Loheetha Ragupathi

Availability, Use, and Barriers to Cardiac Rehabilitation in LMIC

BACKGROUND Cardiac rehabilitation (CR) is a cornerstone of secondary prevention of ischemic heart disease. It is critically important in low- and middle-income countries (LMIC), where the burden of ischemic heart disease is substantial and growing. However, the availability and utilization of CR in LMIC is not systematically known. OBJECTIVES This study sought to characterize the availability, use, and barriers to the use of CR. METHODS Electronic databases (Cochrane Library, EMBASE, PubMed, Web of Science) were searched from January 1, 1980 to May 31, 2013 for articles on CR in LMIC. Citations on availability, use, and/or barriers to CR were screened for inclusion by title, abstract, and full text. Data were summarized by region or country to determine the characteristics of CR in LMIC and gaps in the peer-reviewed biomedical publications. RESULTS Our search yielded a total of 5,805 citations, of which 34 satisfied full inclusion and exclusion criteria. The total number of CR programs available ranged from 1 in Algeria and Paraguay to 51 in Serbia. Referral rates for CR ranged from 5.0% in Mexico to 90.3% in Lithuania. Attendance rates ranged from 31.7% in Bulgaria to 95.6% in Lithuania, and CR attendance was correlated with higher educational background. The most commonly cited barrier to CR in LMIC was lack of physician referral. CONCLUSIONS Our results illustrate that the published reports reflects heterogeneity of CR availability and use in LMIC. Overall, CR is insufficiently available and underutilized. Further characterization of CR in LMIC, especially in Asia and Africa, is necessary to develop targeted strategies to improve availability and utilization. Patient, physician, and systems factors must be addressed to overcome barriers to participation in CR in LMIC.

Right Ventricular Enlargement within Months of Arteriovenous Fistula Creation in 2 Hemodialysis Patients.

Surgically created arteriovenous fistulae (AVF) for hemodialysis can contribute to hemodynamic changes. We describe the cases of 2 male patients in whom new right ventricular enlargement developed after an AVF was created for hemodialysis. Patient 1 sustained high-output heart failure solely attributable to the AVF. After AVF banding and subsequent ligation, his heart failure and right ventricular enlargement resolved. In Patient 2, the AVF contributed to new-onset right ventricular enlargement, heart failure, and ascites. His severe pulmonary hypertension was caused by diastolic heart failure, diabetes mellitus, and obstructive sleep apnea. His right ventricular enlargement and heart failure symptoms did not improve after AVF ligation. We think that our report is the first to specifically correlate the echocardiographic finding of right ventricular enlargement with AVF sequelae. Clinicians who treat end-stage renal disease patients should be aware of this potential sequela of AVF creation, particularly in the upper arm. We recommend obtaining preoperative echocardiograms in all patients who will undergo upper-arm AVF creation, so that comparisons can be made postoperatively. Alternative consideration should be given to creating the AVF in the radial artery, because of less shunting and therefore less potential for right-sided heart failure and pulmonary hypertension. A multidisciplinary approach is optimal when selecting patients for AVF banding or ligation.

Tools for risk stratification of sudden cardiac death: a review of the literature in different patient populations.

While various modalities to determine risk of sudden cardiac death (SCD) have been reported in clinical studies, currently reduced left ventricular ejection fraction remains the cornerstone of SCD risk stratification. However, the absolute burden of SCD is greatest amongst populations without known cardiac disease. In this review, we summarize the evidence behind current guidelines for implantable cardioverter defibrillator (ICD) use for the prevention of SCD in patients with ischemic heart disease (IHD). We also evaluate the evidence for risk stratification tools beyond clinical guidelines in the general population, patients with IHD, and patients with other known or suspected medical conditions.

