Anna Grodzinsky

Performance of the Medtronic Sentrino continuous glucose management (CGM) system in the cardiac intensive care unit

Background Maintaining glucose in the target range, while avoiding hypoglycemia, is challenging in critically ill patients. We investigated the performance and safety of Medtronic Sentrino, a newly developed continuous glucose management (CGM) system for critically ill adults. Methods This was a prospective, single-center, single-arm, open-label study in adult patients with cardiac ICU admission. Sentrino subcutaneous glucose sensors were inserted into patients’ thigh with planned study participation of 72 h. Sensor glucose results were displayed, and the systems alerts and alarms fully enabled. Reference blood glucose was collected from central venous catheter and analyzed with a blood gas analyzer. Treatment decisions were made independently of sensor glucose values, according to the existing standard of care. Results A total of 21 patients were enrolled; all successfully completed the study. Sensor glucose values were displayed 96% of the time, and 870 paired blood glucose–sensor glucose points were analyzed. Overall mean absolute relative difference (MARD) was 12.8% (95% CI 11.9% to 13.6%). No clinically significant differences in accuracy were seen within subgroups of hemodynamic status (MARD 12.3% and 13.1% for compromised vs stable hemodynamics). Consensus grid analysis showed >99% of sensor glucose values within A/B zones. No device or study-related adverse events were reported. 100% of clinicians found Sentrino easy to use after two patients. Conclusions In our single-center experience, Sentrino CGM system demonstrated good accuracy and reliability, with no device-related adverse events in critically ill cardiac patients, and was easy to use and integrate in the cardiac ICU. Trial registration number NCT01763567.

Predictors of Physician Under-Recognition of Angina in Outpatients With Stable Coronary Artery Disease

Background—Under-recognition of angina by physicians may result in undertreatment with revascularization or medications that could improve patients’ quality of life. We sought to describe characteristics associated with under-recognition of patients’ angina. Methods and Results—Patients with coronary disease from 25 US cardiology outpatient practices completed the Seattle Angina Questionnaire before their clinic visit, quantifying their frequency of angina during the previous month. Immediately after the clinic visit, physicians independently quantified their patients’ angina. Angina frequency was categorized as none, monthly, and daily/weekly. Among 1257 patients, 411 reported angina in the previous month, of whom 173 (42%) were under-recognized by their physician, defined as the physician reporting a lower frequency category of angina than the patient. In a hierarchical logistic model, heart failure (odds ratio, 3.06, 95% confidence interval, 1.89–4.95) and less-frequent angina (odds ratio for monthly angina [versus daily/weekly], 1.69; 95% confidence interval, 1.12–2.56) were associated with greater odds of under-recognition. No other patient or physician factors were associated with under-recognition. Significant variability across physicians (median odds ratio, 2.06) was observed. Conclusions—Under-recognition of angina is common in routine clinical practice. Although patients with less-frequent angina and those with heart failure more often had their angina under-recognized, most variation was unrelated to patient and physician characteristics. The large variation across physicians suggests that some physicians are more accurate in assessing angina frequency than others. Standardized prospective use of a validated clinical tool, such as the Seattle Angina Questionnaire, should be tested as a means to improve recognition of angina and, potentially, improve appropriate treatment of angina.

Prevalence and Prognosis of Hyperkalemia in Patients with Acute Myocardial Infarction

BACKGROUND Hyperkalemia is common and potentially dangerous in hospitalized patients; its contemporary prevalence and prognostic importance after acute myocardial infarction are not well described. METHODS In 38,689 consecutive patients with acute myocardial infarction from the Cerner Health Facts database, we evaluated the association between maximum in-hospital potassium levels and in-hospital mortality. Patients were stratified by dialysis status and grouped by maximum potassium as follows: <5 mEq/L, 5 to <5.5 mEq/L, 5.5 to <6.0 mEq/L, 6.0 to <6.5 mEq/L, and ≥6.5 mEq/L. Multivariable logistic regression was used to adjust for multiple patient and site characteristics. The relationship between the number of hyperkalemic values and the in-hospital mortality was evaluated. RESULTS Of 38,689 patients with acute myocardial infarction, 886 were on dialysis. The rate of hyperkalemia (maximum potassium ≥5.0 mEq/L) was 22.6% in patients on dialysis and 66.8% in patients not on dialysis. Moderate to severe hyperkalemia (maximum potassium ≥5.5 mEq/L) occurred in 9.8% of patients. There was a steep increase in mortality with higher maximum potassium levels. In-hospital mortality exceeded 15% once maximum potassium was ≥5.5 mEq/L regardless of dialysis status. The relationship between higher maximum potassium and increased mortality risk persisted after multivariable adjustment. In addition, patients with a greater number of hyperkalemic values (vs a single value) experienced higher in-hospital mortality. CONCLUSIONS Hyperkalemia is common in patients who are hospitalized with acute myocardial infarction. Higher maximum potassium levels and number of hyperkalemic events are associated with a steep mortality increase, with higher risks for adverse outcomes observed even at mild levels of hyperkalemia. Whether more intensive management of hyperkalemia may improve outcomes in patients with acute myocardial infarction merits further study.

