Carsten Schmalfuss

Systolic compression of the left anterior descending coronary artery: a case series, review of the literature, and therapeutic options including stenting.

Six cases in our institution of various presentations of left anterior descending (LAD) myocardial bridging were found on coronary angiography. Generally a benign condition, this finding can result in ischemia or infarction as seen in some of our cases. We found one case in which the bridge resulted in an anterior myocardial infarction in an elderly patient, one case with fixed stenoses at the entry and exit point of the bridge causing ischemia, another with vasospasm within the bridged segment, one case in which the patient was referred for intervention of a fixed stenosis which after intracoronary nitroglycerin (NTG) was found to be an LAD bridge, another case in which the thallium myocardial perfusion scan revealed a reversible anterior defect, and finally one case with anginal chest pain despite a normal coronary flow reserve proximal and distal to the bridged segment. Our treatments varied from stenting in three patients to medical therapy in the remaining patients. We concluded that a thorough evaluation in this population should include functional testing for ischemia, intravascular ultrasound to assess wall thickness, and coronary flow reserve measurements in order to determine the significance of the these bridges. Stenting may have a role in select patients. However, additional studies are needed. Cathet Cardiovasc Intervent 2002;56:58–63.

Superoxide Anion Generation, Superoxide Dismutase Activity, and Nitric Oxide Release in Human Internal Mammary Artery and Saphenous Vein Segments

Background: Internal mammary artery (IMA) as conduit for a coronary artery bypass graft (CABG) stays patent longer and more often than saphenous vein (SV). However, the pre cise differences in the biology of IMA and SV are unclear. Methods and Results: To examine inherent difference in superoxide anion, superoxide dis mutase (SOD) and nitric oxide (NO) formation in IMA and SV as a basis for differences in patency rates, we measured these parameters in vascular segments of patients undergoing CABG. Superoxide anion generation was measured by lucigenin chemiluminescence and reduction of cytochrome c, SOD by inhibition of pyrogallol auto-oxidation, and NO as nitrite/nitrate fluorometrically using 2-3-diaminonaphthalene as a probe. Generation of superoxide anion, SOD activity, and NO formation were all greater in the IMA than in the SV segments (IMA:SV = 2.6:1, 2.9:1, 1, and 3.0:1, respectively, all P < .01). There was a pos itive correlation between superoxide anion generation and SOD activity (r = 0.65, P < .05; r = 0.70, P < .05 in IMA and SV, respectively) and NO release (r = 0.68, P < .05; r = 0.75, P < .03 in IMA and SV, respectively). Western blot analysis showed no differences in SOD and NO synthase protein expression in IMA and SV segment homogenates. To examine whether greater superoxide anion generation, SOD activity, and NO formation are unique to IMA, we studied pulmonary artery (PA) and pulmonary vein (PV) segments taken from patients undergoing lung resection. Superoxide anion generation, SOD activity, and NO formation were also found to be greater in PA than in PV segments. Conclusions: Inherently greater superoxide anion generation and subsequently increased formation of SOD and NO release in IMA (vs SV) may be a factor in the greater patency of the former as CABG conduit. Because both IMA and PA are exposed to pulsatile stretch and carry blood at higher pressure than the SV and PV, it is likely that these 2 factors account for the observed differences.

Pharmacological treatment of patients with peripheral arterial disease.

Atherosclerosis is a disease process that affects the coronary, cerebral and peripheral arterial circulation. While great emphasis has been placed on the aggressive pharmacological management of coronary artery disease, less attention has been paid to the pharmacological management of peripheral vascular disease, despite its significant morbidity and mortality. The purpose of medical management in peripheral arterial disease is to relieve symptoms of claudication and to prevent thrombotic vascular events. These goals are best achieved through aggressive risk factor modification and pharmacotherapy. Risk factor modification includes smoking cessation, adequate control of blood pressure and cholesterol, as well as aggressive glycaemic control in patients with diabetes mellitus. Antiplatelet therapy and relief of claudication is also achieved through pharmacotherapy. With aggressive risk factor modification and adequate pharmacotherapy, patients with peripheral arterial disease can have an improved quality of life as well as prolonged survival.

Tako-Tsubo Cardiomyopathy and Cardiac Magnetic Resonance Imaging

The author has no funding, financial relationships, or conflicts of interest to disclose.

