Mouhamad Abdallah

Upper gastrointestinal bleeding in patients with acute coronary syndromes: clinical predictors and prophylactic role of proton pump inhibitors.

Objectives To determine the risk and the clinical predictors of in-hospital upper gastrointestinal (UGI) bleeding in patients with acute coronary syndromes (ACS), and to study the prophylactic role of proton pump inhibitors (PPI) in this setting. Background Patients with ACS are usually treated by a combination of antiplatelet, antithrombotic and thrombolytic medications, thereby increasing the risk of bleeding. Study A retrospective study of 1023 patients hospitalized with ACS at the American University of Beirut Medical Center from September 2001 to November 2005. The main outcome measurements were the incidence of in-hospital UGI bleeding and its predictors; the utilization rate of PPI and its determinants. Results Seven patients developed in-hospital UGI bleeding (0.7%) and 2 had major bleeding (0.2%). All required blood transfusion and none died in the hospital. Significant predictors of UGI bleeding were prior history of UGI bleeding or peptic ulcer disease (P<0.01), creatinine > 2 mg/dL (P=0.01), and home intake of aspirin, clopidogrel (P<0.05), or nonsteroidal anti-inflammatory drugs (P<0.05). Sixty-nine percent of patients received PPI during their hospital stay. There was no significant difference in the incidence of UGI bleeding between patients receiving and those not receiving PPI (0.7% vs. 0.6%, P= 0.88). Conclusions The risk of UGI bleeding is relatively low in patients hospitalized with ACS and does not appear to be significantly reduced by the use of PPI. The utilization rate of PPI was relatively high. Better patient selection and risk stratification for the prophylactic use of PPI are warranted.

Will Imaging Assist in the Selection of Patients With Heart Failure for an ICD

Sudden cardiac death remains the leading cause of death in the U.S. A left ventricular ejection fraction (LVEF)<30% to 35% identifies a population of patients at increased risk for sudden cardiac death. Once identified, an implantable cardioverter-defibrillator (ICD) is effective in reducing the occurrence of sudden cardiac death. Yet in a substantial proportion of patients who receive an ICD based on reduced LVEF, the device never delivers therapy. Furthermore, the majority of patients who die suddenly do not qualify for ICD placement under current LVEF-based criteria in the guidelines. This review considers the potential role of cardiac imaging in improving the selection of patients most likely to benefit from an ICD. The presence of myocardial scar and/or unrevascularized myocardial ischemia provides an important substrate for the occurrence of potentially fatal ventricular arrhythmias. The presence of clinical heart failure further increases the risk of ventricular arrhythmia. The sympathetic nervous system provides an important trigger for major arrhythmic events, both through global overactivity and through regional heterogeneity of sympathetic activity. A mismatch of myocardial perfusion and innervation may pose a particularly great risk. Imaging modalities provide unique opportunities to investigate the anatomic and pathophysiologic substrates, as well as the triggering effects of cardiac sympathetic innervation. Combining imaging and electrophysiologic modalities offers promise for improved accuracy in future selection of patients with heart failure for ICD placement.

The Role of Vascular Imaging in Guiding Routine Percutaneous Coronary Interventions: A Meta‐Analysis of Bare Metal Stent and Drug‐Eluting Stent Trials

