Jaya Mallidi

Meta-analysis of catheter ablation as an adjunct to medical therapy for treatment of ventricular tachycardia in patients with structural heart disease

BACKGROUND Most studies of catheter ablation for the treatment of ventricular tachycardia (VT) are relatively small observational trials. OBJECTIVE The purpose of this study was to define the relative risk of VT recurrence in patients undergoing catheter ablation as an adjunct to medical therapy versus medical therapy alone in a pooled analysis of controlled studies. METHODS Randomized and nonrandomized controlled trials of patients who underwent adjunctive catheter ablation of VT versus medical therapy alone were sought. MEDLINE, EMBASE, the Cochrane central register of controlled trials (CENTRAL), and Web of Science were searched from 1965 to July 2010. Supplemental searches included Internet resources, reference lists, and reports of arrhythmia experts. Three authors independently reviewed and extracted the data regarding baseline characteristics, ablation methodology, medical therapy, complications, VT recurrences, mortality, and study quality. RESULTS Five studies were included totaling 457 participants with structural heart disease. Adjunctive catheter ablation was performed in 58% of participants, whereas 42% received medical therapy alone for VT. Complications of catheter ablation included death (1%), stroke (1%), cardiac perforation (1%), and complete heart block (1.6%). Using a random-effects model, a statistically significant 35% reduction in the number of patients with VT recurrence was noted with adjunctive catheter ablation (P<.001). There was no statistically significant difference in mortality. CONCLUSIONS Catheter ablation as an adjunct to medical therapy reduces VT recurrences in patients with structural heart disease and has no impact on mortality.

Outcomes of Patients Admitted for Observation of Chest Pain

BACKGROUND Low-risk chest pain is a common cause of hospital admission; however, to our knowledge, there are no guidelines regarding the appropriate use of stress testing in such cases. METHODS We performed a retrospective cohort study of patients 21 years and older who were admitted to our tertiary care center with chest pain in 2007 and 2008. Using electronic records and chart review, we sought (1) to identify differences in the use of stress testing based on patient demographics and comorbidities, pretest probability of coronary artery disease, and house staff coverage and (2) to describe the results of stress testing and patient outcomes, including revascularization procedures and 30-day readmissions for myocardial infarction. RESULTS Of 2107 patients, 1474 (69.9%) underwent stress tests, and the results were abnormal in 184 patients (12.5%). Within 30 days, 22 patients (11.6%) with abnormal test results underwent cardiac catheterization, 9 (4.7%) underwent revascularization, and 2 (1.1%) were readmitted for myocardial infarction. In a multivariable model, stress test ordering was positively associated with age younger than 70 years (RR [relative risk], 1.12; 95% CI, 1.02-1.23), private insurance (vs Medicare/Medicaid: RR, 1.19; 95% CI, 1.11-1.27), and no house staff coverage (RR, 1.39; 95% CI, 1.28-1.50). Of patients with low (<10%) pretest probability, 68.0% underwent stress testing, but only 4.5% of these had abnormal test results. CONCLUSIONS Most patients who are admitted with low-risk chest pain undergo stress testing, regardless of pretest probability, but abnormal test results are uncommon and rarely acted on. Ordering stress tests based on pretest probability could improve efficiency without endangering patients.

Decongestive Treatment of Acute Decompensated Heart Failure: Cardiorenal Implications of Ultrafiltration and Diuretics

In patients with acute decompensated heart failure (ADHF), treatment aimed at adequate decongestion of the volume overloaded state is essential. Despite diuretic therapy, many patients remain volume overloaded and symptomatic. In addition, adverse effects related to diuretic treatment are common, including worsening kidney function and electrolyte disturbances. The development of decreased kidney function during treatment affects the response to diuretic therapy and is associated with important clinical outcomes, including mortality. The occurrence of diuretic resistance and the morbidity and mortality associated with diuretic therapy has stimulated interest to develop effective and safe treatment strategies that maximize decongestion and minimize decreased kidney function. During the last few decades, extracorporeal ultrafiltration has been used to remove fluid from diuretic-refractory hypervolemic patients. Recent clinical studies using user-friendly machines have suggested that ultrafiltration may be highly effective for decongesting patients with ADHF. Many questions remain regarding the comparative impact of diuretics and ultrafiltration on important clinical outcomes and adverse effects, including decreased kidney function. This article serves as a summary of key clinical studies addressing these points. The overall goal is to assist practicing clinicians who are contemplating the use of ultrafiltration for a patient with ADHF.

Long-term outcomes following fractional flow reserve-guided treatment of angiographically ambiguous left main coronary artery disease: A meta-analysis of prospective cohort studies

To define the long term outcomes of Fractional Flow Reserve (FFR) guided revascularization of ambiguous left main coronary artery (LMCA) lesions by performing a pooled meta‐analysis of all available studies.

