Kaushang Gandhi

Incidence of perioperative myocardial infarction and of 2-year mortality in 577 elderly patients undergoing noncardiac vascular surgery treated with and without statins

Of 577 patients, mean age 74 years, undergoing noncardiac vascular surgery, 300 (52%) had carotid endarterectomy, 179 (31%) had lower extremity revascularization, and 98 (17%) had abdominal aortic aneurysm repair. Of the 577 patients, 302 (52%) were treated with statins. Perioperative myocardial infarction (MI) occurred in 18 of 302 patients (6%) treated with statins and in 38 of 275 patients (14%) not treated with statins (p=0.001). Two-year mortality occurred in 18 of 302 patients (6%) treated with statins and in 43 of 275 patients (16%) not treated with statins (p=0.0002). Perioperative MI or mortality occurred in 34 of 302 patients (11%) treated with statins and in 74 of 275 patients (27%) not treated with statins (p<0.0001). Stepwise Cox regression analysis showed that significant independent prognostic factors for perioperative MI or death were use of statins (risk ratio=RR=0.43, p<0.0001), use of beta blockers (RR=0.55, p=0.002), carotid endarterectomy (RR=0.60, p=0.009), and diabetes (RR=1.5, p=0.045). In conclusion, patients undergoing noncardiac vascular surgery treated with statins had a 57% less chance of having perioperative MI or death at 2-year follow-up after controlling for other variables.

Cardiovascular Manifestations in Patients With Thrombotic Thrombocytopenic Purpura: A Single‐center Experience

Cardiovascular manifestation in patients with thrombotic thrombocytopenic purpura.

RESPeRATE: nonpharmacological treatment of hypertension.

Systemic hypertension has been well documented as a major risk factor for premature cardiovascular morbidity and mortality. Reduction of high blood pressure (BP) by nonpharmacological means is widely recommended, either as a primary prevention therapy or as an adjunctive treatment with antihypertensive drugs. RESPeRATE is a commercially available electronic device that presents a novel nonpharmacological approach to the treatment of hypertension. RESPeRATE-guided slow-paced breathing aimed at achieving a respiratory frequency of <10 breaths per minute has been shown, in multiple studies, to reduce BP in hypertensive individuals by improving the autonomic balance through respiratory control. This article discusses RESPeRATE and the scientific evidence that supports the use of device-guided slow breathing to reduce BP.

Statins Reduce Appropriate Cardioverter-Defibrillator Shocks and Mortality in Patients With Heart Failure and Combined Cardiac Resynchronization and Implantable Cardioverter-Defibrillator Therapy

Of 209 patients with heart failure treated with combined cardiac resynchronization therapy and implantable cardioverter-defibrillator therapy, appropriate cardioverter-defibrillator shocks occurred at 34-month follow-up in 22 of 121 patients (18%) on statins and in 30 of 88 patients (34%) not on statins (P = .009). Deaths occurred in 3 of 121 patients (2%) on statins and in 9 of 88 patients (10%) not on statins (P = .017). Stepwise Cox regression analysis showed that significant independent prognostic factors for appropriate shocks were use of statins (risk ratio = 0.46), smoking (risk ratio = 3.5), and diabetes (risk ratio = 0.34). Significant independent prognostic factors for the time to mortality were use of statins (risk ratio = 0.05), use of digoxin (risk ratio = 4.2), systemic hypertension (risk ratio = 14.2), diabetes (risk ratio = 4.3), and left ventricular ejection fraction (risk ratio = 1.1).

Mesenteric vein thrombosis after laproscopic gastric sleeve procedure.

Laparoscopic procedures for morbid obesity are becoming standard of care. In experienced hands it has very low mortality and morbidity [1]. Thrombosis of mesenteric and portal vein is a rare phenomenon. A few case reports in literature suggest their occurrence after various laparoscopic procedures [2–5]. Our institution is a leading center for obesity surgery and we do over 350 laparoscopic bariatric surgeries each year. We present a case of intraabdominal vein thrombosis after laparoscopic surgery and review of literature [6].

Thiazide-induced severe hypercalcemia: a case report and review of literature.

Most common causes of hypercalcemia are hyperparathyroidism, malignancy, vitamin D-mediated conditions such as sarcoidosis, and vitamin D toxicity. Less commonly, hypercalcemia can be caused by drugs such as thiazide diuretics and lithium. Mild hypercalcemia is usually asymptomatic but severe hypercalcemia is associated with nausea, vomiting, abdominal pain, excessive thirst, muscle weakness, lethargy, confusion, and fatigue. We are reporting a case of abdominal pain and altered mental status caused by thiazide-induced severe hypercalcemia of 19.8 mg/dL. This is the most severe case of thiazide-induced hypercalcemia that we have seen reported. Patients on thiazide diuretics should have their electrolytes frequently checked, especially patients on calcium supplements. Management usually includes hydration and discontinuation of drugs causing hypercalcemia.

