James Maher

The STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) Trial Improves Outcomes

OBJECTIVES The goal of this study was to evaluate the impact of the STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) network on outcomes in the treatment of patients presenting with ST-segment elevation myocardial infarction (STEMI). BACKGROUND Shortening door-to-balloon (D2B) time remains a national priority for the treatment of STEMI. We previously reported a fully automated wireless network (STAT-MI) for transmission of electrocardiograms (ECGs) for suspected STEMI from the field to offsite cardiologists, allowing early triage with shortening of subsequent D2B times. We now report the impact of the STAT-MI wireless network on infarct size, length of hospital stay (LOS), and mortality. METHODS A fully automated wireless network (STAT-MI) was developed to enable automatic 12-lead ECG transmission and direct communication between emergency medical services personnel and offsite cardiologists that facilitated direct triage of patients to the cardiac catheterization laboratory. Demographic, laboratory, and time interval data of STAT-MI network patients were prospectively collected over a 33-month period and compared with concurrent control patients who presented with STEMI through non-STAT-MI pathways. RESULTS From June 2006 through February 2009, 92 patients presented via the STAT-MI network, and 50 patients presented through non-STAT-MI pathways (control group). Baseline clinical and demographic variables were similar in both groups. Overall, compared with control subjects, STAT-MI patients had significantly shorter D2B times (63 [42 to 87] min vs. 119 [96 to 178] min, U = 779.5, p < 0.00004), significantly lower peak troponin I (39.5 [11 to 120.5] ng/ml vs. 87.6 [38.4 to 227] ng/ml, U = 889.5, p = 0.005) and creatine phosphokinase-MB (126.1 [37.2 to 280.5] ng/ml vs. 290.3 [102.4 to 484] ng/ml, U = 883, p = 0.001), higher left ventricular ejection fractions (50% [35 to 55] vs. 35% [25 to 52], U = 1,075, p = 0.004), and shorter LOS (3 [2 to 4] days vs. 5.5 [3.5 to 10.5] days, U = 378, p < 0.001). CONCLUSIONS A fully automated, field-based, wireless network that transmits ECGs automatically to offsite cardiologists for the early evaluation and triage of patients with STEMI shortens D2B times, reduces infarct size, limits ejection fraction reduction, and shortens LOS.

Unicuspid unicommissural aortic valve: an extremely rare congenital anomaly.

Unicuspid aortic valve is a rare congenital malformation that usually presents in the 3rd to 5th decade of life-and usually with severe aortic stenosis or regurgitation. It often requires surgical correction. Diagnosis can be made with 2- or 3-dimensional transthoracic or transesophageal echocardiography, cardiac computed tomography, or cardiac magnetic resonance imaging. We report the case of a 31-year-old man who presented with dyspnea on exertion due to severe aortic stenosis secondary to a unicuspid unicommissural aortic valve. After aortic valve replacement, this patient experienced complete heart block that required the placement of a permanent pacemaker.

In-Hospital Outcomes and Complications of Coronary Artery Bypass Grafting in the United States Between 2008 and 2012

OBJECTIVE To investigate the frequency and predictors of in-hospital complications among patients undergoing coronary artery bypass grafting (CABG) in the United States. DESIGN Retrospective national database analysis SETTINGS: United States hospitals. PARTICIPANTS A weighted sample of 1,910,236 patients undergoing CABG surgery identified from the National (Nationwide) Inpatient Sample from 2008 to 2012. INTERVENTIONS CABG surgery MEASUREMENTS AND MAIN RESULTS: The number of CABG surgeries decreased from 436,275 in 2008 to 339,749 in 2012. The Deyo comorbidity index showed a steady increase from 2008 to 2012. The rate of in-hospital mortality decreased from 2.7% in 2008 to 2.2% in 2012 (p<0.001). The most common in-hospital complication was postoperative hemorrhage (30.4%), followed by cardiac (11.34%) and respiratory complications (2.3%). During the 5-year period, the rates of in-hospital cardiac, respiratory and infectious complications decreased (p<0.001), while the rate of postoperative hemorrhage showed a 35.8% relative increase in 2012 compared to 2008. CONCLUSION The annual number of CABG surgeries is declining in the United States. While the burden of comorbidities is increasing, the rates of mortality and most in-hospital complications are improving. The increasing rate of postoperative bleeding necessitates the need to develop strategies to improve the risk of bleeding in this patient population.

