Elizabeth Hill

Hyperammonemia results in reduced muscle function independent of muscle mass.

The mechanism of the nearly universal decreased muscle strength in cirrhosis is not known. We evaluated whether hyperammonemia in cirrhosis causes contractile dysfunction independent of reduced skeletal muscle mass. Maximum grip strength and muscle fatigue response were determined in cirrhotic patients and controls. Blood and muscle ammonia concentrations and grip strength normalized to lean body mass were measured in the portacaval anastomosis (PCA) and sham-operated pair-fed control rats (n = 5 each). Ex vivo contractile studies in the soleus muscle from a separate group of Sprague-Dawley rats (n = 7) were performed. Skeletal muscle force of contraction, rate of force development, and rate of relaxation were measured. Muscles were also subjected to a series of pulse trains at a range of stimulation frequencies from 20 to 110 Hz. Cirrhotic patients had lower maximum grip strength and greater muscle fatigue than control subjects. PCA rats had a 52.7 ± 13% lower normalized grip strength compared with control rats, and grip strength correlated with the blood and muscle ammonia concentrations (r(2) = 0.82). In ex vivo muscle preparations following a single pulse, the maximal force, rate of force development, and rate of relaxation were 12.1 ± 3.5 g vs. 6.2 ± 2.1 g; 398.2 ± 100.4 g/s vs. 163.8 ± 97.4 g/s; -101.2 ± 22.2 g/s vs. -33.6 ± 22.3 g/s in ammonia-treated compared with control muscle preparation, respectively (P < 0.001 for all comparisons). Tetanic force, rate of force development, and rate of relaxation were depressed across a range of stimulation from 20 to 110 Hz. These data provide the first direct evidence that hyperammonemia impairs skeletal muscle strength and increased muscle fatigue and identifies a potential therapeutic target in cirrhotic patients.

An alarming trend: Change in the risk profile of patients with ST elevation myocardial infarction over the last two decades

BACKGROUND Coronary artery disease (CAD) is the leading cause of mortality around the world. We sought to study changes in the risk profile of patients presenting with ST elevation myocardial infarction (STEMI). METHODS We retrospectively studied all patients presenting with STEMI to our center between 1995 and 2014. Patients were divided into four quartiles, 5years each. Baseline risk factors and comorbidities were recorded. Sub-analysis was done for patients with established CAD and their household incomes. RESULTS A total of 3913 patients (67.9% males) were included; 42.5% presented with anterior STEMI and 57.5% inferior STEMI. Ages were 64±12, 62±13, 61±13 and 60±13 in the four quartiles respectively. Obesity prevalence was 31, 37, 38 and 40% and diabetes mellitus prevalence was 24, 25, 24 and 31%, while hypertension was 55, 67, 70 and 77%, respectively, p<0.01 for all. Smoking prevalence was 28, 32, 42 and 46, p<0.01. When subgroup analysis was done for patients with history of CAD, prevalence of smoking, obesity, diabetes and hypertension significantly increased across the four quartiles. When patients were divided to four groups based on household income (poor, low middle, middle and high income), prevalence of diabetes, hypertension, smoking and obesity were significantly higher in patients with low income. CONCLUSION Despite better understanding of cardiovascular risk factors and more focus on preventive cardiology, patients presenting with STEMI over the past 20years are getting younger and more obese, with more prevalence of smoking, hypertension, and diabetes mellitus. This trend is greater in the lower income population.

Resident-Led Handoffs Training for Interns: Online Versus Live Instruction with Subsequent Skills Assessment

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Has anyone been listening? Post-SPECT MPI referral rates to catheterization