Incidence of Appropriate Cardioverter-Defibrillator Shocks and Mortality in Patients With Heart Failure Treated With Combined Cardiac Resynchronization Plus Implantable Cardioverter-Defibrillator Therapy Versus Implantable Cardioverter-Defibrillator Therapy

Of 529 patients with heart failure and a mean left ventricular ejection fraction of 29%, 209 (40%) were treated with cardiac resynchronization therapy (CRT) plus an implantable cardioverter-defibrillator (ICD) and 320 (60%) with an ICD. Mean follow-up was 34 months for both groups. Stepwise logistic regression analysis showed that significant independent variables for appropriate ICD shocks were statins (risk ratio = 0.35, P < .0001), smoking (risk ratio = 2.52, P < .0001), and digoxin (risk ratio = 1.92, P = .0001). Significant independent variables for time to deaths were use of CRT (risk ratio = 0.32, P = .0006), statins (risk ratio = 0.18, P < .0001), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (risk ratio = 0.10, P < .0001), hypertension (risk ratio = 24.15, P < .0001), diabetes (risk ratio = 2.54, P = .0005), and age (risk ratio = 1.06, P < .0001). In conclusion, statins reduced and smoking and digoxin increased appropriate ICD shocks. Use of CRT, statins, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers reduced mortality and hypertension, diabetes, and older age increased mortality.

The impact of statin therapy on long-term cardiovascular outcomes in an outpatient cardiology practice

Introduction Statins reduce coronary events in patients with coronary artery disease. Material and methods Chart reviews were performed in 305 patients (217 men and 88 women, mean age 74 years) not treated with statins during the first year of being seen in an outpatient cardiology practice but subsequently treated with statins. Based on the starting date of statins use, the long-term outcomes of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABGs) before and after statin use were compared. Results Mean follow-up was 65 months before statins use and 66 months after statins use. Myocardial infarction occurred in 31 of 305 patients (10%) before statins, and in 13 of 305 patients (4%) after statins (p < 0.01). Percutaneous coronary intervention had been performed in 66 of 305 patients (22%) before statins and was performed in 41 of 305 patients (13%) after statins (p < 0.01). Coronary artery bypass graft surgery had been performed in 56 of 305 patients (18%) before statins and in 20 of 305 patients (7%) after statins (p < 0.001). Stepwise logistic regression showed statins use was an independent risk factor for MI (odds ratio = 0.0207, 95% CI, 0.0082-0.0522, p < 0.0001), PCI (odds ratio = 0.0109, 95% CI, 0.0038-0.0315, p < 0.0001) and CABGs (odds ratio = 0.0177, 95% CI = 0.0072-0.0431, p < 0.0001) Conclusions Statins use in an outpatient cardiology practice reduces the incidence of MI, PCI, and CABGs.

Reduction in atherosclerotic events: a retrospective study in an outpatient cardiology practice

Introduction Although atherosclerotic disease cannot be cured, risk of recurrent events can be reduced by application of evidence-based treatment protocols involving aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statin medications. We studied atherosclerotic event rates in a patient population treated before and after the development of aggressive risk factor reduction treatment protocols. Material and methods We performed a retrospective chart review of patients presenting for follow-up treatment of coronary artery disease in a community cardiology practice, comparing atherosclerotic event rates and medication usage in a 2-year treatment period prior to 2002 and a 2-year period in 2005-2008. Care was provided in both the early and later eras by 7 board-certified cardiologists in a suburban cardiology practice. Medication usage was compared in both treatment eras. The primary outcome was a composite event rate of myocardial infarction, cerebrovascular events, and coronary interventions. Results Three hundred and fifty-seven patients were studied, with a follow-up duration of 12.1 (±3.5) years. There were 132 composite events in 104 patients (29.1%) in the early era compared to 40 events in 33 patients (9.2%) in the later era (p < 0.0001). From the early to the later eras, there was an increase in use of β-blockers (66% to 83%, p < 0.0001), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (34% to 80%, p < 0.0001), and statins (40% to 90%, p < 0.0001). Conclusions Application of aggressive evidence-based medication protocols for treatment of atherosclerosis is associated with a significant decrease in atherosclerotic events or need for coronary intervention.

Prevalence of transthoracic echocardiographic abnormalities in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage

Introduction This study investigated the prevalence of transthoracic echocardiographic abnormalities in patients with ischemic stroke (IS), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH) in sinus rhythm. Material and methods The patients included 120 with IS, 30 with SAH, and 41 with ICH. All diagnoses were confirmed by magnetic resonance imaging or brain computed tomography. Two-dimensional echocardiograms were taken at the time stroke was diagnosed. All echocardiograms were interpreted by an experienced echocardiographer. Results Of 120 IS patients, 1 (1%) had a left ventricular (LV) thrombus, 1 (1%) had mitral valve vegetations, 30 (25%) had LV hypertrophy, 26 (22%) had abnormal LV ejection fraction, 4 (3%) had mitral valve prolapse, 33 (28%) had mitral annular calcium (MAC), 40 (33%) had aortic valve calcium (AVC), 3 (3%) had a bioprosthetic aortic valve, 10 (8%) had aortic stenosis (AS), 6 (5%) had atrial septal aneurysm, 2 (2%) had patent foramen ovale, and 40 (33%) had no abnormalities. Of 30 SAH patients, 5 (17%) had LV hypertrophy, 1 (3%) had abnormal LV ejection fraction, 1 (3%) had AS, 4 (13%) had MAC, 5 (17%) had AVC, and 20 (67%) had no abnormalities. Of 41 ICH patients, 9 (22%) had LVH, 1 (2%) had abnormal LV ejection fraction, 1 (3%) had AS, 6 (15%) had MAC, 8 (20%) had AVC, and 22 (54%) had no abnormalities. Conclusions Transthoracic echocardiographic abnormalities are more prevalent in patients with IS than in patients with SAH or ICH.