Auras R. Atreya

Long-term outcomes following fractional flow reserve-guided treatment of angiographically ambiguous left main coronary artery disease: A meta-analysis of prospective cohort studies

To define the long term outcomes of Fractional Flow Reserve (FFR) guided revascularization of ambiguous left main coronary artery (LMCA) lesions by performing a pooled meta‐analysis of all available studies.

Validation and Comparison of Seven Mortality Prediction Models for Hospitalized Patients With Acute Decompensated Heart Failure

Background—Heart failure (HF) inpatient mortality prediction models can help clinicians make treatment decisions and researchers conduct observational studies; however, published models have not been validated in external populations. Methods and Results—We compared the performance of 7 models that predict inpatient mortality in patients hospitalized with acute decompensated heart failure: 4 HF-specific mortality prediction models developed from 3 clinical databases (ADHERE [Acute Decompensated Heart Failure National Registry], EFFECT study [Enhanced Feedback for Effective Cardiac Treatment], and GWTG-HF registry [Get With the Guidelines-Heart Failure]); 2 administrative HF mortality prediction models (Premier, Premier+); and a model that uses clinical data but is not specific for HF (Laboratory-Based Acute Physiology Score [LAPS2]). Using a multihospital, electronic health record–derived data set (HealthFacts [Cerner Corp], 2010–2012), we identified patients ≥18 years admitted with HF. Of 13 163 eligible patients, median age was 74 years; half were women; and 27% were black. In-hospital mortality was 4.3%. Model-predicted mortality ranges varied: Premier+ (0.8%–23.1%), LAPS2 (0.7%–19.0%), ADHERE (1.2%–17.4%), EFFECT (1.0%–12.8%), GWTG-Eapen (1.2%–13.8%), and GWTG-Peterson (1.1%–12.8%). The LAPS2 and Premier models outperformed the clinical models (C statistics: LAPS2 0.80 [95% confidence interval 0.78–0.82], Premier models 0.81 [95% confidence interval 0.79–0.83] and 0.76 [95% confidence interval 0.74–0.78], and clinical models 0.68 to 0.70). Conclusions—Four clinically derived, inpatient, HF mortality models exhibited similar performance, with C statistics near 0.70. Three other models, 1 developed in electronic health record data and 2 developed in administrative data, also were predictive, with C statistics from 0.76 to 0.80. Because every model performed acceptably, the decision to use a given model should depend on practical concerns and intended use.

Flecainide toxicity—treatment with intravenous fat emulsion and extra corporeal life support

ventricular arrhythmias include phase two re-entry as well as triggered automaticity following intracellular calcium accumulation in epicardial cells (5). Cardiac arrhythmias seen with hypothermia usually resolve spontaneously with rewarming (6). It has been noted that hypothermic myocardium is less responsive to antiarrhythmic drugs and defi brillation at temperatures below 28 ° C/82.4 ° F (6), as noted in our patient. When cardiac instability with loss of circulation is noted, the best available care includes extra-corporeal membrane oxygenation (ECMO) or CPB (7). Th e neurologically intact survival rate in cardiac arrest patients treated with these modalities is approximately 50% (8). In patients with return of spontaneous circulation, the rates of multi-organ failure are high and pulmonary edema is encountered frequently (8). Th is is probably why ECMO has slightly better outcomes than traditional CPB as it is capable of providing pulmonary support (7). Remarkably, the patient walked home, neurologically intact aft er a prolonged hospital stay complicated by acute respiratory distress syndrome, prolonged delirium, clostridium diffi cile colitis and acute tubular necrosis due to rhabdomyolysis. In summary, it is important to anticipate life-threatening arrhythmias when managing a severely hypothermic patient and recognize that usual resuscitative measures may fail. Early activation of surgical/trauma protocols to institute appropriate re-warming including CPB/ECMO is vital. Declaration of interest: Th e authors report no confl icts of interest. Th e authors alone are responsible for the content and writing of the paper.

ST segment elevation myocardial infarction as a presenting feature of thrombotic thrombocytopenic purpura.