Predictors of short‐ and long‐term mortality in hospitalized veterans with elevated troponin

BACKGROUND Cardiac troponin elevation is associated with mortality. We compared the mortality risk related to elevated troponin from acute coronary syndrome (ACS) and non-ACS causes in a hospitalized elderly veteran population. METHODS AND RESULTS As part of a quality initiative at our Veterans Affairs hospital, all patients with elevated troponin were evaluated by a cardiologist to determine if ACS was present and to recommend management. We selected a sample (n = 761) of consecutive patients studied between February 2006 and February 2007 and examined all-cause mortality over extended follow-up. Nearly all were men (99.1%), and about half had coronary disease (n = 385, 50.5%) and diabetes (n = 339, 44.4%). ACS patients had lower mortality that non-ACS patients. Mortality began to diverge at 30 days; at 1 year it was 42.0% versus 29.0% (odds ratio [OR]: 0.56, 95% confidence interval [CI]: 0.41-0.78) and at 6 years 77.7% versus 58.7% (OR: 0.41, 95% CI: 0.30-0.56). Cox regression models for mortality at multiple time points yielded several independent factors associated with mortality; however, the distribution of the factors was not sufficient to explain the observed difference in mortality. CONCLUSIONS In this elderly, male veteran population, mortality related to an elevated troponin was higher at 1 and 6 years for non-ACS patients compared with ACS patients. Factors independently associated with a higher mortality risk were predominantly markers of general systemic illness, but did not elucidate the reasons why troponin elevation secondary to non-ACS causes carries this higher risk. A better understanding of these cardiac troponin elevations and implications for future mortality requires additional investigation. Journal of Hospital Medicine 2016;11:773-777.

Incidence of acute kidney injury after intravenous administration of iodixanol for computed tomographic angiography.

a North Florida/South Georgia Veterans Affairs Health System, Gainesville, FL, United States b Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States c Department of Radiology, Washington University School of Medicine, St. Louis, MO, United States d Appleton Cardiology, Appleton, WI, United States e Sacramento Heart and Vascular Research Center, Sacramento, CA, United States f Department of Radiology, University of California, San Diego Medical Center, San Diego, CA, United States

CONTINUOUS WEARABLE MONITORING ANALYTICS PREDICT HEART FAILURE DECOMPENSATION: THE LINK-HF MULTI-CENTER STUDY

Implantable devices have shown promise in reducing rehospitalization for heart failure (HF), but less expensive non-invasive approaches are needed. The LINK-HF study examined the performance of a personalized analytics platform using continuous multivariate data streams to predict rehospitalization

A specialty-specific, multimodality educational quality improvement initiative to deimplement rarely appropriate myocardial perfusion imaging

Objective Investigations of Appropriate Use Criteria (AUC) education have shown a mixed effect on changing provider behaviour. At our facility, rarely appropriate myocardial perfusion imaging (MPI) differs by specialty; awareness of AUC is low. Our objective is to investigate if specialty-specific, multimodality education could reduce rarely appropriate MPI. Methods We designed education focused on the rarely appropriate MPI ordered most often by each specialty. We tracked appropriateness of MPI in three cohorts: pre, post (immediately after) and late-post (4 months after) intervention. Results A total of 889 MPI were evaluated (n=287 pre, n=313 post, n=289 late-post), 95.3% were men. Chest pain was the most common symptom (n=530, 59.6%), while 14.1% (n=125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3% and remained at 1.4% in the late-post cohort (p<0.0001). In logistic regression, lack of symptoms (OR 31.3, 95% CI 10.3 to 94.8, p≤0.0001) and being in the post or late-post cohorts (OR 0.27, 95% CI 0.11 to 0.68, p=0.006) were associated with rarely appropriate MPI. Preoperative MPI in patients with good exercise capacity was a common rarely appropriate indication. Ischaemia was not observed among patients with rarely appropriate indication for MPI. Conclusions In certain clinical settings, education may be an effective approach for deimplementing rarely appropriate MPI. The effect of education may be enhanced when focused on improving patient care, delivered by a peer, and needs assessment indicates low awareness of guidelines. Lack of symptoms and preoperative MPI continue to be the predominant rarely appropriate MPI ordered.

Simulation-based training of transesophageal echocardiography for cardiology fellows.

Cardiology fellows learn procedures by performing them on patients under faculty supervision. Such training may increase procedure times, compromise image quality, and cause complications. Simulators provide an opportunity to teach procedures where patients are not at risk. We created a simulation-based curriculum to teach transesophageal echocardiography (TEE) to first-year cardiology fellows and measured the change in their reported self-confidence in TEE skills.