Emad F. Aziz

The utility of 12-lead Holter monitoring in patients with permanent atrial fibrillation for the identification of nonresponders after cardiac resynchronization therapy.

OBJECTIVESnThis study sought to determine the incidence of ineffective capture using 12-lead Holter monitoring and to assess whether this affects response to cardiac resynchronization therapy (CRT).nnnBACKGROUNDnCardiac resynchronization therapy is used in patients with atrial fibrillation (AF), prolonged QRS duration, and heart failure in the setting of ventricular dysfunction. The percentage of ventricular pacing is used as an indicator of adequate biventricular (BiV) pacing. Although device counters show a high pacing percentage, there may be ineffective capture because of underlying fusion and pseudo-fusion beats.nnnMETHODSnWe identified 19 patients (age 72 +/- 8 years, ejection fraction 18 +/- 5%), with permanent AF who underwent CRT. All patients received digoxin, beta-blockers, and amiodarone for rate control; device interrogation showed >90% BiV pacing. Patients had a 12-lead Holter monitor to assess the presence of effective (>90% fully paced beats/24 h) pacing. At 12 months post-CRT, the New York Heart Association functional class was reassessed and an echocardiogram was obtained and compared with pre-CRT.nnnRESULTSnOnly 9 (47%) patients had effective pacing. The other 10 (53%) patients had 16.4 +/- 4.6% fusion and 23.5 +/- 8.7% pseudo-fusion beats. Long-term responders (> or =1 New York Heart Association functional class improvement) to CRT had a significantly higher percentage of fully paced beats (86.4 +/- 17.1% vs. 66.8 +/- 19.1%; p = 0.03) than nonresponders.nnnCONCLUSIONSnPacing counters overestimate the degree of effective BiV pacing in patients with permanent AF undergoing CRT therapy. Only patients with complete capture responded clinically to CRT. These findings have important implications for the application of CRT to patients with permanent AF and heart failure.

Malnutrition as Assessed by Nutritional Risk Index is Associated with Worse Outcome in Patients Admitted with Acute Decompensated Heart Failure: An ACAP-HF Data Analysis:

Malnutrition is common at hospital admission and tends to worsen during hospitalization. This controlled population study aimed to determine if serum albumin or moderate and severe nutritional depletion by Nutritional Risk Index (NRI) at hospital admission are associated with increased length of hospital stay (LOS) in patients admitted with acute decompensated heart failure (ADHF). Serum albumin levels and lymphocyte counts were retrospectively determined at hospital admission in 1740 consecutive patients admitted with primary and secondary diagnosis of ADHF. The Nutrition Risk Score (NRI) developed originally in AIDS and cancer populations was derived from the serum albumin concentration and the ratio of actual to usual weight, as follows: NRI = (1.519 × serum albumin, g/dL) + {41.7 × present weight (kg)/ideal body weight(kg)}. Patients were classified into four groups as no, mild, moderate or severe risk by NRI. Multiple logistic regressions were used to determine the association between nutritional risk category and LOS. Three hundred and eighty-one patients (34%) were at moderate or severe nutritional risk by NRI score. This cohort had lower BMI (24 ± 5.6 kg/m2), albumin (2.8±0.5 g/dL), mean NRI (73.5±9) and lower eGFR (50±33 mL/min per 1.73 m2). NRI for this cohort, adjusted for age, was associated with LOS of 10.1 days. Using the Multiple Logistic regression module, NRI was the strongest predictor for LOS (OR 1.7, 95% CI: 1.58–1.9; P=0.005), followed by TIMI Risk Score [TRS] (OR 1.33, 95% CI: 1.03–1.71; P=0.02) and the presence of coronary artery disease (OR 2.29, 95%CI: 1.03–5.1; P=0.04). Moderate and severe NRI score was associated with higher readmission and death rates as compared to the other two groups. Nutritional depletion as assessed by Nutritional Risk Index is associated with worse outcome in patients admitted with ADHF. Therefore; we recommend adding NRI to further risk stratify these patients.

High dose statin loading prior to percutaneous coronary intervention decreases cardiovascular events: a meta-analysis of randomized controlled trials.

We performed a meta‐analysis of randomized controlled trials of statin loading prior to percutaneous coronary intervention (PCI).

