Jayakumar Sreenivasan

Sodium-glucose co-transporter 2 inhibitors and cardiovascular outcomes: A systematic review and meta-analysis:

Background The risks and benefits of sodium-glucose co-transporter 2 (SGLT2) inhibitors on cardiovascular outcomes have not been well established. We pooled evidence from all available clinical trials to assess the cardiovascular effects of this drug. Design A systematic review and meta-analysis of randomised controlled trials. Methods We queried electronic databases (MEDLINE, Scopus, CENTRAL and clinicaltrials.gov) from their inception to July 2017 for published and unpublished placebo controlled trials of SGLT2 inhibitors. Only studies with a follow-up period of at least 24 weeks and reporting at least one cardiovascular outcome were included. Results from trials were presented as odds ratios (ORs) with 95% confidence intervals (CIs) and were pooled using a random-effects model. Results Thirty-five eligible studies (canagliflozin, nine; empagliflozin, eight; dapagliflozin, 18), consisting of 34,987 patients with type 2 diabetes mellitus were included. Pooled results show that SGLT2 inhibitors, when compared to placebo, significantly reduce all-cause mortality (OR 0.79, 95% CI 0.70–0.89; Pu2009<u20090.001), major adverse cardiac events (OR 0.8, 95% CI 0.76–0.92; Pu2009<u20090.001), non-fatal myocardial infarction (OR 0.85, 95% CI 0.73–0.98; Pu2009=u20090.03) and heart failure/hospitalisation for heart failure (OR 0.67, 95% CI 0.59–0.76; Pu2009<u20090.001) in patients with type 2 diabetes mellitus. No significant difference was noted in the occurrence of stroke (OR 1.02, 95% CI 0.85–1.21; Pu2009=u20090.87), atrial fibrillation (OR 0.61, 95% CI 0.31–1.19; Pu2009=u20090.15) or unstable angina (OR 0.95, 95% CI 0.73–1.25; Pu2009=u20090.73). In addition, there was no heterogeneity between different drugs in the SGLT2 inhibitor class for all of the clinical outcomes studied (I2u2009=u20090). Conclusions SGLT2 inhibitors significantly reduce the incidence of mortality, major adverse cardiac events, non-fatal myocardial infarction and heart failure in patients with type 2 diabetes mellitus. Subtypes of SGLT2 inhibitors appear to have similar cardiovascular effects.

Does natriuretic peptide monitoring improve outcomes in heart failure patients? A systematic review and meta-analysis

BACKGROUNDnCurrent guidelines do not support the use of serial natriuretic peptide (NP) monitoring for heart failure with preserved (HFpEF) or reduced ejection fraction (HFrEF) treatment, despite some studies showing benefit. We conducted an updated meta-analysis to address whether medical therapy in HFpEF or HFrEF should be titrated according to NP levels.nnnMETHODSnMEDLINE, Scopus and Cochrane CENTRAL databases were searched for randomized controlled trials (RCTs) comparing NP versus guideline directed titration in HF patients through December 2017. The key outcomes of interest were mortality, HF hospitalizations and all-cause hospitalizations. Risk ratios and 95% confidence intervals were pooled using random effects model. Sub-group analyses were performed for type of NP used, average age and acute or chronic HF.nnnRESULTSnEighteen trials including 5116 patients were included. Meta-analysis showed no significant difference between the NP-guided arm versus guideline directed titration in all-cause mortality (RRu202f=u202f0.91 [0.81, 1.03]; pu202f=u202f0.13), HF hospitalizations (RRu202f=u202f0.81 [0.65, 1.01]; pu202f=u202f0.06), and all cause hospitalizations (RRu202f=u202f0.93 [0.86, 1.01]; pu202f=u202f0.09). The results were consistent upon subgroup analysis by biomarker type (NT-proBNP or BNP) and type of heart failure (acute or chronic and HFrEF or HFpEF). Sub-group analysis suggested that NP-guided treatment was associated with decreased all-cause hospitalizations in patients younger than 72u202fyears of age.nnnCONCLUSIONnThe available evidence suggests that NP-guided therapy provides no additional benefit over guideline directed therapy in terms of all-cause mortality and HF-related hospitalizations in acute or chronic HF patients, regardless of their ejection fraction.

Rare Cause of Late Recurrent Angina following Coronary Artery Bypass Grafting: Iatrogenic Aortocoronary Arteriovenous Fistula Causing Coronary Steal

Iatrogenic aortocoronary arteriovenous fistula is a very rare complication of coronary artery bypass grafting in which one of the arterial grafts inadvertently forms a fistulous tract with a cardiac vein, shunting blood from the anastomosed coronary artery. We report a patient with an iatrogenic left internal mammary artery graft to cardiac vein fistula presenting with recurrent angina three years after a three-vessel coronary artery bypass grafting.

