Ameya Kulkarni

Comparison of Clinical Characteristics and Outcomes of Cardiac Arrest Survivors Having Versus Not Having Coronary Angiography

Prompt percutaneous coronary intervention is associated with improved survival in patients presenting with cardiac arrest. Few studies, however, have focused on patients with cardiac arrest not selected for coronary angiography. The aim of the present study was to evaluate the clinical characteristics and outcomes of patients with cardiac arrest denied emergent angiography. Patients with cardiac arrest were identified within a registry that included all catheterization laboratory activations from 2008 to 2012. Logistic regression and proportional-hazards models were created to assess the clinical characteristics and mortality associated with denying emergent angiography. Among 664 patients referred for catheterization, 110 (17%) had cardiac arrest, and 26 of these patients did not undergo emergent angiography. Most subjects (69%) were turned down for angiography for clinical reasons and a minority for perceived futility (27%). After multivariate adjustment, pulseless electrical activity as the initial arrest rhythm (adjusted odds ratio [AOR] 13.27, 95% confidence interval [CI] 1.76 to 100.12), <1.0 mm of ST-segment elevation (AOR 10.26, 95% CI 1.68 to 62.73), female gender (AOR 4.45, 95% CI 1.04 to 19.08), and advancing age (AOR 1.10 per year, 95% CI 1.04 to 1.16) were associated with increased odds of withholding angiography. The mortality rate was markedly higher for patients who were denied emergent angiography (hazard ratio 3.64, 95% CI 2.05 to 6.49), even after adjustment for medical acuity (hazard ratio 2.29, 95% CI 1.19 to 4.41). In conclusion, older subjects, women, and patients without ST-segment elevation were more commonly denied emergent angiography after cardiac arrest. Patients denied emergent angiography had increased mortality that persisted after adjustment for illness severity.

Electrocardiographic Criteria for ST-Elevation Myocardial Infarction in Patients With Left Ventricular Hypertrophy

Patients with electrocardiographic (ECG) left ventricular hypertrophy (LVH) have repolarization abnormalities of the ST segment that may be confused with an ischemic current of injury. We analyzed the ACTIVATE-SF database, a registry of consecutive emergency department ST-segment elevation (STE) myocardial infarction diagnoses from 2 medical centers. Univariate analysis was performed to identify ECG variables associated with presence of an angiographic culprit lesion. Recursive partitioning was then applied to identify a clinical decision-making rule that maximizes sensitivity and specificity for presence of an angiographic culprit lesion. Seventy-nine patients with ECG LVH underwent emergency cardiac catheterization for primary angioplasty. Patients with a culprit lesion had greater magnitude of STE (3.0 ± 1.8 vs 1.9 ± 1.0 mm, p = 0.005), more leads with STE (3.1 ± 1.6 vs 2.0 ± 1.8 leads, p = 0.002), and a greater ratio of STE to R-S-wave magnitude (median 25% vs 9.2%, p = 0.003). Univariate application of ECG criteria had limited sensitivity and a high false-positive rate for identifying patients with an angiographic culprit lesion. In patients with anterior territory STE, using a ratio of ST segment to R-S-wave magnitude ≥25% as a diagnostic criteria for STE myocardial infarction significantly improved specificity for an angiographic culprit lesion without decreasing sensitivity (c-statistic 0.82), with a net reclassification improvement of 37%. In conclusion, application of an ST segment to R-S-wave magnitude ≥25% rule may augment current criteria for determining which patients with ECG LVH should undergo primary angioplasty.

Delaying primary percutaneous coronary intervention for computed tomographic scans in the emergency department.

