Mahendra Mandawat

Hospitalization rates and in-hospital mortality among centenarians

The number of Americans at least 100 years old is expected to grow dramatically over the coming years. In December 2010, 71 991 centenarians lived in the United States, almost double the number there were 20 years ago.1, 2 By 2050, the number of centenarians is expected to reach 601 000, a 735% increase.2 Despite the growing numbers, the health care use of this population remains largely unexamined. In particular, the rates and outcomes of hospitalization for persons 100 years or older are unknown. The goal of this study was to determine rates of hospital admission as well as in-hospital all-cause and diagnosis-specific mortality in patients 100 years or older.

Pharmacologic stress myocardial perfusion imaging.

Abstract: Pharmacologic stress agents (dipyridamole, adenosine and dobutamine) allow virtually all patients to be safely assessed for ischemic heart disease. These agents have mild but significant side effects, mandating a thorough knowledge of indications, contraindications, side effects and management before their use. Adjunctive exercise improves image quality in vasodilator pharmacologic myocardial perfusion imaging. Diabetics, especially women, have a much higher cardiac event rate than nondiabetics for an equal amount of ischemia. They also have a higher incidence of asymptomatic ischemia. There is growing support for screening with myocardial perfusion imaging (MPI) for asymptomatic ischemia in diabetics. The ability of MPI to identify hypocontractile but viable myocardium, thus predicting improvement in myocardial function after revascularization, is one of the most powerful uses of the modality. Vasodilator MPI should be used as the initial test in patients with left bundle branch block or paced ventricular rhythm, even if they are able to exercise.

The D-dimer assay: A possible tool in the evaluation of atrial thrombosis

Atrial fibrillation (AF) is a common arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age. Peripheral thromboembolism contributes significantly to the observed morbidity and mortality. Symptomatic AF, before cardioversion to normal sinus rhythm, requires either exclusion of atrial thrombi using transesophageal echocardiography (TEE) or the conventional use of three weeks of adequate anticoagulation. The exclusion of atrial thrombi by TEE, a nontomographic technique but comparable with conventional treatment of AF in outcomes, has inherent limitations due to the complex three-dimensional multilobed anatomy of the left atrial appendage, where the majority of atrial thrombi arise. Also, the conventional treatment of three weeks of therapeutic anticoagulation before cardioversion reportedly does not always eliminate atrial thrombi. Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombosis and, hence, may improve the evaluation of a patient with AF before cardioversion in addition to a TEE. A case is presented in which a positive D-dimer resulted in performing TEE to document atrial thrombosis and the complications of previous bacterial endocarditis. In the present case, this involved aortic root abscess formation and acute aortic regurgitation because of flailing of the noncoronary cusp that resulted in recurrent pulmonary edema.

UTILITY AND COST ANALYSIS OF THE D-DIMER ASSAY IN DIAGNOSIS OF PULMONARY EMBOLISM USING COMPUTERIZED TOMOGRAPHIC ANGIOGRAPHY IN THE EMERGENCY DEPARTMENT

Methods: We conducted a retrospective analysis of patients who underwent CTAV in the Emergency Department at the Medical College of Georgia from 08/04 to 07/05. We included 359 consecutive patients who had CTAV for suspected VTE based on positive DD (Group1) or clinical suspicion (Group 2). We reviewed available history, physical examination and investigations for VTE. The modified Well’s score was used to subdivide the groups into high Well’s (score >4) and low Well’s (score ≤4). Actual billed costs were used for cost analysis. The primary objective was to compare the cost per positive diagnosis. Subgroup analysis was performed for both cost and yield.

Fractional Flow Reserve: A Review for Cardiac Catheterization Lab Personnel

Coronary angiography (CA) is the gold standard for the diagnosis and subsequent management of coronary artery disease. It provides us with a luminal outline of a three-dimensional structure. By looking at a lumen in different angles, we deduct the obstruction in the lumen caused by plaque in the vessel wall of coronary arteries. The severity of lesions can be well represented by CA when a person has severe luminal narrowing (>70%) or minimal luminal irregularities (<40%), particularly when combined with clinical presentation (Mintz et al., 1996). However, it is not uncommon for patients to have intermediate lesions of 40% to 70% or have angiographic lesions such as ostial locations, areas of vessel foreshortening, calcified vessels, and branch vessel overlap that are inherently difficult to interpret on angiography. To complicate the matter further, some patients have multiple intermediate lesions dotted in various parts of the artery, and it is difficult to know which lesions require treatment and which can be managed medically (Topol & Nissen, 1995).