Refractory Case of Paroxysmal Autonomic Instability With Dystonia Syndrome Secondary to Hypoxia

Paroxysmal autonomic instability with dystonia (PAID) is a syndrome commonly related to traumatic brain injury (TBI) and rarely to anoxia associated with symptoms of dystonia, tachycardia, tachypnea, and diaphoresis. This is a case of a 20-year-old man who was stabbed in the heart. He underwent surgical repair of a ventricular septal defect and mitral valve replacement. Postoperatively, he developed dystonia with tachycardia and tachypnea consistent with PAID syndrome, secondary to prolonged hypoxia. Traditionally, this poorly understood syndrome is treated with morphine, clonazepam, and nonselective β-blockers. Second-line medications commonly used are baclofen, dantrolene, and gabapentin, which are aimed at the dystonia itself. In this case, both first- and second-line agents were ineffective. A 72-hour dexmedetomidine infusion resulted in complete resolution of symptoms. This is the first case of anoxia-induced PAID syndrome to be effectively treated with dexmedetomidine, which was previously used in a case induced by TBI.

Hypertension in African Americans with Heart Failure: Progression from Hypertrophy to Dilatation; Perhaps Not

AimConcentric hypertrophy is thought to transition to left ventricular (LV) dilatation and systolic failure in the presence of long standing hypertension (HTN). Whether or not this transition routinely occurs in humans is unknown.MethodsWe consecutively enrolled African American patients hospitalized for acute decompensated volume overload heart failure (HF) in this retrospective study. All patients had a history of HTN and absence of obstructive coronary disease. Patients were divided into those with normal left ventricular ejection fraction (LVEF) and reduced LVEF. LV dimensions were measured according to standard ASE recommendations. LV mass was calculated using the ASE formula with Devereux correction.ResultsPatients with normal LVEF HF were significantly older, female and had a longer duration of HTN with higher systolic blood pressure on admission. LV wall thickness was similarly elevated in both groups. LV mass was elevated in both groups however was significantly greater in the reduced LVEF HF group compared to the normal LVEF HF group. Furthermore, gender was an independent predictor for LV wall thickness in normal LVEF HF group.ConclusionIn African American patients with HF our study questions the paradigm that concentric hypertrophy transitions to LV dilatation and systolic failure in the presence of HTN. Genetics and gender likely play a role in an individual’s response to long standing hypertension.

New oral anticoagulants: good but not good enough!

In the recent article by the European Society of Cardiology Working Group on anticoagulants in heart disease ([1][1]), the authors describe in great clarity the emerging data regarding new anticoagulants for the treatment of nonvalvular atrial fibrillation. In the closing segment of conclusions and

TRENDS IN UTILIZATION OF INPATIENT PALLIATIVE CARE SERVICES AND RACIAL DISPARITY OF DISPOSITION TO HOSPICE CARE AMONG PATIENTS WITH HEART FAILURE IN THE UNITED STATES BETWEEN 2003 AND 2012

Background: The latest American Heart Association guidelines have recommended palliative/hospice care in selected patients with end-stage heart failure (HF). However, limited information exists regarding the trends in utilization of hospice care in this patient population. Methods: Data from the

PREDICTIVE VALUE OF SELVESTER SCORE IN ESTIMATING INFARCT SIZE IN PATIENTS UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

We have previously reported from our institution outcomes in patients with ST-elevation myocardial infarction (STEMI) based on mode of arrival i.e., fully automated pathway for pre-hospital ECG transmission (STAT-MI pathway) versus other. We now report on the use of ECG Selvester score (SS) in

Complementary non-culprit revascularization during ST-elevation myocardial infarction…get to know your patient first to the editor†

The recent meta-analysis Sethi et al. [1] discussed the lack of benefit or harm of complete revascularization (CR) over culprit only revascularization (COR) in patients undergoing primary percutaneous coronary intervention (PCI) during ST-elevation myocardial infarction (STEMI). This is in agreement with other metaanalysis [2,3] which processed data sets emerging predominantly from observational studies and registries [4]. The available data are faulted by considerable heterogeneity, bias, and quality shortcomings. Moreover, CR is poorly defined by most studies. The authors suggested appropriately that in the absence of high quality studies, any meta-analysis is not robust enough to definitively support or negate CR as a preferred strategy. The following editorial [5] further delineates the limitations of CR in view of difficulty in assessing lesion severity and concerns related to CR of hemodynamic non-significant lesions (which are unlikely to cause neither ischemia nor symptoms) under suboptimal conditions. CR strategy raises a few other serious concerns: