John Moscona

Effect of Hurricane Katrina on incidence of acute myocardial infarction in New Orleans three years after the storm.

To detect a long-term increase in the incidence of acute myocardial infarction (AMI) after Hurricane Katrina and to investigate the pertinent contributing factors, we conducted a single-center retrospective cohort observational study. The patients admitted with AMI to Tulane University Hospital in the 2 years before Katrina and the 3 years after the hospital reopened were identified from the hospital medical records. The pre- and post-Katrina groups were compared for prespecified demographic and clinical data. In the 3-year post-Katrina group, 418 admissions (2.0%) for AMI occurred of a total census of 21,092 patients compared to 150 (0.7%) of a census of 21,079 in the 2-year pre-Katrina group (p <0.0001). The post-Katrina group had a greater prevalence of unemployment (p <0.0001), lack of medical insurance (p <0.001), smokers (p <0.01), medical noncompliance (p <0.0001), first-time hospitalizations (p <0.001), history of coronary artery disease (p <0.01), multiple vessel disease (p <0.05), and percutaneous coronary interventions (p <0.0001). The mean age of onset of AMI decreased from 62 years before Katrina to 59 years after Katrina (p <0.05), and a significantly greater percentage of patients were men (p <0.05). No significant differences were found between the two groups in terms of race, substance abuse, and a history of hypertension or diabetes mellitus. Our data suggest that chronic stress after natural disasters may significantly affect cardiovascular risk factors such as tobacco abuse and increase medical noncompliance. In conclusion, our data is consistent with a significant change in the overall health of the population and support the need for additional study into the health effects of chronic stress after natural disasters.

May-Thurner syndrome: a not so uncommon cause of a common condition

May-Thurner syndrome is a rarely diagnosed condition in which patients develop iliofemoral deep venous thrombosis (DVT) due to an anatomical variant in which the right common iliac artery overlies and compresses the left common iliac vein against the lumbar spine. This variant has been shown to be present in over 20% of the population; however, it is rarely considered in the differential diagnosis of DVT, particularly in patients with other risk factors. Systemic anticoagulation alone is insufficient treatment, and a more aggressive approach is necessary to prevent recurrent DVT. Herein, we present a patient with multiple risk factors for DVT. With a comprehensive diagnostic approach, she was found to have May-Thurner syndrome. Local infusion of thrombolytics as well as mechanical thrombectomy failed to resolve the thrombus. Subsequently the patient underwent successful stent placement in the area that was compressed followed by 6 months of chronic anticoagulation with warfarin. There has been no recurrence of DVT in the ensuing 18 months.

Natural Disasters and Myocardial Infarction: The Six Years After Hurricane Katrina

OBJECTIVE To determine the prolonged effect of Hurricane Katrina on the incidence and timing of acute myocardial infarction (AMI) in the city of New Orleans. PATIENTS AND METHODS Our study population consisted of 1476 patients with AMI before (August 29, 1999, to August 28, 2005) and after (February 14, 2006, to February 13, 2012) Hurricane Katrina at Tulane University Health Sciences Center to determine post-Katrina alterations in the occurrence and timing of AMI. RESULTS Compared with pre-Katrina values, there was a more than 3-fold increase in the percentage of admissions for AMI during the 6 years after Hurricane Katrina (P<.001). The percentage of admissions for AMI after Hurricane Katrina increased significantly on nights (P<.001) and weekends (P<.001) and decreased significantly on mornings (P<.001), Mondays (P<.001), and weekdays (P<.001). Patients with AMI after Hurricane Katrina also had significantly higher rates of psychiatric comorbidities (P=.01), smoking (P<.001), lack of health insurance (P<.05), and unemployment (P<.001). CONCLUSION These results indicate that the effect of natural disasters on the occurrence of AMI may persist for at least a 6-year period and may be related to various factors including population shifts, alterations in the health care system, and the effects of chronic stress and associated behaviors.

Effect of Hurricane Katrina on Chronobiology at Onset of Acute Myocardial Infarction During the Subsequent Three Years

The onset of acute myocardial infarction (AMI) has been shown to occur in a nonrandom pattern, with peaks in midmorning and on weekdays (especially Monday). The incidence of AMI has been shown to increase locally after natural disasters, but the effect of catastrophic events on AMI biorhythms is largely unknown. To assess the differences in the chronobiology of AMI in residents of New Orleans before and after Hurricane Katrina, the onset of AMI in patients at Tulane University Health Sciences Center in the 6 years before and the 3 years after Hurricane Katrina was retrospectively examined. Compared to the pre-Katrina group, the post-Katrina cohort demonstrated significant decreases in the onset of AMI during mornings (p = 0.002), Mondays (p <0.0001), and weekdays (p <0.0001) and significant increases in onset during weekends (p <0.0001) and nights (p <0.0001). These changes persisted during all 3 years after the storm. In conclusion, the normal pattern of AMI onset was altered after Hurricane Katrina, and expected morning, weekday, and Monday peaks were eliminated.

Acute profound thrombocytopenia secondary to local abciximab infusion.

