Geetha P. Bhumireddy

Utilization of Trained Volunteers Decreases 30-Day Readmissions for Heart Failure

BACKGROUND This study evaluated the effectiveness of using trained volunteer staff in reducing 30-day readmissions of congestive heart failure (CHF) patients. METHODS From June 2010 to December 2010, 137 patients (mean age 73 years) hospitalized for CHF were randomly assigned to either: an interventional arm (arm A) receiving dietary and pharmacologic education by a trained volunteer, follow-up telephone calls within 48 hours, and a month of weekly calls; or a control arm (arm B) receiving standard care. Primary outcomes were 30-day readmission rates for CHF and worsening New York Heart Association (NYHA) functional classification; composite and all-cause mortality were secondary outcomes. RESULTS Arm A patients had decreased 30-day readmissions (7% vs 19%; P < .05) with a relative risk reduction (RRR) of 63% and an absolute risk reduction (ARR) of 12%. The composite outcome of 30-day readmission, worsening NYHA functional class, and death was decreased in the arm A (24% vs 49%; P < .05; RRR 51%, ARR 25%). Standard-care treatment and hypertension, age ≥65 years and hypertension, and cigarette smoking were predictors of increased risk for readmissions, worsening NYHA functional class, and all-cause mortality, respectively, in the multivariable analysis. CONCLUSIONS Utilizing trained volunteer staff to improve patient education and engagement might be an efficient and low-cost intervention to reduce CHF readmissions.

Prevalence and Prognostic Significance of Left Ventricular Noncompaction in Patients Referred for Cardiac Magnetic Resonance ImagingCLINICAL PERSPECTIVE

Background— Presence of prominent left ventricular trabeculation satisfying criteria for left ventricular noncompaction (LVNC) on routine cardiac magnetic resonance examination is frequently encountered; however, the clinical and prognostic significance of these findings remain elusive. This registry aimed to assess LVNC prevalence by 4 current criteria and to prospectively evaluate an association between diagnosis of LVNC by these criteria and adverse events. Methods and Results— There were 700 patients referred for cardiac magnetic resonance: 42% were women, median age was 70 years (range, 45–71 years), mean left ventricular ejection fraction was 51% (±17%), and 32% had late gadolinium enhancement on cardiac magnetic resonance. The cohort underwent diagnostic assessment for LVNC by 4 separate imaging criteria—referenced by their authors as Petersen, Stacey, Jacquier, and Captur, with LVNC prevalence of 39%, 23%, 25% and 3%, respectively. Primary clinical outcome was combined end point of time to death, ischemic stroke, ventricular tachycardia/ventricular fibrillation, and heart failure hospitalization. Secondary clinical outcomes were (1) all-cause mortality and (2) time to the first occurrence of any of the following events: cardiac death, ischemic stroke, ventricular tachycardia/ventricular fibrillation, or heart failure hospitalization. During a median follow-up of 7 years, there were no statistically significant differences in assessed outcomes noted between patients with and without LVNC irrespective of the applied criteria. Conclusions— Current criteria for the diagnosis of LVNC leads to highly variable disease prevalence in patients referred for cardiac magnetic resonance. The diagnosis of LVNC, by any current criteria, was not associated with adverse clinical events on nearly 7 years of follow-up. Limited conclusions can be made for Captur criteria due to low observed prevalence.

Serial Cardiac Magnetic Resonance Imaging of a Rapidly Progressing Liquefaction Necrosis of Mitral Annulus Calcification Associated With Embolic Stroke

Mitral annulus calcification (MAC) is a common finding in the elderly. A rare manifestation of MAC is liquefaction necrosis that can be mistaken for a tumor or an abscess. Because its course is most often benign, a correct diagnosis is imperative to avoid unnecessary workup or treatment. A 76-year-old woman with history of hypertension and dyslipidemia presented with chest pain and elevated cardiac enzymes. A coronary angiogram revealed no significant coronary artery disease. Echocardiogram (Figure 1) revealed a large, solid mass within the atrioventricular groove and the lateral wall of the left ventricle. There was moderate calcification of the mitral valve annulus. Computed tomography scan of the chest (Figure 2) revealed a soft tissue density inseparable from the region of the mitral valve and the left ventricular wall. Cardiac magnetic resonance (CMR) showed a large mass involving the basal lateral wall near the atrioventricular groove, extending into the left atrium (Figure 3A and 3B). The mass was slightly hyperintense on T1 (Figure 4) and hypointense on T2 imaging (Figure 5). The mass was homogenous on delayed enhancement with a bright ring (Figure 6), the characteristics were not changed with fat saturation, and it was avascular by perfusion (Figure 7). The patient was discharged from the hospital with a scheduled outpatient workup to continue. Figure 1. Echocardiography images before and after biopsy. A , 4-chamber view performed on presentation, reveals a soft tissue mass involving the atrio-ventricular groove, the left atrium, and left ventricle. There is moderate calcification of the mitral valve. B , 4-chamber view performed after biopsy. The mass has decreased in size and appears cystic. White arrows indicate the mass. Figure 2. Computed tomography image performed on first admission. This is a 5-chamber …

Clinical application of cine-MRI in the visual assessment of mitral regurgitation compared to echocardiography and cardiac catheterization.

