Bhanu Gupta

Prognostic Implications of Normal (<0.10 ng/ml) and Borderline (0.10 to 1.49 ng/ml) Troponin Elevation Levels in Critically Ill Patients Without Acute Coronary Syndrome

Borderline increase of troponin I (cTnI) is associated with higher rates of cardiovascular events compared with normal levels in the setting of acute coronary syndrome (ACS), but the significance of borderline cTnI levels in patients without chest pain may differ. The aim of this study was to determine the prognostic implications of intermediate serum cTnI levels in patients without ACS in the intensive care unit (ICU). This was a 12-month retrospective study of 240 patients without ACS in the ICU with normal (<0.1 ng/ml) or intermediate (0.1 to 1.49 ng/ml) cTnI levels. End points included in-hospital mortality, lengths of ICU and hospital stays, and rates of postdischarge readmission and mortality. Overall in-hospital mortality was 13%, with 5% in the normal cTnI group and 28% in the intermediate cTnI group. By multivariate analysis, intermediate cTnI was independently associated with in-hospital mortality (p = 0.004) and length of ICU stay (p = 0.028). The only other independent risk factor for inpatient mortality was a standardized ICU prognostic measurement (Simplified Acute Physiology Score II score). Intermediate cTnI had no prognostic implications regarding length of hospital stay, readmission rate, or postdischarge mortality at 6 months. In conclusion, an intermediate level of cTnI in patients without ACS in the ICU is an independent prognostic marker predicting in-hospital mortality and length of ICU stay. Patients with intermediate cTnI levels who survive to discharge have equivalent out-of-hospital courses for up to 6 months compared with patients with normal cTnI levels.

Effects of statins on coronary and peripheral endothelial function in humans: a systematic review and meta-analysis of randomized controlled trials

Objective: The purpose of this study was to quantify the effect of statins on peripheral and coronary endothelial function in patients with and without established cardiovascular disease. Background: Early atherosclerosis is characterized by endothelial dysfunction, a known prognostic factor for cardiovascular disease. Methods and results: The search included MEDLINE, Cochrane Library, Scopus, and EMBASE to identify studies up to 1 December 2009. Eligible studies were randomized controlled trials on the effects of statins compared with placebo on endothelial function. Two reviewers extracted data on study characteristics, methods, and outcomes. Forty-six eligible trials enrolled a total of 2706 patients: 866 (32%) were women and 432 (16%) had established cardiovascular disease. Meta-analysis using random-effects models showed treatment with statins significantly improved endothelial function [standardized mean difference (SMD) 0.66, 95% CI 0.46–0.85, p < 0.001]. Subgroup analyses demonstrated statistically significant improvement in endothelial function assessed both peripherally by flow-mediated dilatation (SMD 0.68, 95% CI 0.46–0.90, p < 0.001) and venous occlusion plethysmography (SMD 0.59, 95% CI 0.06–1.13, p = 0.03) and centrally in the coronary circulation by infusion of acetylcholine (SMD 1.58, 95% CI 0.31–2.84, p = 0.01). Significant heterogeneity observed across studies was explained in part by the type of endothelial function measurement, statin type and dose, and study population differences. Exclusion of outlier studies did not significantly alter the results. Conclusion: Statin therapy is associated with significant improvement in both peripheral and coronary endothelial function. The current study supports a role for statin therapy in patients with endothelial dysfunction.

Coronary artery diseasePrognostic Implications of Normal (<0.10 ng/ml) and Borderline (0.10 to 1.49 ng/ml) Troponin Elevation Levels in Critically Ill Patients Without Acute Coronary Syndrome

Borderline increase of troponin I (cTnI) is associated with higher rates of cardiovascular events compared with normal levels in the setting of acute coronary syndrome (ACS), but the significance of borderline cTnI levels in patients without chest pain may differ. The aim of this study was to determine the prognostic implications of intermediate serum cTnI levels in patients without ACS in the intensive care unit (ICU). This was a 12-month retrospective study of 240 patients without ACS in the ICU with normal (<0.1 ng/ml) or intermediate (0.1 to 1.49 ng/ml) cTnI levels. End points included in-hospital mortality, lengths of ICU and hospital stays, and rates of postdischarge readmission and mortality. Overall in-hospital mortality was 13%, with 5% in the normal cTnI group and 28% in the intermediate cTnI group. By multivariate analysis, intermediate cTnI was independently associated with in-hospital mortality (p = 0.004) and length of ICU stay (p = 0.028). The only other independent risk factor for inpatient mortality was a standardized ICU prognostic measurement (Simplified Acute Physiology Score II score). Intermediate cTnI had no prognostic implications regarding length of hospital stay, readmission rate, or postdischarge mortality at 6 months. In conclusion, an intermediate level of cTnI in patients without ACS in the ICU is an independent prognostic marker predicting in-hospital mortality and length of ICU stay. Patients with intermediate cTnI levels who survive to discharge have equivalent out-of-hospital courses for up to 6 months compared with patients with normal cTnI levels.

