D. Lynn Morris

Cocaine and the heart.

The use of cocaine may be associated with either acute or chronic toxicity, and approximately 5% to 10% of emergency department visits in the United States are believed to be secondary to cocaine usage. Chest pain is the most common cocaine‐related medical problem, leading to the evaluation of approximately 64 000 patients annually for possible myocardial infarction, of which approximately 57% are admitted to the hospital, resulting in an annual cost greater than

Improvement in Left Ventricular Systolic and Diastolic Performance During Ranolazine Treatment in Patients With Stable Angina

83 million. There is a plethora of cocaine‐related cardiovascular complications, including acute myocardial ischemia and infarction, arrhythmias, sudden death, myocarditis, cardiomyopathy, hypertension, aortic ruptures, and endocarditis. There is no evidence to suggest that preexisting vascular disease is a prerequisite for the development of a cocaine‐related cardiovascular event, although it may be a potentiating factor, as may be nicotine and alcohol. Copyright

Patterns and Predictors of Early Hospital Readmission in Patients With Congestive Heart Failure

Purpose: Ranolazine is a novel antianginal medication that acts by ameliorating disturbed sodium and calcium homeostasis. By preventing myocyte sodium and calcium overload, ranolazine also have potential beneficial effects on myocardial function. Experimental models support this concept, as do 2 small studies in human participants receiving ranolazine intravenously. We evaluated changes in parameters of left ventricular function in stable angina patients treated with oral ranolazine. Methods: Twenty-two participants were enrolled with Doppler echocardiography performed at baseline and a mean of 2 months after initiation of treatment. Results: Global left ventricular function, as assessed by the myocardial performance index, was significantly improved on drug therapy (P < .0001). This was due to improvement in both diastolic and systolic parameters. Of 21 patients, 17 reported less angina and 8 patients reported an increase in activity level. Conclusions: We report improved parameters of left ventricular function in response to ranolazine as used in the clinical setting.

Two-Year Results of Paclitaxel-Eluting Stents in Patients With Medically Treated Diabetes Mellitus from the TAXUS ARRIVE Program

Little is known about factors related to rehospitalizations that occur soon after discharge in patients with congestive heart failure (CHF). The aim of this study was to determine if there are specific characteristics common to CHF patients readmitted within 30 days. Study methods included retrospective chart review. Patients included all those hospitalized and readmitted to a large community teaching hospital for CHF exacerbation within 30 days between January 7, 2005 and June 30, 2006. A total of 58 patients were responsible for 79 readmissions. Half of all patients readmitted for CHF exacerbation were incorrectly labeled, raising doubt about reliance on administrative data alone to determine overall quality performance. Forty-five percent of all readmitted patients had underlying chronic renal insufficiency/failure (CRI/CRF) compared with 26% of CHF patients who were not readmitted within 30 days. Therefore, specifically targeting CHF patients with CRI/CRF could lead to major improvement of early readmission rates. (Am J Med Qual 2008;23:18-23)

Comparison of intravenous adenosine and intravenous regadenoson for the measurement of pressure-derived coronary fractional flow reserve.

Drug-eluting stents decrease revascularization compared with bare metal stents in diabetic patients, but few studies have compared drug-eluting stent use in diabetic versus nondiabetic patients. The objective of this study was to assess whether paclitaxel provides equivalent revascularization decrease in diabetic and nondiabetic patients. The ARRIVE registries enrolled 7,492 patients receiving TAXUS Express stents, including 2,112 with medically treated diabetes; results were compared with those in the remaining 5,380 nondiabetic patients. Two-year target lesion revascularization (TLR) was comparable in diabetic and nondiabetic patients (8.2% vs 7.7%, p = 0.59) and remained similar after multivariate adjustment for baseline differences (7.1% vs 6.8%, p = 0.41). There were no significant TLR differences between diabetic and nondiabetic patients with small vessels (9.7% vs 9.5%, p = 0.96) or left main coronary artery, 3-vessel, or bifurcation stenting (10.7% vs 13.1%, p = 0.41). Diabetes was not a significant TLR predictor (hazard ratio 0.92, 95% confidence interval 0.77 to 1.12, p = 0.41). Stent thrombosis (2.6% vs 2.4%, p = 0.55) and myocardial infarction (3.8% vs 3.0%, p = 0.09) rates were also similar for diabetic and nondiabetic patients. However, 2-year mortality was significantly increased in diabetic compared with nondiabetic patients (9.7% vs 5.3%, p <0.001). Increased mortality drove significantly increased major cardiac events in diabetics; however, there was no difference in stent-related major cardiac events (8.9% vs 10.1%, p = 0.13). In conclusion, these results suggest that TAXUS paclitaxel-eluting stents abrogate the increased diabetic risk of clinical restenosis previously reported with bare metal stents, with similar low risk of myocardial infarction or stent thrombosis for diabetic and nondiabetic patients. However, diabetic patients still have increased risk of 2-year mortality.

Myocardial infarct artery patency and reocclusion rates after treatment with duteplase at the dose used in the International Study of Infarct Survival-3

AIMS Defining the clinical and physiologic significance of an intermediate coronary artery stenosis is aided by measurement of fractional flow reserve (FFR). Adenosine is the most common agent used in the cardiac catheterisation laboratory for the measurement of FFR. Regadenoson, a selective adenosine receptor agonist, with fewer side effects than adenosine has been used extensively in stress testing to induce hyperaemia. We postulated that FFR measurements would be equivalent following administration of regadenoson and adenosine. METHODS AND RESULTS Twenty patients with an angiographic intermediate coronary artery stenosis (50% to 80%) were included in the study. FFR was measured during three minutes of intravenous (IV) adenosine infusion and for five minutes after an injection of regadenoson. The mean difference between the FFR measured by IV adenosine and IV regadenoson was 0.0040 (min -0.04, max +0.04, standard deviation [SD] 0.025). There was a strong linear correlation between the FFR measured by IV adenosine and IV regadenoson (R2 linear=0.933). The FFR at maximum hyperaemia was achieved earlier using regadenoson than adenosine (59±24.5 sec vs. 93±44.5 sec, p=0.01). CONCLUSIONS Regadenoson produces similar pressure-derived FFR compared to IV adenosine infusion.

Patient specific 3D print of left atrial appendage for closure device

Duteplase, 98% double-chain recombinant tissue-type plasminogen activator, was administered intravenously in 488 patients with acute myocardial infarction in a multicenter, open, safety and patency study. Duteplase dosing was based on body weight. Duteplase was administered as a bolus of 0.04 MIU/kg of thrombolytic activity followed by 0.36 MIU/kg over 1 hour and 0.067 MIU/kg/hour for 3 additional hours. The patency rate of the infarct-related artery at 90 minutes was 69% (330 of 478). The reocclusion rate at 3 to 48 hours was 6% (18 of 301). Reinfarction occurred in 7.6% of patients (37 of 488), but 12 reinfarctions occurred after coronary angioplasty. Serious bleeding occurred in 7.6% of patients (37 of 488), predominantly at the catheterization entry site. There were 3 instances of central nervous system bleeding, 1 fatal. Fibrinogen levels declined to 83% of baseline at 24 hours. Weight-based dosing may explain the low incidence of serious bleeding in this study. The in-hospital mortality was 6.6% (32 of 488). This study documents that the dose of duteplase used in the International Study of Infarct Survival-3 results in a 90-minute coronary artery patency rate and safety profile comparable to those reported in published studies on the approved dose of alteplase.

Combined cardiac catheterization for uncomplicated ischemic heart disease in a medicare population

hypertension, semi-invasive pulmonary aspergillosis with recurrent hemoptysis, and diabetes mellitus. His risk scores were CHA2DS2-VASC = 6 and HAS-BLED = 8. The LAA was diminutive and possibly unable to tolerate full deployment of even the smallest diameter device. TEE showed a “chicken wing” LAA with uncertain measurements (Fig. 1a, b). We reproduced the LAA using a 3D printer (Fig. 1d, e). We then inserted a 21 mm WD into our latex model with a near perfect fit (Fig. 1f). We inserted the same device in our patient with multi-modality imaging intra-operatively including: fluoroscopy, TEE, and intra-cardiac echocardiography (Fig. 1g–j). The procedure was done in 30 min (half the time of previous ones) with one deployment, and no size adjustment. PASS (position, anchor, size, seal) criteria were met and no para-device leak was seen. The patient was discharged with no procedural complications. He will continue a vitamin K antagonist for 45 days and follow-up in our cardiology clinic. The 3D printed LAA may improve closure device sizing, procedure time (including delivery time and deployment attempts) and prospectively discourage or encourage (as in our case) proceeding with the closure procedure when other modalities are ambiguous. Prospective studies are warranted.

Significance of QRS duration in non-ST elevation myocardial infarction

PURPOSE Experts recommend left heart catheterization alone to evaluate uncomplicated ischemic heart disease, reserving right heart catheterization for specific indications. Yet some centers routinely perform combined cardiac catheterization (left heart catheterization and right heart catheterization together). SUBJECTS AND METHODS Using 1992-1993 Pennsylvania Medicare claims for cardiac catheterizations (n = 41,180), we examined rates of combined cardiac catheterization for patients with uncomplicated ischemic heart disease for each hospital (n = 73) that performed catheterizations. We compared combined cardiac catheterization rates among hospitals and developed a multivariable model to identify hospital characteristics associated with high combined cardiac catheterization rates. A random sample of cases from the 10 hospitals with the highest combined cardiac catheterization rates were reviewed to determine justification, complications, and results of combined cardiac catheterization. RESULTS Of the 41,180 cardiac catheterizations, 14,177 (34%) were combined procedures. Among hospitals, combined cardiac catheterization rates varied from 2% to 98%. Hospital characteristics associated with high combined cardiac catheterization rates included having a cardiology fellowship program (relative risk [RR] 1.7, 95% confidence interval [CI] 1.1-2.7), location in eastern Pennsylvania (RR 2.5, 95% CI: 1.8-3.5), and volume of catheterizations performed (RR 0.95, 95% CI: 0.91-0.99/100 procedures). For reviewed cases, the most common justification for combined cardiac catheterization was planned revascularization (44%), which is not a specific indication. Only 49% of cases had at least one specific indication for right heart catheterization (range by hospital, 30%-74%). The abnormal findings on the right heart catheterization rarely appeared to change management. CONCLUSION There is wide variation in the practice of combined cardiac catheterization, which appears to be related to teaching status and geographic location. The most common justification for the procedure was planned revascularization, which is not one of the specific indications supported by current literature.

Novel Predictors of Left Ventricular Systolic Function Recovery in Patients with ST Elevation Myocardial Infarction who Underwent Reperfusion Therapy

Part of the Cardiology Commons This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson Universitys Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship.Significance of QRS duration in non-ST elevation myocardial infarction.