David Leibowitz

The Predictive Ability of Pre-Operative B-Type Natriuretic Peptide in Vascular Patients for Major Adverse Cardiac Events: An Individual Patient Data Meta-Analysis

OBJECTIVES The aims of this study were to perform an individual patient data meta-analysis of studies using B-type natriuretic peptides (BNPs) to predict the primary composite endpoint of cardiac death and nonfatal myocardial infarction (MI) within 30 days of vascular surgery and to determine: 1) the cut points for a natriuretic peptide (NP) diagnostic, optimal, and screening test; and 2) if pre-operative NPs improve the predictive accuracy of the revised cardiac risk index (RCRI). BACKGROUND NPs are independent predictors of cardiovascular events in noncardiac and vascular surgery. Their addition to clinical risk indexes may improve pre-operative risk stratification. METHODS Studies reporting the association of pre-operative NP concentrations and the primary study endpoint, post-operative major adverse cardiovascular events (defined as cardiovascular death and nonfatal MI) in vascular surgery, were identified by electronic database search. Secondary study endpoints included all-cause mortality, cardiac death, and nonfatal MI. RESULTS Six data sets were obtained, 5 for BNP (n = 632) and 1 for N-terminal pro-BNP (n = 218). An NP level higher than the optimal cut point was an independent predictor for the primary composite endpoint (odds ratio: 7.9; 95% confidence interval: 4.7 to 13.3). BNP cut points were 30 pg/ml for screening (95% sensitivity, 44% specificity), 116 pg/ml for optimal (highest accuracy point; 66% sensitivity, 82% specificity), and 372 pg/ml for diagnostic (32% sensitivity, 95% specificity). Subsequent to revised cardiac risk index stratification, reclassification using the optimal cut point significantly improved risk prediction in all groups (net reclassification improvement 58%, p < 0.000001), particularly in the intermediate-risk group (net reclassification improvement 84%, p < 0.001). CONCLUSIONS Pre-operative NP levels can be used to independently predict cardiovascular events in the first 30 days after vascular surgery and to significantly improve the predictive performance of the revised cardiac risk index.

Brain Natriuretic Peptide Levels Predict Perioperative Events in Cardiac Patients Undergoing Noncardiac Surgery: A Prospective Study

Objectives: Brain natriuretic peptide (BNP) levels correlate with prognosis in patients with cardiac disease and may be useful in the risk stratification of cardiac patients undergoing noncardiac surgery (NCS). The objective of this study was to examine whether BNP levels predict perioperative events in cardiac patients undergoing NCS. Methods: Patients undergoing NCS with at least 1 of the following criteria were included: a clinical history of congestive heart failure (CHF), ejection fraction <40%, or severe aortic stenosis. All patients underwent echocardiography and measurement of BNP performed using the ADVIA-Centaur BNP assay (Bayer HealthCare). Clinical endpoints were death, myocardial infarction or pulmonary congestion requiring intravenous diuretics at 30 days of follow-up. Results: Forty-four patients were entered into the study; 15 patients (34%) developed cardiac postoperative complications. The mean BNP level was 1,366 ± 1,420 pg/ml in patients with events and 167 ± 194 pg/ml in patients without events, indicating a highly significant difference (p < 0.001). The ROC area under the curve was 0.91 (95% CI 0.83–0.99) with an optimal cutoff of >165 pg/ml (100% sensitivity, 70% specificity). Conclusions: BNP levels may predict perioperative complications in cardiac patients undergoing NCS, and the measurement of BNP should be considered to assess the preoperative cardiac risk.

The incidence and haemodynamic significance of gas emboli during operative hysteroscopy: a prospective echocardiographic study

AIMS Operative hysteroscopy is associated with complications including the development of gas embolism. The aim of this study was to utilize continuous echocardiographic imaging during operative hysteroscopy to assess the extent and the haemodynamic effects of gas embolism in these patients. METHODS AND RESULTS Women undergoing operative hysteroscopy under general anaesthesia without a history of cardiac disease were eligible. Transthoracic echocardiography (TTE) was performed continuously in all study participants with assessment of the extent and frequency of gas embolism, right ventricular function and pulmonary hypertension. Twenty-three women (mean age: 48.0 +/- 9.4 years) participated in the study. All subjects had evidence of bubble embolism in the right atrium (RA) and 20 of 23 (85%) had evidence of continuous flow of bubbles. In the 17 patients with adequate assessment, estimated pulmonary artery systolic pressure was 19.1 +/- 3.7 mmHg prior to the procedure and 23.3 +/- 3.4 following the procedure, a statistically significant difference (P < 0.05). There were no significant changes between the two groups in right ventricular end-diastolic area, end-systolic area, or fractional area change. CONCLUSION Our study demonstrates a high frequency of continuous gas embolism during hysteroscopy, which is associated with a small but statistically significant increase in pulmonary artery systolic pressure without affecting right ventricular function.

Aging, resting pulse rate, and longevity.

To examine the relationship between resting pulse rate (RPR) and longevity in individuals aged 70 to 90.

