Jeffrey Marbach

Optimal Mean Arterial Pressure in Comatose Survivors of Out-of-hospital Cardiac Arrest: An Analysis of Area Below Blood Pressure Thresholds

AIM OF THE STUDYnTo determine the optimal mean arterial pressure (MAP) during the early-to-intermediate phase care of comatose survivors of out-of-hospital cardiac arrest (OHCA).nnnMETHODSnWe identified consecutive comatose survivors of OHCA with an initial shockable rhythm. Using blood pressure-over-time plots, we calculated the area below pre-specified MAP thresholds (ABT; mmHg*hours) during the first 96u202fh of admission. We used incremental MAP thresholds ranging between 65 and 85u202fmmHg. Logistic regression analyses were used to examine the association between ABT and clinical outcomes for each MAP threshold and to adjust for age, duration of cardiac arrest, and bystander CPR. The primary outcome was severe neurological dysfunction as defined by a cerebral performance category (CPC) ≥3.nnnRESULTSnWe identified 122 consecutive OHCA patients meeting inclusion criteria. The rate of the primary outcome was 33%. There was a significant association between ABT and the rate of the primary outcome when MAP thresholds of 60 (pu202f=u202f0.01), 65 (pu202f<u202f0.01), 70 (pu202f<u202f0.01), 75 (pu202f<u202f0.01), and 80u202fmmHg (pu202f<u202f0.01) were used. This association was lost once a MAP threshold of 85u202fmmHg was reached (pu202f=u202f0.63). In the adjusted analysis, the association between ABT and the primary outcome was no longer present when the MAP threshold reached 75u202fmmHg.nnnCONCLUSIONSnIn comatose survivors of OHCA with an initial shockable rhythm, higher ABT is associated with increased rates of severe neurological dysfunction when MAP thresholds <75u202fmmHg are used. The current findings support the hypothesis that higher MAP targets (≥75u202fmmHg) may be indicated in this patient population.

Effect of a Formalized Research Curriculum on Fellows-in-Training and Early Career Research Productivity

Scholastic development of fellows-in-training (FIT) has been a recurrent theme in the Journal’s Fellows-in-Training & Early Career Page [(1,2)][1]. Although the importance of establishing mentorship and the benefits of peer collaboration have been emphasized, the role of the fellowship program as

Predicting Acute Kidney Injury following Transcatheter Aortic Valve Replacement

PURPOSEnAcute kidney injury occurs in up to a quarter of patients following transcatheter aortic valve replacement (TAVR) and has been associated with increased short and long-term mortality rates. A variety of patient characteristics predictive of post-TAVR acute kidney injury (AKI) have been identified, however discrepancies among studies exist almost uniformly. We investigated the hypothesis that the change in glomerular filtration rate (ΔGFR) in response to contrast administered during pre-TAVR coronary angiography is predictive of ΔGFR post-TAVR.nnnMETHODSnThe study comprised 195 patients who underwent TAVR at a single center between August 2008 and June 2015 and were prospectively included in the CAPITAL TAVR registry. Multiple linear regression analysis was conducted to estimate the effect of independent variables on the change in renal function post-TAVR.nnnRESULTSnThere was no relationship identified between the ΔGFR post-angiogram and the ΔGFR post-TAVR (r=0.043, P=0.582). Multiple linear regression analysis revealed that a significant amount of the change in renal function post-TAVR can be explained by the patients baseline creatinine (beta coefficient, -0.310, P.

In-hospital outcomes of STEMI patients on warfarin undergoing primary PCI

We sought to describe the safety and efficacy outcomes of patients on warfarin presenting with ST‐elevation myocardial infarction (STEMI).

The Next Generation of Physician-Scientists: Adapting to Academic Cardiology in the 21st Century

More than 3 decades ago, Wyngaarden and Gill first warned of the challenges facing physician-scientists in their seminal papers The Clinical Investigator as an Endangered Species and The End of the Physician-Scientist. In the years since these papers were published, there has been expansion of stage I-II preclinical research focusing on discovery and exploratory studies. Expansion has often come at the expense of physician-scientists whose traditional role has been to bridge the gap between early preclinical research (stage I-II) and clinical trials (stage IV). Consequently, a paradigm shift has occurred, and increasing pressure has been placed on physician-scientists to choose between clinical practice and fundamental research. This shift is particularly concerning in the field of cardiovascular medicine, where the ubiquitous nature and clinical significance of cardiovascular disease make the role of the translational scientist essential. The challenges facing academic cardiologists have then further been amplified by the necessity not only to maintain clinical competence but also to maintain competence in highly technical fields with rapidly advancing technology. Potential solutions to these problems include increasing support from postgraduate training programs, increased participation of trainees in physician-scientist development programs, and recognition of the pivotal role physician-scientists play in translational research by funding agencies. Although the physician-scientist remains an endangered species, multifaceted solutions with a focus on collaboration among institutions, training programs, and funding agencies have the potential to maximize efficiency in biomedical research and successfully translate scientific discoveries from bench to bedside.

The Impact of a Transition of Care Program on Acute Myocardial Infarction Readmission Rates

Hospital discharge is a high-risk time period, and acute myocardial infarction (AMI) patients often have early readmissions. The authors hypothesized that a multifaceted AMI care coordination program would reduce early hospital readmission rates. The outcomes of patients receiving care coordination (n = 304) were compared to patients receiving standard care (n = 192). Multivariable analyses of the outcomes were conducted by conditional logistic regression of propensity score matched sets. The primary outcome—hospital readmission within 30 days of discharge—occurred in 18% of standard care patients and 11.8% of care coordination patients. Patients receiving care coordination demonstrated a 48% reduction in odds of readmission within 30 days (odds ratio = 0.52; P = .04; 95% CI = 0.28-0.97). These results are the first to demonstrate that inclusion in an AMI-specific care coordination program is associated with a significantly lower risk of 30-day hospital readmission.

Multiple inappropriate implantable cardiac defibrillator therapies in rapid succession

Inappropriate implantable cardiac defibrillator (ICD) shocks are associated with significant morbidity and have the potential to trigger ventricular arrhythmias, cardiac decompensation, and death. We present a case of multiple inappropriate ICD therapies in rapid succession due electromagnetic interference from a Dr‐Hos transcutaneous electric nerve stimulator machine, and subsequently from a faulty electrical outlet.