Leili Pourafkari

The Predictive Value of Total Neutrophil Count and Neutrophil/ Lymphocyte Ratio in Predicting In-hospital Mortality and Complications after STEMI

Introduction: Leukocytosis, predominantly neutrophilia, has previously been described following ST elevation myocardial infarction (STEMI). The exact contribution of this phenomenon to the clinical outcome of STEMI is yet to be shown. We examined cellular inflammatory response to STEMI in the blood and its association with in-hospital mortality and/or adverse clinical events. Methods: In this cross-sectional study, 404 patients who were admitted with the diagnosis of acute STEMI at Madani Heart Hospital from March 2010 to March 2012 were studied. The complete blood cell count (CBC) was obtained from all patientswithin12-24 hours of the onset of symptoms. Total leukocytes were counted and differential count was obtained for neutrophils, lymphocytes and neutrophil/lymphocyte ratio (NLR) were evaluated. Association of cellular response with the incidence of post-MI mortality/complications was assessed by multiple logistic regression analyses. Results: In-hospital mortality and post-STEMI complication rate were 3.7% and 43.6%, respectively. Higher age (P=0.04), female gender (0.002), lower ejection fraction (P<0.001) and absolute neutrophil count (P=0.04) were predictors of mortality. Pump failure in the form of acute pulmonary edema or cardiogenic shock occurred in 35 (8.9%) of patients. Higher leukocyte (P<0.03) and neutrophil counts (P<0.03) and higher NLR (P=0.01) were predictors of failure. The frequency of ventricular tachyarrhythmias (VT/VF) at the first day was associated with higher neutrophil count (P<0.001) and higher NLR level (P<0.001). In multivariate analysis neutrophil count was an independent predictor of mortality (OR=2.94; 1.1-8.4, P=0.04), and neutrophil count [OR=1.1, CI (1.01-1.20), P=0.02], female gender [OR=2.34, CI (1.02-4.88), P=0.04] and diabetes [OR=2.52, CI (1.21-5.2), P=0.003] were independent predictors of heart failure. Conclusion: A single CBC analysis may help to identify STEMI patients at risk for mortality and heart failure, and total neutrophil count is the most valuable in predicting both.

The effect of adding functional classification to ASA status for predicting 30-day mortality.

BACKGROUND:The functional capacity to perform the activities of daily living is identified as an independent predictor of perioperative mortality but is not formally incorporated in the American Society of Anesthesiologists (ASA) classification. Our primary objective was to assess whether functional capacity is an independent predictor of 30-day and long-term mortality in a general population and, if so, to define how it may formally be incorporated into the routine preoperative ASA classification assessment. METHODS:This retrospective, observational cohort study was conducted using 1998 to 2009 data extracted from the Veterans Affairs Surgical Quality Improvement Program of Western New York, a perioperative prospectively maintained database. Mortality follow-up was performed for all records in 2013. This population-based sample included all patients undergoing any noncardiac surgery (n = 12,324). Each patient’s ASA class (assigned preoperatively) was appended with subclasses A or B, with A representing patients who were functionally independent and B representing partially or fully dependent patients. The primary outcome was all-cause mortality during the follow-up period. Secondary outcomes included 30-day postoperative complications and mortality. Multivariate logistic regression was used to identify independent risk factors for mortality. RESULTS:The likelihood for mortality was significantly lower for A patients than B patients within each ASA class. The odds ratios for mortality for group A patients significantly favored survival over group B within each ASA class (0.14, 0.29, and 0.50, for ASA class II, III, and IV, respectively, each P < 0.0001). The odds ratio for mortality of IIB over IIIA patients was 1.92 (95% confidence interval [CI], 1.19–3.11; P = 0.01); 1.29 (95% CI, 1.04–1.60; P = 0.03) for IIIB over IVA patients; and 2.03 (95% CI, 0.99–4.12, P=0.11) for IVB over ASA V patients, despite each higher class carrying a greater disease burden, by definition. The area under the curve the receiver operator characteristic curve was 0.811 ± 0.010 for traditional ASA classification in predicting death within 30 days, which improved 4.7% to 0.848 ± 0.008 using the modified ASA classification, P < 0.00001. CONCLUSIONS:Functional capacity was an independent predictor of mortality within each ASA class, indicating that it should be considered for incorporation into the routine preoperative evaluation. Functional dependence may be an indication for increasing a patient’s ASA class by 1 class-point to better reflect his or her perioperative risk, but prospective validation of these findings is recommended, as this is a preliminary study.

Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography.

Renal artery stenosis (RAS) is a major comorbid condition in patients with coronary artery disease (CAD). Although the reported prevalence of significant RAS among patients undergoing coronary angiography varies from 6.2 to 28% in Western countries, little information is available on the prevalence and predictors of RAS in Middle Eastern countries. From April 2007 to May 2008, 732 hypertensive patients with suspected CAD immediately after selective coronary angiography underwent abdominal aortography with or without selective renal angiography. Coronary angiography revealed stenosis of ⩾50% in at least one of the main coronary vessels in 434 (59.3%) patients, including 100 (13.7%) cases with single-vessel CAD, 114 (15.6%) with two-vessel CAD and 220 (30.1%) with three-vessel CAD. Significant RAS was present in 87 patients (11.9%), severe (⩾75%) RAS in 35 patients (4.8%) and bilateral RAS in 37 patients (5.1%). Higher serum creatinine level, severity of CAD, history of coronary artery bypass graft surgery (CABG), congestive heart failure, and pulmonary edema together with atrial fibrillation were the most powerful predictors of significant RAS. In multivariate logistic regression analysis, three-vessel CAD (odds ratio 1.61, 95% confidence interval (1.36–1.91), P<0.001), history of CABG (odds ratio 4.40, 95% confidence interval (1.17–16.5), P=0.028) and serum creatinine level of >1.2 mg per 100 ml (odds ratio 2.12, 95% confidence interval (1.09–4.12), P=0.026) were the most powerful predictors of significant RAS. The prevalence of RAS in our patients was similar to that reported in the Western countries. The presence of multi-vessel CAD or a history of CABG along with a higher serum creatinine level in hypertensive patients undergoing coronary angiography was found to be a risk factor for RAS.

Factors associated with atrial fibrillation in rheumatic mitral stenosis

Background Atrial fibrillation is a complication of mitral valve stenosis that causes several adverse neurologic outcomes. Our objective was to establish a mathematical model to predict the risk of atrial fibrillation in patients with mitral stenosis. Methods Of 819 patients with mitral stenosis who were screened, 603 were enrolled in the study and grouped according to whether they were in sinus rhythm or atrial fibrillation. Demographic, echocardiographic, and hemodynamic data were recorded. Logistic regression models were constructed to identify the relative risks for each contributing factor and calculate the probability of developing atrial fibrillation. Receiver operating characteristic curves were plotted. Results Two hundred (33%) patients had atrial fibrillation; this group was older, in a higher functional class, more likely to have suffered previous thromboembolic events, and had significantly larger left atrial diameters, lower ejection fractions, and lower left atrial appendage emptying flow velocity. The factors independently associated with atrial fibrillation were left atrial strain (odds ratio = 7.53 [4.47–12.69], p < 0.001), right atrial pressure (odds ratio = 1.09 [1.02–1.17], p = 0.01), age (odds ratio = 1.14 [1.05–1.25], p = 0.002), and ejection fraction (odds ratio = 0.92 [0.87–0.97], p = 0.003). The area under the curve for the combined receiver operating characteristic for this model was 0.90 ± 0.12. Conclusion Age, right atrial pressure, ejection fraction, and left atrial strain can be used to construct a mathematical model to predict the development of atrial fibrillation in rheumatic mitral stenosis.

Aneurysmal coronary arteriovenous fistula closing with covered stent deployment: a case report and review of literature.