Background Detecting and quantifying the severity of mitral regurgitation is essential for risk stratification and clinical decision-making regarding timing of surgery. Our objective was to assess specific visual parameters by cine-magnetic resonance imaging (MRI) in the determination of the severity of mitral regurgitation and to compare it to previously validated imaging modalities: echocardiography and cardiac ventriculography. Methods The study population consisted of 68 patients who underwent a cardiac MRI followed by an echocardiogram within a median time of 2.0 days and 49 of these patients who had a cardiac catheterization, median time of 2.0 days. The inter-rater agreement statistic (Kappa) was used to evaluate the agreement. Results There was moderate agreement between cine MRI and Doppler echocardiography in assessing mitral regurgitation severity, with a kappa value of 0.47, confidence interval (CI) 0.29–0.65. There was also fair agreement between cine MRI and cardiac catheterization with a kappa value of 0.36, CI of 0.17–0.55. Conclusion Cine MRI offers a reasonable alternative to both Doppler echocardiography and, to a lesser extent, cardiac catheterization for visually assessing the severity of mitral regurgitation with specific visual parameters during routine clinical cardiac MRI.

The aorta wall of patients presenting to the emergency department with acute myocardial infarction by cardiac magnetic resonance

BACKGROUND Inflammation has been shown to be a major component in the pathophysiology of acute coronary syndrome (ACS). In patients presenting with acute myocardial infarction (AMI), a critical component of the ACS spectrum, multiple coronary arteries are involved during this inflammatory process. In addition to the coronary vasculature, the inflammatory cascade has also been shown to affect the carotid arteries and possibly the aorta. PURPOSE To assess the involvement of the aorta during AMI by cardiac magnetic resonance (CMR). METHODS We prospectively evaluated the aortic wall by CMR in 123 patients. 78 patients were enrolled from the emergency department (ED), who presented with chest pain and were classified as either: (1) AMI: elevated troponin levels and typical chest pain or (2) non-cardiac chest pain (CP): negative troponins and a normal stress test or normal cardiac catheterization. We compared these 2 groups to a group of 45 asymptomatic diabetic patients. The descending thoracic aortic wall area (AWA) and maximal aortic wall thickness (AWT) were measured using a double inversion recovery T-2 weighted, ECG-gated, spin echo sequence by CMR. RESULTS Patients with AMI were older, more likely to smoke, had a higher incidence of claudication, and had higher CRP levels. The AWA and maximal AWT were greater in patients who presented to the ED with ACS (2.11+/-0.17 mm(2), and 3.17+/-0.19 mm, respectively) than both patients presenting with non-cardiac CP (1.52+/-0.58 mm(2), p<0.001; and 2.57+/-0.10 mm, p<0.001) and the diabetic patients (1.38+/-0.58 mm(2), p<0.001; and 2.30+/-0.131 mm, p<0.001). The difference in the aortic wall characteristics remained significant after correcting for body mass index, hyperlipidemia, statins and C-reactive protein. There was no difference in maximal AWT or AWA between patients with non-cardiac CP and patients with diabetes. CONCLUSION Patients with AMI have a significantly greater maximal aortic wall thickness and area compared to patients with non-cardiac CP. Longitudinal studies are needed to assess whether this increase is due to inflammation or a higher atherosclerotic burden.

Review and Analysis of Publication Trends over Three Decades in Three High Impact Medicine Journals

