Naveen Rajpurohit

Effectiveness of Percutaneous Coronary Intervention With Drug-Eluting Stents Compared With Bypass Surgery in Diabetics With Multivessel Coronary Disease: Comprehensive Systematic Review and Meta-analysis of Randomized Clinical Data

Background Controversy persists regarding the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD). Coronary artery bypass grafting (CABG) has been compared with percutaneous coronary intervention (PCI) using drug‐eluting stents (DES) in recent randomized controlled trials (RCTs). Methods and Results RCTs comparing PCI with DES versus CABG in diabetic patients with MVD who met inclusion criteria were analyzed (protocol registration No. CRD42013003693). Primary end point (major adverse cardiac events) was a composite of death, myocardial infarction, and stroke at a mean follow‐up of 4 years. Analyses were performed for each outcome by using risk ratio (RR) by fixed‐ and random‐effects models. Four RCTS with 3052 patients met inclusion criteria (1539 PCI versus 1513 CABG). Incidence of major adverse cardiac events was 22.5% for PCI and 16.8% for CABG (RR 1.34, 95% CI 1.16 to 1.54, P<0.0001). Similar results were obtained for death (14% versus 9.7%, RR 1.51, 95% CI 1.09 to 2.10, P=0.01), and MI (10.3% versus 5.9%, RR 1.44, 95% CI 0.79 to 2.6, P=0.23). Stroke risk was significantly lower with DES (2.3% versus 3.8%, RR 0.59, 95% CI 0.39 to 0.90, P=0.01) and subsequent revascularization was several‐fold higher (17.4% versus 8.0%, RR 1.85, 95% CI 1.0 to 3.40, P=0.05). Conclusions These data demonstrate that CABG in diabetic patients with MVD at low to intermediate surgical risk (defined as EUROSCORE <5) is superior to MVD PCI with DES. CABG decreased overall death, nonfatal myocardial infarction, and repeat revascularization at the expense of an increase in stroke risk.

Chronic Inflammation and Coronary Atherosclerosis in Patients with End-Stage Renal Disease

The key role of chronic inflammation in the pathogenesis of atherosclerosis has become increasingly apparent in recent years based on the results of experimental, epidemiologic and clinical studies. Coronary artery disease and its complications occur with disproportionately high frequency in patients with end-stage renal disease (ESRD) and contribute substantially to cardiovascular morbidity and mortality in this population. Traditional cardiovascular risk factors occur commonly in patients with ESRD. In addition, a variety of patient-related and dialysis-related factors unique to ESRD predispose to chronic inflammation and by doing so are thought to contribute to coronary atherosclerosis and its complications. These risk factors may serve as therapeutic targets and as such may offer the potential for altering the natural history of coronary atherosclerosis in ESRD.

Relation of Activated Clotting Times During Percutaneous Coronary Intervention to Outcomes.

Monitoring anticoagulation using the activated clotting time (ACT) in patients treated with heparin and undergoing percutaneous coronary intervention (PCI) is one of the most frequently used tests in invasive cardiology. However, despite its widespread use and guideline endorsement, uncertainty remains regarding the association of ACT with outcomes in contemporary practice. We reviewed all PCI procedures performed at the Mayo Clinic (Rochester, Minnesota) from October 2001 to December 2012 and evaluated the association between the ACT before device activation and in-hospital and 1-year outcomes. ACT values were grouped into tertiles for descriptive purposes and analyzed as a continuous variable for assessment of outcomes. We used logistic and Cox proportional hazards regression models to estimate the association of ACT and outcomes. Of the 12,055 patients who underwent PCI with an ACT value before device activation, 3,977 (33.0%) had an ACT <227, 4,046 (33.6%) had an ACT 227 to 285, and 4,032 (33.4%) had an ACT >285. Baseline and procedural characteristics were similar across ACT tertiles. In unadjusted analysis, higher ACT values were associated with death (p <0.001), bleeding (p = 0.024), procedural complication (p <0.001), and higher 1-year events (cardiac death, p <0.001; cardiac death/myocardial infarction, p = 0.022). After multivariable adjustment for baseline and procedural characteristics, ACT was not independently associated with in-hospital or 1-year ischemic, thrombotic, or bleeding outcomes. In conclusion, ACT values before device activation are not independently associated with clinically important outcomes in contemporary PCI practice.