BACKGROUND The routine use of vascular imaging including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in guiding percutaneous coronary interventions (PCI) is still controversial especially when using drug-eluting stents. A meta-analysis of trials using bare metal stents was previously published. METHODS We conducted a meta-analysis of available published trials that compared imaging-guided PCI and angiography-guided PCI in patients undergoing routine PCI only. Trials that enrolled patients with acute coronary syndrome were excluded to decrease heterogeneity. We aimed to study both drug-eluting stents (DES) as well as bare metal stents (BMS). We identified seven randomized controlled trials on IVUS-guided bare metal stents. We also identified three randomized controlled trials on IVUS-guided drug-eluting stents. To improve the power of the drug-eluting stent data, we identified, and included, nine registries that compared IVUS-guided PCI to angiography-guided PCI in the drug-eluting stent era. Nonrandomized registries that included BMS only were excluded as there are multiple previous meta-analyses that studied these patients. Finally, we identified one registry that compared OCT-guided PCI to angiography-guided PCI using either a BMS or a DES. A total of 14,197 patients were studied overall. The meta-analysis was conducted using a random effect model. RESULTS Imaging guidance was associated with a significantly larger postintervention minimal luminal diameter (SMD: 0.289. 95% CI: 0.213-0.365. P < 0.01). Imaging-guided stenting was associated with a significant decrease in the major adverse cardiac events (MACE) in the DES patients (odds ratio: 0.810. 95% CI: 0.719-0.912. P < 0.01) and combined DES and BMS patients (odds ratio: 0.782. 95% CI: 0.686-0.890. P < 0.01). Imaging guidance was associated with significantly lower events of death from all causes in DES patients (odds ratio: 0.654. 95% CI: 0.468-0.916. P < 0.01) and in the combined DES and BMS patients (odds ratio: 0.727. 95% CI: 0.540-0.980. P < 0.01). The risk of myocardial infarction (MI) was significantly lower with imaging guidance in both, DES patients (odds ratio: 0.551. 95% CI: 0.363-0.837. P < 0.01) and combined DES and BMS patients (odds ratio: 0.589. 95% CI: 0.425-0.816. P < 0.01). This may, in part, be explained by the significantly lower risk of stent thrombosis in imaging-guided DES patients (odds ratio: 0.651. 95% CI: 0.499-0.850. P < 0.01) and combined DES and BMS patients (odds ratio: 0.665. 95% CI: 0.513-0.862. P < 0.01). Patients who received a DES showed no difference between imaging guidance and angiography guidance in repeated target lesion revascularization, while the analysis of BMS alone and the DES and BMS combined showed significant superiority of the imaging-guided PCI group. CONCLUSION Imaging-guided PCI significantly lowered the risk of death, MI, stent thrombosis, and the combined MACE in DES-implanted patients and all stented patients (DES or BMS). However, imaging guidance had no significant effect on repeated target vessel or target lesion revascularization in patients who received DES, likely due to the effect of the drug in the stent.

Profound regression of coronary atherosclerosis with statins.

A 60-year-old man was admitted to hospital because of chest pain. His only risk factor for coronary artery disease was hypercholesterolemia (cholesterol 7.64 mmol/L). Quantitative coronary angiography showed a 52% lesion in the proximal left anterior descending artery (Figure 1A). The patient was placed on acetylsalicylic acid and atorvastatin, and was followed up on a yearly basis with an exercise sestamibi nuclear scan, which was normal. A repeat coronary angiogram performed five years later for follow-up showed marked regression in the severity of the lesion in the proximal left anterior descending (15% stenosis by quantitative angiography) (Figure 1B). The patient’s cholesterol concentration decreased to 4.45 mmol/L. Figure 1 A Coronary angiography at baseline showing a 52% lesion in the proximal left anterior descending artery (LAD) (arrow). B Repeat angiogram after five years, with intensive statin therapy, showing significant regression of the LAD lesion (arrow) to 15% ... Statins have been proven to stabilize coronary atherosclerotic plaques and prevent coronary events in primary and secondary prevention clinical trials (1–3). Furthermore, Nissen et al (4) recently showed that intensive lipid-lowering therapy with atorvastatin reduces the progression of coronary atherosclerosis as assessed by intravascular ultrasound. These findings were extrapolated into clinical end points by Cannon et al (5), who showed that in patients recently hospitalized with an acute coronary syndrome, intensive lipid-lowering statin therapy reduces the incidence of future cardiac events. Our case report suggests that lipid-lowering therapy with statins can sometimes be associated with profound regression of coronary atherosclerosis.

A Phase Ib, Open Label, Single Arm Study to Assess the Safety, Pharmacokinetics, and Impact on Humoral Sensitization of SANGUINATE Infusion in Patients with End-Stage Renal Disease

The endeavor to study desensitization in kidney transplantation has not been matched by an effort to investigate strategies to prevent sensitization. In this study (NCT02437422), we investigated the safety, impact on sensitization, and pharmacokinetics of SANGUINATE (SG), a hemoglobin‐based oxygen carrier, as a potential alternative to packed red blood cells (PRBC) in transplant candidates with end‐stage renal disease (ESRD). Ten ESRD subjects meeting inclusion/exclusion (I/E) criteria were planned to receive three weekly infusions of SG (320 mg/kg). The study was stopped after five subjects were enrolled, and their data were analyzed after completing a follow‐up period of 90 days. Two subjects had elevated troponin I levels in setting of SG infusion, one of which was interpreted as a non‐ST elevation myocardial infarction. All other adverse events were transient. SG pharmacokinetic analysis showed mean (SD) Cmax, Tmax, AUC, and half‐life of 4.39 (0.69) mg/mL, 2.42 (0.91) hours, 171.86 (52.35) mg h/mL, and 40.60 (11.96) hours, respectively. None of the subjects developed new anti‐HLA antibodies following SG infusion and throughout the study period. In conclusion, SG is a potential alternative to PRBCs in ESRD patients considered for kidney transplantation as it was not associated with humoral sensitization. Larger studies in highly sensitized patients are required to further evaluate for potential safety signals.