Patients presenting with suspected ST-segment elevation myocardial infarction (STEMI) may have important alternative diagnoses (e.g., aortic dissection, pulmonary emboli) or safety concerns for STEMI management (e.g., head trauma). Computed tomographic (CT) scanning may help in identifying these alternative diagnoses but may also needlessly delay primary percutaneous coronary intervention (PCI). We analyzed the ACTIVATE-SF Registry, which consists of consecutive patients with a clinical diagnosis of STEMI admitted to the emergency departments of 2 urban hospitals. Of 410 patients with a suspected diagnosis of STEMI, 45 (11%) underwent CT scanning before primary PCI. Presenting electrocardiograms, baseline risk factors, and presence of an angiographic culprit vessel were similar in those with and without CT scanning before PCI. Only 2 (4%) of these CT scans changed clinical management by identifying a stroke. Patients who underwent CT scanning had far longer door-to-balloon times (median 166 vs 75 minutes, p <0.001) and higher in-hospital mortality (20% vs 7.8%, p = 0.006). After multivariate adjustment, CT scanning in the emergency department before primary PCI remained independently associated with longer door-to-balloon times (100% longer, 95% confidence interval 60 to 160, p <0.001) but was no longer associated with mortality (odds ratio 1.4, p = 0.5). In conclusion, CT scanning before primary PCI rarely changed management and was associated with significant delays in door-to-balloon times. More judicious use of CT scanning should be considered.

A novel minimally-invasive method to sample human endothelial cells for molecular profiling.

Objective The endothelium is a key mediator of vascular homeostasis and cardiovascular health. Molecular research on the human endothelium may provide insight into the mechanisms underlying cardiovascular disease. Prior methodology used to isolate human endothelial cells has suffered from poor yields and contamination with other cell types. We thus sought to develop a minimally invasive technique to obtain endothelial cells derived from human subjects with higher yields and purity. Methods Nine healthy volunteers underwent endothelial cell harvesting from antecubital veins using guidewires. Fluorescence-activated cell sorting (FACS) was subsequently used to purify endothelial cells from contaminating cells using endothelial surface markers (CD34 / CD105 / CD146) with the concomitant absence of leukocyte and platelet specific markers (CD11b / CD45). Endothelial lineage in the purified cell population was confirmed by expression of endothelial specific genes and microRNA using quantitative polymerase chain reaction (PCR). Results A median of 4,212 (IQR: 2161 – 6583) endothelial cells were isolated from each subject. Quantitative PCR demonstrated higher expression of von Willebrand Factor (vWF, P<0.001), nitric oxide synthase 3 (NOS3, P<0.001) and vascular cell adhesion molecule 1 (VCAM-1, P<0.003) in the endothelial population compared to similarly isolated leukocytes. Similarly, the level of endothelial specific microRNA-126 was higher in the purified endothelial cells (P<0.001). Conclusion This state-of-the-art technique isolates human endothelial cells for molecular analysis in higher purity and greater numbers than previously possible. This approach will expedite research on the molecular mechanisms of human cardiovascular disease, elucidating its pathophysiology and potential therapeutic targets.

Soluble endothelial cell selective adhesion molecule and cardiovascular outcomes in patients with stable coronary disease: A report from the Heart and Soul Study

BACKGROUND AND AIMS Endothelial cell-selective adhesion molecule (ESAM) is selectively expressed on vascular endothelium and is postulated to play a role in atherogenesis. We investigated the association of serum soluble ESAM (sESAM) levels with subsequent cardiovascular outcomes in patients with stable ischemic heart disease. METHODS We measured sESAM levels in 981 patients with stable coronary disease enrolled between September 2000 and December 2002 in a prospective cohort study. Poisson regression models were used to define the relationship between baseline sESAM levels and cardiovascular outcomes, including myocardial infarction, heart failure hospitalization, and mortality. RESULTS There were 293 occurrences of the composite endpoint over a median follow-up of 8.9 years. After adjusting for demographic and clinical risk factors, participants in the highest sESAM quartile (compared to the lower three sESAM quartiles) had a higher rate of the composite endpoint (incident rate ratio (IRR) 1.52 (95% CI 1.16-1.99) as well as of its individual components: myocardial infarction (IRR 1.64 (1.06-2.55)), heart failure hospitalizations (IRR 1.96 (1.32-2.81)), and death (IRR 1.5 (1.2-1.89)). These associations were no longer significant after adjustment for estimated glomerular filtration rate. CONCLUSIONS sESAM levels associate with myocardial infarction, heart failure, and death after adjustment for demographic and clinical risk factors, but not after adjustment for kidney function. sESAM may be involved in the pathogenesis of concurrent kidney and cardiovascular disease.

