Heidi Lumish

Effect of Omega-3 Acid Ethyl Esters on Left Ventricular Remodeling After Acute Myocardial Infarction: The OMEGA-REMODEL Randomized Clinical Trial.

Background: Omega-3 fatty acids from fish oil have been associated with beneficial cardiovascular effects, but their role in modifying cardiac structures and tissue characteristics in patients who have had an acute myocardial infarction while receiving current guideline-based therapy remains unknown. Methods: In a multicenter, double-blind, placebo-controlled trial, participants presenting with an acute myocardial infarction were randomly assigned 1:1 to 6 months of high-dose omega-3 fatty acids (n=180) or placebo (n=178). Cardiac magnetic resonance imaging was used to assess cardiac structure and tissue characteristics at baseline and after study therapy. The primary study endpoint was change in left ventricular systolic volume index. Secondary endpoints included change in noninfarct myocardial fibrosis, left ventricular ejection fraction, and infarct size. Results: By intention-to-treat analysis, patients randomly assigned to omega-3 fatty acids experienced a significant reduction of left ventricular systolic volume index (–5.8%, P=0.017), and noninfarct myocardial fibrosis (–5.6%, P=0.026) in comparison with placebo. Per-protocol analysis revealed that those patients who achieved the highest quartile increase in red blood cell omega-3 index experienced a 13% reduction in left ventricular systolic volume index in comparison with the lowest quartile. In addition, patients in the omega-3 fatty acid arm underwent significant reductions in serum biomarkers of systemic and vascular inflammation and myocardial fibrosis. There were no adverse events associated with high-dose omega-3 fatty acid therapy. Conclusions: Treatment of patients with acute myocardial infarction with high-dose omega-3 fatty acids was associated with reduction of adverse left ventricular remodeling, noninfarct myocardial fibrosis, and serum biomarkers of systemic inflammation beyond current guideline-based standard of care. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00729430.

Cost-Effectiveness of Follow-Up of Pulmonary Nodules Incidentally Detected on Cardiac Computed Tomographic Angiography in Patients With Suspected Coronary Artery Disease

Background— Pulmonary nodules (PNs) are often detected incidentally during coronary computed tomographic (CT) angiography, which is increasingly being used to evaluate patients with chest pain symptoms. However, the efficiency of following up on incidentally detected PN is unknown. Methods and Results— We determined demographic and clinical characteristics of stable symptomatic patients referred for coronary CT angiography in whom incidentally detected PNs warranted follow-up. A validated lung cancer simulation model was populated with data from these patients, and clinical and economic consequences of follow-up per Fleischner guidelines versus no follow-up were simulated. Of the 3665 patients referred for coronary CT angiography, 591 (16%) had PNs requiring follow-up. The mean age of patients with PNs was 59±10 years; 66% were male; 67% had ever smoked; and 21% had obstructive coronary artery disease. The projected overall lung cancer incidence was 5.8% in these patients, but the majority died of coronary artery disease (38%) and other causes (57%). Follow-up of PNs was associated with a 4.6% relative reduction in cumulative lung cancer mortality (absolute mortality: follow-up, 4.33% versus non–follow-up, 4.54%), more downstream testing (follow-up, 2.34 CTs per patient versus non–follow-up, 1.01 CTs per patient), and an average increase in quality-adjusted life of 7 days. Costs per quality-adjusted life-year gained were

Effect of the 2010 task force criteria on reclassification of cardiovascular magnetic resonance criteria for arrhythmogenic right ventricular cardiomyopathy

154 700 to follow up the entire cohort and

Reporting Scan Time Reduces Cardiac MR Examination Duration

129 800 per quality-adjusted life-year when only smokers were included. Conclusions— Follow-up of PNs incidentally detected in patients undergoing coronary CT angiography for chest pain evaluation is associated with a small reduction in lung cancer mortality. However, significant downstream testing contributes to limited efficiency, as demonstrated by a high cost per quality-adjusted life-year, especially in nonsmokers.

