Marvin Lu

Utility of the QT interval in predicting outcomes in patients presenting to the emergency department with chest pain.

ObjectivesThe aim of this study was to investigate whether prolongation of the heart rate-corrected QT interval (QTc) is an independent risk factor for predicting future acute coronary syndrome (ACS) occurrence or mortality in patients with at least one cardiac risk factor presenting with chest pain to the emergency department (ED). MethodsThis is a single-center, retrospective study of patients presenting with chest pain to the ED of Einstein Medical Center, Philadelphia, between 2011 and 2012. Proportional hazards models were used to calculate hazard ratios (HRs) for occurrence of ACS or death within 1 year. Kaplan–Meier curves were used to determine the time to event for QTc low (<460 ms) versus QTc high (≥460 ms) groups. ResultsA total of 595 patients met the inclusion criteria. Older age, hypertension, diabetes mellitus, and hyperlipidemia were more common in the QTc high group. Patients in the QTc high group were more likely to experience subsequent ACS or death (HR 8.12, 95% confidence interval 4.00–16.72), even after adjusting for traditional cardiac risk factors (HR 7.68, 95% confidence interval 3.57–16.61). ConclusionQTc prolongation at ED presentation with chest pain and at least one cardiac risk factor predicts subsequent ACS and death.

Etiologies, Predictors and Economic Impact of 30 Day Readmissions among Patients with Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a pregnancy-associated cause of heart failure. Given the significant impact of heart failure on healthcare, we sought to identify etiologies and predictive factors for readmission in PPCM. We queried the 2013 to 2014 National Readmissions Database to identify patients admitted with a diagnosis of PPCM. Patients who were readmitted within 30 days were evaluated to identify etiologies and predictors of readmission. We identified 6,977 index admissions with PPCM. Of the 6,880 (98.6%) patients who survived the index hospitalization, 30-day readmission rate was 13%. Seventy-six percent of readmitted patients were admitted once, and the other 24% were readmitted at least twice within 30 days of discharge. Length of stay was ≥8 days (adjusted odds ratio [aOR] 2.80, 95% confidence interval [CI] 2.08 to 3.77), multiparity (aOR 2.07, 95% CI 1.09 to 3.92), coronary artery disease (aOR 2.28, 95% CI 1.42 to 3.67), and long-term anticoagulation use (aOR 2.51, 95% CI 1.73 to 3.64) were independently associated with increased risk of 30-day readmission. Among the readmissions, 48% were due to cardiac causes, where PPCM and related complications (24%) were the most common cardiac cause followed by heart failure (16%). The annual cost of stay for index admissions was

Ivc filters—trends in placement and indications, a study of 2 populations

64.2 million (average cost for index admission was

Clinical utility of the HEART score in patients admitted with chest pain to an inner-city hospital in the USA

16,892). The annual charges attributed to readmission within 30 days were ≈

Ventricular tachyarrhythmia in a 78-year-old woman with essential thrombocythaemia

9 million. Cardiac etiologies were the most common cause for 30-day readmissions in PPCM patients, with a readmission rate of 13%. Long-term anticoagulation use, multiparity, coronary disease and length of stay predicted higher 30-day readmission.

Usefulness of the Echocardiographic Calcium Score to Refine Risk of Major Adverse Cardiovascular Events Beyond the Traditional Framingham Risk Score

Abstract Inferior vena cava filter (IVCF) placement appears to be expanding over time despite absence of clear directing evidence. Two populations were studied. The first population included patients who received an IVCF between January 2005 and August 2013 at our community hospital center. Demographic information, indications for placement, and retrieval rate was recorded among other variables. The second population comprised of patients receiving an IVCF from 2005 to 2012 according to the Nationwide Inpatient Sample (NIS) using ICD-9CM coding. Patients were divided into 2 groups based on the year of admission for comparison, that is, first group from 2005 to 2008 and the second from 2009 to 2012. In addition, we analyzed annual trends in filter placement, acute venothromboembolic events (VTE) and several underlying comorbidities within this population. At our center, 802 IVCFs were placed (55.2% retrievable); 34% for absolute, 61% for relative, and 5% for prophylactic indications. Major bleeding (27.5%), minor self-limited bleeding (13.7%), and fall history (11.2%) were the commonest indications. Periprocedural complication rate was 0.7%, and filter retrieval rate was 7%. The NIS population (811,487 filters) saw a decline in IVCF placement after year 2009, following an initial uptrend (Ptrend < 0.01). IVCF use among patients with neither acute VTE nor bleeding among prior VTE saw a 3-fold absolute reduction from 2005 to 2012 (33,075–11,655; Ptrend < 0.01). Patients from 2009 to 2012 were more likely to be male and had higher rates of acute VTE, thrombolytic use, cancer, bleeding, hypotension, acute cardiorespiratory failure, shock, prior falls, blood product transfusion, hospital mortality including higher Charlson comorbidity scores. The patients were younger, had shorter length of stay, and were less likely to be associated with strokes including hemorrhagic or require ventilator support. Prior falls (adjusted odds ratio—aOR 2.8), thrombolytic use (aOR 1.76), and shock (aOR 1.45) were most predictive of IVCF placement between 2009 and 2012 on regression analysis. Recent trends suggest that a higher proportion of patients receive temporary IVCF, for predominantly relative indications. Nationally, the number of filters being placed is decreasing, especially among those who did not experience acute VTE or bleeding events. Prior falls, thrombolytic therapy, and shock were most predictive of IVCF placement in latter half of the study period.

Clinical Characteristics, Management, and Outcomes of Suspected Poststroke Acute Coronary Syndrome.

