Georges Khoueiry

Neutrophil to lymphocyte ratio and cardiovascular diseases: a review.

The role of inflammatory markers in cardiovascular diseases has been studied extensively and a consistent relationship between various inflammatory markers and cardiovascular diseases has been established in the past. Neutrophil to lymphocyte ratio (NLR) is a new addition to the long list of these inflammatory markers. NLR, which is calculated from complete blood count with differential, is an inexpensive, easy to obtain, widely available marker of inflammation, which can aid in the risk stratification of patients with various cardiovascular diseases in addition to the traditionally used markers. It has been associated with arterial stiffness and high coronary calcium score, which are themselves significant markers of cardiovascular disease. NLR is reported as an independent predictor of outcome in stable coronary artery disease, as well as a predictor of short- and long-term mortality in patients with acute coronary syndromes. It is linked with increased risk of ventricular arrhythmias during percutaneous coronary intervention (PCI) and higher long-term mortality in patients undergoing PCI irrespective of indications of PCI. In patients admitted with advanced heart failure, high NLR was reported with higher inpatient mortality. Recently, NLR has been reported as a prognostic marker for outcome from coronary artery bypass grafting and postcoronary artery bypass grafting atrial fibrillation.

Mean platelet volume/platelet count ratio as a predictor of long-term mortality after non-ST-elevation myocardial infarction

Previous studies reported an association between elevated mean platelet volume (MPV) and post-myocardial infarction mortality. This study explores the association between long-term mortality after non-ST-segment elevation myocardial infarction (NSTEMI) and the peripheral blood platelet indices (i.e., the mean platelet volume (MPV), platelet count, and the MPV/platelet (MPV/P) ratio). Two physicians independently reviewed the data of 619 NSTEMI patients. The blood samples were drawn and analyzed within 1 h of admission, the second, and the last hospital days. Patients were stratified into equal tertiles according to the platelet count, MPV, and MPV/platelet ratio. The primary outcome, 4-year all-cause mortality, was compared among the platelet indices tertile models. According to MPV, platelet count, and MPV/platelet ratio tertile models, there was a trend of higher 4-year mortality for the lower and upper tertiles in comparison to the middle tertiles. However, only the admission MPV/platelet ratio tercile model was statistically significant for predicting the 4-year mortality. The mortality rate of the highest MPV/platelet (48/207 (23%)) and the lowest (41/206 (20%)) tertiles were significantly higher than the middle tertile (19/206 (9%)), p = 0.0004 by the chi-squared test. After adjusting for Global Registry of Acute Coronary Events, the patients in the combined first and third MPV/P tertiles had higher mortality in reference to those in the middle MPV/P tercile (hazard ratio 1.951, confidence interval 1.032–3.687, and p < 0.0396). Our novel finding is that the MPV/platelet ratio is superior to the MPV alone in predicting long-term mortality after NSTEMI. We suggest that using this ratio will magnify any existing relationship between platelet indices and mortality post-NSTMI. Further studies are needed to confirm our finding.

Reverse Takotsubo Cardiomyopathy in the Setting of Anaphylaxis Treated with High-dose Intravenous Epinephrine

BACKGROUND Takotsubo cardiomyopathy is seen, though rarely, in anaphylaxis treated with epinephrine. Stress cardiomyopathy is most likely to occur in middle-aged women. The underlying etiology is believed to be related to catecholamine release in periods of intense stress. Catecholamines administered exogenously, and those secreted by neuroendocrine tumors (e.g., pheochromocytoma) or during anaphylaxis have been reported to cause apical ballooning syndrome, or takotsubo syndrome. However, reverse takotsubo stress cardiomyopathy is rarely seen or reported in anaphylaxis treated with epinephrine. OBJECTIVES To report a case illustrating that high-dose intravenous epinephrine can trigger stress cardiomyopathy, and that the risk is heightened with inappropriate dosing in the treatment of anaphylaxis. CASE REPORT We report a rare case of iatrogenic reverse takotsubo syndrome in a young woman who was inappropriately treated with high-dose intravenous epinephrine for mild anaphylaxis. CONCLUSION Inappropriately high doses of intravenous epinephrine can trigger stress cardiomyopathy. Emergency physicians should be familiar with the diagnosis, grading, and appropriate treatments of anaphylaxis to avoid this unnecessary complication.