Association of Smoking Status With Health-Related Outcomes After Percutaneous Coronary Intervention

Background—Patients who smoke at the time of percutaneous coronary intervention (PCI) would ideally have a strong incentive to quit, but most do not. We sought to compare the health status outcomes of those who did and did not quit smoking after PCI with those who were not smoking before PCI. Methods and Results—A cohort of 2765 PCI patients from 10 US centers were categorized into never, past (smoked in the past but had quit before PCI), quitters (smoked at time of PCI but then quit), and persistent smokers. Health status was measured with the disease-specific Seattle Angina Questionnaire and the EuroQol 5 dimensions, adjusted for baseline characteristics. In unadjusted analyses, persistent smokers had worse disease-specific and overall health status when compared with other groups. In fully adjusted analyses, persistent smokers showed significantly worse health-related quality of life when compared with never smokers. Importantly, of those who smoked at the time of PCI, quitters had significantly better adjusted Seattle Angina Questionnaire angina frequency scores (mean difference, 2.73; 95% confidence interval, 0.13–5.33) and trends toward higher disease specific (Seattle Angina Questionnaire quality of life mean difference, 1.97; 95% confidence interval, −1.24 to 5.18), and overall (EuroQol 5 dimension visual analog scale scores mean difference, 2.45; 95% confidence interval, −0.58 to 5.49) quality of life when compared with persistent smokers at 12 months. Conclusions—Smokers at the time of PCI have worse health status at 1 year than those who never smoked, whereas smokers who quit after PCI have less angina at 1 year than those who continue smoking.

Angina frequency after acute myocardial infarction in patients without obstructive coronary artery disease

BACKGROUND Myocardial infarction (MI) patients without obstructive coronary artery disease (CAD) are at increased risk for recurrent ischemic events, but angina frequency post-MI has not been described. METHODS AND RESULTS Among MI patients who underwent angiography, we assessed angina at baseline, 1, 6, and 12 months using the Seattle Angina Questionnaire (SAQ). A hierarchical repeated measures modified Poisson model assessed the association between the absence of obstructive CAD (defined as epicardial stenoses >70% or left main >50%) and angina. Among 5539 MI patients from 31 US hospitals (mean age 60, 68% male), 6.9% had no angiographic obstructive CAD. More patients without obstructive CAD (vs. obstructive CAD) were female (57% vs 30%), non-white (51% vs 24%) and had NSTEMI (87% vs 51%). In unadjusted analyses, patients without obstructive CAD had less angina prior to MI but more angina and worse health status post-discharge. After adjustment for socio-demographic and clinical factors, the risk of post-MI angina was similar in patients without vs. with obstructive CAD (IRR=0.89, 95% CI 0.77-1.02). Among patients without obstructive CAD, depression and self-reported avoidance of care due to cost were independently associated with angina (IRR=1.28 per 5 points on PHQ, 95% CI 1.17-1.41; IRR=1.34, 95% 1.02-1.1.74). CONCLUSIONS Following MI, patients without obstructive CAD experience an angina burden at least as high as those with obstructive CAD, affecting 1 in 4 patients at 12 months. As these patients are not candidates for revascularization, other anti-anginal strategies are needed to improve their health status and quality of life.

Bleeding risk following percutaneous coronary intervention in patients with diabetes prescribed dual anti-platelet therapy

BACKGROUND Patients with diabetes mellitus (DM) experience higher rates of in-stent restenosis and greater benefit from drug-eluting stents implant at the time of percutaneous coronary intervention (PCI), necessitating prolonged dual anti-platelet therapy (DAPT). While DAPT reduces risk of ischemic events post-PCI, it also increases risk of bleeding. Whether bleeding rates differ among patients with and without DM, receiving long-term DAPT is unknown. METHODS Among patients who underwent PCI and were maintained on DAPT for 1 year in a multicenter US registry, we assessed patient-reported bleeding over one year following PCI in patients with and without DM. Multivariable, hierarchical Poisson regression was used to evaluate the association of DM with bleeding during follow-up. RESULTS Among 2334 PCI patients from 10 US hospitals (mean age 64, 54% ACS), 32.6% had DM. In unadjusted analyses, patients with DM had fewer bleeding events over the year following PCI (DM vs no DM: BARC = 1: 78.0% vs 87.7%, P < .001; BARC ≥2: 4.3% vs 5.3%, P = .33). Following adjustment, patients with (vs without DM) had a lower risk of BARC ≥1 bleeding during follow-up (relative risk [RR] 0.89, 95% CI 0.83-0.96). This decreased bleeding risk persisted after removing bruising from the endpoint definition. CONCLUSIONS In a real-world PCI registry, patients with DM experienced lower risk of bleeding risk on DAPT. As patients with DM also derive greater ischemic benefit from drug-eluting stents, which requires prolonged DAPT, our findings suggest that the balance between benefit and risk of this therapeutic approach may be even more favorable in patients with DM than previously considered.

