Neha Yadav

Reporting nuclear cardiology studies: Is the cup half-full or half-empty?

In this issue of the journal, Maddux et al. present their findings on improved compliance with reporting guidelines in U.S. nuclear cardiology laboratories seeking accreditation from the Intersocietal Accreditation Commission (IAC). The nuclear cardiology report is studded with a wealth of clinical, exercise, safety, physiologic, hemodynamic, electrocardiographic, and perfusion data that not only yield diagnostic and prognostic implications, but also guide decision-making. For the past 15 years, the American Society of Nuclear Cardiology (ASNC) has spearheaded the movement to elevate the nuclear cardiology report to a standardized, all-encompassing document that contains essential elements needed for timely clinical decision-making. The 2009 ASNC standardized reporting guidelines serve as a framework for accreditation agencies to establish reporting standards for nuclear laboratories seeking accreditation. Over the past decade, physician-leaders, inter-disciplinary societies as well as healthcare organizations have spent considerable energy and resources to educate care teams and laboratories on best practices in nuclear cardiology, including ‘‘habit-building’’ exercises in issuing comprehensive, intelligible clinical reports. Tilkemeier et al. reported a high degree of noncompliance with the IAC standards among nuclear cardiology laboratories applying for accreditation in 2008. They also determined that feedback from prior accreditation applications improves compliance with reporting standards on subsequent reaccreditation cycles. In this study, Maddux et al. retrospectively compared adherence to reporting guidelines between the years 2008 and 2014 among over 1800 laboratories that applied for IAC accreditation or reaccreditation in those calendar years.

Rare Cause of Late Recurrent Angina following Coronary Artery Bypass Grafting: Iatrogenic Aortocoronary Arteriovenous Fistula Causing Coronary Steal

Iatrogenic aortocoronary arteriovenous fistula is a very rare complication of coronary artery bypass grafting in which one of the arterial grafts inadvertently forms a fistulous tract with a cardiac vein, shunting blood from the anastomosed coronary artery. We report a patient with an iatrogenic left internal mammary artery graft to cardiac vein fistula presenting with recurrent angina three years after a three-vessel coronary artery bypass grafting.

Statins and incidence of contrast-induced acute kidney injury following coronary angiography - Five year experience at a tertiary care center

BACKGROUND Role of statins in prevention of contrast-induced acute kidney injury (CI-AKI) in patients undergoing coronary angiography remains controversial. We studied the use of statins in decreasing CI-AKI following coronary angiography. METHODS We reviewed all patients who underwent coronary angiography with or without PCI and had a follow-up creatinine from January 2012 to December 2016 at a single tertiary care center in the United States. CI-AKI was defined as 0.3 mg/dL absolute rise in creatinine. Patients who were on moderate to high-intensity statins or received moderate to high-intensity statins prior to coronary angiography were included in the statin group. Crude and adjusted odds ratios (AOR) were calculated using univariate multiple logistic regression analysis. RESULTS Out of 2055 patients (females = 30.7%, mean age 58.0 ± 12.5 years, statin group = 886, non-statin group = 1169), 293 (14.3%) developed CI-AKI. Mean estimated glomerular filtration rate (eGFR) was not significantly different between the statin and the non-statin group (86.5 mL/min/1.73 m2 vs 87.1 mL/min/1.73 m2, p = 0.65). There was no significant difference in the incidence of CI-AKI between statin and non-statin group (14.4% vs 14.1%, p = 0.83). When adjusted for other risk factors, statin use was not significantly associated with decreased risk of CI-AKI (AOR) = 0.8, [95% confidence interval (CI) = 0.6-1.1, p = 0.19]. Results remained statistically non-significant on subgroup analysis of patients with acute coronary syndrome (ACS) (OR = 0.8, 95% CI = 0.6-1.2, p = 0.27), patients who had percutaneous coronary intervention (PCI) (OR = 1.1, 95% CI = 0.6-1.7, p = 0.81) and patients with eGFR < 60 mL/min/1.73 m2 (OR = 0.9, 95% CI = 0.6-1.5, p = 0.9). CONCLUSION Statin use prior to coronary angiography is not associated with decreased incidence of CI-AKI.

Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction

ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2 = 14.2%; p = 0.099); however, PIT significantly decreased short-term mortality (OR = 1.46 [1.08 to 1.96]; I2 = 0%; p = 0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (OR = 0.69 [0.49 to 0.97]; I2 = 0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (OR = 1.48 [1.13 to 1.94]; I2 = 0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.

Meta-Analysis Evaluating the Effect of Left Coronary Dominance on Outcomes After Percutaneous Coronary Intervention

Prognostic significance of coronary circulation dominance remains controversial. The primary objective of this meta-analysis was to pool all the available evidence to assess the influence of left coronary dominance (LD) on outcomes in patients who underwent percutaneous coronary intervention (PCI). MEDLINE, Cochrane CENTRAL, and Scopus databases were searched for all observational studies and randomized controlled trials that investigated the association between coronary dominance and outcomes in patients who underwent PCI. Odds ratios (OR) and 95% confidence intervals from individual studies were pooled using a random effects model. A total of nine studies including 266,119 patients were included. On pooled analysis, it was noted that LD was associated with significantly increased odds of in-hospital (OR: 1.54 [1.12, 2.11]; p = 0.007), 30-day (OR: 2.16 [1.22, 3.84]; p = 0.008), and long-term mortality (OR: 1.83 [1.33 to 2.50]; p < 0.001). LD patients also experienced a significantly higher incidence of major adverse cardiac events (OR: 1.27 [1.03, 1.58]; p = 0.03) and failed PCI (OR: 1.30 [1.03, 1.65]; p = 0.03). In contrast, no significant difference was noted between LD and non-LD patients in the incidence of stent thrombosis (OR: 1.28 [0.55, 3.01]; p = 0.57; I2 = 0%) or reinfarction (OR: 1.73 [0.90, 3.35]; p = 0.10; I2 = 63%). In conclusion, this meta-analysis suggests that patients with LD coronary anatomy are at significantly increased risk for mortality after PCI compared with patients with a non-LD anatomy.

Congenital Absence of Left Circumflex Artery: A Case Report and Review of the Literature

Congenital absence of the left circumflex artery is a rare coronary anomaly with few reported cases in the literature. These patients are usually diagnosed incidentally when they undergo coronary angiography or coronary CT to rule out underlying coronary artery disease. In this article, we report a case of a 46-year-old man who was incidentally found to have a congenitally absent left circumflex artery with a superdominant right coronary artery after a workup was initiated for frequent premature ventricular contractions and regional wall motion on echocardiogram. A review of the clinical presentation, symptoms, and diagnostic modalities used to diagnose this entity is presented.