Association Between Coronary Artery Disease Diagnosed by Coronary Angiography and Breast Arterial Calcifications on Mammography: Meta-Analysis of the Data

BACKGROUND Previous studies evaluating breast arterial calcifications (BAC) as a risk marker for coronary artery disease (CAD) have been limited by sample size and have yielded mixed results. Our objective was to evaluate the association of BAC and CAD. METHODS Data sources included Medline (1970-2010), the Cochrane Controlled Trials Register electronic database (1970-2010), and CINAHL (1970-2010). The search strategy included the keywords, breast artery calcification, vascular calcification on mammogram, coronary angiography, and meta-analysis. Eligible studies included female patients who had undergone coronary angiography, the gold standard for diagnosing CAD, and had screening mammograms that revealed the presence or absence of BAC. Information on eligibility criteria, baseline characteristics, results, and methodologic quality was extracted by two reviewers. Disagreements were resolved by consensus. RESULTS A total of 927 patients were enrolled in the five studies. There was a 1.59 (95% confidence interval [CI] 1-21-2.09) increased odds of angiographically defined CAD in patients with BAC seen on mammography. CONCLUSIONS The presence of BAC on mammography appears to increase the risk of having obstructive CAD on coronary angiography; thus, BAC may not be a benign finding.

Using Six Sigma Methodology to Reduce Patient Transfer Times from Floor to Critical‐Care Beds

&NA; Introduction: In response to concerns regarding delays in transferring critically ill patients to intensive care units (ICU), a quality improvement project, using the Six Sigma process, was undertaken to correct issues leading to transfer delay. Objective: To test the efficacy of a Six Sigma intervention to reduce transfer time and establish a patient transfer process that would effectively enhance communication between hospital caregivers and improve the continuum of care for patients. Methods: The project was conducted at a 714‐bed tertiary care hospital in Staten Island, New York. A Six Sigma multidisciplinary team was assembled to assess areas that needed improvement, manage the intervention, and analyze the results. Results: The Six Sigma process identified eight key steps in the transfer of patients from general medical floors to critical care areas. Preintervention data and a root‐cause analysis helped to establish the goal transfer‐time limits of 3 h for any individual transfer and 90 min for the average of all transfers. Conclusions: The Six Sigma approach is a problem‐solving methodology that resulted in almost a 60% reduction in patienttransfer time from a general medical floor to a critical care area. The Six Sigma process is a feasible method for implementing healthcare related quality of care projects, especially those that are complex.

Ginseng: a potential cause of long QT.

Ginseng is a frequently used food additive and considered to be relatively safe. Long QT syndrome can be hereditary or acquired. It presents as syncope, sudden cardiac death, or seizures. We report the novel case of a female patient without cardiovascular risk factors who developed prolonged QT with subsequent torsades de pointes during periods in which she was drinking large amounts of ginseng.

Depression, disability, and quality of life after off-pump coronary artery bypass grafting: A prospective 9-month follow-up study

BACKGROUND Several studies have looked at the effects on mood and quality of life (QOL) among patients who underwent on-pump coronary artery bypass grafting (CABG), but few have reported on off-pump CABG (OPCABG). METHODS We recruited 50 patients undergoing OPCABG. The day before CABG, patients were interviewed using 4 questionnaires: the Beck Depression Index (BDI), Beck Anxiety Index (BAI), Sheehan Disability Scale (SDS), and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). The process was repeated at 1, 3, 6, and 9 months. RESULTS One month postoperatively, patients showed increased levels of depression (Δ 1.67 in the mean BDI score, P < .05) and disability (Δ 5.28 in the mean SDS score, P < .001) and decreases levels of anxiety (Δ 3.7 in the mean BAI score, P < .001) and QOL compared with baseline. When compared with the first month, at 9 months patients were significantly less depressed (Δ 3.58 in the mean BDI score, P < .001), were less disabled (Δ 5.34 in the mean SDS score, P < .001), and had better QOL (Δ 3.82 in the mean Q-LES-Q score, P = .014). At 9 months, 44% had some degree of depression and 48% had low QOL. CONCLUSION Despite that all scores returned to or below baseline at 9 months, a high percentage of patients still had depressive symptoms and overall poor quality of life (QOL). BDI scores at baseline are good predictors of QOL at all measured intervals. This should make physicians more prudent in diagnosing and observing these patients.