Myocardial infarction after physical exertion in a healthy young patient with coronary artery ectasia and sickle cell trait

Fig. 1. Panel A. Coronary angiography on admission reveals diffuse ectasia of the proximal and mid segments of the left anterior descending and left circumflex arteries. A large thrombus (arrow) is visualized in the proximal-to-mid segment of the left circumflex arA 29-year-old African American male was admitted for non-STsegment-elevation myocardial infarction (MI). He was previously a healthy person who did not take medications. His past medical history included sickle cell trait (SCT), chronic hematuria and hospitalization for sickle pain crisis as a child. He was hunting for deer and started to have substernal chest pain while dragging one uphill for 400 m. He was inmild distress, but his vital signswere normal. Laboratoryworkup revealed white blood cell count of 8400/mm, hemoglobin of 14.8 g/dL, hematocrit of 43.60%, and platelet count of 161,000/mm. Chemistry panel was within normal limits. Troponin I level was 2.84 ng/mL. Lipid panel revealed lowand high-density lipoproteins of 216 mg/dL and 47 mg/dL, respectively. Initial medical therapy included Aspirin, Clopidogrel, Metoprolol, and intravenousHeparin andNitroglycerin drips. Coronary angiography revealed diffuse proximal andmid vessel ectasia. There was a large partially occlusive thrombus in the proximal-to-mid dilated segment of the left circumflex artery (LCx)with TIMI grade 1 flow distally (Fig. 1, Panel A). Thrombectomywas planned in 24–48 h in the hope that antiplatelet and anticoagulation therapies may decrease the thrombus burden and make thrombectomy safer and more effective. His chest pain resolved over the following two days. Transthoracic echocardiography showed mild concentric left ventricular hypertrophy (LVH) with left ventricular ejection fraction (LVEF) N55%. There was no

Intravascular Ultrasound Its Use and Limitations in Cardiac Catheterization Laboratory

Coronary angiography is the gold standard for evaluating coronary atherosclerotic heart disease, yet it has well-known limitations. Intravascular ultrasound (IVUS) is an invasive technique that is used to improve the assessment and management of coronary artery disease. IVUS is a readily available imaging modality that is easy to learn and interpret with low complication rates. In this literature review, the authors will review the technique and discuss the various current usages of IVUS and its limitations, safety, and complications.

Encircling reperfusion pattern on the stress-minus-delay bull's-eye map improves sensitivity of myocardial perfusion scans.

BackgroundMyocardial perfusion imaging is subject to considerable noise due to re-registration and attenuation artifact. MethodsOn a retrospective review, we identified 51 studies that showed encircling reperfusion pattern on a stress-minus-delay bulls-eye map with concurrent cardiac catheterization within 4 months. Encircling reperfusion was defined as a band of reversibility ≥2.5 standard deviations above that of the gender-matched and age-matched normal studies. This had to surround the delay defect for at least two-thirds of its circumference on the stress-minus-delay bulls-eye map. Three expert readers, blinded to cardiac catheterization results, individually interpreted myocardial perfusion imaging without and with a stress-minus-delay bulls-eye map. A certainty index of 1–100 (100 being the highest certainty for the presence of perfusion defects) was recorded for image interpretation. ResultsThe intra-class correlation coefficient between readers indicated a strong agreement. Using encircling reperfusion pattern on a stress-minus-delay bulls-eye map, the mean increase in certainty index scores was 8.0±7.30 (P<0.0001). This increase in certainty index scores was associated with a significant increase in sensitivity from 67 to 83% (P=0.01) without any significant decrease in specificity (P=0.16). ConclusionsThe pattern of encircling reperfusion on the stress-minus-delay bulls-eye map can improve the interpreters confidence and sensitivity without significantly compromising specificity for identifying true myocardial perfusion defects.