Prognostic value of different cardiac MRI parameters for the diagnosis of myocarditis

BackgroundWe sought to evaluate the effect of application of the revised 2010 Task Force Criteria (TFC) on the prevalence of major and minor Cardiovascular Magnetic Resonance (CMR) criteria for Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) versus application of the original 1994 TFC. We also assessed the utility of MRI to identify alternative diagnoses for patients referred for ARVC evaluation.Methods968 consecutive patients referred to our institution for CMR with clinical suspicion of ARVC from 1995 to 2010, were evaluated for the presence of major and minor CMR criteria per the 1994 and 2010 ARVC TFC. CMR criteria included right ventricle (RV) dilatation, reduced RV ejection fraction, RV aneurysm, or regional RV wall motion abnormalities. When quantitative measures of RV size and function were not available, and in whom abnormal size or function was reported, a repeat quantitative analysis by 2 qualified CMR physicians in consensus.ResultsOf 968 patients, 220 (22.7%) fulfilled either a major or a minor 1994 TFC, and 25 (2.6%) fulfilled any of the 2010 TFC criterion. Among patients meeting any 1994 criteria, only 25 (11.4%) met at least one 2010 criterion. All patients who fulfilled a 2010 criteria also satisfied at least one 1994 criterion. Per the 2010 TFC, 21 (2.2%) patients met major criteria and 4 (0.4%) patients fulfilled at least one minor criterion. Eight patients meeting 1994 minor criteria were reclassified as satisfying 2010 major criteria, while 4 patients fulfilling 1994 major criteria were reclassified to only minor or no criteria under the 2010 TFC.Eighty-nine (9.2%) patients had alternative cardiac diagnoses, including 43 (4.4%) with clinically significant potential ARVC mimics. These included cardiac sarcoidosis, RV volume overload conditions, and other cardiomyopathies.ConclusionsApplication of the 2010 TFC resulted in reduction of total patients meeting any diagnostic CMR criteria for ARVC from 22.7% to 2.6% versus the 1994 TFC. CMR identified alternative cardiac diagnoses in 9.2% of patients, and 4.4% of the diagnoses were potential mimics of ARVC.

Adherence to the 2010 American College of Cardiology Foundation Appropriate Use Criteria for Cardiac Computed Tomography: Quality Analysis at a Tertiary Referral Center.

CardiacMR(CMR)imagingisusedfor a variety of indications, rangingfrom suspected cardiomyopathy toevaluationofcongenitalheartdefects[1-3].Atourinstitution,theseexam-inations are monitored and tailoredby physicians, with the potential tobecome lengthy and resource inten-sive. CMR examinations have comeunder particular scrutiny in the set-ting of rising health care costs [4,5].Although quality improvementinitiatives typically focus on care im-provement, waste reduction is an al-ternativequalitymeasure [6-9].Onaclinical CMR imaging service, wastetakestheformofaddedscantimeduetoextraneouspulsesequences,repeti-tion of sequences not necessary foraccurate diagnosis, or any extensionof the examination time withoutadded diagnostic value [7]. Waitingtime, whether time spent waiting fora scan to finish or for a radiologist’sassistance, and consequent “under-utilization” of the scanner are exam-plesofwasteonaclinicalservice [10].We observed low compliancewith allotted time slots for CMRexaminationsatourinstitution,de-spite allotted slot times of 90 min(the longest in the department). In2010, more than half of the 518CMR examinations performed ex-ceeded 90 min in length (Table 1).

ST2 is reduced by high-dose omega-3 fatty acid treatment following acute MI and is correlated with reduction of the extracellular volume fraction of non-infarcted myocardium

Results 209 cases were reviewed; mean age 47 and 58% men. 74 (35%) patients were diagnosed with myocarditis based on CMR. The number of patients with 0, 1, 2 and 3 criteria positive was 70 (33%), 65 (31%), 49 (23%) and 25 (12%) respectively. Age, gender, diabetes, hypertension, smoking, CAD, prior CHF and CRI were similar among all groups. There was a trend for higher prevalence of NYHA class III or IV in myocarditis patients (17% vs 7.8 %; P=0.05). Baseline LVEF was 48.44±18 by TTE and 46±21 by CMR with no significant differences between groups. Mean increase in LVEF at 6 months by TTE for patients with 0, 1, 2 and 3 criteria positive was 5±10, 13±11, 11±10 and 6±12 (P=0.147). Mean change in LVEF for three myocarditis groups based on abnormal T1 and T2, T1 and DE or T2 and DE was 10±9, 10±7 and 7±9 (P=0.39). MACE was achieved in 20 (37%) patients with myocarditis and 21 (23%) patients without the diagnosis (P=0.078). The rate of MACE in patients with 0, 1, 2 and 3 positive criteria was 11 (22%), 10 (25%), 13 (37%) and 7 (37%) (P=0.127 and 0.21 for 0 vs 2 and 0 vs 3 criteria). The three groups based on positive T1 and T2, T1 and DE or T2 and DE had MACE rates of 3 (23%), 5 (38%) and 5 (38%) with no significant differences on pairwise comparisons.