Right Ventricular Dysfunction is a Strong Predictor of Developing Atrial Fibrillation in Acutely Decompensated Heart Failure Patients, ACAP-HF Data Analysis

BACKGROUNDnHeart failure and atrial fibrillation (AFib) are the twin epidemics of modern cardiovascular disease. The incidence of new-onset AFib in acute decompensated heart failure (ADHF) patients is difficult to predict and the short- and long-term outcomes of AFib in a cohort of patients admitted with ADHF are unknown.nnnMETHODS AND RESULTSnA total of 904 patients admitted with ADHF were studied. Incidence of AFib on admission was recorded and a multivariate analysis was performed using echocardiographic parameters to specify the predictors of AFib incidence in this cohort. In 904 ADHF patients (57% male, mean age 69 ± 14 years), 81% had history of hypertension, 40% were diabetics, and 51% were smokers. A total of 63% of the patients had known heart failure (HF) with mean ejection fraction of 34% ± 21%, and 33% of the patients had ischemic cardiomyopathy as the etiology of HF. Echocardiographic parameters were: left atrial (LA) diameter 4.5 ± 0.8 cm, left ventricular end-systolic 4.1 ± 1.3 cm, left ventricular end-diastolic 5.3 ± 1.1 cm. Right ventricular dysfunction (RVD) was present in 34% of the patients. A total of 191 (21%) patients subsequently developed AFib with two thirds of the cases occurring in patients with RVD. Using a univariate analysis, older age (OR 1.02; P < .0001), history of HF (OR 2.93; P < .0001), LA dilation (OR 1.58; P < .0001), the presence of left ventricular hypertrophy (OR 3.01, P < .0001), and RVD (OR 4.93; P < .00001) were the strongest predictors for AFib. Controlling for LA size and left ventricular hypertrophy using a forward stepwise regression, RVD remained the strongest predictor (OR 4.45; P < .0001). Patients with RVD had more events (cardiac readmission and mortality) than those with normal RV (56% versus 38%; P < .00001), notably; all-cause mortality was 4.7%/year in the abnormal RV group versus 2.9%/year in the normal RV group; P < .05. RV function analyses by echocardiography further risk stratified these patients based on their rhythm categorizing those patients with abnormal RV and AFib as the ones with the worse prognosis.nnnCONCLUSIONnRV dysfunction is a strong predictor for developing AFib in acutely decompensated systolic failure patients. Patients with AFib and RVD have the worse outcome specially when is combined with LV dysfunction, therefore; evaluation of RV function may substantiate the difference in HF prognosis.

Acute conversion of persistent atrial fibrillation during dofetilide initiation.

Background: Dofetilide (D) is a highly selective blocker of the rapid component of the delayed rectifier potassium current and was approved for the treatment of atrial fibrillation (AF) based on a satisfactory safety/efficacy profile from trials in patients with left ventricle (LV) dysfunction or heart failure. The dose‐dependant acute conversion rates (<72 hours) were reported to be in the range of 6–30%. We hypothesized that the acute pharmacological conversion rate of D is higher than previously reported if used in a healthier cohort of patients with persistent AF.

Effect of adding nitroglycerin to early diuretic therapy on the morbidity and mortality of patients with chronic kidney disease presenting with acute decompensated heart failure.

Abstract Background: Loop diuretics are considered first-line therapy for patients with acute decompensated heart failure (ADHF). Adding nitroglycerin (NTG) to diuretic therapy for alleviation of acute shortness of breath has been advocated in our institution. We evaluated the benefits of adding NTG to diuretics in the emergency department for patients with ADHF and chronic kidney disease (CKD). Methods: 430 consecutive patients with ADHF who were admitted with a chief complaint of dyspnea were included in this retrospective study. Patients were divided into 3 groups. Group A patients were treated with neither diuretics nor NTG; Group B patients were treated with diuretics only; and Group C patients were treated with both diuretics and NTG. Estimated glomerular filtration rate (GFR) was calculated according to the Cockcroft-Gault formula. Follow-up was 36 ± 9 (mean ± standard deviation [SD]) months. Primary endpoints were readmission rate at 30 days and mortality at 24 months. Results: 430 patients were included in this study (42% men; age, 69 ± 14 [mean ± SD] years); mean New York Heart Association class was 2.4 ± 0.7 (mean ± SD) and mean ejection fraction was 28% ± 17% (mean ± SD). Group A included 257 (59%) patients, Group B had 127 (29%) patients, and Group C had 46 (11%) patients. Group C patients were older (mean age, 72 ± 13 years) with lower body mass index (26 ± 7 kg/m2), lower estimated GFR (55.8 ± 38 mL/min per 1.73 m2), higher B-type natriuretic peptide levels (1112 ± 876 pg/mL; P = nonsignificant [NS]), and higher systolic and diastolic blood pressures on admission (P = 0.001). The primary endpoint was assessed as a composite of all-cause mortality and ADHF readmission seen in 143 (56%) Group A patients, 68 (53%) Group B patients, and 22 (48%) Group C patients (P = NS). At 30 days there were 53 (12%) readmissions—26 in Group A, 20 in Group B, and 7 in Group C (P = NS). However, survival at 24 months was higher in Group C (87%) compared with Groups A (79%) and B (82%) (P = 0.002). Using the Cox proportional-hazards regression module, early administration of NTG and Lasix (95% confidence interval [CI], 1.06–1.62; P = 0.01) followed by CKD stage (95% CI, 1.00–1.35; P = 0.04) were the only predictors for survival. Conclusion: There is a role for early administration of NTG in addition to diuretic therapy in patients admitted to the emergency department with ADHF, with resultant decreased length of stay and a trend toward a decrease in the composite endpoint of all-cause mortality and ADHF readmission. The mortality benefit at 2 years reported in our study is thought-provoking and raises a premise to be proven in randomized clinical trials.

