Jeremy Mazurek

Prevalence of Hemoglobin A1c Greater Than 6.5% and 7.0% among Hospitalized Patients without Known Diagnosis of Diabetes at an Urban Inner City Hospital

CONTEXT Bronx, New York, an urban county with a large low-income, immigrant and minority population, has a prevalence of diabetes that is among the highest in the United States. OBJECTIVE The aim of the study was to evaluate the utility of hemoglobin A1c (HbA1c) in identifying patients at risk for diabetes on an in-patient medical service of a hospital serving a high prevalence community. DESIGN AND SETTING We conducted a prospective cohort study at an urban public hospital. PATIENTS The study included 971 patients (1132 admissions) admitted to the general medicine service over 4 months. MAIN OUTCOME MEASURES HbA1c was measured on all patients. Records were checked for prior diagnosis of diabetes and other clinical data. Follow-up data were obtained for those with repeat HbA1c testing or glucose within 1 yr after admission. RESULTS We found that 35.2% of the patients (n = 342) had an established diagnosis of diabetes. The remaining 629 patients defined the study cohort of patients without known diabetes. Mean HbA1c was 6.05 +/- 0.87%. A total of 152 patients (24%) had admission HbA1c of at least 6.5% and 62 (9.9%) had HbA1c of at least 7.0%. Fifty-five patients with HbA1c of at least 6.5% had follow-up HbA1c within 1 yr. Of those, 44 (80.0%) met the criteria for diabetes as proposed by The International Expert Committee using repeated HbA1c testing. CONCLUSION In communities with high prevalence of diabetes, a large percentage of patients without a diagnosis of diabetes who are admitted as in-patients have HbA1c of at least 6.5% and 7.0%. Hospital-based HbA1c testing might identify patients for whom further testing is indicated to make the diagnosis of diabetes.

The Effect of Nesiritide on Renal Function and Other Clinical Parameters in Patients With Decompensated Heart Failure and Preserved Ejection Fraction

The role of nesiritide in patients with decompensated heart failure with preserved ejection fraction (dHFpEF) has not been previously studied. In this investigation, the authors retrospectively analyzed the effect of nesiritide on renal function and clinical outcomes in patients admitted with dHFpEF. Of the 658 patients included, 328 were treated with nesiritide while 330 patients were treated with standard diuretic therapy. In both the nesiritide and no nesiritide groups, there was a significant change in mean glomerular filtration rate (GFR) and creatinine at 72 hours as well as at day of discharge (P<.001). This trend did not progress at 1 month in the nesiritide group, although it did in the no nesiritide group. At 1 month after therapy, however, there was a significant difference between the two groups in the mean change of GFR and creatinine (P<.001). There was no significant difference in >25% decrease of GFR anytime through day 30 (25% vs 29.69%, P=.236) between the two groups. On multivariate analysis, nesiritide was an important predictor of renal function at 1 month (P<.05). Thus, nesiritide can be administered safely without negatively impacting long-term renal function in patients admitted with dHFpEF.

Recurrent takotsubo cardiomyopathy in the setting of transient neurological symptoms: a case report

IntroductionFirst described in Japan, takotsubo cardiomyopathy is increasingly becoming recognized worldwide as a cause of sudden and reversible diminished left ventricular function characterized by left apical ballooning and hyperkinesis of the basal segments, often with symptoms mimicking a myocardial infarction. Associated with physical or emotional stress, its exact pathogenesis has not been established, though evidence supports a neurohumoral etiology. Additionally, recurrence of this condition is rare. In this report, we present a rare case of recurrent takotsubo cardiomyopathy in a post-menopausal woman who presented with transient neurological complaints on both occasions.Case presentationWe present a rare case of a 76-year-old Caucasian woman with no history of congestive heart failure who presented to our emergency department twice with transient neurological complaints. On the first occasion, she was found to have transient aphasia which resolved within 24 hours, yet during that period she also developed symptoms of congestive heart failure and was noted to have a new, significantly depressed ejection fraction with apical akinesis and possible apical thrombus. One month after her presentation a repeat echocardiogram revealed complete resolution of all wall motion abnormalities and a return to baseline status. Seven months later she presented with ataxia, was diagnosed with vertebrobasilar insufficiency, and again developed symptoms and echocardiography findings similar to those of her first presentation. Once again, at her one-month follow-up examination, all wall motion abnormalities had completely resolved and her ejection fraction had returned to normal.ConclusionThough the exact etiology of takotsubo cardiomyopathy is unclear, a neurohumoral mechanism has been proposed. Recurrence of this disorder is rare, though it has been reported in patients with structural brain abnormalities. This report is the first to describe recurrent takotsubo cardiomyopathy in a patient with transient neurological symptoms. In our patient, as expected in patients with this condition, complete resolution of all left ventricular abnormalities occurred within a short period of time. It is important for clinicians to be aware of this increasingly recognized syndrome, including its association with recurrence, especially in the clinical setting of neurologic dysfunction.