Coronary arteriovenous fistula (CAVF) is a rarely encountered congenital coronary anomaly, in which coronary artery blood flow bypasses the myocardial capillary network and usually drains to a heart chamber or great vessel. It is usually asymptomatic. However, the risk of symptoms and complications increases with age. High output heart failure, pulmonary hypertension, myocardial ischemia and infective endocarditis may complicate the course of this anomaly. The appearance, and even rupture, of a saccular aneurysm is one of the even rarer complications of CAVF. Here we describe a 57 year-old patient with incidental finding of an aneurysmal CAVF which was treated successfully using covered stent.

Dual effects of tumor necrosis factor alpha on myocardial injury following prolonged hypoperfusion of the heart

Objective: To examine the dose response of TNFα in an ex vivo rat model of myocardial ischemia reperfusion. Methods and Results: Seventy-two rat hearts were mounted on Langendorff apparatus and perfused with oxygenated Krebs-Henseleit solutions. Ischemia was induced by reducing the perfusate flow rate. During reperfusion, incremental doses of recombinant TNFα were infused as a part of perfusate. TNFα was blocked with monoclonal TNFα antibody. Myocardial function was measured by dP/dT and relaxation time (IVRT). Cellular injury was assessed by released myoglobin and tissue concentration of malondialdehyde activity of the heart homogenates. Baseline +dP/dT was 1645 ± 125 mmHg/sec, –dP/dT was 945 ± 73 mmHg/sec and IVRT was 65 ± 5 msec. At the conclusion of reperfusion period, lower doses of TNFα increased +dP/dT and lowered IVRT. In contrast, the higher doses of TNFα decreased +dP/dT and prolonged IVRT. Pretreating the hearts with monoclonal TNFα antibody completely abolished the effects of TNFα on myocardial contractility and relaxation comparable to ischemia controls. Conclusion: Low dose TNFα improved myocardial function and decreased resultant cellular injury while high dose TNFα decreased myocardial function and increased myocardial injury following ischemia and reperfusion.

Statin use is associated with improved overall survival without affecting patency and limb salvage rates following open or endovascular revascularization

The aim of the study was to determine statin drug association with patency, limb salvage rates and survival after revascularization in patients with chronic limb ischemia. We retrospectively reviewed all patients who underwent revascularization for intermittent claudication or critical limb ischemia between 05/2001 and 12/2009. Patients were grouped based on statin therapy at the time of revascularization. Early postoperative outcomes as well as patency, limb salvage, and survival rates were compared between groups. Of 717 patients, 397 (55.4%) were on statins. The incidence of major adverse cardiac events (MACE) was significantly lower in the statin group. Patency and limb salvage rates were similar; however, survival was significantly better in the statin group. Non-statin use, coronary artery disease, chronic pulmonary obstructive disease, renal insufficiency, critical limb ischemia, and age >70 years were found to be independently associated with decreased survival. Statin use was associated with improved survival, but not with long-term patency and limb salvage.

Predictive value of the fragmented QRS complex in 6-month mortality and morbidity following acute coronary syndrome.

Background Fragmented QRS encompasses different RSR’ patterns showing various morphologies of the QRS complexes with or without the Q wave on a resting 12-lead electrocardiogram. It has been shown possibly to cause adverse cardiac outcomes in patients with some heart diseases, including coronary artery disease. In view of the need for risk stratification of patients presenting with acute coronary syndrome in the most efficacious and cost-effective way, we conducted this study to clarify the value of developing fragmented QRS in a cohort of patients presenting with their first acute coronary syndrome in predicting 6-month mortality and morbidity. Methods One hundred consecutive patients admitted to the coronary care unit at Shahid Madani Heart Center in Tabriz from December 2008 to March 2009 with their first acute coronary syndrome were enrolled in this prospective study. Demographic and electrocardiographic data on admission, inhospital mortality, and need for revascularization were recorded. Electrocardiography performed 2 months after the index event was examined for development of fragmented QRS. Mortality and morbidity was evaluated at 6-month follow-up in all patients. Results The patients were of mean age 57.7 ± 12.8 years, and 84% were men. The primary diagnosis was unstable angina in 17 (17%) patients, non-ST elevation myocardial infarction (MI) in 11 (11%), anterior or inferior ST elevation MI in 66 (66%), and postero-inferior MI in six (6%). Fragmented QRS was present in 30 (30%) patients during the first admission, which increased to 44% at the 2-month follow-up and to 53% at the 6-month follow-up. The presence of various coronary risk factors and drug therapy given, including fibrinolytic agents, had no effect on development of fragmented QRS. Mortality was significantly higher (P = 0.032) and left ventricular ejection fraction was significantly lower (P = 0.001) in the fragmented QRS group at the 6-month follow-up. Conclusion This study strongly suggests that fragmented QRS on initial presentation with acute coronary syndrome is not predictive of subsequent events but, if present 6 months later, could be predictive of an adverse outcome.

