Faraz Khan Luni

Cardioprotective role of ischemic postconditioning in acute myocardial infarction: A systematic review and meta-analysis

BACKGROUND Evidence suggests that ischemic postconditioning (IPoC) may reduce the extent of reperfusion injury. We performed a meta-analysis of randomized controlled trials, which compared the role of IPoC during primary percutaneous coronary intervention (PCI) to PCI alone (control group) in ST-segment elevation myocardial infarction. METHODS Several databases were searched, which yielded 19 studies. The outcomes of interest were measures of myocardial damage (serum cardiac enzymes and infarct size by imaging) and left ventricular function (left ventricular ejection fraction and wall motion score index). Mean difference (MD) and standardized mean difference (SMD) were used to assess the treatment effect. An inverse variance method was used to pool data into a random-effects model. RESULTS Ischemic postconditioning demonstrated a decrease in serum cardiac enzymes (SMD -0.48, 95% CI -0.92 to -0.05, I(2) = 92%), reduction in infarct size by imaging (SMD -0.30, 95% CI -0.58 to -0.01, I(2) = 80%), wall motion score index (MD -0.19, 95% CI -0.29 to -0.09, I(2) = 44%), and showed improvement in left ventricular ejection fraction (IPoC 52 ± 0.4, control 49.7 ± 0.4) (MD 2.78, 95% CI 0.66-4.91, I(2) = 69%). All included studies were limited by high risk of performance and publication bias. CONCLUSIONS Ischemic postconditioning during PCI in ST-segment elevation myocardial infarction appears to be superior to PCI alone in reduction of both myocardial injury or damage and improvement in global and regional left ventricular function. The effect seems to be more pronounced when a greater myocardial area is at risk. Given the limitations of the current available evidence, additional data from large randomized controlled trials are warranted.

Safety and Use of Anticoagulation After Aortic Valve Replacement With Bioprostheses: A Meta-Analysis

Background—The American College of Cardiology guidelines recommend 3 months of anticoagulation after replacement of the aortic valve with a bioprosthesis. However, there remains great variability in the current clinical practice and conflicting results from clinical studies. To assist clinical decision making, we pooled the existing evidence to assess whether anticoagulation in the setting of a new bioprosthesis was associated with improved outcomes or greater risk of bleeding. Methods and Results—We searched the PubMed database from the inception of these databases until April 2015 to identify original studies (observational studies or clinical trials) that assessed anticoagulation with warfarin in comparison with either aspirin or no antiplatelet or anticoagulant therapy. We included the studies if their outcomes included thromboembolism or stroke/transient ischemic attacks and bleeding events. Quality assessment was performed in accordance with the Newland Ottawa Scale, and random effects analysis was used to pool the data from the available studies. I2 testing was done to assess the heterogeneity of the included studies. After screening through 170 articles, a total of 13 studies (cases=6431; controls=18210) were included in the final analyses. The use of warfarin was associated with a significantly increased risk of overall bleeding (odds ratio, 1.96; 95% confidence interval, 1.25–3.08; P<0.0001) or bleeding risk at 3 months (odds ratio, 1.92; 95% confidence interval, 1.10–3.34; P<0.0001) compared with aspirin or placebo. With regard to composite primary outcome variables (risk of venous thromboembolism, stroke, or transient ischemic attack) at 3 months, no significant difference was seen with warfarin (odds ratio, 1.13; 95% confidence interval, 0.82–1.56; P=0.67). Moreover, anticoagulation was also not shown to improve outcomes at time interval >3 months (odds ratio, 1.12; 95% confidence interval, 0.80–1.58; P=0.79). Conclusions—Contrary to the current guidelines, a meta-analysis of previous studies suggests that anticoagulation in the setting of an aortic bioprosthesis significantly increases bleeding risk without a favorable effect on thromboembolic events. Larger, randomized controlled studies should be performed to further guide this clinical practice.

Mortality Effect of ICD in Primary Prevention of Nonischemic Cardiomyopathy: A Meta-Analysis of Randomized Controlled Trials

Implantation of an implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death (SCD) is controversial in view of the recent DANISH trial which suggested no benefit with ICD for primary prevention in patients with non‐ischemic cardiomyopathy (NICMP).

Egg Consumption and Incidence of Heart Failure: A Meta-Analysis of Prospective Cohort Studies

Introduction Heart failure (HF) remains a major health problem affecting 5.7 million adults in USA. Data on the association of egg consumption with incident HF have been inconsistent. We, therefore, conducted this meta-analysis of prospective cohort studies to assess the relation of egg consumption with incident HF in the general population. Methods Using extensive online search, we conducted a meta-analysis of new onset HF following exposure to egg consumption. A random effects model was used and between studies heterogeneity was estimated with I2. Publication bias was assessed graphically using a funnel plot. All analyses were performed with Comprehensive Meta-Analysis (version 2.2.064). Results We identified four prospective cohorts for a total of 105,999 subjects and 5,059 cases of new onset HF. When comparing the highest (≥1/day) to the lowest category of egg consumption, pooled relative risk of HF was 1.25 (95% confidence interval = 1.12–1.39; p = 0.00). There was no evidence for heterogeneity (I2 = 0%) nor publication bias. On sensitivity analysis, stratification by gender differences, follow-up duration, and region where study was conducted did not alter the main conclusion. Conclusion Our meta-analysis suggests an elevated risk of incident HF with frequent egg consumption.

Fanconi Syndrome and Antiretrovirals: It Is Never Too Late.