Radionuclide single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has retained its steadfast role in the assessment of suspected or known coronary artery disease (CAD). Both guidelines and appropriate use criteria continue to support its role in numerous clinical settings. At a time when there is increasing emphasis on quality and appropriateness in testing, there is an ongoing need to scrutinize the value of all cardiovascular imaging modalities. This scrutiny has encompassed the continuum from patient selection to correct image acquisition and interpretation of the reporting of results to referring physicians. Indeed, the importance of selecting the ‘‘right’’ patients for testing and the importance of considering how test results will change subsequent management have been embraced as a mantra. Although they are infrequently reported, patterns of post-SPECT MPI patient management are informative for this purpose and likely represent the most pragmatic insight we can gain with respect to the use of this modality in daily practice. To this end, prior studies have examined referral rates to catheterization, revascularization, and medical therapy after exercise stress testing and stress MPI, often focusing on whether systematic sex-related or age-related posttest differences in patient management were present.– On the basis of these studies, a number of generalizations can be made. First, the likelihood of referral to catheterization after MPI is overwhelmingly driven by the results of the test. Further, the dominant drivers of this referral are markers of ischemia—predominantly the extent and severity of MPI-defined ischemia, but also presenting symptoms, stress-induced symptoms, and ST segment changes with stress. Other factors, of unclear appropriateness, also inform this decision. Referral rates vary among patient populations. Despite the widely reported issues with sex-related bias in cardiovascular care, catheterization rates remain greater in men compared to women. These differences remain after consideration of baseline patient characteristics, site-related practice differences, and other factors. Similarly, previous studies have also shown that in older patients, absolute catheterization rates were lower in patients aged[80 years compared to patients aged 50 to 64 years or 65 to 79 years. A 40 site prospective, multicenter study—the Study of myocardial Perfusion and coronary Anatomy imaging Roles in Coronary artery disease (SPARC)—examined posttest patient management in a cohort of 1703 patients with intermediate-tohigh pretest likelihood of CAD who were referred for a clinically ordered PET, SPECT, or CCTA in 40 sites. These results confirmed the impact of patient sex and age on catheterization referral rates. Men were found to have a significantly greater rate of referral to catheterization compared to women after all other factors were considered (odds ratio 1.82). Catheterization referral increased progressively with increasing age—patients in their 50s, 60s, and 70s had greater catheterization rates compared to patients aged younger than 40 years—but patients aged [80 had a lower odds ratio compared to patients \40 years of age. Hence, both these factors—patient age and sex—appear to impact catheterization referral rates. Whether the difference in referral rates related to these two factors are clinically appropriate or not is a challenging question. Undoubtedly the most concerning finding in studies to date is the relatively low absolute rate of referral to Reprint requests: Rory Hachamovitch, MD, MSc, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, J1-5, 9500 Euclid Avenue, Cleveland, OH 44195; hachamr@ccf.org J Nucl Cardiol 2017;24:1662–5. 1071-3581/

Outcomes of ischaemic mitral regurgitation in anterior versus inferior ST elevation myocardial infarction

34.00 Copyright 2016 American Society of Nuclear Cardiology.

IMPACT OF MAJOR BLEEDING AS DEFINED BY NATIONAL CARDIOVASCULAR DATA REGISTRY ACROSS DIFFERENT BASELINE HEMOGLOBIN LEVELS IN PATIENTS UNDERGOING ELECTIVE PERCUTANEOUS CORONARY INTERVENTION

Background Ischaemic mitral regurgitation (IMR) is a detrimental complication of ST elevation myocardial infarction (STEMI). Objective We sought to determine patient characteristics and outcomes of patients with IMR with focus on anterior or inferior location of STEMI. Methods All patients presenting with STEMI complicated by IMR to our centre who underwent primary percutaneous coronary intervention within the first 12 hours of presentation from 1995 to 2014 were included. IMR was graded from 1+ to 4+ within 3 days of index myocardial infarction by echocardiography, divided into 2 groups based on infarct location and outcomes were compared. Results Overall, 805 patients were included. There were 302 (17.8%) patients with mitral regurgitation (MR) out of the 1700 patients with anterior STEMI while 503 (21.8%) had MR out of the 2305 patients with inferior STEMI. There was no significant difference between both groups in comorbidities, clinical presentation or door-to-balloon time (DBT; median 104 vs 106 min, p=0.5). 30-day and 1-year mortality were higher in anterior STEMI compared with inferior STEMI (14.9% vs 6.8% and 26.4% vs 14.3%, respectively, p<0.001 both), as well as 5-year mortality (39.7% vs 24.8%, p<0.01). When analysis was performed for each grade of IMR, anterior was associated with worse outcomes in every grade. On multivariate cox survival analysis, after adjustment for age, gender, comorbidities, grade of IMR, ejection fraction and DBT, anterior STEMI was still associated with worse outcomes (HR 1.62 (95% CI 1.23 to 2.12), p<0.001). Conclusions Although IMR occurs more frequently with inferior infarction, outcomes are worse following anterior infarction.