Quantification of Pericardial Effusions by Echocardiography and Computed Tomography

Echocardiography is a well-accepted tool for the diagnosis and quantification of pericardial effusion (PEff). Given the increasing use of computed tomographic (CT) scanning, more PEffs are being initially diagnosed by computed tomography. No study has compared quantification of PEff by computed tomography and echocardiography. The objective of this study was to assess the accuracy of quantification of PEff by 2-dimensional echocardiography and computed tomography compared to the amount of pericardial fluid drained at pericardiocentesis. We retrospectively reviewed an institutional database to identify patients who underwent chest computed tomography and echocardiography before percutaneous pericardiocentesis with documentation of the amount of fluid withdrawn. Digital 2-dimensional echocardiographic and CT images were retrieved and quantification of PEff volume was performed by applying the formula for the volume of a prolate ellipse, π × 4/3 × maximal long-axis dimension/2 × maximal transverse dimension/2 × maximal anteroposterior dimension/2, to the pericardial sac and to the heart. Nineteen patients meeting study qualifications were entered into the study. The amount of PEff drained was 200 to 1,700 ml (mean 674 ± 340). Echocardiographically calculated pericardial effusion volume correlated relatively well with PEff volume (r = 0.73, p <0.001, mean difference -41 ± 225 ml). There was only moderate correlation between CT volume quantification and actual volume drained (r = 0.4, p = 0.004, mean difference 158 ± 379 ml). In conclusion, echocardiography appears a more accurate imaging technique than computed tomography in quantitative assessment of nonloculated PEffs and should continue to be the primary imaging in these patients.

Seasonal Variation in Myocardial Infarction Is Limited to Patients with ST‐Elevations on Admission

Previous studies have demonstrated seasonal variation in the incidence of acute myocardial infarction (AMI) with an increase in cases during the winter months. However, they did not assess whether ST‐elevation MI (STEMI) and non‐ST‐elevation MI (NSTEMI) exhibit similar changes. The object of this study was to compare the seasonal variation of STEMI and NSTEMI. All patients who presented with AMI and underwent coronary angiography within seven days of admission were identified via the institutional database. STEMI diagnosis required admission ECG demonstrating ST elevation in at least two continguous leads. All AMIs not meeting criteria for STEMI were defined as NSTEMI. Patients were divided into monthly and seasonal groups based on the date of admission with MI. A total of 784 patients were included: 549 patients with STEMI and 235 with NSTEMI. When STEMI patients were analyzed by season, there were 170 patients (31%) in the winter months, a statistically significant difference of excess MI (p<0.005). When NSTEMI patients were analyzed, there were 62 patients (26%) in the winter with no statistically significant difference in the seasonal variation. Our findings suggest that the previously noted seasonal variation in the incidence of AMI is limited to patients presenting with STEMI, and that there are important physiological differences between STEMI and NSTEMI, the nature of which remains to be elucidated.

The efficacy of cardiac shock wave therapy in the treatment of refractory angina: A pilot prospective, randomized, double-blind trial