Antiretroviral medications such as tenofovir have been associated with Fanconi syndrome (FS) usually identified within the first 1–29 months after exposure to the medication. We present a case of life-threatening FS which developed in a 37-year-old woman with HIV after 8 years of asymptomatic tenofovir use. The patient was diagnosed with HIV in 1996 at 20 years of age, hepatitis C 10 years later, and Staphylococcus aureus sepsis with secondary osteomyelitis of the spine 3 years before admission for FS. She developed nausea, vomiting, diarrhea, and generalized weakness over a 2-week time period and presented to the hospital. In the emergency department, her serum potassium was 1.5 mEq/L, bicarbonate was 12 mEq/L, chloride was 111 mEq/L, phosphorus was 1.8 mg/dL, and creatinine was 1.95 mg/dL (baseline, 1.4). Arterial blood gas revealed a non–anion gap (hyperchloremic) metabolic acidosis. Type 2 renal tubular acidosis induced by antiretroviral therapy (ART) was suspected and the ART was discontinued with resolution of the renal abnormalities within 7 days. A non–tenofovir-containing ART regimen consisting of lamivudine/abacavir and efavirenz was begun, and over the next 8 months, the patient was without recurrence of the FS. This case report demonstrates the acute development of FS after prolonged exposure to tenofovir without exposure to additional nephrotoxins such as nonsteroidal medications or aminoglycosides. Tenofovir can cause FS at any time and should be considered in any patient presenting with renal tubular acidosis type 2 while on tenofovir regardless of the duration of drug exposure.

Reverse Takotsubo Cardiomyopathy: A Story of a Critically Ill Man with Transient Cardiac Dysfunction

Reverse Takotsubo cardiomyopathy (TCM) is a recently described variant of classic TCM. In contrast to classic TCM, the regional wall motion abnormalities are localized in the basal segments. The condition can be triggered by acute stressful events, including acute medical illnesses. The wall motion abnormalities and left ventricular dysfunction are usually completely reversible. We present a case of an 84-year-old man with a complicated postoperative course after laparoscopic cholecystectomy with multiple laparotomies and recurrent sepsis. Echocardiographic evaluation demonstrated left ventricular dysfunction and wall motion abnormalities in a pattern resembling reverse TCM. He had no significant coronary disease on angiography and follow-up echocardiography showed complete resolution of left ventricular systolic dysfunction and regional wall motion abnormalities.

Risk of Ischemic Heart Disease in Patients With Sjögren’s Syndrome

Background: Ischemic heart disease (IHD) has emerged as a major cause of morbidity and mortality in patients with autoimmune conditions such as systemic lupus erythematosus and rheumatoid arthritis, but the risk of IHD in Sjögren’s syndrome (SjS) is unknown. To fill this knowledge gap, we estimated the prevalence and risk of IHD with SjS compared to controls from the general population using the Healthcare Cost and Utilization Project National Inpatient Sample 2011 database. Materials and Methods: The Healthcare Cost and Utilization Project administrative longitudinal database contains encounter‐level information on inpatient stays, emergency department visits and ambulatory surgery in all U.S. hospitals. We conducted a cross‐sectional study among the inpatient population diagnosed with SjS and matched 1:4 with controls for age, sex and hospital region. Odds ratio for IHD was calculated as cases compared to controls. The contribution of various risk factors to IHD was also evaluated by logistic regression. Results: Analysis demonstrated that 7,154 of 13,086 cases (54.7%) of SjS had IHD compared to 27,367 of 52,448 controls (52.2%). The adjusted odds ratio for IHD in those with SjS was 0.898 (95% CI: 0.844‐0.955). Patients with SjS were significantly more likely to have hypertension, diabetes, apnea and lipid disorders. Conclusions: To our knowledge, this is the largest population‐based study investigating the risk of IHD in patients with SjS. We found a modest, though statistically significant, decrease in the risk of IHD in SjS compared to controls.

Transient Complete Heart Block Secondary to Bed Bug Insecticide: A Case of Pyrethroid Cardiac Toxicity

Pyrethroids are the major components of various commercially used insect repellants. These are less toxic to humans due to their slow absorption and rapid metabolism. However, cases of suicidal and accidental poisoning with household insecticides are not uncommon. We report a case of a 59-year-old female who presented with syncope after an accidental exposure to bed bug repellant spray at home. She was found to be in complete heart block and was treated conservatively. There was complete resolution of symptoms and atrioventricular conduction abnormality on day 2 of hospitalization. She was discharged in a stable condition with an uneventful follow-up course. Cardiac involvement in pyrethroid toxicity is rare. We describe various clinical manifestations and the pathophysiology of toxicity caused by pyrethroid-containing insecticides.

Clinical outcomes associated with per-operative discontinuation of aspirin in patients with coronary artery disease: A systematic review and meta-analysis.

Background: Postoperative state is characterized by increased thrombotic risk by virtue of platelet activation. Whether aspirin ameliorates this risk in patients with established coronary artery disease undergoing cardiac or noncardiac surgery is unknown. We conducted a systematic review and meta‐analysis to compare the risk of major adverse cardiac events (MACE) and the risk of bleeding in patients with early (3–5 or more days before surgery) vs. late discontinuation(<3–5 days)/no discontinuation of aspirin.

Isolated rupture of bicuspid aortic valve following blunt chest trauma: a case report and systematic review of literature

Blunt trauma to chest cause injury to various cardiac structures. Isolated rupture of aortic valve without aortic dissection is rare complication of blunt chest trauma and can be caused by a tear or avulsion of the valve. We report a case of a 35-year-old male who presented with severe aortic insufficiency due to rupture of a non-infected congenital bicuspid aortic valve following non-penetrating chest trauma. The diagnosis was suggested by echocardiography and was confirmed by intra-operative and histological findings. The patient was successfully treated with surgical valve replacement with uneventful postoperative course and recovery. We describe patho-physiology, clinical manifestations, management and the literature review of traumatic rupture of bicuspid aortic valve.