients undergoing coronary artery bypass graft surgery (CABG), with blacks and females showing higher operative mortality (OM) in some series and not others. Materials and Methods: The medical records of 176 black patients undergoing isolated CABG by a single surgeon from 2000 to 2014 were retrospectively reviewed. The mean age was 61.9 ± 11.2 years and majority 93 (52.8%) were males. Identified risk profiles were peripheral vascular disease 53 (30.1%) patients, insulin-dependent diabetes mellitus 49 (27.8%), end-stage renal disease (ESRD) 27 (15.3%), chronic obstructive pulmonary disease 27 (15.3%), cerebrovascular disease 24 (13.6%), and HIV/AIDS 5 (2.8%). One hundred and forty (79.5%) had severe triple vessel disease, 30 (17.0%) left main disease, and ejection fraction mean 43.0 ± 14.3. Results: One hundred and twenty-eight patients (72.7%) underwent on-pump and 48 patients (27.3%) off-pump coronary artery bypass graft (OPCAB), with 150 (85.2%) urgent surgeries. EuroSCORE-II (ES-II) score was 3.86 ± 3.18 while observed OM was 6.81% (12/176). There was no difference in OM between males and females 6.45% versus 7.22% ( P = 0.924) and on-pump and OPCAB 7.81% versus 4.16% ( P = 0.604). Univariate analysis identified ESRD and ES as predictors but on multivariate analysis only ESRD with odds ratio 4.630 (95% CI: 1.321-16.229, P = 0.017). The society of thoracic surgeons (STS) quality measurement task force major complications were acute kidney injury 6.81%, prolonged ventilation 6.81%, stroke 3.40%, deep sternal wound infection 2.27%, and reoperation 1.70%. Overall 1 and 5 years survival was 90.0% and 73.9%, respectively, with no significant difference between males and females 92.4% and 75.0% versus 86.4% and 70.9%, respectively, when P = 0.764. Conclusion: The observed/expected 1.76 ratio may partly be due to higher number of urgent and ESRD patients of 85.2% and 15.3% compared to 27.9% and 2.36-7.90%, respectively, in the STS database. Our ESRD patients had 4΍ times odds of death than non-ESRD. Despite males having slightly higher risk profiles, long-term survival was similar with females and overall 1 and 5 years survival comparable to blacks in other series.

Experience with implantable cardioverter defibrillator in african-americans: Is there an effect of cocaine usage on defibrillation threshold?

Objective: Some earlier studies have suggested that cocaine use in African-Americans (AAs) results in higher defibrillation thresholds. We are therefore reviewing our own experience with this racial group for comparison. Materials and Methods: We retrospectively reviewed the medical records of AA patients who had placement by a single operator of implantable cardioverter defibrillator (ICD) at an inner city hospital from January 2006 to December 2015. Results: Seventy-four patients, mean age 59.2 ± 12.9 years, comprising 37 (50.0%) males, underwent ICD implantation of which 67.6% were single chamber and 32.4% dual chamber devices. Diagnosis was nonischemic cardiomyopathy in 68.9% and indication for device therapy was primary prevention in 87.8%. Sixty-six (89.2%) patients were noncocaine users, whereas 8 (10.8%) were cocaine abusers. The mean age, ejection fraction, and defibrillation threshold between the noncocaine and cocaine users were 60.2 ± 12.8 versus 51.3 ± 12.4 ( P = 0.642), 21.6 ± 8.3 versus 16.1 ± 4.6 ( P = 0.0704), and 23.5 ± 5.0 versus 25.0 ± 8.4 ( P = 0.447), respectively. Biotronik device patients had complete follow-up and they had an all-cause mortality of 28.8% (15/52), while 27.0% (10/37) of the survivors had at least one or more antitachycardia pacing or high voltage shock therapies. Conclusion: There was no statistically significant difference in defibrillation threshold testing observed in AA patients in our series between noncocaine and cocaine users as previously seen in some earlier small reviews. Larger studies or meta-analysis of several studies to accumulate a substantial number of AAs using cocaine may be required for a definitive answer to the question.