Antihypertensive therapy in hypertrophic cardiomyopathy.

Patients with coexisting hypertrophic cardiomyopathy (HC) and hypertension present diagnostic and therapeutic dilemmas. A retrospective cohort study of patients with HC with coexisting hypertension referred to a specialized HC program was conducted. HC and hypertension were confirmed by strict criteria. Echocardiographic data were reviewed for peak instantaneous left ventricular outflow tract gradients, at rest and with provocation. Symptom control, left ventricular outflow tract gradients, and hypertension control were compared between the first and last visits. One hundred fifteen patients (94 obstructed and 21 nonobstructed) met the eligibility criteria for the study and were included in the analysis, with the mean follow-up duration of 36 months. Because of the treatment strategy, there was a significant decrease in the number of patients treated with direct vasodilators and an increase in the use of β blockers and disopyramide. Twenty-one obstructed patients (22%) required septal reduction therapy. Overall, in obstructed patients, peak instantaneous left ventricular outflow tract gradient at rest decreased from 48 to 14 mm Hg (p <0.01), which was accompanied by significant improvement in functional class (2.4 vs 1.8, p <0.01). The prevalence of uncontrolled hypertension decreased from 56% at the initial visit to 37% at the last visit (p = 0.01). The cohort had a low rate of adverse cardiovascular outcomes such as death, acute coronary syndromes, and stroke. In conclusion, the present study demonstrates that stepwise, symptom-oriented therapy is feasible and effective in patients with coexisting HC and hypertension.

Computational Method to Predict Esophageal Temperature Elevations During Pulmonary Vein Isolation

Background: u2002The esophagus is in close proximity to the posterior wall of the left atrium, which renders it susceptible to thermal injury during radiofrequency (RF) ablation procedures for atrial fibrillation (AF). Real‐time assessment of esophageal position and temperature (Tu2003°) during pulmonary vein (PV) isolation has not been extensively explored.

Association of BMI and Cardiovascular Risk Stratification in the Elderly African-American Females

We aimed to estimate the association of BMI and risk of systemic hypertension in African‐American females aged 65 years and older. In this retrospective, cross‐sectional study, medical charts were randomly reviewed after obtaining institutional review board approval and data collection was conducted for height, weight, BMI, age, ethnicity, gender, and hypertension. A multivariable logistic regression analysis was performed. The mean BMI was significantly higher in hypertensive subjects than normotensives (30.3 vs. 29 kg/m2; P = 0.003). A higher proportion of hypertensive subjects had a BMI >23 kg/m2 as compared to normotensives (88.9% vs. 83.5%; P = 0.023). When the log odds of having a history of hypertension was plotted against BMI as a continuous variable, we found that the odds showed an increasing trend with increasing BMI and a steep increase after a BMI of 23 kg/m2. When BMI was analyzed as a categorical variable, a BMI of 23–30 kg/m2 was found to have an odds ratio of 1.43 (95% confidence interval 1.01–2.13; P = 0.05) and a BMI of >30 kg/m2 had an odds ratio of 1.76 (95% confidence interval 1.17–2.65; P = 0.007) when compared to a BMI of <23 kg/m2. This association remained significant in both univariate and multivariate analysis. We conclude that BMI is an independent predictor of hypertension in elderly African‐American females. Our results indicate that the risk of hypertension increased significantly at BMI of >23 kg/m2 in this ethnic group. Weight reduction to a greater extent than previously indicated could play an integral role in prevention and control of high blood pressure in this particular population.

Device stratified comparison among transfemoral, transapical and transubclavian access for Transcatheter Aortic Valve Replacement (TAVR): A meta-analysis

a Department of Internal Medicine/Cardiology, University of Miami/Jackson Memorial Hospital, Miami, FL, United States b Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States c Department of Cardiology, Baylor College of Medicine, Houston, TX, United States d Department of Cardiology, Columbia College of Physicians and Surgeons, St. Lukes Hospital, New York, NY, United States