George R. Marzouka

QRS duration on electrocardiography and cardiovascular mortality (from the National Health and Nutrition Examination Survey-III).

The relation of bundle branch block (BBB) with adverse outcome is controversial. We hypothesized that increased QRS duration is an independent predictor of cardiovascular (CV) mortality in a cross-sectional US population. This is a retrospective cohort study on prospectively collected data to assess the relationship between QRS duration on routine ECG and CV mortality. Participants included 8,527 patients with ECG data available from the National Health and Nutrition Examination Survey data set, representing 74,062,796 individuals in the United States. Mean age was 60.5 ± 13.6 years. Most subjects were white (87%) and women (53%). During the follow-up period of 106,244.6 person-years, 1,433 CV deaths occurred. Multivariate analysis revealed that the highest quartile of QRS duration was associated with higher CV mortality than lowest quartile (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.01 to 1.7, p = 0.04) after adjustment for established risk factors. Both left BBB (HR 2.4, 95% CI 1.3 to 4.7, p = 0.009) and right BBB (HR 1.90, 95% CI 1.2 to 3.0, p = 0.008) were significantly associated with increased CV mortality. The addition of the QRS duration in 10-millisecond increments to the Framingham Risk Score model resulted in 4.4% overall net reclassification improvement (95% CI 0.02 to 0.04; p = 0.00006). In conclusion, increased QRS duration was found to be an independent predictor of CV mortality in this cross-sectional US population. A model including QRS duration in addition to traditional risk factors was associated with improved CV risk prediction.

Combined use of Impella left ventricular assist device and extracorporeal membrane oxygenation as a bridge to recovery in fulminant myocarditis.

Myocarditis may result in cardiogenic shock, and when medical therapy is unable to maintain adequate cardiac output, mechanical circulatory support is indicated. This is the first reported case of a percutaneous left ventricular assist device being used in combination with extracorporeal membrane oxygenation in a patient with biventricular and respiratory failure, as a bridge to recovery.

ST-T wave abnormality in lead aVR and reclassification of cardiovascular risk (from the National Health and Nutrition Examination Survey-III).

Electrocardiographic lead aVR is often ignored in clinical practice. The aim of this study was to investigate whether ST-T wave amplitude in lead aVR predicts cardiovascular (CV) mortality and if this variable adds value to a traditional risk prediction model. A total of 7,928 participants enrolled in the National Health and Nutrition Examination Survey (NHANES) III with electrocardiographic data available were included. Each participant had 13.5 ± 3.8 years of follow-up. The study sample was stratified according to ST-segment amplitude and T-wave amplitude in lead aVR. ST-segment elevation (>8 μV) in lead aVR was predictive of CV mortality in the multivariate analysis when not accounting for T-wave amplitude. The finding lost significance after including T-wave amplitude in the model. A positive T wave in lead aVR (>0 mV) was the strongest multivariate predictor of CV mortality (hazard ratio 3.37, p <0.01). The addition of T-wave amplitude in lead aVR to the Framingham risk score led to a net reclassification improvement of 2.7% of subjects with CV events and 2.3% of subjects with no events (p <0.01). Furthermore, in the intermediate-risk category, 20.0% of the subjects in the CV event group and 9.1% of subjects in the no-event group were appropriately reclassified. The absolute integrated discrimination improvement was 0.012 (p <0.01), and the relative integrated discrimination improvement was 11%. In conclusion, T-wave amplitude in lead aVR independently predicts CV mortality in a cross-sectional United States population. Adding T-wave abnormalities in lead aVR to the Framingham risk score improves model discrimination and calibration with better reclassification of intermediate-risk subjects.

Isolated Nonspecific ST-Segment and T-Wave Abnormalities in a Cross-Sectional United States Population and Mortality (from NHANES III)

Most clinicians regard isolated, minor, or nonspecific ST-segment and T-wave (NS-STT) abnormalities to be incidental, often transient, and benign findings in asymptomatic patients. We sought to evaluate whether isolated NS-STT abnormalities on routine electrocardiograms (ECGs) are associated with increased risk of cardiovascular mortality (CM) and all-cause mortality (AM) in a cross-sectional United States population without known coronary artery disease. We included all adults 40 to 90 years of age without known coronary artery disease or risk equivalent based on history and laboratory values, enrolled in the NHANES III from 1988 to 1994, with electrocardiographic data available, and a total follow-up period of 59,781.75 patient-years. NS-STT abnormalities were defined by Minnesota Coding. Subjects were excluded if their mortality data were missing or if they had major electrocardiographic abnormalities, heart rate >120 beats/min, nonsinus rhythm, cardiac infarction/injury score ≥ 20 on ECG, left ventricular hypertrophy by Minnesota Codes 3.1 and 3.3, or patient-reported history coronary artery disease, congestive heart failure, stroke, diabetes, or peripheral arterial disease. The remaining 4,426 subjects were stratified by presence or absence of NS-STT abnormalities. Mortality was judged based on International Classification of Diseases, Tenth Revision coding linked to the National Death Index. Cox proportional hazard ratio was used for multivariate analysis, showing that CM (hazards ratio 1.71, 95% confidence interval 1.04 to 2.83, p = 0.04) and AM (hazards ratio 1.37, 95% confidence interval 1.03 to 1.81, p = 0.02) were significantly higher in the isolated NS-STT abnormalities group. In conclusion, isolated NS-STT abnormalities on ECG were associated with a higher incidence of CM and AM in this large nationally representative cross-sectional cohort without known coronary artery disease or coronary artery disease risk equivalents.

