Matthew DeCaro

Risk of Major Bleeding with Concomitant Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients Receiving Long-Term Warfarin Therapy

Study Objectives. To characterize the safety of concomitant aspirin, clopidogrel, and warfarin therapy after percutaneous coronary intervention (PCI), and to identify patient characteristics that increase the risk of hemorrhage.

Inferior Vena Cava Variation Compared to Pulse Contour Analysis as Predictors of Fluid Responsiveness: A Prospective Cohort Study

Background: Both occult hypoperfusion and volume overload are associated with increased morbidity and mortality in critically ill patients. Accurately predicting fluid responsiveness (FRes) allows for optimization of cardiac performance while avoiding fluid overload and prolonged mechanical ventilation. Objective: To simultaneously assess the ability to predict FRes using the stroke volume variation (SVV) obtained with the Vigileo/Flotrac monitor and inferior vena cava respiratory variation (ΔIVC) measured by standard echocardiography ([ECHO) during mechanical ventilation. Methods: We included medical intensive care unit (ICU) patients undergoing mechanical ventilation that required vasopressors, had worsening organ function, and that were well adapted to the ventilator. We excluded patients requiring escalating doses of vasopressors, hemodialysis, with ascites and patients with atrial fibrillation or a heart rate >120/min. Stroke volume index (SVI) and SVV were obtained from the Vigileo monitor whereas ΔIVC was obtained with ECHO (M-mode). Doppler ECHO was used to measure SVI and used to determine FRes (defined by SVI increase ≥10%). A data set was obtained before and 30 minutes after a 10-minute fluid challenge (FC) with 500 mL of saline. Results: In all, 25 patients were prospectively enrolled over an 8-month period. A total of 12 patients had acute respiratory distress syndrome (ARDS), 3 had a cardiac arrest, and 10 had sepsis. The patients’ mean age was 61.36 years (±13.7), study enrollment since ICU admission was 3.4 days (±3.39), the Sequential Organ Failure Assessment (SOFA) score was 12.44 (±2.59), and the tidal volume 8.6 mL/kg (±1.68). Of the 25 patients, 8 (32%) were FRes. The correlation coefficient between the baseline ΔIVC and percentage increase in SVI (by ECHO) after an FC was R2 = .51 with a receiver operating characteristic (ROC) curve of 0.81 while that for the baseline SVV by Vigileo was R2 = .12 with an ROC curve of 0.57. The mean SVI bias between ECHO and Vigileo was -2 mL/m2, the precision was -18 to 14 and the mean error was 46%. Conclusions: ECHO assessment of the IVC variation during mechanical ventilation may prove to be a useful technique to predict FRes and guide fluid resuscitation in the ICU. The SVV obtained with the Vigileo monitor failed to predict FRes likely due to lack of calibration and the use of a complex algorithm that may be unreliable in patients with sepsis.

The changing face of postoperative atrial fibrillation prevention: a review of current medical therapy.

Atrial fibrillation is the most common postoperative arrhythmia with significant consequences on patient health. Postoperative atrial fibrillation (POAF) complicates up to 8% of all noncardiac surgeries, between 3% and 30% of noncardiac thoracic surgeries, and between 16% and 46% of cardiac surgeries. POAF has been associated with increased morbidity, mortality, and longer, more costly hospital stays. The risk of POAF after cardiac and noncardiac surgery may be affected by several epidemiologic and intraoperative factors, as well as by the presence of preexisting cardiovascular and pulmonary disorders. POAF is typically a transient, reversible phenomenon that may develop in patients who possess an electrophysiologic substrate for the arrhythmia that is present before or as a result of surgery. Numerous studies support the efficacy of &bgr;-blockers in POAF prevention; they are currently the most common medication used in POAF prophylaxis. Perioperative amiodarone, sotalol, nondihydropyridine calcium channel blockers, and magnesium sulfate have been associated with a reduction in the occurrence of POAF. Biatrial pacing is a nonpharmacologic method that has been associated with a reduced risk of POAF. Additionally, recent studies have demonstrated that hydroxymethylglutaryl-CoA reductase inhibitors may decrease the risk of POAF. Finally, based on recent evidence that angiotensin converting enzyme inhibitors and angiotensin receptor blockers reduce the risk of permanent atrial fibrillation, these medications may also hold promise in POAF prophylaxis. However, there is a need for further large-scale investigations that incorporate standard methodologies and diagnostic criteria, which have been lacking in past trials.