Context Over the past three decades, industry sponsored research expanded in the United States. Financial incentives can lead to potential conflicts of interest (COI) resulting in underreporting of negative study results. Objective We hypothesized that over the three decades, there would be an increase in: a) reporting of conflict of interest and source of funding; b) percentage of randomized control trials c) number of patients per study and d) industry funding. Data sources and Study Selection Original articles published in three calendar years (1988, 1998, and 2008) in The Lancet, New England Journal of Medicine and Journal of American Medical Association were collected. Data Extraction Studies were reviewed and investigational design categorized as prospective and retrospective clinical trials. Prospective trials were categorized into randomized or non-randomized and single-center or multi-center trials. Retrospective trials were categorized as registries, meta-analyses and other studies, mostly comprising of case reports or series. Study outcomes were categorized as positive or negative depending on whether the pre-specified hypothesis was met. Financial disclosures were researched for financial relationships and profit status, and accordingly categorized as government, non-profit or industry sponsored. Studies were assessed for reporting COI. Results 1,671 original articles were included in this analysis. Total number of published studies decreased by 17% from 1988 to 2008. Over 20 year period, the proportion of prospective randomized trials increased from 22 to 46% (p < 0.0001); whereas the proportion of prospective non-randomized trials decreased from 59% to 27% (p < 0.001). There was an increase in the percentage of prospective randomized multi-center trials from 11% to 41% (p < 0.001). Conversely, there was a reduction in non-randomized single-center trials from 47% to 10% (p < 0.001). Proportion of government funded studies remained constant, whereas industry funded studies more than doubled (17% to 40%; p < 0.0001). The number of studies with negative results more than doubled (10% to 22%; p<0.0001). While lack of funding disclosure decreased from 35% to 7%, COI reporting increased from 2% to 84% (p < 0.0001). Conclusion Improved reporting of COI, clarity in financial sponsorship, increased publication of negative results in the setting of larger and better designed clinical trials represents a positive step forward in the scientific publications, despite the higher percentage of industry funded studies.

Papillary muscle infarction and cardiovascular outcomes

Recent studies suggest that papillary muscle infarction (PMI) detected by contrast enhancement cardiac magnetic resonance (ce-CMR) may correlate with mitral regurgitation and reduced left ventricular ejection fraction (LVEF). However, there is scant data about the association of PMI with cardiovascular outcomes.

Importance of papillary muscle infarction detected by cardiac magnetic resonance imaging in predicting cardiovascular events

BACKGROUND Recent studies suggest that papillary muscle infarction (PMI) following recent myocardial infarction (MI) correlates with adverse cardiovascular outcomes. The purpose of this study is to determine the prevalence and prognostic significance of PMI by cardiac magnetic resonance (CMR) in a large cohort of patients. METHODS Retrospective study of patients who underwent CMR between January 2007 and December 2009 were evaluated for the presence of PMI in one or both of the left ventricle papillary muscles. The primary outcome was a time to a combined endpoint of all-cause mortality and worsening heart failure. Secondary outcomes were time to individual components of the combined outcome. RESULTS 419 patients were included in our analysis, 232 patients (55%) had ischemic cardiomyopathy. Patients were followed at six-month intervals for a median follow-up time of 3.7 (interquartile range (IQR): 1.6; 6.3) years after initial imaging. During this period 196 patients (46.8%) had a primary outcome and 92 patients (22%) died. PM infarct was identified in 204 (48.7%) patients with twice as many posteromedial (PRM) (27%) than anterolateral (ARL) lesions (11%) and a similar number with infarct in both (11%). There was no association between studied outcomes and the presence of PMI in either PRM or ARL PM. The presence of infarct in both PM was a predictor of both the primary outcome (HR 1.69, CI[1.01-2.86], p<0.049.) and mortality (HR 1.69, CI[1.01-4.2], p<0.046). CONCLUSION The presence of infarct in either papillary muscle was not associated with outcomes. However, infarct involving both papillary muscles was associated with worse outcomes.

LEFT VENTRICULAR NON-COMPACTION AND LONG-TERM CARDIOVASCULAR OUTCOMES: ANALYSIS OF 769 PATIENTS BY CARDIAC MAGNETIC RESONANCE

Left ventricular non-compaction (LVNC) is a rare congenital morphogenetic disorder, and its prevalence and clinical significance has not been clearly determined. Historically, LVNC has been associated with worse cardiac outcomes, but recent studies have showed a relatively mild clinical course.

The Accuracy of the Electrocardiogram during Exercise Stress Test Based on Heart Size

Background Multiple studies have shown that the exercise electrocardiogram (ECG) is less accurate for predicting ischemia, especially in women, and there is additional evidence to suggest that heart size may affect its diagnostic accuracy. Hypothesis The purpose of this investigation was to assess the diagnostic accuracy of the exercise ECG based on heart size. Methods We evaluated 1,011 consecutive patients who were referred for an exercise nuclear stress test. Patients were divided into two groups: small heart size defined as left ventricular end diastolic volume (LVEDV) <65 mL (Group A) and normal heart size defined as LVEDV ≥65 mL (Group B) and associations between ECG outcome (false positive vs. no false positive) and heart size (small vs. normal) were analyzed using the Chi square test for independence, with a Yates continuity correction. LVEDV calculations were performed via a computer-processing algorithm. SPECT myocardial perfusion imaging was used as the gold standard for the presence of coronary artery disease (CAD). Results Small heart size was found in 142 patients, 123 female and 19 male patients. There was a significant association between ECG outcome and heart size (χ2 = 4.7, p = 0.03), where smaller hearts were associated with a significantly greater number of false positives. Conclusions This study suggests a possible explanation for the poor diagnostic accuracy of exercise stress testing, especially in women, as the overwhelming majority of patients with small heart size were women.