Glycoprotein (GP) IIb/IIIa receptor antagonists are powerful antiplatelet agents that are typically used in percutaneous coronary intervention. All three GP IIb/IIIa agents currently approved for use in the United States cause thrombocytopenia as a rare side effect. Abciximab is unique to the class in that it is a modified monoclonal antibody to the GP IIb/IIIa receptor, a property that can lead to increased platelet destruction. Presented herein is a patient who received a local infusion of abciximab for a lower-extremity thrombus and within 2 hours developed an acute profound thrombocytopenia that likely caused a large retroperitoneal hematoma. This case demonstrates the importance of checking platelet count within 2 to 4 hours after local (in addition to systemic) abciximab administration. Additionally, this report outlines how other causes of acute precipitous platelet drops, such as heparin-induced thrombocytopenia and pseudothrombocytopenia, can be rapidly excluded and allow for the prompt initiation of optimal therapy to minimize bleeding.

THE EFFECTS OF HURRICANE KATRINA ON ACUTE MYOCARDIAL INFARCTION FIVE YEARS AFTER THE STORM

Results: During the 5-year post-Katrina group, there were 849 admissions for AMI out of a total census of 38,521 patients (2.2%) compared to 150 admissions out of a census of 21,079 (0.7%) in the 2-year pre-Katrina group (p<0.0001). The post-Katrina group had a higher prevalence of known coronary artery disease (48.5% vs. 30.7%, p<0.001), prior coronary artery bypass grafts (14.1% vs. 9.3%, p<0.05), hyperlipidemia (53.8% vs. 45.0%, p<0.01), psychiatric comorbidities (11.0% vs. 6.7%, p<0.05), smoking (56.4% vs. 39.3%, p<0.0005), and substance abuse (15.9% vs. 6.7%, p<0.005). While the post-Katrina group had more often been prescribed aspirin (42.4% vs. 31.3%, p<0.05), ACE inhibitors or angiotensin receptor blockers (47.4% vs. 36.0%, p<0.05), and statins (44.0% vs. 28.0%, p<0.005), medication adherence was less (53.3% vs. 70.7%, p<0.0001). The post-Katrina group was also more likely to be unemployed (17.9% vs. 2.0%, p<0.0001), uninsured (11.5% vs. 6.0%, p<0.0001), and reside in New Orleans (88.1% vs. 70.0%, p<0.0001). There were no significant differences between the two groups in terms of age, sex, ethnicity, diabetes mellitus, and hypertension. Conclusion: Hurricane Katrina placed an arduous physical, psychological, and social burden on the residents of New Orleans. After five years of study at our institution, we find a three-fold increased incidence of AMI along with increased rates of coronary artery disease, hyperlipidemia, psychiatric comorbidities, smoking, substance abuse, medication non-adherence, unemployment, and lack of medical insurance. The higher prevalence of these clinical and psychosocial risk factors suggests that this profound natural disaster has had a long-standing impact on cardiovascular health in our community.

Valvular Heart Disease

Abstract Cardiovascular three-dimensional (3D) printing is particularly suited for the study and management of cardiac valve pathology. The application of 3D printing to the personalized treatment of patients with cardiac valve pathology is rapidly progressing. Using high-quality volumetric data from advanced cross-sectional imaging and echocardiography, anatomic modeling with 3D printing can help better assess cardiac valve function, plan structural interventions, and test percutaneous structural devices. However, while 3D printing undoubtedly provides unique information, it has not yet been demonstrated to affect clinical outcome. In the meantime, all aspects of heart valve anatomic modeling with 3D printing must be further optimized. The hope is that materials similar to native human tissues will be developed so that anatomic and functional modeling with 3D printing will allow design and testing of biologically adaptable and patient-specific cardiac valve prosthesis.

Persistent giant U wave inversion with anoxic brain injury

Various electrocardiographic changes have been reported in the setting of acute neurological events, among them large, upright U waves. In contrast, the occurrence of inverted U waves is strongly suggestive of cardiovascular disease, most commonly hypertension, coronary artery disease, or valvular abnormalities. Presented herein is the case of a 29-year-old man with previous anoxic brain injury (but without apparent cardiovascular disease) whose electrocardiogram demonstrated persistent giant inverted U waves.

ACUTE MYOCARDIAL INFARCTION BEFORE AND AFTER THE STORM: HURRICANE KATRINA

 In the 4-year post-Katrina group, there were 629 confirmed admissions for AMI out of a total census of 29,228 patients (2.2%), as compared to 150 out of a census of 21,229 (0.7%) in the 2-year pre-Katrina group (p<0.0001). The post-Katrina group had a higher prevalence of unemployment (17% vs. 2%, p<0.0001), lack of medical insurance (12% vs. 6%, p<0.0001), smokers (58% vs. 17%, p<0.001), medical non-compliance (25% vs. 7%, P<0.0001), substance abuse (16% vs. 7%, p < 0.01), psychiatric comorbidities (10% vs. 6%, p< 0.05) history of hyperlipidemia ( 45% vs. 52%, p= 0.01), coronary artery disease (46% vs. 31%, p=0.001), and percutaneous coronary interventions (66% vs. 52%, p<0.0001). More people in the post-Katrina group were single/divorced as compared to pre-Katrina group (37% vs. 26%, p<0.0009). Compared to pre-katrina, post-Katrina group had higher level of LDL cholesterol and HDL Cholesterol, and more like to be on statins at the time of acute event. There were no significant differences between the two groups in terms of age, race, and gender, and history of hypertension, diabetes mellitus and chronic renal disease. Results