DECLINING IMPACT OF ISCHEMIC MITRAL REGURGITATION ON LONG TERM MORTALITY FOLLOWING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

The National Cardiovascular Data Registry defines major bleeding after percutaneous coronary intervention (PCI) as an absolute drop of hemoglobin (Hb) ≥3 g/dL. We sought to study impact of this across different baseline Hb levels. 2238 patients who underwent elective PCI in our center from 2011-

In vivo impact of intra-aortic balloon counterpulsation on reducing ischemia and improving myocardial blood flow: Proof from a PET rubidium-82 study

Ischemic mitral regurgitation (IMR) is an established complication of ST elevation myocardial infarction (STEMI). We studied the change in incidence and outcomes of IMR in the past 20 years in a tertiary center. Amongst 3914 patients undergoing primary percutaneous coronary intervention within 12

Prognostic Significance of Ischemic Mitral Regurgitation on Outcomes in Acute ST-Elevation Myocardial Infarction Managed by Primary Percutaneous Coronary Intervention

A 57-year-old man presented to our facility with chest discomfort and dyspnea. Five years earlier, this patient with type 2 diabetes mellitus and active tobacco abuse was diagnosed with coronary artery disease (CAD) and an ischemic cardiomyopathy. He underwent stenting of the left circumflex artery (LCX) at the time. Over the one year prior to presentation, he was admitted multiple times to his local hospital for decompensated heart failure. A coronary angiogram showed severe 3vessel CAD with total occlusions of the LCX and right coronary artery (RCA) as well as severe disease in the mid and distal left anterior descending artery (LAD) (Figure 1). He presented to our facility seeking surgical revascularization. Upon arrival, he was found to be in decompensated systolic heart failure. Initial cardiac biomarkers were mildly elevated. His ECG was notable for an ageindeterminant anterior myocardial infarction and nonspecific ST-T abnormalities (Figure 2). He was admitted to the Cardiac Intensive Care Unit and started on heparin and nitroglycerin infusions. A transthoracic echocardiogram showed severe left ventricular (LV) systolic dysfunction with moderate mitral valve regurgitation. His chest discomfort and dyspnea persisted despite maximal medical therapy, and an IABP was placed. To evaluate the extent of ischemic/viable/hibernating myocardium, the patient was referred for PET imaging using rubidium-82 (Rb) followed by fluorine18 fluorodeoxyglucose (F-FDG) administration (Figure 3). The challenges of PET imaging in patients with an IABP are minimal and limited to transportation of the patient. To obtain the rest images, the patient was injected with Rb with 1:1 IABP counterpulsation. The IABP counterpulsation ratio was then reduced to 1:3 to simulate stress in lieu of pharmacologic vasodilation, and the patient was again injected with Rb to obtain the stress images. The rest and stress images were both obtained utilizing gated, dynamic acquisition. The viability images were obtained utilizing non-gated, dynamic acquisition. There were no ECG changes during the study, but the patient developed chest discomfort during the stress portion of the test. The rest images revealed a moderate perfusion defect in the mid inferior, mid inferolateral, apical inferior, and apical segments. The stress images revealed a severe perfusion defect in the mid inferolateral, apical Electronic supplementary material The online version of this article (doi:10.1007/s12350-015-0227-z) contains supplementary material, which is available to authorized users. Reprint requests: Newton B. Wiggins, MD, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195; wigginn@ccf.org J Nucl Cardiol 2016;23:331–3. 1071-3581/

KICKBOXING A CARDIOMYOPATHY: A CASE WHERE MITOCHONDRIAL SEQUENCING PROVIDES NOVEL ANSWER FOR YOUNG ATHLETE AND HER FAMILY

34.00 Copyright 2015 American Society of Nuclear Cardiology.