Clinical and electrophysiological characteristics of patients with paroxysmal intra-His block with narrow QRS complexes

BACKGROUND Atrioventricular (AV) block is usually due to infranodal disease and associated with a wide QRS complex; such patients often progress to complete AV block and pacemaker dependency. Uncommonly, infranodal AV block can occur within the His bundle with a narrow QRS complex. OBJECTIVES The aims of this study were to define clinical/echocardiographic characteristics of patients with AV block within the His bundle and report progression to pacemaker dependency. METHODS We retrospectively identified patients with narrow QRS complexes and documented intra-His delay or block at electrophysiology study (group A) or with electrocardiogram-documented Mobitz II AV block/paroxysmal AV block (group B). Clinical, electrophysiological, and echocardiographic variables at presentation and pacemaker parameters at the last follow-up visit were evaluated. RESULTS Twenty-seven patients (19 women) were identified (mean age 64 ± 13 years; range, 38-85 years). Four patients who had <1 month of follow-up were excluded. There were 12 patients in group A and 11 in group B; 21 of 23 presented with syncope/presyncope. All patients received pacemakers: 8 single chamber and 15 dual chamber. After a median follow-up of 6.4 years, the median percentage of ventricular pacing was 1% (interquartile range 0%-4.66%). One patient developed true pacemaker dependency. Aortic and/or mitral annular calcification was present in 13 of 22 patients with available echocardiograms. CONCLUSION Patients who present with syncope and narrow QRS complexes with intra-His delay or Mobitz II paroxysmal AV block with narrow QRS complexes rarely progress to pacemaker dependency and require infrequent pacing. This entity is more common in women, with a higher prevalence of aortic and/or mitral annular calcification. If confirmed by additional studies, single-chamber pacemaker may be sufficient.

PROVIDER ADHERENCE TO CHOLESTEROL GUIDELINES FOLLOWING HOSPITALIZATION FOR ACUTE CORONARY SYNDROME OR STOKE

The 2013 (“new”) ACC/AHA guidelines for cholesterol management represent a paradigm shift from the ATP III (“old”) guidelines, changing the focus from LDL targets to a risk assessment model to guide therapeutic choices, with emphasis on statin therapy. Evaluation of statin prescribing

FLECAINIDE TOXICITY MIMICKING INCESSANT VENTRICULAR TACHYCARDIA

Flecainide is a Vaughan-Williams Class 1c antiarrhythmic drug indicated for use in pharmacologic cardioversion and maintenance of sinus rhythm in atrial fibrillation and other supraventricular tachycardias in patients without structural heart disease. However, flecainide has a narrow therapeutic