IMPLEMENTATION OF A POST-TRANSCATHETER VALVE REPLACEMENT (TAVR) FAST-TRACK CARE PROTOCOL WITH A FOCUS ON NEXT-DAY DISCHARGE

Recent studies have demonstrated that TAVR can be safely performed with a minimalist approach. We demonstrate the results of implementing a fast-track protocol aimed at streamlining hospital care of post-TAVR patients. The Mid-Atlantic Permanente Medical Group TAVR program was established in

IMPLEMENTATION OF THE FIRST REPORTED ROUTINE ONE-DAY TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) PATIENT EVALUATION

Background: The evaluation required to determine patient candidacy for TAVR can take more than three weeks or longer at many centers. This presents logistical hardships for patients and families. We demonstrate the first reported one-day TAVR evaluation. The Mid-Atlantic Permanente Medical Group (

Pulmonary Vein Stenting for Atrial Fibrillation Ablation–Induced Pulmonary Vein Stenosis

Pulmonary vein stenosis (PVS) is a known complication of pulmonary vein isolation in the treatment of atrial fibrillation. Patients with PVS can present with a great variety of symptoms. Clinicians should have a low threshold to evaluate for this potentially morbid and treatable condition. PVS can be treated by stenting affected pulmonary veins via transseptal access to the left atrium and use of bare metal biliary stents.

TCT-504 Long Term Outcomes Among Patients With ‘False-positive’ STEMI Activations: A Report From The ACTIVATE-SF Registry

vessel PPCI in our unit. Methods: We included all patients who underwent PPCI in our unit between Sept 2009 and May 2011. They were divided into two groups according to the size of the largest balloon or stent used in the culprit lesion. Results: Of the 1132 patients who underwent PPCI in our unit during the study period, we excluded 30 (2.7%) patients who did not have either a balloon or stent used in the culprit lesion. Of the remaining 1102 patients, 569 (51.6%) had small ( 3 mm) vessel PPCI and 533 (48.4%) had large ( 3 mm) vessel PPCI. Patients with small vessel PPCI were significantly older, more likely to be female and have anterior STEMI with less use of thrombectomy device, but with significantly higher drug eluting stent (DES) usage. There was significantly higher in-hospital mortality (5.3% vs 2.8%, OR 1.9, 95% CI 1-3.6, p 0.047), 30-day mortality (8.4% vs 3.6%,OR 2.5, 95% CI 1.4-4.3, p 0.0009) and 30-day stent thrombosis (1.2% vs 0, p 0.02) in the small vessel PPCI group compared to large vessel PPCI group. On binary logistic regression analysis of small vessel PPCI patients (covariates used: female sex, Age 75 yrs, cardiogenic shock, diabetes, LAD PCI and DES use), the positive predictors of 30-day mortality were age 75 yrs (OR 6.1, 95% CI 2.9 to 12.5, p 0.0001) and cardiogenic shock (OR 9.9, 95% CI 4.3-22.6, p 0.0001) with DES use (OR 0.4, 95% CI 0.2-0.8, p 0.01) being the only negative predictor of mortality.

CLINICAL AND ELECTROCARDIOGRAPHIC CHARACTERISTICS ASSOCIATED WITH ST ELEVATION MYOCARDIAL INFARCTION AMONG WOMEN: A REPORT FROM THE ACTIVATE-SF REGISTRY

Gender specific differences in acute coronary syndromes are well known. We sought to evaluate clinical and electrocardiographic factors associated with misdiagnosis among women presenting to the emergency department originally diagnosed as having an ST-segment elevation myocardial infarction (STEMI