Refractory angina pectoris (RAP) is a growing clinical problem [1]. Prognosis in these patients is poor and conventional medical therapy is frequently inadequate for symptom relief. The aim of this pilot prospective, double-blind, placebo-controlled study was to test the hypothesis that low-energy extracorporeal shockwave myocardial revascularization (ESMR) can reduce clinical symptoms and improve exercise tolerance in patients with RAP. Patients over the age of 18 with at least three months of RAP with ischemia on SPECT-thallium testing, coronary disease not amenable for revascularization, and stable medical therapy for at least 6 weeks were eligible for inclusion in the study. Patients who experienced an acute coronary syndrome or who underwent revascularization within three months were excluded. The study was approved by the institutional review board and informed consent was obtained from all participants prior to inclusion. All candidates underwent exercise testing and filled out a Seattle Angina Questionnaire (SAQ) within two weeks of beginning shock wave therapy. Patients were randomized in a 2:1 fashion to treatment with active therapy or placebo. Following ESMR therapy, exercise testing was repeated at one-month and threemonth follow-up. SAQ was repeated at 3-month follow-up. The primary study endpoints were change in exercise treadmill duration and SAQ score from baseline to three months. Shockwaves were applicated with a commercially available cardiac shock wave generator system (CardiospecTM, Medispec, Germantown, MD, USA) under echocardiographic guidance. The placebo patients were treated with a placebo applicator created by placing a shield internally which did not alter the external appearance of the applicator. Real shockwaves were generated and heard by the patient and treating physician but were blocked inside the applicator. The initial step of ESMR is to locate the ischemic region of interest after which, a full cardiac cycle is recorded with the echocardiography system. These measurements are calibrated into the shockwave applicator head to ensure the position of the focal treatment zone on the ischemic zone and shockwaves were then applied. The treatment schedule was divided into three sessions with three treatments per week every 4 weeks. The ischemic area of interest was divided into 3 zones, corresponding to the 3 weeks of treatments. SW application started at the border zone and then progressed to the interior zones. Each treatment for each target spot consisted of 100 pulses gated by R wave trigger. Up to 5 target spots (total of 500 pulses) were treated at each individual session. The authors of this manuscript certify that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. As data was not normally distributed, results are presented as medians±interquartile ranges. Differences between patient groups were analyzed using chi-square or Fishers exact tests for categorical variables and unpaired t-tests for normally distributed continuous variables with Kruskal–Wallis test for non-normally distributed continuous values. A p-value of b0.05 was considered statistically significant. 28 patients were included and clinical characteristics of the two groups are displayed in Table 1. There were no significant differences in any of the parameters examined. All patients tolerated the treatment well without any arrhythmias, chest pain or skin discomfort/reactions. One patient in the placebo group developedmild peripheral edema and one patient in the treatment group developed bradycardia on beta blocker therapy several weeks after completion of the treatment protocol and underwent pacemaker implantation. In the active treatment group (n=18) baseline exercise time rose from 394 (25–75% IQR 294.5–510.25) seconds at baseline to 423 (368–745) seconds at one-month follow-up and then fell to 381 (359– 639.5) seconds at three-month follow-up. Corresponding figures for the placebo group were 523.5 (363–573.25) seconds at baseline to 596 (511–636.5) seconds at one month follow-up and 554 (449.25– 624.75) seconds at three-month follow-up. The degree of physical limitation as assessed by the SAQ significantly improved in the treatment group as compared to placebo (34±23% versus 6±20%; pb0.04) (Table 2). The overall composite SAQ score including all 5 parameters improved by 19.1±18.6% in the treatment group as opposed to 2.7±15.1% in the placebo group, a difference that was close to statistical significance (pb0.07). The study demonstrates the potential efficacy of ESMR for the treatment of refractory angina pectoris in a prospective, randomized, and placebo-controlled double-blind trial. Previous studies have demonstrated that ESMR can induce the development of collateral arteries, increase capillary density and facilitate recruitment of endothelial progenitor cells in an animal model of hindlimb ischemia [2,3]. In animal models of myocardial ischemia ESMR reduced remodeling, and improved left ventricular systolic function as well as regional myocardial blood flow [4–6].

Bordetella holmesii meningitis in an asplenic patient with systemic lupus erythematosus

Bordetella holmesii is a slow-growing, Gram-negative, non-oxidizing bacillus with colonies that produce a brown soluble pigment and was originally described by Weyant et al. (1995) as CDC nonoxidizer group 2 (NO-2). It has recently been shown that B. holmesii may be isolated from nasopharyngeal specimens of up to 20% of patients with pertussis-like symptoms. However, invasive B. holmesii has rarely been reported and in the vast majority of cases the patients were immune deficient, mostly as a result of splenectomy or functional asplenia. Clinical presentations have included endocarditis, pneumonia, cellulitis, suppurative arthritis, pyelonephritis and septicaemia but no previous reports have documented meningitis secondary to this organism. Here we report what we believe to be the first clinical description of an adult with B. holmesii meningitis and bacteraemia with a brief review of published cases.

Chronicle of a death foretold: a case of catastrophic vascular Behcet's disease

A 20-year-old man with Behcets disease characterized by recurrent arterial aneurysms presented with a new aortic root aneurysm. This patient previously had aneurysms of the coronary arteries and vein, as well as ruptured renal artery aneurysm. Chronic maintenance immunosuppressive therapy was recommended due to the catastrophic nature of the disease, which the patient refused to take. The patient died shortly after admission. This case demonstrates the unique catastrophic natural history of vascular Behcets disease with recurrent life-threatening arterial events, and this case stresses the therapeutic dilemma of maintenance immunosuppressive therapy in selected patients.

Optic nerve head drusen mimicking papilledema and malignant hypertension

A 41 years old manwith a history of mild hypertensionwas seen at an ophthalmology clinic for routine visual acuity testing. Fundoscopy revealed papilledema and the patient was referred to the emergency room. The patient was not taking any medications on a regular basis. In the emergency room the patient was anxious with a blood pressure of 160/100 mm Hg and a pulse of 75/min. He was afebrile, neck was supple, lungs were clear, heart sounds were normal and neurological exam was unremarkable. Fundoscopy confirmed the presence of papilledema. The patient was transferred to the intensive care unit with a provisional diagnosis of malignant hypertension. Treatment with IV nitroprusside was initiated but discontinued few minutes later due to a significant decrease in blood pressure. Treatment with captopril 12.5mg Q8hwas instituted. The next morning the patient was asymptomatic with a blood pressure of 120/80 mm Hg. The clinical picture of papilledema with only mildly elevated blood pressure that quickly responded to oral treatment put the provisional diagnosis of malignant hypertension in question and a head CT scan was ordered. The CT was unremarkable except for calcification of the optic nerves head bilaterally (Fig. 1), a finding typical of optic disc drusen. The diagnosis was changed accordingly and the patient was discharged.