Global and regional extracellular volume and myocardial circumferential strain correlate significantly in a heterogeneous patient population

Background Myocardial extracellular volume (ECV) quantification by cardiovascular magnetic resonance (CMR) T1 mapping technique has shown great promises in detecting diffuse fibrosis and interstitial diseases of the myocardium. In hypertensive and left ventricle hypertrophy (LVH) patients, increased ECV has been found to be associated with impaired myocardial strain, which is an early indicator of cardiac dysfunction. We hypothesized that in a heterogeneous patient population, ECV was significantly associated with myocardial strain, on the global and the more localized segmental bases.

Comparison of noninvasive three dimensional delayed enhancement MRI of left atrial scar with invasive voltage map by using robust 4D point-to-point registration in patients with atrial fibrillation

Background Left Atrial scar imaging using delayed enhancement MRI (DE-MRI) has been proposed as a promising tool to guide ablation strategies in patients with atrial fibrillation (AF). Studies have shown that the scar areas detected by DE-MRI correlate with the low voltage areas on the co-registered electroanatomic voltage map based on surface matching. However, such matching methods did not consider the misalignment of the scar areas: a point-to-point comparison between DE-MRI and voltage map remains problematic. In this study, we proposed a robust 4D (3D of geometry and 1D of scar degree) registration algorithm for the point-to-point comparison of DE-MRI and voltage map. Based on the registered images, we hypothesized that by utilizing complex image information extracted from DE-MRI, we were able to predict the low voltage areas in the coregistered voltage maps.

Large Aortic Necrotizing Granuloma: A Rare Manifestation of Mycobacterial Infection

We report a rare case of an 80-year-old man with an ascending aortic mass that was found to be a necrotizing granuloma secondary to disseminated atypical mycobacteria. He presented with a 3to 4-week history of fevers, aches, nights sweats, and a 10-pound weight loss. Computed tomography of the chest showed an ascending aortic mass (Fig 1, red arrow). Intraoperative transesophageal echocardiography showed a large freely mobile pedunculated mass on the anterior surface of the aorta close to the sinotubular junction (Fig 2, blue arrow). The patient underwent successful aortic mass excision. A 3 3 cm friable pedunculated mass on the anterior surface of the aorta with a stalk about 4 mm thick attached to the sinotubular junction was excised (Fig 3). In addition to the aortic mass, the patient was also found

Clopidogrel hydrogen sulphate for atrial fibrillation.

Introduction: Atrial fibrillation is a common cardiac rhythm abnormality with a considerable cardiovascular disease burden worldwide. It is an independent major risk factor for stroke. Stroke prevention with anticoagulation or antiplatelet agents has been an important area of clinical research. Warfarin is the most widely used antithrombotic therapy for stroke prophylaxis for last several years, and now dabigatran (150 mg b.i.d.) is more effective than warfarin in stroke prevention in individuals at increased of stroke. In addition, several studies have evaluated the efficacy of clopidogrel for stroke prophylaxis either alone or in combination with aspirin. Areas covered: This review summarizes the key findings of the trials looking at the efficacy of clopidogrel in stroke prevention. A literature search was performed using PubMed and Google Scholar. The trials that evaluated the efficacy of clopidogrel in preventing atherothrombotic events or stroke were also included. Expert opinion: Clopidogrel prevents more vascular events, including stroke, in patients with a recent myocardial infarction, stroke or peripheral vascular disease than aspirin. Combination of clopidogrel and aspirin provides a greater reduction of stroke than aspirin or clopidogrel monotherapy, but at an increased risk of bleeding. Dual antiplatelet therapy (clopidogrel and aspirin) is inferior to warfarin in primary stroke prevention for patient with atrial fibrillation and thus should be considered for stroke prophylaxis only in patients ineligible for warfarin. However, with the advent of newer agents, like direct thrombin inhibitors and Factor Xa inhibitors, the role of antiplatelet therapy for stroke prevention in atrial fibrillation remains unclear.