Myocardial infarction with ST segment elevation (STE) on electrocardiography (ECG) is a common presentation in emergency rooms across the world. Myocardial injury and necrosis are infrequently the initial presentation in patients with thrombotic thrombocytopenic purpura (TTP). A 48-year-old woman presented with STE myocardial infarction from outside hospital for primary percutaneous coronary intervention. However, her clinical picture was not consistent. Rapid evaluation revealed symptoms associated with microangiopathic hemolytic anemia, thrombocytopenia, acute kidney injury with waxing and waning mental status. A diagnosis of TTP was made with low ADAMST-13 activity. Plasmapheresis was initiated along with intravenous steroid therapy. The patient had a full recovery and went home after full recovery of left ventricular ejection fraction and normal myocardial perfusion studies. Rapid evaluation is needed to identify infrequent causes of STE myocardial infarction. As swift protocols are activated in the emergency room and catheterization laboratories to ensure quality control, it is equally important to integrate all aspects of the patients clinical and objective data to detect unusual disease entities.

Toxoplasma encephalitis in an HIV-infected patient on highly active antiretroviral therapy despite sustained immune response:

Toxoplasma encephalitis (TE) is usually diagnosed in advanced stages of HIV infection when the CD4+ count is <100–200 cells/µl. A 55-year-old woman with HIV/AIDS, well controlled on antiretroviral therapy (ART), CD4+ count in the 300 cells/μl range for >1 year presented with acute onset of headache, nausea and vomiting. She had been on her current ART regimen consisting of raltegravir, co-formulated emtricitabine/tenofovir and etravirine for three years and had been off Pneumocystis prophylaxis for 10 months (trimethoprim-sulfamethoxazole). Brain MRI showed multiple ring-enhancing, supratentorial and infra-tentorial parenchymal lesions suspicious for metastases. She had no other evidence of metastatic disease in her body. The possibilities of TE and primary CNS lymphoma were considered but deemed unlikely given the high CD4+ count. A brain biopsy demonstrated Toxoplasma tachyzoites. There was no evidence of lymphoma or carcinoma. Anti-toxoplasma treatment yielded good initial clinical and radiographic responses. While on TE maintenance therapy, she developed similar symptoms. Repeat MRI showed progression of lesions. Further work-up including CSF Epstein-Barr virus PCR and SPECT Th 201 imaging was not conclusive for CNS lymphoma. The patient’s clinical condition deteriorated and she died. We postulate that functional immunological dysfunction is a possible mechanism by which our patient developed TE despite demonstrating sustained immune response on ART.

Complications arising from cardiac implantable electrophysiological devices: review of epidemiology, pathogenesis and prevention for the clinician.

ABSTRACT Cardiac implantable electronic devices (CIEDs) which include devices such as permanent pacemakers, implantable cardioverter-defibrillators and cardiac resynchronization therapy devices are well established therapies that have been shown to improve quality of life and prolong survival in appropriately selected patients, and are being increasing utilized across the world. However, CIED implantations are invasive procedures and a thorough understanding of the potential complications is required to prevent deleterious patient outcomes. In this review, we will discuss frequent complications (infection, hematoma or bleeding, and procedural mechanical complications) that may harm patients after CIED implantation, and the steps that can be taken to minimize their risk. This is particularly relevant to trainees/ clinicians who either perform these procedures or refer patients for CIED implantation.

The heavy LEGACY: Should weight management be part of every atrial fibrillation clinic?

As the global burden of atrial fibrillation (AF) and its attendant economic impact on the healthcare system surges, there is increasing interest in the secondary prevention of AF with various therapies. Of the several identified risk factors for AF, obesity is an important contributor that may be managed with intensive lifestyle modification. Prior studies have demonstrated the short-term and long-term benefits of weight loss in reduction of AF symptoms. In the LEGACY study [Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study], the investigators evaluated the long-term effects of a weight management program on AF symptoms. Of the 355 patients included in this cohort, outcomes such as AF symptom burden, arrhythmia-free survival, inflammatory markers and structural cardiac changes all appear to have improved in the intense weight loss group as compared to the 2 other groups. Further, the benefits of weight loss appear to be lost when > 5% weight fluctuation (WF) occurred over the 5-year follow-up period. In this review, we discuss the design of the weight management clinic and its impact on the management of AF in the LEGACY study. Given that weight management appears to be an effective intervention that will not have the marketing and financial push that pharmaceutical and device based therapies enjoy, it behooves administrators of AF clinics to develop innovative funding strategies to incorporate weight management programs in order to improve patient-centered outcomes.