Late Recurrence of Rheumatic Fever

A 59-year-old man with a history of systolic heart failure (HF) was admitted to another hospital in March 2015, with severe dyspnea on exertion for 1 week. He was found to be in decompensated HF, treated with intravenous diuretics and transferred to a quaternary care hospital for evaluation for advanced HF therapies. He was born in 1955 in the Dominican Republic and had multiple febrile illnesses in childhood and decreased exercise tolerance as a young adult. At the age of 19, he immigrated to the United States at which time he was diagnosed with rheumatic heart disease (RHD). He underwent aortic valve replacement with a Bjork–Shiley valve at the age of 21. He was never treated with antibiotic prophylaxis for rheumatic fever (RF). In 2012, he underwent redo sternotomy with suture repair of a periprosthetic aortic valve leak. At that time, he underwent placement of a single lead implantable cardioverter defibrillator for severely depressed left ventricular systolic function, with subsequent upgrade to a biventricular implantable cardioverter defibrillator and ablation of the atrioventricular node for atrial fibrillation. On presentation to the quaternary care hospital, further questioning revealed an 1-week history of mild sore throat, severe and persistent migratory joint pains, which was initially localized to the left hip and left ankle, and a diffuse, erythematous rash on the extremities that had resolved before admission. He was febrile at 101.6°F, and physical exam was significant for volume overload and tenderness over the left hip at the greater trochanter. Radiographs of the left hip showed evidence of arthritis. There was no significant abnormality in xrays of the left ankle. An echocardiogram revealed mildly thickened mitral valve leaflets with diastolic doming of the anterior leaflet, and a calcified and immobile posterior leaflet suggesting a rheumatic etiology. There was mild mitral stenosis and mild mitral regurgitation. A mechanical aortic valve was in place, and the left ventricular ejection fraction was 40%. Laboratory studies revealed sterile blood cultures drawn on days 2 to 6 of hospital stay, elevated erythrocyte sedimentation rate of 107 mm/hr (normal , 10), elevated C reactive protein of 14.3 mg/dL (normal , 0.8), and a negative rapid streptococcal antigen detection test on throat swab. The patient’s throat culture was positive for light growth of group A streptococcus (GAS). Antistreptolysin O antibody titers were elevated to 1,300 IU/mL (normal , 117 IU/mL). On day 2 of hospitalization, he developed left knee pain and was noted to have an effusion. Arthrocentesis did not show any evidence of infection, and synovial fluid cultures were sterile. Based on clinical and laboratory findings, he was diagnosed with acute RF. He was treated with a single dose of intramuscular benzathine penicillin G 1.2 million units. He was additionally started on choline magnesium trisalicylate 1g 3 times daily for anti-inflammatory effect. He had rapid improvement of his joint pain, improvement of HF symptoms and resolution of fevers. For this reason, his HF symptoms were attributed to carditis from RF, and evaluation for advanced therapies for HF was put on hold. He was discharged after 7 days of hospitalization with follow-up with his primary care physician and cardiologist, with plans to initiate oral penicillin prophylaxis in 4 weeks of time. Recurrences of RF in adults have been reported between 2 and 30 years after the index episode. In the last 20 years, reports of recurrent RF in the medical literature have been few and far between, and none have been reported from the United States. There are estimated 15 million cases of RHD worldwide and leading to 233,000 annual deaths. Although RHD remains a major cause of morbidity and mortality globally, the overall incidence of acute RF is decreasing, and it is rarely encountered by physicians in the United States. From 1970 to 2009, in the United States, the prevalence of acute RF was reported to be up to 40 cases/100,000 persons, whereas in some developing countries, it was reported to be over 100 cases/100,000 persons. This case highlights the importance of continued attention to RF in the United States in patients with previous episodes of the disease. RF is an immune response to GAS pharyngitis. Streptococcal skin infections have not been implicated in RF. At least one third of cases of acute RF result from clinically unrecognized GAS infections. The basis of the diagnosis of RF remains the Jones criteria (Table 1), which was initially published in 1944, with successive revisions, most recently in 2015, that have progressively increased its specificity and decreased its sensitivity. Until 1992, the Jones criteria represented consensus guidelines; the 2015 revision was the first to classify recommendations by the Classification of Recommendations and Level of Evidence categories. Additionally, the 2015 guidelines reflect a major change in paradigm for the diagnosis of RF, with the incorporation of echocardiographic parameters for the diagnosis of carditis. This change was based on over 25 studies showing the utility of echocardiography with Doppler in the diagnosis of subclinical carditis. In the 2015 revision, a diagnosis of recurrent RF may be made with 2 major, 1 major and 2 minor, or 3 minor criteria alone in the setting of preceding GAS pharyngitis. However, this revision did not address the echocardiographic diagnosis of carditis in the context of recurrent RF in the presence of chronic RHD. In this patient, 2 major and 3 minor Jones criteria were satisfied (clinical carditis, polyarthritis, fever and elevated acute phase reactants) in the presence of positive throat cultures and elevated streptococcal antibody titers. Prolongation of the PR interval was not assessed in the setting of atrial fibrillation. Primary prevention of RF is accomplished by identification and treatment of GAS pharyngitis. Penicillin remains the cornerstone of treatment for GAS pharyngitis, with 100% of GAS demonstrating in vitro susceptibility to all beta-lactam agents. Current guidelines from the American Heart Association recommend the following regimens for the treatment of GAS pharyngitis for primary prevention of acute RF: oral penicillin V at a dose of 500 mg 2 to 3 times daily for 10 days, amoxicillin 50 mg/kg once daily for 10 days or intramuscular benzathine penicillin G 1.2 million units once. Patients with penicillin allergy may be treated with narrow spectrum cephalosporins, clindamycin, azithromycin or clarithromycin. Antimicrobial treatment for acute RF mirrors that for GAS pharyngitis, regardless of the presence of pharyngitis at the time of diagnosis of acute RF. HF management, with attention to valvular heart disease, is necessary in patients with carditis. Aspirin remains the mainstay of anti-inflammatory therapy in practice. The evidence for the efficacy of antiinflammatory medications in acute RF is antiquated, and data on the efficacy of recently developed anti-inflammatory medications are necessary. In this patient, choline magnesium trisalicylate was chosen for anti-inflammatory effect. This has a decreased effect on platelet inhibition in comparison with