Statins and incidence of contrast-induced acute kidney injury following coronary angiography - Five year experience at a tertiary care center

BACKGROUNDnRole of statins in prevention of contrast-induced acute kidney injury (CI-AKI) in patients undergoing coronary angiography remains controversial. We studied the use of statins in decreasing CI-AKI following coronary angiography.nnnMETHODSnWe reviewed all patients who underwent coronary angiography with or without PCI and had a follow-up creatinine from January 2012 to December 2016 at a single tertiary care center in the United States. CI-AKI was defined as 0.3u202fmg/dL absolute rise in creatinine. Patients who were on moderate to high-intensity statins or received moderate to high-intensity statins prior to coronary angiography were included in the statin group. Crude and adjusted odds ratios (AOR) were calculated using univariate multiple logistic regression analysis.nnnRESULTSnOut of 2055 patients (femalesu202f=u202f30.7%, mean age 58.0u202f±u202f12.5u202fyears, statin groupu202f=u202f886, non-statin groupu202f=u202f1169), 293 (14.3%) developed CI-AKI. Mean estimated glomerular filtration rate (eGFR) was not significantly different between the statin and the non-statin group (86.5u202fmL/min/1.73u202fm2 vs 87.1u202fmL/min/1.73u202fm2, pu202f=u202f0.65). There was no significant difference in the incidence of CI-AKI between statin and non-statin group (14.4% vs 14.1%, pu202f=u202f0.83). When adjusted for other risk factors, statin use was not significantly associated with decreased risk of CI-AKI (AOR)u202f=u202f0.8, [95% confidence interval (CI)u202f=u202f0.6-1.1, pu202f=u202f0.19]. Results remained statistically non-significant on subgroup analysis of patients with acute coronary syndrome (ACS) (ORu202f=u202f0.8, 95% CIu202f=u202f0.6-1.2, pu202f=u202f0.27), patients who had percutaneous coronary intervention (PCI) (ORu202f=u202f1.1, 95% CIu202f=u202f0.6-1.7, pu202f=u202f0.81) and patients with eGFRu202f<u202f60u202fmL/min/1.73u202fm2 (ORu202f=u202f0.9, 95% CIu202f=u202f0.6-1.5, pu202f=u202f0.9).nnnCONCLUSIONnStatin use prior to coronary angiography is not associated with decreased incidence of CI-AKI.

Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction

ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2u202f=u202f14.2%; pu202f=u202f0.099); however, PIT significantly decreased short-term mortality (ORu202f=u202f1.46 [1.08 to 1.96]; I2u202f=u202f0%; pu202f=u202f0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (ORu202f=u202f0.69 [0.49 to 0.97]; I2u202f=u202f0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (ORu202f=u202f1.48 [1.13 to 1.94]; I2u202f=u202f0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.

Anemia (Hemoglobin ≤ 13 g/dL) as a Risk Factor for Contrast-Induced Acute Kidney Injury Following Coronary Angiography

Contrast-induced acute kidney injury (CI-AKI) following coronary angiography is associated with increased mortality. The association between severity of anemia and CI-AKI following coronary angiography is not well-established. In this retrospective study, we aimed at assessing the association of anemia of various severity with the risk of CI-AKI in patients who underwent coronary angiography. We included all patients who underwent coronary angiography with or without percutaneous coronary intervention from January 2012 to December 2016 at a single tertiary care hospital. CI-AKI was defined as ≥0.3xa0mg/dL increase in creatinine from baseline and anemia was defined as baseline hemoglobin ≤13xa0g/dL. Patients were stratified into three subgroups-mild (11.1 to 13.0 g/dL), moderate (9.1 to 11.0 g/dL) and severe anemia (7.0 to 9.0 g/dL). Crude and adjusted odds ratios (AOR) were calculated using univariate multiple logistic regression analysis. Of 2,055 patients (femalesu202f=u202f30.7%, mean age 58.0 ± 12.5 years) who underwent coronary angiography, 293 (14.3%) developed CI-AKI. Presence of anemia was associated with increased risk of developing CI-AKI (AORu202f=u202f5.3, 95% confidence interval [CI]u202f=u202f3.8 to 7.3, p < 0.001). Risk of CI-AKI was increasingly higher with increasing severity of the anemia; mild (AORu202f=u202f3.4, 95% CIu202f=u202f2.5 to 4.7, p < 0.001), moderate (AORu202f=u202f9.8, 95% CIu202f=u202f6.9 to 14.2, p < 0.001) and severe (AORu202f=u202f13.7, 95% CIu202f=u202f8.2 to 23.1, p < 0.001). In conclusion, severity of anemia is a strong predictor of CI-AKI following coronary angiography.

The vanishing lung

Axa048-year-old woman with medical history significant for 20 pack-years of smoking presented with decreased exercise tolerance for the last year. On examination, her respiratory rate was 18 and oxygen saturation was 96% on room air with absent breath sounds within the left lung field. Alpha-1 antitrypsin levels were normal. Chest radiograph revealed giant emphysematous bulla with concern for concurrent pneumothorax (figure 1). CT scan of the chest revealed a massive bulla without a ‘double wall sign’ making superimposed pneumothorax unlikely (figure 2). Chest tube insertion was deferred and patient underwent bullectomy. Prior to surgery, her exercise tolerance …