Intraoperative administration of vasopressin during coronary artery bypass surgery is associated with acute postoperative kidney injury

BACKGROUND Severe vasodilatation is commonly seen upon weaning from cardiopulmonary bypass (CPB). We examined the effects of vasopressin (arginine vasopressin [AVP]) on acute kidney injury (AKI) in postoperative period. METHODS The records of 483 patients undergoing coronary bypass surgery on CPB from 2004 to 2008 were retrospectively reviewed. Demographic, anthropometric, comorbid condition, and perioperative clinical/laboratory data were collected along with postoperative complications. Patients were grouped based on the perioperative use of AVP, and AKI was used as the primary end point. Univariate and multivariate logistic regression analyses were used, followed by propensity score matching for AKI. Null hypothesis was rejected at P < .05. RESULTS Postoperative AKI occurred in 14.5% of patients. Arginine vasopressin was administered to 280 patients during the perioperative period. The prevalence of AKI in AVP was 20%, whereas it was 6.1% in controls (P < .0001). Arginine vasopressin was an independent factor that predicted the occurrence of AKI (odds ratio, 3.60; 95% confidence interval, 1.22-10.62; P = .02). However, after propensity score matching, the association between AKI and AVP was lost (P = .073). CONCLUSION Acute kidney injury is a common complication after cardiac surgery, and vasopressin use increases its incidence; however, this effect may rely on several clinical factors, and its true effect should be examined by large randomized trials.

The role of perioperative transfusion on long-term survival of veterans undergoing surgery.

OBJECTIVE To examine the influence of perioperative blood transfusions on perioperative outcomes and late survival. BACKGROUND Perioperative blood transfusion has been reported to have a negative impact on perioperative morbidity but its long-term effect on survival is unknown. The purpose of this study was to evaluate the effects of perioperative transfusion on perioperative outcomes and survival. METHODS We studied 12,345 surgical procedures from Veteran Administration Surgical Quality Improvement Program database from July 1998 through 2010. Patients with transfusion were compared with a severity-matched control group. We performed the Fisher exact test for comparison of categorical values and Wilcoxon rank sum test for continuous values. Multivariate regression was used to eliminate other confounding factors. The predictive value of multivariate risk model was tested with receiver-operator curves. Patients were matched using an optimal 1:1 digit-matching algorithm. All analyses were performed with NCSS-2007 version 1-12. P < 0.05 was considered statistically significant. RESULTS The 848 patients who received perioperative transfusions had higher unadjusted rates of mortality and decreased long-term survival. The odds ratio (OR) for 10 years mortality in transfused group was 2.92 and after adjusting for preoperative risk factors decreased to 1.40 (P < 0.01). However, after data were filtered for any perioperative complications, such an association was seen before, OR = 2.05 (P = 0.006), and was lost after propensity matching, OR = 1.19 (P = 0.35). CONCLUSIONS After filtering out perioperative complications and adjusting for preoperative morbidity, our final analysis did not reveal an increased long-term mortality. We conclude that transfusion may reduce long-term survival through its effects on perioperative complications.