Effect of Omega-3 Acid Ethyl Esters on Left Ventricular Remodeling After Acute Myocardial InfarctionClinical Perspective: The OMEGA-REMODEL Randomized Clinical Trial

Background In November 2010, the American College of Cardiology Foundation published revised appropriateness criteria (AC) for cardiac computed tomography (CT). We evaluated adherence to these criteria by providers of different subspecialties at a tertiary referral center. Methods Reports of 383 consecutive patients who underwent clinically indicated cardiac CT from December 1, 2010, to July 31, 2011, were reviewed by physicians with appropriate training in cardiac CT. Scans were classified as appropriate, inappropriate, or uncertain based on the revised 2010 AC. Studies that did not fall under any of the specified indications were labeled as unclassified. Adherence to the AC was also analyzed as a function of provider type. Research scans were excluded from this analysis. Results Three hundred eight exams (80%) were classified as appropriate; 26 (7%), as inappropriate; 30 (8%), as uncertain; and 19 (5%), as unclassified. Of the 19 (5%) unclassified cardiac CT exams, the most common indication was for evaluation of suspected aortic dissection. Three hundred five exams (80%) were referred by cardiologists; 73 (19%), by internists; and 5 (1%), by neurologists. Of the 305 cardiology-referred studies, 221 (73%) were ordered by general cardiologists; 28 (9%), by interventional cardiologists; and 56 (19%), by electrophysiologists. There was no significant difference in adherence to the criteria between provider specialties or between cardiology subspecialties (P > 0.05). Conclusions high across provider specialties.

Effect of Omega-3 Acid Ethyl Esters on Left Ventricular Remodeling After Acute Myocardial InfarctionClinical Perspective

ST2 is reduced by high-dose omega-3 fatty acid treatment following acute MI and is correlated with reduction of the extracellular volume fraction of non-infarcted myocardium Bobby Heydari, Shuaib Abdullah, James V Pottala, Ravi V Shah, Siddique A Abbasi, Damien Mandry, Heidi Lumish, Udo Hoffmann, Evan Appelbaum, Jiazuo Feng, Ron Blankstein, Michael Steigner, Joseph P McConnell, William Harris, Michael Jerosch-Herold, Raymond Y Kwong

Effect of Omega-3 Acid Ethyl Esters on Left Ventricular Remodeling After Acute Myocardial Infarction

Background: Omega-3 fatty acids from fish oil have been associated with beneficial cardiovascular effects, but their role in modifying cardiac structures and tissue characteristics in patients who have had an acute myocardial infarction while receiving current guideline-based therapy remains unknown. Methods: In a multicenter, double-blind, placebo-controlled trial, participants presenting with an acute myocardial infarction were randomly assigned 1:1 to 6 months of high-dose omega-3 fatty acids (n=180) or placebo (n=178). Cardiac magnetic resonance imaging was used to assess cardiac structure and tissue characteristics at baseline and after study therapy. The primary study endpoint was change in left ventricular systolic volume index. Secondary endpoints included change in noninfarct myocardial fibrosis, left ventricular ejection fraction, and infarct size. Results: By intention-to-treat analysis, patients randomly assigned to omega-3 fatty acids experienced a significant reduction of left ventricular systolic volume index (–5.8%, P=0.017), and noninfarct myocardial fibrosis (–5.6%, P=0.026) in comparison with placebo. Per-protocol analysis revealed that those patients who achieved the highest quartile increase in red blood cell omega-3 index experienced a 13% reduction in left ventricular systolic volume index in comparison with the lowest quartile. In addition, patients in the omega-3 fatty acid arm underwent significant reductions in serum biomarkers of systemic and vascular inflammation and myocardial fibrosis. There were no adverse events associated with high-dose omega-3 fatty acid therapy. Conclusions: Treatment of patients with acute myocardial infarction with high-dose omega-3 fatty acids was associated with reduction of adverse left ventricular remodeling, noninfarct myocardial fibrosis, and serum biomarkers of systemic inflammation beyond current guideline-based standard of care. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00729430.