Background Chest pain is one of the most common presentations to a hospital, and appropriate triaging of these patients can be challenging. The HEART score has been used for such purposes in some countries and only a few validation studies from the USA are available. We aim to determine the utility of the HEART score in patients presenting with chest pain to an inner-city hospital in the USA. Patients and methods We retrospectively screened 417 consecutive patients admitted with chest pain to the observation/telemetry units at Einstein Medical Center Philadelphia. After applying inclusion and exclusion criteria, 299 patients were included in the analysis. Patients were divided into low-risk (0–3) and intermediate-high (≥4)-risk HEART score groups. Baseline characteristics, thrombolysis in myocardial infarction score, need for revascularization during index hospitalization, and major adverse cardiovascular events (MACE) at 6 weeks and 12 months were recorded. Results There were 98 and 201 patients in the low-score group and intermediate-high-score group, respectively. Compared with the low-score group, patients in the intermediate-high-risk group had a higher incidence of revascularization during the index hospital stay (16.4 vs. 0%; P=0.001), longer hospital stay, higher MACE at 6 weeks (9.5 vs. 0%) and 12 months (20.4 vs. 3.1%), and higher cardiac readmissions. HEART score of at least 4 independently predicted MACE at 12 months (odds ratio 7.456, 95% confidence interval: 2.175–25.56; P=0.001) after adjusting for other risk factors in regression analysis. Conclusion HEART score of at least 4 was predictive of worse outcomes in patients with chest pain in an inner-city USA hospital. If validated in multicenter prospective studies, the HEART score could potentially be useful in risk-stratifying patients presenting with chest pain in the USA and could impact clinical decision-making.

CLINICAL UTILITY OF HEART SCORE IN PATIENTS ADMITTED WITH CHEST PAIN TO AN INNER CITY HOSPITAL

Anagrelide is a phosphodiesterase-3 inhibitor used in the treatment of essential thrombocythaemia. Cardiovascular side effects such as ventricular tachycardia and cardiomyopathy are rare but potentially fatal and should be made known to patients before starting the medication. It usually arises within the first 6 months after initiation of therapy and may be dose related. The elderly population are particularly susceptible. These cardiotoxicities result from an increase in cyclic AMP that induces positive inotropic and chronotropic effects and are often reversible with cessation of use. We report a case of a 78-year-old woman with essential thrombocythaemia and recently started on anagrelide who presented with syncope and multiple bruises and facial trauma and found to have developed ventricular tachyarrhythmia.

ELECTROCARDIOGRAPHIC CHANGES CONSISTENT WITH ATRIAL INFARCTION IS A POTENTIAL INDEPENDENT PREDICTOR OF 30 DAY AND 1 YEAR MORTALITY IN PATIENTS WITH ACUTE ST-ELEVATION MYOCARDIAL INFARCTION

Echocardiographic calcifications are associated with major adverse cardiovascular events (MACE). A recently described semiquantitative Global Cardiac Calcium Score (GCCS) has been associated with mortality and stroke, with increasing scores associated with increasing risk. This score assigns points for calcium in the aortic root and valve, mitral valve and annulus, and submitral apparatus, with additional points for restricted leaflet mobility. We tested the hypothesis that the GCCS could improve prediction of MACE beyond traditional risk scores. This was a retrospective study of 216 subjects from a general echocardiography database (mean age 59 ± 15; 51% male). Follow-up was 3.8 ± 1.7 years. The Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) were applied to each patient. Mean GCCS was 3.2 ± 2. In the total cohort, GCCS predicted MACE (myocardial infarction, stroke, all-cause mortality), even after adjusting for FRS (odd ratio 1.19, p = 0.03). There were 106 subjects (49%) in the low-risk FRS group, 71 (33%) in the intermediate-risk group, and 39 (18%) in the high-risk group. GCCS ≥3 was associated with increased MACE (vs <3) in the low-risk group (p = 0.03), while GCCS <3 was associated with decreased MACE (vs ≥3) in the high-risk group (p = 0.04). When applied to the PCE risk estimate (dichotomized at <7.5% vs ≥7.5%) the GCCS similarly refined risk prediction. In conclusion, the semiquantitative GCCS appears to be a marker of additional unaccounted risk factors; it is easily applied and can further stratify risk of MACE beyond traditional FRS or PCE estimates.

THE ROAD TO RECOVERY: THE ROLE OF MARITAL STATUS AND LIVING CONDITION ON THE OUTCOMES OF AFRICAN AMERICANS WITH HEART FAILURE

Background Acute coronary syndrome (ACS) can complicate acute ischemic stroke, causing significant morbidity and mortality. To date, literatures that describe poststroke acute coronary syndrome and its morbidity and mortality burden are lacking. Methods This is a single center, retrospective study where clinical characteristics, cardiac evaluation, and management of patients with suspected poststroke ACS were compared and analyzed for their association with inpatient mortality and 1-year all-cause mortality. Results Of the 82 patients, 32% had chest pain and 88% had ischemic ECG changes; mean peak troponin level was 18, and mean ejection fraction was 40%. The medical management group had older individuals (73 versus 67 years, p < 0.05), lower mean peak troponin levels (12 versus 49, p < 0.05), and lower mean length of stay (12 versus 25 days, p < 0.05) compared to those who underwent stent or CABG. Troponin levels were significantly associated with 1-year all-cause mortality. Conclusion Age and troponin level appear to play a role in the current clinical decision making for patient with suspected poststroke ACS. Troponin level appears to significantly correlate with 1-year all-cause mortality. In the management of poststroke acute coronary syndrome, optimal medical therapy had similar inpatient and all-cause mortality compared to PCI and/or CABG.