New-onset versus prior history of atrial fibrillation: Outcomes from the AFFIRM trial

BACKGROUND There are limited data on prognosis and outcomes of patients with new-onset atrial fibrillation (AF) compared with those with a prior history of AF. METHODS AND RESULTS We conducted a comparison of these 2 groups in the AFFIRM trial. New-onset AF was the qualifying arrhythmia in 1,391 patients (34%). Compared with patients with prior history of AF, patients with new-onset AF were more likely to have a history of heart failure. There was no mortality difference between rate control (RaC) and rhythm control (RhC) among patients with new-onset AF (17% vs 20%, P = .152). In the univariate model, new-onset AF was associated with increased risk of mortality compared with history of prior AF (RaC unadjusted hazard ratio [HR] 1.36 [P = .010], RhC unadjusted HR 1.39 [P = .003]). However, after multivariate adjustments, new-onset AF did not carry an increased risk of mortality (RaC adjusted HR 1.14 [P = .370], RhC adjusted HR 1.16 [P = .248]). Subjects with new-onset AF randomized to the RhC arm were more likely to remain in normal sinus rhythm at follow-up (adjusted HR 0.79, P = .012) compared with patients with prior history of AF. CONCLUSIONS In a multivariable analysis adjusting for confounders, new-onset AF was not associated with increased mortality compared with prior history of AF regardless of the treatment strategy. Patients with new-onset AF treated with the rhythm control strategy were more likely to remain in normal sinus rhythm on follow-up.

Electrocardiographic Abnormalities and Reclassification of Cardiovascular Risk: Insights from NHANES-III

BACKGROUND We aimed to assess the additive value of electrocardiogram (ECG) findings to risk prediction models for cardiovascular disease. METHODS Our dataset consisted of 6025 individuals with ECG data available from the National Health and Nutrition Examination Survey-III. This is a self-weighting sample with a follow-up of 79,046.84 person-years. The primary outcomes were cardiovascular mortality and all-cause mortality. We compared 2 models: Framingham Risk Score (FRS) covariates (Model A) and ECG abnormalities added to Model A (Model B), and calculated the net reclassification improvement index (NRI). RESULTS Mean age of our study population was 58.7 years; 45.6% were male and 91.7% were white. At baseline, 54.6% of individuals had ECG abnormalities, of which 545 (9%) died secondary to a cardiovascular event, compared with 194 individuals (3.2%) (P <.01) without ECG abnormalities. ECG abnormalities were significant predictors of cardiovascular mortality after adjusting for traditional cardiovascular risk factors (hazard ratio 1.44; 95% confidence interval, 1.13-1.83). Addition of ECG abnormalities led to an overall NRI of 3.6% subjects (P <.001) and 13.24% in the intermediate risk category. The absolute integrated discrimination index was 0.0001 (P <.001). CONCLUSION Electrocardiographic abnormalities are independent predictors of cardiovascular mortality, and their addition to the FRS improves model discrimination and calibration. Further studies are needed to assess the prospective application of ECG abnormalities in cardiovascular risk prediction in individual subjects.

Prevalence of Vaccination Rates in Systolic Heart Failure: A Prospective Study of 549 Patients by Age, Race, Ethnicity, and Sex in a Heart Failure Disease Management Program

Healthy People 2010 aims at immunizing 60% of high-risk adults annually against influenza and once against pneumococcal disease. The aim of this study was to evaluate the use of a standardized approach to improve vaccination rates in patients with heart failure (HF); to determine whether disparities exist based on age, race, ethnicity, or sex at baseline and follow-up; and to evaluate the impact of clinical variables on the odds of being vaccinated. A prospective study of 549 indigent patients enrolled in a systolic HF disease management program (HFDMP) began enrollment from August 2007 to January 2009 at Jackson Memorial Hospital. Patients were interviewed at their initial visit for immunization status; those without vaccinations were offered the vaccines. Prevalence of vaccination (POV) for influenza and pneumococcal disease was obtained at baseline and at follow-up. The odds ratio for being vaccinated was calculated using logistic regression. The study population comprised mostly Hispanic (56%), black (37%), and male (70%) patients, with a mean age of 56 ± 12 years and a mean ejection fraction of 25% ± 10%. The initial POV for both was 22% at baseline. At follow-up, POV improved to 60.5%. Of those not vaccinated at baseline, 17.5% refused vaccination. Odds ratios at baseline for age, race/ethnicity, and sex were 0.99 (P=.99), 0.63 (P=.08), and 0.62 (P=.14), respectively. These did not change significantly at follow-up. Prevalence of vaccination in our cohort was low. Enrollment into the HFDMP improved immunization prevalence without creating age, race, ethnicity, or sex disparities.