Galectin-3 Levels Are Elevated and Predictive of Mortality in Pulmonary Hypertension

BACKGROUND Galectin-3, a novel binding-lectin involved in inflammation and fibrosis, is elevated in heart failure and is independently predictive of mortality in this condition. We sought to evaluate galectin-3 levels and its prognostic value in patients with pulmonary hypertension (PH), a known inflammatory state, in the setting of pulmonary arterial hypertension (PAH) and in heart failure with preserved ejection fraction-associated PH (HFpEF-PH). METHODS We measured galectin-3 levels in 76 patients with PH; 37 patients with PAH and 39 patients with HFpEF-PH. Baseline characteristics, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were assessed. Univariate and multivariate analyses were used to assess the prognostic value of galectin-3. RESULTS Median (IQR) galectin-3 (ng/mL) for the entire cohort was 24.65 (IQR=10.39, 32.90); 22.33 (IQR=18.94, 27.30) and 28.94 (IQR=21.67, 39.85) in the PAH and HFpEF-PH, respectively (p=0.07). After evaluation of the galectin-3 levels by tertile, mortality rates were 16% (4/25), 34.6% (9/26), and 48% (12/25) in tertiles 1-3, respectively, and Kaplan-Meier analysis revealed a significant increase in mortality across increasing galectin-3 tertiles (log-rank p=0.014). On Cox regression analysis, galectin-3 was a strong predictor of mortality on both univariate HR=2.09 per tertile (95% CI=1.21, 3.62 per tertile; p-trend=0.008) and multivariate analysis HR=2.19 per tertile (95% CI=1.06, 4.54; p-trend=0.035) after adjusting for age, sex, race, glomerular filtration rate (eGFR), NT-proBNP, medications, and aetiology of PH (PAH vs. HFpEF-PH). CONCLUSION Galectin-3 is a strong, independent prognostic marker in PH, regardless of aetiology. Larger studies should further evaluate the role of galectin-3 as a prognostic biomarker and possible therapeutic target in PH.

Effect of Nesiritide in Isolated Right Ventricular Failure Secondary to Pulmonary Hypertension

Treatment of right ventricular failure (RVF) can be challenging due to the correlation between RVF and worsening renal function with diuretic therapy. Nesiritide has been studied in patients with left ventricular failure but has not been evaluated in isolated RVF. The authors retrospectively analyzed 140 patients admitted with RVF, pulmonary hypertension (PH), and preserved left ventricular systolic function. Seventy patients were treated with nesiritide while the remaining patients received only furosemide (no nesiritide group). Serum creatinine and GFR at baseline, 72 hours, discharge, and 1 month post-treatment, as well as hemodynamic data were compared between the groups. In the nesiritide group, there was a significant decrease in mean GFR (42.77±25.33, P<.001) at day of discharge and 1 month post-nesiritide infusion (41.17±24.94, P<.001) but not in the no nesiritide group. There was a significant difference in >25% decrease in GFR anytime through day 30 (47.14% vs. 25.71%, P=.036) between the two groups. On multivariate analysis, nesiritide remained an important predictor of renal function at discharge and at 1 month (P<.01) as well as a predictor of >25% decrease in GFR anytime through day 30 (P=.007). Thus, nesiritide is associated with worsening kidney function in patients with RVF in the setting of PH.

THE RED CELL DISTRIBUTION WIDTH AND THE CBC RISK SCORE MEASURED PRIOR TO LEFT VENTRICULAR ASSIST DEVICE IMPLANTATION PREDICT POST-IMPLANT SURVIVAL

The red cell distribution width (RDW) predicts mortality in many cardiovascular (CV) diseases. The sex-specific complete blood count (CBC) risk score uses the RDW and other CBC components to predict mortality. Very few risk models are known for predicting survival in patients undergoing left

ENDOTHELIN-1 LEVELS IN PULMONARY HYPERTENSION: A COMPARISON BETWEEN PULMONARY ARTERIAL HYPERTENSION AND DIASTOLIC HEART FAILURE-INDUCED PULMONARY HYPERTENSION

Endothelin-1 (ET-1), a potent vasoconstrictor, is elevated in heart failure states as well as in pulmonary arterial hypertension (PAH). Additionally, ET-1 receptor blockade is a mainstay of PAH treatment. Diastolic heart failure (DHF) is a common cause of secondary pulmonary hypertension (D-PH), and

CLINICAL IMPROVEMENT IN PATIENTS WITH EXERCISE INDUCED PULMONARY ARTERY HYPERTENSION AFTER 6 MONTHS OF PHOSPHODIESTERASE-5 INHIBITORS OR ENDOTHELIAL RECEPTOR ANTAGONISTS OR BOTH

Pulmonary arterial hypertension (PAH) is a rapidly progressive disorder with high mortality rates despite traditional medical treatment. With the availability of PA targeted therapy, early PAH detection improves treatment outcomes. Exercise- induced Pulmonary Artery Hypertension (EiPAH) represents

CLINICAL IMPROVEMENT IN PATIENTS WITH EXERCISE INDUCED PULMONARY ARTERY HYPERTENSION IS SIMILAR TO PULMONARY ARTERIAL HYPERTENSION

Exercise-induced Pulmonary Artery Hypertension (EiPAH) represents an early phase of Pulmonary Arterial Hypertension (PAH) in which screening and early detection might facilitate treatment aimed at preventing progression of EiPAH to resting PAH. In this study we sought to compare change in 6MWD after

STIMULATION OF PULMONARY ARTERIAL ENDOTHELIUM IN DIASTOLIC HEART FAILURE INDUCED PULMONARY HYPERTENSION SIMILAR TO PULMONARY ARTERIAL HYPERTENSION

Background: Von Willebrand Factor (vWF) is secreted by the endothelium at elevated levels with endothelial dysfunction. Diastolic heart failure is the most common cause of secondary pulmonary hypertension (DHF-PH). In vitro, similar to PAH, DHF-PH has additional pre-capillary active pro-inflammatory changes. However, there is no evidence of in-vivo localized endothelial dysfunction in DHF-PH. We compared levels of pulmonary arterial (PA) vWF Ag and factor VIII (F8) in patients with both PAH and DHF-PH.