Decision Analytic Model for Evaluation of Suspected Coronary Disease with Stress Testing and Coronary CT Angiography

RATIONALE AND OBJECTIVES The aim of this study was to apply a decision analytic model for the evaluation of coronary artery disease (CAD) to define the optimal utilization of coronary computed tomographic angiography (cCTA) and stress testing. MATERIALS AND METHODS The model tested in this study assumes that CAD is evaluated with a stress test and/or cCTA and that a patient with positive evaluation results undergoes cardiac catheterization. On the basis of values of sensitivity, specificity, and radiation dose from the published literature and test costs from the Medicare fee schedule, a decision tree model was constructed as a function of disease prevalence. RESULTS The false-negative rate is lowest when cCTA is used as an isolated test. The false-positive rate is minimized when cCTA is used in combination with stress echocardiography. Effective radiation is minimized by use of stress electrocardiography or stress echocardiography alone or prior to cCTA. When the pretest probability of CAD is low, a strategy that uses stress echocardiography followed by cCTA minimizes the false-positive rate and effective radiation exposure, with relatively low imaging costs and with a false-negative rate only slightly higher than a strategy including stress myocardial scintigraphy. As the pretest probability of CAD increases above 20%, the false-negative rate of stress echocardiography followed by cCTA increases by >5% relative to cCTA alone. CONCLUSION Effective radiation dose and imaging costs for the workup of CAD may be minimized by an appropriate combination of stress testing and cCTA. A strategy that uses stress echocardiography followed by cCTA is most appropriate for the evaluation of low-risk patients with CAD with a pretest probability < 20%, while cCTA alone may be more appropriate in intermediate-risk patients.

ACC/AHA/SCAI 2014 Health Policy Statement on Structured Reporting for the Cardiac Catheterization Laboratory A Report of the American College of Cardiology Clinical Quality Committee

Table of Contents This document has been developed as a health policy statement (HPS) by the American College of Cardiology (ACC). HPSs are intended to promote or advocate a position, be informational in nature, and offer guidance to the stakeholder community regarding the stance of the ACC …

The physician-hospital team: a successful approach to improving care in a large academic medical center.

Initiatives to improve the quality and efficiency of care in academic medical centers (AMCs, teaching hospitals) can benefit the performance of academic departments as well as the hospital. However, the value of performance improvement programs in an AMC is often challenging. At Jefferson Medical College, clinical efficiency and bed availability are important priorities to the Department of Medicine. To this end, a multidisciplinary program was designed to (1) improve the quality and consistency of care by adapting and adopting national guidelines for patients with heart failure and acute coronary syndrome; (2) identify and improve hospital operational supports and maximize resource utilization; (3) increase hospital functional capacity to make way for increased volume; and (4) improve housestaff education and practice by using evidence-based approaches and by optimizing teaching relationships between housestaff and attending faculty. The eight-month project (November 2002 to July 2003) resulted in improvement in several quality measures including increased use of beta blockers and angiotensin converting enzyme inhibitors for heart failure patients, reduced length of stay for heart failure and acute coronary syndrome patients, and increased satisfaction of the clinicians involved in caring for these patients. However, the project was not without barriers including individual physician’s unwillingness to embrace change and an inability to incentivize change. Development of faculty leadership skills and enhanced physician accountability helped in overcoming the challenges of change.

Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases

Background: Pericardial decompression syndrome (PDS) is a rare and potentially fatal complication of pericardial drainage, either by needle pericardiocentesis or surgical pericardiostomy. It manifests with paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. We sought to elucidate factors associated with mortality in PDS. Methods: MEDLINE was systematically searched for PDS case reports and case series published between 1983 and 2013. For this analysis, clinical variables, echocardiographic and hemodynamic variables, details of drainage procedure and clinical outcomes were collected for each case. Results: A total of 35 cases (12 male, 23 female) were identified. PDS developed after pericardiocentesis, pericardiostomy, or both, in 18, 16, and one patients, respectively. Cardiac tamponade was the indication in 33 cases (94%). The mean age was 47 ± 17 years. The mean amount of effusion drained was 888 mL. The minimum amount of effusion drained was 450 mL. The onset of PDS after the procedure varied widely, ranging from ‘immediate’ to 48 hours. Presentations included 10 (29%) with cardiogenic pulmonary edema without shock, 14 (40%) with left ventricular failure, three (9%) with right ventricular failure, seven (20%) with biventricular failure, and one (3%) with non-cardiogenic pulmonary edema. Ten patients (29%) died of PDS. Mortality was associated only with surgical drainage (p<0.001). Severe LV dysfunction normalized in PDS survivors. Conclusions: PDS is a rare complication of pericardial drainage with a high mortality rate. Surgical pericardiostomy was associated with mortality in PDS.

