Christine Gerula

New index for assessing the chronotropic response in patients with end‐stage liver disease who are undergoing dobutamine stress echocardiography

The inability to achieve 85% of the maximum predicted heart rate (MPHR) on dobutamine stress echocardiography (DSE) is defined as chronotropic incompetence and is a predictor of major cardiac events after orthotopic liver transplantation (OLT). The majority of patients with end‐stage liver disease (ESLD) receive beta‐blockers for the prevention of variceal bleeding. In these patients, it is impossible to determine whether chronotropic incompetence is secondary to cirrhosis‐related autonomic dysfunction or is merely a beta‐blocker effect. We evaluated the usefulness of the maximum achieved heart rate (MAHR) and the heart rate reserve (HRR) in the detection of chronotropic incompetence in ESLD patients on beta‐blocker therapy before DSE. We also evaluated the usefulness of a new index, the modified heart rate reserve (MHRR), in diagnosing chronotropic incompetence and predicting major cardiovascular adverse events after OLT. The study population consisted of 284 ESLD patients. The mean values of MAHR (expressed as a percentage of 85% of MPHR) and HRR were significantly lower for patients on beta‐blockers versus patients off beta‐blockers [97.1% versus 101.6% (t = 5.01, P < 0.001) and 71.7% versus 77.3% (t = 4.03, P < 0.001), respectively], whereas the values of MHRR were similar in patients on beta‐blockers and patients off beta‐blockers [102.3% versus 102.1% (t = 0.04, P = 0.97)]. A regression analysis showed a significant association of MAHR (P < 0.001) and HRR (P < 0.001) with beta‐blockers, whereas MHRR was not associated with beta‐blocker treatment (P = 0.92). MAHR and HRR were found to have no value for diagnosing chronotropic incompetence in ESLD patients. MHRR was not affected by beta‐blocker therapy. Patients who developed heart failure (HF) and myocardial infarction (MI) after OLT had significantly lower MHRR values according to pretransplant DSE. MHRR was significantly associated with the subsequent development of HF (P = 0.01) and MI (P = 0.01) after OLT. MHRR may be useful for the determination of the target heart rate for stress testing, the diagnosis of chronotropic incompetence, and the prediction of adverse cardiac events after OLT. Liver Transpl 18:355–360, 2012.

In-Hospital Outcomes and Complications of Coronary Artery Bypass Grafting in the United States Between 2008 and 2012

OBJECTIVEnTo investigate the frequency and predictors of in-hospital complications among patients undergoing coronary artery bypass grafting (CABG) in the United States.nnnDESIGNnRetrospective national database analysis SETTINGS: United States hospitals.nnnPARTICIPANTSnA weighted sample of 1,910,236 patients undergoing CABG surgery identified from the National (Nationwide) Inpatient Sample from 2008 to 2012.nnnINTERVENTIONSnCABG surgery MEASUREMENTS AND MAIN RESULTS: The number of CABG surgeries decreased from 436,275 in 2008 to 339,749 in 2012. The Deyo comorbidity index showed a steady increase from 2008 to 2012. The rate of in-hospital mortality decreased from 2.7% in 2008 to 2.2% in 2012 (p<0.001). The most common in-hospital complication was postoperative hemorrhage (30.4%), followed by cardiac (11.34%) and respiratory complications (2.3%). During the 5-year period, the rates of in-hospital cardiac, respiratory and infectious complications decreased (p<0.001), while the rate of postoperative hemorrhage showed a 35.8% relative increase in 2012 compared to 2008.nnnCONCLUSIONnThe annual number of CABG surgeries is declining in the United States. While the burden of comorbidities is increasing, the rates of mortality and most in-hospital complications are improving. The increasing rate of postoperative bleeding necessitates the need to develop strategies to improve the risk of bleeding in this patient population.

Hypertension in African Americans with Heart Failure: Progression from Hypertrophy to Dilatation; Perhaps Not

AimConcentric hypertrophy is thought to transition to left ventricular (LV) dilatation and systolic failure in the presence of long standing hypertension (HTN). Whether or not this transition routinely occurs in humans is unknown.MethodsWe consecutively enrolled African American patients hospitalized for acute decompensated volume overload heart failure (HF) in this retrospective study. All patients had a history of HTN and absence of obstructive coronary disease. Patients were divided into those with normal left ventricular ejection fraction (LVEF) and reduced LVEF. LV dimensions were measured according to standard ASE recommendations. LV mass was calculated using the ASE formula with Devereux correction.ResultsPatients with normal LVEF HF were significantly older, female and had a longer duration of HTN with higher systolic blood pressure on admission. LV wall thickness was similarly elevated in both groups. LV mass was elevated in both groups however was significantly greater in the reduced LVEF HF group compared to the normal LVEF HF group. Furthermore, gender was an independent predictor for LV wall thickness in normal LVEF HF group.ConclusionIn African American patients with HF our study questions the paradigm that concentric hypertrophy transitions to LV dilatation and systolic failure in the presence of HTN. Genetics and gender likely play a role in an individual’s response to long standing hypertension.

PREDICTIVE VALUE OF SELVESTER SCORE IN ESTIMATING INFARCT SIZE IN PATIENTS UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

We have previously reported from our institution outcomes in patients with ST-elevation myocardial infarction (STEMI) based on mode of arrival i.e., fully automated pathway for pre-hospital ECG transmission (STAT-MI pathway) versus other. We now report on the use of ECG Selvester score (SS) in

LEFT VENTRICULAR DIASTOLIC DYSFUNCTION IS AN INDEPENDENT PREDICTOR OF LONG-TERM MORTALITY IN PATIENTS WHO UNDERWENT LIVER TRANSPLANT FOR END STAGE LIVER DISEASE

Patients with end-stage liver disease (ESLD) may develop left ventricular diastolic dysfunction in the absence of coronary artery disease or hypertension. Prognostic value of the presence of diastolic dysfunction on post orthotopic liver transplant (OLT) survival is unknown. We report on the