Is directly measured low-density lipoprotein clinically equivalent to calculated low-density lipoprotein?

BACKGROUND Low-density lipoprotein cholesterol (LDL-C) can either be calculated or measured directly. Clinical guidelines recommend the use of calculated LDL-C (C-LDL-C) to guide therapy because the evidence base for cholesterol management is derived almost exclusively from trials that use C-LDL-C, with direct measurement of LDL-C (D-LDL-C) being reserved for those patients who are nonfasting or with significant hypertriglyceridemia. OBJECTIVE Our aim was to determine the clinical equivalence of directly measured-LDL-C, using a Siemens Advia Chemistry System, and fasting C-LDL-C. METHODS Eighty-one subjects recruited for two cholesterol treatment studies had at least one C-LDL-C and D-LDL-C performed simultaneously; 64 had a repeat lipid assessment after 4 to 6 weeks of therapy, resulting in 145 pairs of C-LDL-C and D-LDL-C. RESULTS There was significant correlation between D-LDL-C and C-LDL-C (r² = 0.86). Correlation was significantly better in those with lower total cholesterol, triglycerides, and high-density lipoprotein. In 60% of subjects, the difference between D-LDL-C and C-LDL-C was more than 5 mg/dL and greater than 6%. Clinical concordance between D-LDL-C and C-LDL-C was present in 40% of patients, whereas clinical discordance was noted in 25%. One-third had greater than a 15 mg/dL difference between D-LDL-C and C-LDL-C, whereas 25% had a greater than 20 mg/dL difference. In 47% of subjects, the difference between D-LDL-C and C-LDL-C at baseline and follow-up changed by a minimum of 10% or 10 mg/dL. CONCLUSIONS Our findings suggest that D-LDL-C is not clinically equivalent to C-LDL-C. This puts into question the current recommendation of using D-LDL-C in situations in which C-LDL-C would be inaccurate.

Clinical presentation and outcome of perioperative myocardial infarction in the very elderly following hip fracture surgery

BACKGROUND Patterns of clinical symptoms and outcomes of perioperative myocardial infarction (PMI) in elderly patients after hip fracture repair surgery are not well defined. METHODS A retrospective 1:2 case-control study in a cohort of 1212 elderly patients undergoing hip fracture surgery from 1988 to 2002 in Olmsted County, Minnesota. RESULTS The mean age was 85.3 ± 7.4 years; 76% female. PMI occurred in 167 (13.8%) patients within 7 days, of which 153 (92%) occurred in first 48 hours; 75% of patients were asymptomatic. Among patients with PMI, in-hospital mortality was 14.4%, 30-day mortality was 29 (17.4%), and 1-year mortality was 66 (39.5%). PMI was associated with a higher inpatient mortality rate (odds ratio [OR], 15.1; confidence interval [CI], 4.6-48.8), 30-day mortality (hazard ratio [HR], 4.3; CI, 2.1-8.9), and 1-year mortality (HR, 1.9; CI, 1.4-2.7). CONCLUSION Elderly patients, after hip fracture surgery, have a higher incidence of PMI and mortality than what guidelines indicate. The majority of elderly patients with PMI did not experience ischemic symptoms and required cardiac biomarkers for diagnosis. The results of our study support the measurement of troponin in postoperative elderly patients for the diagnosis of PMI, in order to implement in-hospital preventive strategies to reduce PMI-associated mortality.

Discordance of Non-HDL and Directly Measured LDL Cholesterol: Which Lipid Measure is Preferred When Calculated LDL is Inaccurate?