Plasma Catecholamine Profile of Subarachnoid Hemorrhage Patients with Neurogenic Cardiomyopathy

Purpose: To investigate the connection between sympathetic function and neurogenic cardiomyopathy (NC), and to determine whether NC is mediated primarily by circulating adrenal epinephrine (EPI) or neuronally transmitted norepinephrine (NE), following subarachnoid hemorrhage (SAH). Methods: This is a prospective observational investigation of consecutive severe-grade SAH patients. All participants had transthoracic echocardiography and serological assays for catecholamine levels - dopamine (DA), NE and EPI - within 48 h of hemorrhage onset. Clinical and serological independent predictors of NC were determined using multivariate logistic regression analyses, and the accuracy of predictors was assessed by receiver operating characteristic (ROC) curves. Multivariate linear regression analyses were used to evaluate correlations among the catecholamines. Results: The investigation included a total of 94 subjects: the mean age was 55 years, 81% were female and 57% were Caucasian. NC was identified in approximately 10% (9/94) of cases. Univariate analyses revealed associations between NC and worse clinical severity (p = 0.019), plasma DA (p = 0.018) and NE levels (p = 0.024). Plasma NE correlated with DA levels (ρ = 0.206, p = 0.046) and EPI levels (ρ = 0.392, p < 0.001), but was predicted only by plasma EPI in bivariate [parameter estimate (PE) = 1.95, p < 0.001] and multivariate (PE = 1.89, p < 0.001) linear regression models. Multivariate logistic regression analyses consistently demonstrated the predictive value of clinical grade for NC (p < 0.05 for all analyses) except in models incorporating plasma NE, where NC was independently predicted by NE level (OR 1.25, 95% CI 1.01-1.55) over clinical grade (OR 4.19, 95% CI 0.874-20.1). ROC curves similarly revealed the greater accuracy of plasma NE [area under the curve (AUC) 0.727, 95% CI 0.56-0.90, p = 0.02] over clinical grade (AUC 0.704, 95% CI 0.55-0.86, p = 0.05) for identifying the presence or absence of NC. Conclusions: Following SAH, the development of NC is primarily related to elevated plasma NE levels. Findings implicate a predominantly neurogenic process mediated by neuronal NE (and not adrenal EPI), but cannot exclude synergy between the catecholamines.

The Effects of Type I Antiarrhythmic Drugs on the Signal-Averaged Electrocardiogram in Patients with Malignant Ventricular Arrhythmias

The effects of type I antiarrhythmic drugs on the signal‐averaged electrocardiogram (SAECG) were analyzed in 58 patients with inducible sustained monomorphic ventricular tachycardia. SAECGs were acquired before and after drug therapy. A total of 99 drug trials were analyzed (mean 1.7 per patient). Analysis of temporal domain parameters included the duration of the QRS complex (QHSD), the high frequency total duration of the filtered QRS complex (HFTD), the duration of the signal under 40 μV (D40), initial QRS (HFTD minus D40), and the root mean square amplitude (RMSA)of the terminal 40 msec of the QRS signal. Changes in temporal parameters failed to predict drug efficacy. There were, however, type‐specific drug effects on the SAECG. With the exception of type IB drugs, all drugs increased the QRSD, HFTD, and D40. Type IC drugs caused more prolongation of the QRSD and HFTD than type IA, IB, and the combination of IA + IB drugs. Prolongation of the HFTD was related to prolongation of the late potential and the initial portion of the QRS complex. A preferential effect of these drugs on the late potential was not observed. Type IC drugs also caused more prolongation of ventricular tachycardia cycle length than type IA or IB drugs. However, the increase in ventricular tachycardia cycle length did not correlate with a change in the SAECG. In summary, type I antiarrhythmic drugs cause a global slowing of ventricular activation. Although analysis of the SAECG following drug therapy was not useful for predicting drug efficacy, drug induced changes in the SAECG may be helpful for categorizing antiarrhythmic agents.

T WAVE SLOPES: A NOVEL METHOD FOR ASSESSMENT OF REPOLARIZATION DISPERSION FROM SURFACE ECGS WITH PROLONGED QT AS COMPARED TO NORMAL ECGS

The normal (NL) T wave in health is asymmetric [gentler initial slope (TInit Sl), steeper terminal slope (TTerm Sl)]. The T Peak – T End (TP-TE) interval reflects repolarization dispersion; a prolonged QTc (LQT, Bazett) is associated with TP-TE prolongation and increased arrhythmic risk. We