Quality of Care of Hospitalized Infective Endocarditis Patients: Report from a Tertiary Medical Center

OBJECTIVE: There have been no recent studies describing the management and outcomes of patients with infective endocarditis (IE). PATIENTS AND METHODS: We conducted a retrospective cohort study of adult patients admitted to a tertiary medical center from 2007 to 2011 with a Duke criteria consistent discharge diagnosis of IE. We examined concordance with guideline recommendations. Outcomes included embolic events, inhospital and 1‐year mortality, length of stay (LOS) and cardiac surgery. We used descriptive statistics to describe the cohort and Fisher exact and unpaired t tests to compare native valve endocarditis (NVE) with prosthetic valve endocarditis (PVE). RESULTS: Of 170 patients, definite IE was present in 135 (79.4%) and possible IE in 35 (20.6%); 74.7% had NVE, and 25.3% had PVE. Mean ± standard deviation age was 60.0 ± 17.9 years. Comparing PVE to NVE, patients with PVE were less likely to have embolic events (14.0% vs. 32.3%; P = 0.03), had shorter LOS (median 12.0 days vs. 14.0 days; P = 0.047), but they did not show a statistically significant difference in inhospital mortality (20.9% vs. 12.6%; P = 0.21). Of 170, patients 27.6% (n = 47) underwent valve surgery. Most patients received timely blood cultures and antibiotics. Guideline‐recommended consults were underused, with 86.5%, 54.1%, and 47.1% of patients receiving infectious disease, cardiac surgery, and cardiology consultation, respectively. As the number of consultations increased (from 0 to 3), we observed a nonsignificant trend toward reduction in 6‐month readmission and 12‐month mortality. CONCLUSION: IE remains a disease with significant morbidity and mortality. There are gaps in the care of IE patients, most notably underuse of specialty consultation.

Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial

We readwith great pleasure thework done by Riley et al. [1]. The authors have done commendable work to show that the HEART Pathway as a decision aid for patients with undifferentiated chest pain achieved cost savings. This would be of considerable value if replicated in routine clinical practice, given the burden of chest pain emergency room (ER) visits across the country [2]. We would like to share our concerns and thoughts on the cost analysis reported here and its implications. First, the authors chose to use a healthcare system perspective and not a societal perspectivewhich is typically the norm for economic evaluation [3]. If a societal perspective is considered, the scope of costs to be considered would be much broader, including those that accrue to patients directly, such as transportation costs. This is particularly relevant to a patient presenting with chest pain to the ER whomay be unable to receive care outside of this safety net setting owing to a variety of reasons. Second, although the original randomized controlled study only collected outcomes for 30 days, ideally the period of analysis (time horizon) for this cost analysis should be longer than 30 days. It is easy to imagine a situation where a patient in the HEART pathway was discharged early from the ER but was only able to obtain a primary care appointment 6 weeks from the ER visit. If a stress test was then ordered, this cost would not have been captured in this study. A time horizon of 6 months or 1 year would be more appropriate, with modeling of estimated costs for the purpose of the analysis. If cost-effectiveness is calculated, this would require modeling of outcomes as well. Third, the authors did not perform any sensitivity analysis which is typically

Randomized controlled trial of remote ischemic preconditioning and atrial fibrillation in patients undergoing cardiac surgery

AIM To study whether remote ischemic preconditioning (RIPC) has an impact on clinical outcomes, such as post-operative atrial fibrillation (POAF). METHODS This was a prospective, single-center, single-blinded, randomized controlled study. One hundred and two patients were randomized to receive RIPC (3 cycles of 5 min ischemia and 5 min reperfusion in the upper arm after induction of anesthesia) or no RIPC (control). Primary outcome was POAF lasting for five minutes or longer during the first seven days after surgery. Secondary outcomes included length of hospital stay, incidence of inpatient mortality, myocardial infarction, and stroke. RESULTS POAF occurred at a rate of 54% in the RIPC group and 41.2% in the control group (P = 0.23). No statistically significant differences were noted in secondary outcomes between the two groups. CONCLUSION This is the first study in the United States to suggest that RIPC does not reduce POAF in patients with elective or urgent cardiac surgery. There were no differences in adverse effects in either group. Further studies are required to assess the relationship between RIPC and POAF.