Objective. To determine if non-HDL cholesterol (N-HDL) and directly measured LDL cholesterol (D-LDL) are clinically equivalent measurements. Patients and Methods. Eighty-one subjects recruited for 2 cholesterol treatment studies had at least 1 complete fasting lipid panel and D-LDL performed simultaneously; 64 had a second assessment after 4 to 6 weeks, resulting in 145 triads of C-LDL, D-LDL, and N-HDL. To directly compare N-HDL to D-LDL and C-LDL, we normalized the N-HDL by subtracting 30 from the N-HDL (N-HDLA). Results. There was significant correlation between N-HDLA, D-LDL, and C-LDL. Correlation was significantly greater between N-HDLA and C-LDL than between N-HDLA and D-LDL. A greater than 20 mg/dL difference between measures was observed more commonly between N-HDLA and D-LDL, 29%, than between C-LDL and N-HDLA, 11% (P < 0.001), and C-LDL and D-LDL, 17% (P = 0.028). Clinical discordance was most common, and concordance was least common between N-HDL and D-LDL. Conclusions. Our findings suggest that N-HDL cholesterol and D-LDL cholesterol are not clinically equivalent and frequently discordant. As N-HDL may be superior to even C-LDL for predicting events in statin-treated patients, utilizing N-HDL to guide therapy would appear to be preferable to D-LDL when C-LDL is inaccurate.

The dose of continuous renal replacement therapy for acute renal failure: a systematic review and meta-analysis

Objectives: To conduct a systematic review of the literature to summarize the best available evidence regarding the mortality and morbidity associated with differing dosing regimens of continuous renal replacement therapy (CRRT) for patients with acute renal failure (ARF) in an intensive care unit setting. Patients and Methods: We searched for randomized controlled trials in electronic databases from January 1990 through November 2009. Eligible trials compared two or more dosing regimens of CRRT in patients with ARF. Two reviewers working independently determined trial eligibility and extracted descriptive, methodological, and outcome data. Random-effects meta-analysis was used to assess relative risks (RR) and weighted mean difference. The I2-statistic was used to assess heterogeneity of treatment effect across trials. Results: Seven trials were eligible for meta-analysis. We found no reduction in mortality in patients who received higher doses of CRRT (RR 0.88, 95% CI 0.75–1.03, I2 = 74%). There was no difference in the requirement of renal replacement therapy at the conclusion of the study period (RR 1.12, 95% CI 0.86–1.46, I2 = 3%). The overall quality of evidence was downgraded because of imprecision and heterogeneity. Conclusion: Increased dosing of CRRT is not associated with a decrease in mortality of patients with ARF in an intensive care unit setting.

Incidence and 1‐Year Outcomes of Perioperative Atrial Arrhythmia in Elderly Adults After Hip Fracture Surgery

To determine the incidence and 1‐year outcomes of an elderly population with perioperative atrial arrhythmia (PAA) within 7 days of hip fracture surgery.

Effect on Serum Lipid Levels of Switching Dose of Ezetimibe from 10 to 5 mg

Although during its initial development, lower doses of ezetimibe reduced low-density lipoprotein (LDL) significantly, ezetimibe is available only in 10-mg form. Compliant patients receiving ezetimibe 10 mg were randomized in a blinded fashion to continue therapy with ezetimibe 10 mg or to convert to a split-tablet 5-mg dose. Lipid panels were collected at baseline and after 4 weeks of therapy. The impact of the 2 ezetimibe dosing strategies on LDL and the achievement of the Adult Treatment Panel III LDL goal was evaluated. One hundred thirty patients receiving ezetimibe 10 mg were screened for eligibility. Thirty-nine of the 130 patients were randomized; 36 patients successfully completed the study. All patients who had achieved their Adult Treatment Panel III LDL goals at baseline remained at their LDL goals after conversion to 5 mg. In conclusion, conversion to the lower dose of ezetimibe did not result in any clinically meaningful or statistically significant changes in any lipid parameter.

Thrombosis in the Surgically Corrected Anomalous Right Coronary Artery after Reimplantation in Aorta

A 32-year-old African American female presented with dyspnea, and after several cardiac diagnostic tests, the diagnosis of an anomalous origin of the RCA from the pulmonary trunk was established by multislice coronary CT angiography. She underwent surgical correction with reimplantation of the RCA, from the pulmonary artery to the aortic root. However, 10 days after surgery, she developed frequent episodes of chest pain, and repeat coronary CTA showed a partially occlusive thrombus in the surgically reimplanted RCA. Anticoagulation with warfarin resulted in complete resolution of the patients symptoms.