Anupama Kottam

Uric acid and cardiovascular disease risk reclassification: Findings from NHANES III

Background The studied associations between serum uric acid (sUA) and cardiovascular disease (CVD) events have been controversial. We sought to evaluate the association between sUA and CVD mortality, including its ability to reclassify risk in a multiethnic nationally representative population free of clinical CVD and diabetes at baseline. Methods The study cohort included 11,009 adults enrolled as a part of the National Health and Nutrition Examination Survey (NHANES) III. Multivariate Cox proportional hazard analysis was performed to evaluate sUA as a predictor of CVD and coronary heart disease (CHD) mortality. Discriminative and recalibrative properties of sUA for CHD deaths were also assessed over traditional CVD risk factors. Net reclassification index (NRI) was calculated by comparing regression models incorporating traditional CVD risk factors with and without sUA. Results sUA was not predictive of either CVD mortality [model 4: hazards ratio (HR) 1.06, 95% confidence interval (CI) 0.96–1.16, p = 0.27] or CHD mortality (model 4: HR 1.06, 95% CI 0.94–1.19, p = 0.32). Addition of sUA to traditional CVD risk factors resulted in no significant increment in c-statistic, receiver-operating characteristics–area under curve, absolute NRI (0.5%, 95% CI –1.9 to 2.9%, p = 0.68), or intermediate NRI (2.5%, 95% CI –1.6 to 6.6%, p = 0.24) for prediction of hard CHD deaths. Conclusions sUA was not an independent predictor of both CVD and CHD mortality. Ethnicity did not influence the association of sUA with CVD mortality. Furthermore, sUA did not add to risk assessment beyond traditional CVD risk factors.

Cardiac Magnetic Resonance Imaging in Peripartum Cardiomyopathy

Background:Peripartum cardiomyopathy (PPCM) is a rare life-threatening condition of unclear etiology. Data on the use of cardiac magnetic resonance (CMR) imaging to characterize PPCM are limited. This study was done to assess the role of CMR imaging for the diagnosis and prognostication of patients with PPCM. Methods:Medical records of a tertiary medical center were screened for PPCM patients with CMR imaging done within the past 5 years (2006–2011). Images were reviewed by 2 expert radiologists (blinded to clinical data) using cine sequences for chamber function and size, T2-weighted images for the determination of edema (T2-ratio), and late gadolinium enhancement (LGE) sequences for myocardial tissue characterization. Results:Ten PPCM patients (aged 28 ± 6 years, 90% African American) had a total of 15 CMR examinations: 4 in the acute phase (within 7 days of diagnosis) and 11 during follow-up (median, 12 months; range, 1–72 months). Left ventricular ejection fraction was decreased in all 4 initial scans. Elevated T2 ratio (>2) seen in 1 patient decreased on follow-up imaging. LGE was seen in 1 of the 4 acute-phase scans and in 4 of the 11 follow-up phase scans. These 4 patients had multiple readmissions because of heart failure exacerbations and persistently low left ventricular ejection fraction on subsequent echocardiograms. Conclusions:LGE seems to be associated with a poor prognosis in the setting of PPCM. CMR imaging seems to have promising practical implications in the diagnosis and prognostication of PPCM patients.

Myocardial Cleft, Crypt, Diverticulum, or Aneurysm? Does it Really Matter?

Myocardial clefts are congenital abnormalities related to myocardial fiber or fascicle disarray that have been described in healthy volunteers as well as in the setting of hypertrophic cardiomyopathy. A cleft or crypt can be described as a discrete, approximately “V” shaped fissure extending into but confined by the myocardium, with a tendency to narrow or occlude in systole without local hypokinesia or dyskinesia. While little is known about the clinical significance of this entity, this report elaborates on the confounding terminology and differential diagnosis of this condition. Copyright

Usefulness of Intravenously Administered Fluid Replenishment for Detection of Patent Foramen Ovale by Transesophageal Echocardiography

Patent foramen ovale (PFO) is associated with cryptogenic stroke, migraine headache, decompression sickness, and platypnea-orthodeoxia syndrome. Patients undergoing transesophageal echocardiography are often hypovolemic from preprocedural fasting and might not demonstrate right to left shunting owing to insufficient right atrial pressure generation, despite provocative maneuvers. We hypothesized that volume replenishment with saline loading could potentially unmask a PFO by favorably modulating the interatrial pressure gradient. Our study sought to examine the role of pre- or intraprocedural intravenous fluid replenishment on PFO detection during transesophageal echocardiography. A total of 103 patients were enrolled. An initial series of bubble injections was performed unprovoked and then with provocative maneuvers such as the Valsalva maneuver and coughing. The patients were then given a rapid 500 ml saline bolus, and the same sequence of bubble injections was repeated. The presence, type, and magnitude of the right to left shunts were noted before and after the saline bolus. The detection rate of PFO increased from 10.6% to 26.2% after saline loading without any provocative maneuvers. When combined with provocative maneuvers (Valsalva or cough), saline loading improved the detection rate from 17.4% to 32.0%. Overall, from amongst the 103 enrolled patients, saline bolusing resulted in a de novo diagnosis of PFO in 15 patients, atrial septal aneurysm in 15, PFO coexisting with an atrial septal aneurysm in 10, and pulmonary arteriovenous fistula in 5 patients. In conclusion, saline infusion in appropriately selected patients during transesophageal echocardiography significantly enhances the detection of PFOs and pulmonary arteriovenous fistulas.