Off-pump coronary artery bypass surgery: Intra-aortic balloon pump aides multivessel revascularization in high-risk patients

Objective: Off-pump coronary artery bypass (OPCAB) has been demonstrated to be a safe technique with similar outcomes to on-pump coronary artery bypass (ONCAB) in low-risk patients, while its role and benefits in high-risk patients are the subject of ongoing clinical trials. This review compares our high-risk patients aided by intra-aortic balloon pump (IABP) with low-risk patients undergoing OPCAB to identify any differences in outcomes. Materials and Methods: One hundred and twenty-four patients who underwent OPCAB surgery between January 2004 and December 2013 were retrospectively reviewed. 61.3% were males, 57.3% were African Americans, mean age was 62.7 ± 13.3, and range was 30-90 years. Patients were divided into Group 1, 26 (21.0%) patients with IABP and Group 2, 98 (79.0%) patients without IABP. Group 1 patients had higher risk profile with mean ejection fraction (EF) 26.0 ± 10.8 and EF ≤20 present in 46.1% compared to 45.2 ± 11.9 and 5.1%, respectively, in Group 2 (P < 0.001). Results: 92.35% of Group 1 and 82.7% of Group 2 patients had multivessel disease with a mean number of bypass grafts 2.9 ± 0.97 versus 2.75 ± 0.8, respectively (P < 0.364). Left internal mammary artery (LIMA) to left anterior descending (LAD) was performed in all Group 1 and 97.9% of Group 2 patients, with saphenous vein graft (SVG) to the left circumflex and right coronary arteries in 73.1% versus 62.2% and 57.7% versus 52.0% of Groups 1 and 2, respectively. Complete revascularization occurred in 88.5% and 90.8% of Groups 1 and 2, respectively (P < 0.990). 4.0% were converted to ONCAB for either hemodynamic instability or intramyocardial coronary artery. Major morbidities were re-exploration for bleeding 3.8% versus 1.0%, stroke 3.8% versus 2.0%, acute kidney injury 11.5% versus 0%, and prolonged intubation 15.4% versus 2.0% in Groups 1 and 2, respectively. Euroscore II predicted (P) versus observed (O) mortality was 4.56% versus 4.03%, for Group 1, 7.82% versus 7.69% and Group 2, 3.64% versus 3.06%, and O/P ratios 0.88, 0.98 and 0.84 respectively. Two (2.0%) females in Group 2 with single LIMA to LAD underwent repeat revascularization with SVG to the LAD within 90 days. Conclusion: IABP helps stabilize hemodynamics during OPCAB in high-risk patients with moderate to severe left ventricular dysfunction. Mean number of bypass grafts and predicted versus observed mortality were similar between the low- and high-risk groups.

Off Pump Coronary Artery Bypass Surgery for Multivessel Disease in Pregnancy

A 31 year old female with known history of coronary artery disease and percutaneous coronary intervention presented with acute coronary syndrome. Unknown that patient was pregnant she had inadvertent radiation exposure to the fetus during cardiac catheterization which showed triple vessel disease and severe left ventricular dysfunction. Patient subsequently underwent multivessel off pump coronary artery bypass surgery with intraaortic balloon pump support after declining the recommendation for abortion. Postoperative course was uneventful and patient subsequently delivered a full term healthy baby several months later.Off pump revascularization with its ability to maintain pulsatile perfusion to the fetus should be considered if technically feasible for severe coronary artery disease requiring surgery during pregnancy.

Heart Failure Morbidity, Mortality, and Its Relationship to Hypertension

Heart failure (HF) remains a significant cardiovascular problem, with increasing incidence and prevalence rates: Adult Americans over 40 years of age have a 20 % lifetime risk of developing heart failure. Approximately five million people in the USA have HF, and over 650,000 new cases of HF are diagnosed each year. HF incidence increases with age: from 20 per 1,000 among individuals 65–69 years of age to greater than 80 per 1,000 for individuals who are over 85 years of age.