Achieving Secondary Prevention Low-Density Lipoprotein Particle Concentration Goals Using Lipoprotein Cholesterol-Based Data

Background Epidemiologic studies suggest that LDL particle concentration (LDL-P) may remain elevated at guideline recommended LDL cholesterol goals, representing a source of residual risk. We examined the following seven separate lipid parameters in achieving the LDL-P goal of <1000 nmol/L goal for very high risk secondary prevention: total cholesterol to HDL cholesterol ratio, TC/HDL, <3; a composite of ATP-III very high risk targets, LDL-C<70 mg/dL, non-HDL-C<100 mg/dL and TG<150 mg/dL; a composite of standard secondary risk targets, LDL-C<100, non-HDL-C<130, TG<150; LDL phenotype; HDL-C≥40; TG<150; and TG/HDL-C<3. Methods We measured ApoB, ApoAI, ultracentrifugation lipoprotein cholesterol and NMR lipoprotein particle concentration in 148 unselected primary and secondary prevention patients. Results TC/HDL-C<3 effectively discriminated subjects by LDL-P goal (F = 84.1, p<10−6). The ATP-III very high risk composite target (LDL-C<70, nonHDL-C<100, TG<150) was also effective (F = 42.8, p<10−5). However, the standard secondary prevention composite (LDL-C<100, non-HDL-C<130, TG<150) was also effective but yielded higher LDL-P than the very high risk composite (F = 42.0, p<10−5) with upper 95% confidence interval of LDL-P less than 1000 nmol/L. TG<150 and TG/HDL-C<3 cutpoints both significantly discriminated subjects but the LDL-P upper 95% confidence intervals fell above goal of 1000 nmol/L (F = 15.8, p = 0.0001 and F = 9.7, p = 0.002 respectively). LDL density phenotype neared significance (F = 2.85, p = 0.094) and the HDL-C cutpoint of 40 mg/dL did not discriminate (F = 0.53, p = 0.47) alone or add discriminatory power to ATP-III targets. Conclusions A simple composite of ATP-III very high risk lipoprotein cholesterol based treatment targets or TC/HDL-C ratio <3 most effectively identified subjects meeting the secondary prevention target level of LDL-P<1000 nmol/L, providing a potential alternative to advanced lipid testing in many clinical circumstances.

Diuretics or Ultrafiltration for Acute Decompensated Heart Failure and Cardiorenal Syndrome

In the United States, more than 1 million patients are admitted annually for acute decompensated heart failure (ADHF). Moreover, many patients with ADHF are discharged without clinical evidence of adequate decongestion. Approximately 25% of patients with ADHF are readmitted during the next 30 days, and up to 20% die within 6 months. During the last 10-20 years, several therapies have been shown to have a beneficial impact on the clinical course of patients with chronic congestive heart failure; however, similar advances have not occurred for the treatment of ADHF. Although there are multiple facets to achieving the compensated state in ADHF, the main focus ultimately is on therapies directly responsible for removing excess sodium and water. Declining kidney function during treatment of the congested state (ie, cardiorenal syndrome type I) is one of the strongest predictors of shortand long-term adverse events, including readmission and mortality. The mechanisms behind this relationship are complex and likely are patient specific. Diuretics and blood-based extracorporeal ultrafiltration are the main decongestive therapies. Peritonealbased ultrafiltration has been used as well. Recent studies have shown that ultrafiltration is a very effective method for removing excessive fluid from selected patient populations with ADHF. The UNLOAD (Ultrafiltration Versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure) Study reported that ultrafiltration removed a greater volume of fluid than did a diuretic-based regimen. Patients in the ultrafiltration arm of the UNLOAD Study also had a statistically significant decrease in readmissions without an increase in adverse events. Thus, it appeared that ultrafiltration might affect ADHF favorably. However, there were concerns about whether diuretics were used optimally in the control group in this study. Additionally, although the change in serum creatinine (SCr) levels was not increased significantly in the ultrafiltration arm at any point in follow-up, twice as many patients in the ultrafiltration arm experienced an increase in SCr level 0.3 mg/dL during the first 24 hours of therapy. Finally, questions remained after this trial about which patients with ADHF should receive ultrafiltration (eg, early vs later in the course of cardiorenal syndrome type I), how ultrafiltration should be performed (eg, duration of

Feasibility, safety, and patient satisfaction of same-day discharge following peripheral arterial interventions: A randomized controlled study

To assess feasibility, safety, and patient satisfaction of same‐day discharge (SD) following peripheral arterial interventions.

How to Handle Conflict With Poise?: A Fellow’s Perspective

2:00 am: While on call, the Coronary Care Unit (CCU) intern pages you regarding a hypotensive patient. The nurse started the patient on 2 pressors without orders. You rush to assess the patient. When you reach the CCU, you find that both the nurse and the intern are upset. The nurse is concerned

Fractional Flow Reserve for the Evaluation of Tandem and Bifurcation Lesions, Left Main, and Acute Coronary Syndromes

Fractional flow reserve (FFR) is a well-established invasive tool to assess the physiologic significance of a coronary stenosis. Several randomized trials proved the safety of deferring revascularization based on FFR in subjects with stable coronary artery disease with single or multivessel disease. Subjects with tandem or bifurcations lesions, left main disease, and acute coronary syndromes were not included in these trials. Unique hemodynamic changes occur in each of these situations, making the measurement and interpretation of FFR challenging. This article reviews the technical aspects of assessing FFR and literature supporting FFR-guided revascularization in each of these situations.

Primary testicular lymphoma with cardiac involvement in an immunocompetent patient: case report and a concise review of literature

Primary testicular lymphoma (PTL) is a rare testicular tumor representing less than 9% of all testicular cancers. PTL usually tends to spread to or relapse at nodal structures or extra-nodal sites such as contralateral testes, central nervous system, skin, lung, pleura, waldeyers ring and soft tissues. We present a case of PTL with huge left atrial mass, an extremely unusual site of involvement. Early disease usually carries a good prognosis, whereas advanced stage carries an extremely poor prognosis. Herein, we report the complete remission to date in a patient with advanced stage PTL with huge left atrial mass, treated with systemic rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone and intrathecal methotrexate. A brief review of literature focusing on various aspects of management of primary testicular lymphoma and lymphomatous involvement of heart is also discussed.