Novel oral anticoagulants in patients undergoing cardioversion for atrial fibrillation

Abstract Recent trials on novel oral anticoagulants (NOAC) in patients undergoing cardioversion showed that NOACs are as safe and effective as treatment with vitamin K antagonists in patients with atrial fibrillation undergoing electric or pharmacological cardioversion. We conducted an EMBASE and MEDLINE search for studies in which patients undergoing cardioversion were assigned to treatment with NOACs versus VKAs. We identified one prospective randomized study and three post hoc analysis of randomized trials which enrolled 2,788 controls that received NOACs and 1,729 patients that received VKAs. NOACs and VKAs had comparable effects on the rates of stroke/thromboembolism, major bleeding events and all-cause mortality. NOACs are safe and effective alternatives to VKA in patients with AF undergoing cardioversion.

Purulent Pericardial Effusion From Community-Acquired Methicillin-Resistant Staphylococcus aureus

Abstract: Although the incidence of purulent pericarditis has decreased significantly in the modern antibiotic era, a high index of clinical suspicion should be maintained to diagnose this life-threatening illness at an early stage. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a global pathogen and notorious for its ability to cause infection in otherwise healthy individuals. However, it has been associated with purulent pericarditis only in some sporadic case reports. The authors describe a case of purulent pericardial effusion caused by CA-MRSA infection. To the best of our knowledge, this is only the fourth case of CA-MRSA pericarditis to be reported in English literature.

Non-high-density lipoprotein cholesterol and coronary artery calcium progression in a multiethnic US population.

Non-high-density lipoprotein cholesterol (non-HDLc) is an independent predictor of cardiovascular disease risk, with elevated levels signifying an increased risk beyond low-density lipoprotein. Previous data have shown inconsistent association of lipid subfractions with progression of coronary artery calcium (CAC), a surrogate marker of incident cardiovascular disease. We sought to evaluate the association between non-HDLc and development (incident) and progression of CAC in a cohort of multiethnic asymptomatic subjects. The cohort (n = 5,705) was derived from the limited access data set of the Multi-Ethnic Study of Atherosclerosis obtained from the National Heart Lung and Blood Institute. Multivariable regression analysis was performed to derive the association between non-HDLc and incident CAC (n = 2,927) and non-HDLc and progression of CAC (n = 2,778). In the population without CAC at baseline, non-HDLc, especially >190 mg/dl, was independently associated with incident CAC (relative risk 1.40, 95% confidence interval 1.09 to 1.79, p = 0.008) after adjustments with age, gender, race, systolic blood pressure, antihypertension medication use, smoking, diabetes, lipid-lowering therapy use, follow-up duration, and waist-hip ratio. Similarly, among those with CAC at baseline, non-HDLc levels >190 mg/dl were associated with significant CAC progression in the overall population (β 16.4, 95% confidence interval -5.63 to 27.2, p = 0.003) after adjustments. In conclusion, non-HDLc levels, especially >190 mg/dl, are consistently associated with increased risk of CAC progression. Our results suggest that among lipid fractions, non-HDLc may be best suited for the prediction of future CAC progression.

Echocardiography in Infective Endocarditis: State of the Art

Purpose of ReviewIn this review, we examine the central role of echocardiography in the diagnosis, prognosis, and management of infective endocarditis (IE).Recent Findings2D transthoracic echocardiography (TTE) and transesophageal echocardiography TEE have complementary roles and are unequivocally the mainstay of diagnostic imaging in IE. The advent of 3D and multiplanar imaging have greatly enhanced the ability of the imager to evaluate cardiac structure and function. Technologic advances in 3D imaging allow for the reconstruction of realistic anatomic images that in turn have positively impacted IE-related surgical planning and intervention. CT and metabolic imaging appear to be emerging as promising ancillary diagnostic tools that could be deployed in select scenarios to circumvent some of the limitations of echocardiography.SummaryOur review summarizes the indispensable and central role of various echocardiographic modalities in the management of infective endocarditis. The complementary role of 2D TTE and TEE are discussed and areas where 3D TEE offers incremental value highlighted. An algorithm summarizing a contemporary approach to the workup of endocarditis is provided and major societal guidelines for timing of surgery are reviewed.

URIC ACID AND CARDIOVASCULAR DISEASE RISK RECLASSIFICATION

The association between serum uric acid and cardiovascular (CVD) events has been controversial. However usefulness of a new biomarker is measured in its ability to reclassify CVD events beyond traditional risk factors beyond the mere association. We sought evaluate the association between serum uric

Single-photon emission computed tomography perfusion imaging: is using a "warranty period" warranted?

In business and legal transactions, a warranty is an assurance by one party to the other party that certain facts or conditions are true or will happen; the other party is permitted to rely on that assurance and seek some type of remedy if it is not true or followed. http://en.wikipedia.org/wiki/Warranty As single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has reached scientific and clinical maturity, we have grown to expect that the results of this test when negative, reliably predicts an excellent patient outcome. Typically, less than 1% of patients with a normal study will have a “hard” cardiac event, defined as myocardial infarction or cardiac death, but that 1% can be shortened or lengthened based on the presence of coronary artery disease (CAD), cardiac symptoms, age, sex, the need for pharmacological stress, and coronary risk factors such as diabetes mellitus. The time variability was assessed by Hachamovitch et al,1 and termed the “warranty period” for a normal SPECT MPI, defined the time to 1% risk of a cardiac event per year. The study published in this issue of Circulation: Cardiovascular Imaging by Carryer et al2 sought to explore the timing of follow-up SPECT study after a normal initial study and its prediction of cardiac events during a 5-year follow-up. They identified 3010 patients with a normal SPECT …