THE ROLE OF VASCULAR IMAGING IN GUIDING PERCUTANEOUS CORONARY INTERVENTIONS: A META-ANALYSIS OF BARE METAL STENT AND DRUG-ELUTING STENT TRIALS

The role of the routine use of vascular imaging including intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) in guiding percutaneous coronary interventions (PCI) is still controversial. We conducted a meta-analysis of available trials that compared imaging-guided PCI and

A step forward in the use of SPECT imaging with I-123 MIBG

With the publication of the AdreView Myocardial Imaging for Risk Evaluation in Heart Failure Study (ADMIRE-HF), it has become clear that a simple ratio of heart-to-mediastinum (H/M) activity of I-123 metaiodobenzylguanidine (MIBG), on an anterior planar image is a strong predictor of cardiac prognosis in heart failure patients with a reduced left ventricular ejection fraction and New York Heart Association class II or III symptoms. The planar I-123 MIBG H/M ratio provides predictive information for outcome in heart failure patients beyond that available from clinical variables, left ventricular ejection fraction, and b-type natriuretic peptide. It remains unclear, however, whether further improvement in the prognostic information available from the planar I-123 MIBG H/M ratio can be provided through the use of single-photon emission computed tomography (SPECT). Previously, Chen et al. compared the accuracy of planar and SPECT imagings for noninvasive quantitation of I-123 MIBG activity in a cardiac phantom model. They noted that SPECT imaging with iterative reconstruction produced more accurate heart-to-calibration ratios than planar imaging. Cardiac SPECT imaging is usually performed with a low-energy, high-resolution (LEHR) collimator. In addition to its predominant 159 keV energy, I-123 has a low abundance, high-energy photon that penetrates the septa of a LEHR collimator, blurring the MIBG images, and impairing the accuracy of quantitative estimates. Those authors had previously reported that deconvolution of septal penetration (DSP) by those high-energy photons combined with iterative reconstruction yielded quantitative estimates of I-123 MIBG activity that were similar to measurements without septal penetration using a mediumenergy all-purpose collimator. This suggests that the combination of iterative reconstruction and DSP might substantially improve quantitation of I-123 MIBG activity in the heart in patient studies. These previous investigations notwithstanding, the I-123 MIBG H/M ratio from SPECT imaging has not entered into common use due to a lack of a standardized and practical method for calculation of the H/M ratio, as well as the technical challenges of calculating the H/M ratio in heart failure patients with very low uptake of the tracer into the myocardium. In their study, Chen et al. describe a new method for calculating the I-123 MIBG H/M ratio from SPECT images. The method was initially developed by comparing its ability to separate abnormal I-123 MIBG H/M ratios in 53 patients with coronary artery disease, prior myocardial infarction, and left ventricular ejection fraction B40%, from 14 normal volunteers with no history of heart disease. Three versions of the SPECT method (filtered back-projection, iterative reconstruction, and iterative reconstruction with DSP) plus a standard planar H/M method were then tested for their ability to separate 957 heart failure patients from 94 controls from the ADMIRE-HF study. Using receiver operator characteristics (ROC) analysis, the SPECT method with iterative reconstruction and the planar H/M ratio method provided comparable separation of heart failure patients from controls. A finding that was likely unexpected is that iterative reconstruction with DSP did not separate patients from controls as effectively as iterative reconstruction alone. Improved separation of I-123 MIBG activity in the heart from background and scattered activity results in larger values of the H/M ratio with the SPECT compared to planar methods. Merlet et al. provided an early report documenting the high risk for adverse cardiac events in patients with a planar H/M ratio less than 1.2. In the ADMIRE-HF study, a planar value of 1.6 was prospectively tested to separate high-risk from low-risk patients. The value of 1.6 represents two standard deviations below the mean planar H/M ratio in normal subjects as reported in the literature. In the present study, the optimal cut-off value for the planar H/M ratio for separating heart failure patients from controls in the validation cohort was 1.58, and the optimal H/M ratio using SPECT imaging with iterative reconstruction was 2.61. This difference likely represents less contamination of the heart region of interest from background From the Division of Cardiovascular Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH. Reprint requests: Myron C. Gerson, MD, Division of Cardiovascular Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, P.O. Box 670542, Cincinnati, OH 45267-0542; myron.gerson@uc.edu. J Nucl Cardiol 2012;19:16–8. 1071-3581/

Linear urticarial streaks associated with opioid administration.

34.00 Copyright 2011 American Society of Nuclear Cardiology. doi:10.1007/s12350-011-9495-4

The management of acute myocardial infarction in developing countries

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