Residual angina after elective percutaneous coronary intervention in patients with diabetes mellitus

Background— Previous studies suggest that among patients with stable coronary artery disease, patients with diabetes mellitus (DM) have less angina and more silent ischemia when compared with those without DM. However, the burden of angina in diabetic versus nondiabetic patients after elective percutaneous coronary intervention (PCI) has not been recently examined. Methods and Results— In a 10-site US PCI registry, we assessed angina before and at 1, 6, and 12 months after elective PCI with the Seattle Angina Questionnaire angina frequency score (range, 0–100, higher=better). We also examined the rates of antianginal medication prescriptions at discharge. A multivariable, repeated-measures Poisson model was used to examine the independent association of DM with angina over the year after treatment. Among 1080 elective PCI patients (mean age, 65 years; 74.7% men), 34.0% had DM. At baseline and at each follow-up, patients with DM had similar angina prevalence and severity as those without DM. Patients with DM were more commonly prescribed calcium channel blockers and long-acting nitrates at discharge (DM versus not: 27.9% versus 20.9% [P=0.01] and 32.8% versus 25.5% [P=0.01], respectively), whereas &bgr;-blockers and ranolazine were prescribed at similar rates. In the multivariable, repeated-measures model, the risk of angina was similar over the year after PCI in patients with versus without DM (relative risk, 1.04; range, 0.80–1.36). Conclusions— Patients with stable coronary artery disease and DM exhibit a burden of angina that is at least as high as those without DM despite more antianginal prescriptions at discharge. These findings contradict the conventional teachings that patients with DM experience less angina because of silent ischemia.

The clot thickens: an incompletely ligated left atrial appendage

Summary Our patient presented with known mechanical mitral valve endocarditis documented by 2D transesophageal echocardiogram (TOE) from a recent hospitalization at an outside facility. On admission to our center, there was no prior knowledge of an incompletely ligated left atrial appendage (LAA) according to patient- or family-reported history, review of outside records or the outside facility’s 2D TOE report. A 3D TOE performed at our center to assess her pathology, since a month had passed from her prior hospitalization, revealed a LAA ligation with evidence of communication to the left atrium and with clot present in the appendage. This case report highlights the common finding of incomplete closure of the LAA following surgical ligation, thus making it inadequate for stroke prevention in patients with atrial fibrillation, and that 3D TOE plays a valuable role in assessing the durability of LAA ligation. Learning points: 3D transesophageal echocardiography (TOE) is a valuable tool in assessing the durability of left atrial appendage (LAA) ligation given the superior image granularity as compared with 2D TOE. LAA ligation may not be adequate for stroke prevention in patients with atrial fibrillation as incomplete closure is common following surgical ligation. LAA occlusion should be considered in these cases.

Poorly Understood Maternal Risks of Pregnancy in Women With Heart Disease

One of the most significant accomplishments of modern medicine worldwide is the dramatic 28% decrease in neonatal mortality during the past 20 years. However, although neonatal survival is improving and, for most of the world, maternal mortality is decreasing, this trend has not been seen in the United States. Neonatal survival has improved in the United States, whereas maternal mortality has increased from 7.2 deaths per 100 000 in 1989 to 17 deaths per 100 000 in 2013. In fact, the United States is the only developed nation with a rising maternal mortality rate. Maternal mortality is even higher for black women, approaching 4-fold that of their white, Asian, or Hispanic counterparts. Although cardiac disease complicates a small number of all pregnancies, it has become a leading cause of maternal morbidity and mortality, surpassing both hemorrhage and embolic events. Understanding the causes of this worrisome trend must become a research priority with plans to develop novel interventions to improve maternal outcomes, particularly as the birthrate in women >35 years of age and the associated comorbidities that go along with advanced maternal age continue to increase. Before the widespread institution of penicillin, rheumatic heart disease was the most common form of heart disease encountered in pregnancy. Marked improvements in treating congenital heart disease have led to more women with congenital cardiac malformations reaching reproductive age and …

ASSOCIATION OF SMOKING STATUS WITH HEALTH-RELATED OUTCOMES AFTER PERCUTANEOUS CORONARY INTERVENTION

Patients who smoke at the time of percutaneous coronary intervention (PCI) would ideally have a strong incentive to quit, but most do not. Showing how smoking cessation may be associated with the benefits of PCI, in terms of symptoms, function and quality of life, might provide a stronger incentive