Value of albumin-globulin ratio as a predictor of all-cause mortality after non-ST elevation myocardial infarction.

Low albumin and the albumin–globulin ratio (AGR) were associated with vascular adverse events. Our study explores the AGR as a predictor of mortality after non-ST-segment elevation myocardial infarction (NSTEMI). In an observational study of 570 NSTEMI patients admitted to a tertiary center between 2004 and 2006, patients were stratified into equal tertiles according to AGR. The primary outcome was 4-year all-cause mortality. The 4-year mortality rates in the first, second, and third AGR tertiles were 88 (47%) of 189, 48 (25%)of 190 , and 19 (10%) of 191, respectively (P < .0001). After adjusting for 20 confounding variables, AGR first tertile (AGR <1.12) had a higher mortality versus second tertile (hazard ratio [HR] 2.6, P < .001). Likewise, the AGR second tertile had higher mortality versus the third tertile (AGR ≥1.34; HR 2.3, P = .004). The albumin–globulin ratio is a significant independent predictor of long-term mortality after NSTEMI in patients with normal serum albumin levels. Further studies are needed to explain the underlying mechanisms.

Aortic pulse pressure is associated with the localization of coronary artery disease based on coronary flow lateralization.

BACKGROUND Aortic pulse pressure (APP) is related to arterial stiffness and associated with the presence and extent of coronary artery disease (CAD). Besides, the left coronary artery (LCA) has a predominantly diastolic flow while the right coronary artery (RCA) receives systolic and diastolic flow. Thus, we hypothesized that increased systolic-diastolic pressure difference had a greater atherogenic effect on the RCA than on the LCA. METHODS A random sample of 433 CAD patients (145 females, 288 males, mean age 65.0 ± 11.1 years) undergoing coronary angiography at Staten Island University Hospital between January 2005 and May 2008 was studied. Coronary lesion was defined as a ≥50% luminal stenosis. Patients were divided into three groups, with isolated LCA lesions (n = 154), isolated RCA lesions (n = 36) or mixed LCA and RCA lesions (n = 243). RESULTS APP differed significantly between groups, being highest when the RCA alone was affected (67.6 ± 20.3 mm Hg for LCA vs. 78.8 ± 22.0 for RCA vs. 72.7 ± 22.6 for mixed, P = 0.008 for analysis of variance (ANOVA)). Age and gender were not associated with CAD location. Heart rate was associated with CAD location, lowest in RCA group, and negatively correlated with APP. However, left ventricular ejection fraction (LVEF) was lower in the mixed CAD group and positively correlated with APP. The association between APP and right-sided CAD persisted in multivariate logistic regression adjusting for confounders, including heart rate, LVEF and medication use. A similar but less significant pattern was seen with brachial arterial pressures. CONCLUSIONS Aortic pulse pressure may affect CAD along with coronary flow phasic patterns.

A STEMI Code Protocol Improves Door-to-Balloon Time on Weekdays and Weekends

Abstract: Primary percutaneous coronary intervention (PCI) has emerged as the standard of care for the management of ST‐elevation myocardial infarctions (STEMI). Only 32% of patients with STEMI receive this procedure within the recommended 90 min for door‐to‐balloon time (DTB). We reviewed all STEMI cases that presented to our institution before and after the implementation of a STEMI Code protocol. Before the STEMI Code protocol, 27.1% of weekday cases and 6.3% of weekend cases were performed within 90 min. After the STEMI Code protocol, there was a threefold increase in the number of patients who received PCI within 90 min (p<.0001). A STEMI Code protocol dramatically improves DTB and equalizes disparities between weekday and weekend care.