Association between anti-human heat shock protein-60 and interleukin-2 with coronary artery calcium score

Introduction Based upon evidence suggesting that concentrations of anti-heat shock protein-60 (anti-HSP60) and interleukin-2 (IL-2) are associated with atherogenesis, we tested the hypothesis that anti-HSP60 and IL-2 are associated with coronary artery calcium (CAC) score, a marker of subclinical atherosclerosis. Methods We evaluated 998 asymptomatic adults, age 45–84 years, without known coronary disease from the Multi-Ethnic Study of Atherosclerosis (MESA), who had anti-HSP60 measured at baseline. Tertiles of serum anti-HSP60 were evaluated. The associations of IL-2 and anti-HSP60 with CAC were assessed using multivariate analyses, with adjustments for coronary risk factors and Framingham risk score. Results Patients’ demographics, diabetes, hypertension, obesity, or dyslipidaemia did not show differences in levels of anti-HSP60. The median (IQR) Framingham risk score was 11 (5–22), 8 (5–16), and 9 (5–18) for the first, second, and third tertiles, respectively (p=0.043). IL-2 and tumour necrosis factor α (TNF-α) were associated with increased CAC (IL-2: OR 3.70, p<0.001; TNF-α: OR 4.63, p<0.001). In multivariate regression, the highest tertiles of anti-HSP60 and IL-2 were associated with increased risk of CAC (HSP60 T3: OR 1.49, p=0.022; IL-2: OR 2.49, p<0.001). After adjustment, significant progression of CAC was observed in patients with higher baseline levels of anti-HSP60 (estimate 31.73, p=0.016) and IL-2 (estimate 34.39, p=0.024). Conclusions Increased concentrations of inflammatory markers (IL-2 and anti-HSP60) are associated with an increased CAC at baseline and follow-up in healthy asymptomatic adults. Future studies should be carried out to assess its association with early development of atherosclerosis.

Comparison of rate versus rhythm control in patients with atrial fibrillation and a pacemaker.

The effect of rate versus rhythm control in patients with atrial fibrillation who have undergone previous pacemaker (PM) implantation is unknown. We evaluated the mortality in patients with atrial fibrillation and a PM randomized to rate or rhythm control treatment strategies. The Atrial Fibrillation Follow-up Investigation of Rhythm Management data set was stratified by the presence (n = 250) or absence (n = 3,810) of a PM at randomization into the rate or rhythm control arm. Kaplan-Meier curves were used for univariate analysis, and proportional hazards were used for multivariate analysis. The subjects with a PM (n = 250) were older (73 vs 69 years, p <0.01) and had a greater prevalence of coronary artery disease (53% vs 37%, p <0.01) and congestive heart failure (33% vs 23%, p <0.01). All-cause mortality was significantly greater in the PM patients who were randomized to the rhythm control arm (n = 128) than in the patients enrolled in the rate control arm with or without a PM (n = 2,027, p <0.01) and those in the rhythm control arm without a PM (n = 1,905, p <0.01). Multivariate analysis revealed that predictors of all-cause mortality included PM patients randomized to the rhythm control arm (hazard ratio 2.59, 95% confidence interval 1.46 to 4.58, p <0.01) and the presence of congestive heart failure (hazard ratio 2.42, 95% confidence interval 1.40 to 4.16, p <0.01). In conclusion, all-cause mortality was greater among patients with atrial fibrillation with a PM, who were randomized to the rhythm control arm of the Atrial Fibrillation Follow-up Investigation of Rhythm Management study compared with all other patients enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management study. The rhythm control strategy in patients with a PM was an independent predictor of mortality.

Racial and sex differences in prevalence of hypothyroidism in patients with cardiomyopathies enrolled into a heart failure disease management program.

The authors evaluated the prevalence of hypothyroidism in patients with heart failure (HF) to determine whether there are racial and sex differences and to determine the number of new cases of hypothyroidism. The study included 194 patients in an HF disease management program (HFDMP) in South Florida. Patients were interviewed for a history of hypothyroidism and referred for measurement of thyrotropin. The prevalence of hypothyroidism was calculated by race and sex. The prevalence of hypothyroidism was 18% for all patients with HF and 23% among Hispanics; however, this trend was not statistically significant (P = .06). More men than women had hypothyroidism (P = .04). Patients with hypothyroidism had higher mean lipid profiles (P < .01) and lower mean heart rates (P = .03) than healthy patients. Hypothyroidism is prevalent among HF patients, especially men. Hispanics with HF may have a higher prevalence of hypothyroidism. The standardized protocol of the HFDMP helped identify new cases of hypothyroidism.