Obiora Maludum

Effects of Staged Versus Adhoc Percutaneous Coronary Interventions on Renal Function—Is There a Benefit to Staging?.

AIM The purpose of this study is to determine whether ad hoc (same session) percutaneous coronary intervention, and staged (multiple session) percutaneous coronary intervention (PCI) have different renal outcomes. METHODS AND RESULTS This is a retrospective cohort study that compares the maximal decline in glomerular filtration rate (GFR) at various times points (3-6days, 1-4weeks, 4-12weeks) after either ad hoc or staged PCI. 115 patients undergoing staged PCI and 115 matched ad hoc PCI controls were included in the study. They were equivalent in baseline GFR, left ventricular ejection fraction and intra-procedural volume status based on LVEDP. The group undergoing staged PCI had greater cumulative fluoroscopy time, SYNTAX score and number of stents placed. Staged PCIs used less contrast per catheterization (155.0±5.6mL) but higher cumulative contrast dose (326.6±14.0mL) compared to ad hoc PCIs (193.4±7.2mL). Following intervention, there was a progressive decline in renal function that did not significantly differ between the ad hoc and staged groups. In the subgroup of patients with initial GFR ≤60cm3/min, staged PCI was associated with 2.6-fold greater decline in renal function 4-12weeks after the procedure compared to ad hoc. A propensity match analysis performed in patients with GFR ≤60cm3/min confirmed worse renal function in the staged group at 4-12weeks. CONCLUSIONS Staged PCI exposes patients to greater cumulative contrast agent loads. The decline in renal function observed in both groups did not differ significantly, however worse renal outcomes were observed in the staged PCI group with baseline GFR ≤60cm3/min.

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

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.

QRS duration and left ventricular ejection fraction (LVEF) in non-ST segment elevation myocardial infarction (NSTEMI).

BACKGROUND Non-traditional EKG parameters such as QRS pattern and QRS duration (QRSd) are being investigated in acute coronary syndrome as prognostic markers. Following an infarction, the heart attempts to compensate for myocardial loss through remodeling which eventually lowers the ejection fraction (LVEF). Our objective is to evaluate the relationship between the QRSd at the time of NSTEMI and extent of coronary artery disease (CAD) and changes in LVEF. METHODS AND RESULTS Patients admitted with NSTEMI between 08/01/2006 and 9/30/2012 were included. Patients were classified into high or low QRSd at cutoff value of 90ms noted on initial EKG after excluding bundle-branch block. A total of 536 patients with mean age of 66±14years were included. 49% were male and majority were African American (73%). Patients within the higher QRSd group had a lower LVEF at the time of the NSTEMI compared to those with QRSd <90ms (47±15% vs. 50±13%; p<0.038). The LVEF remained lower in the high QRS group on follow up to 12months (47±15% vs. 52±11%; p<0.001). The high QRSd group had a higher incidence of severe LV dysfunction at baseline (27% vs. 18%; p<0.045). Logistic regression analysis revealed that a QRSd ≥90ms was also independently associated with a severely reduced LVEF on follow-up (OR=2.7; CI 1.55-4.69; p<0.001). CONCLUSION QRSd ≥90ms at the time of NSTEMI is predictive of three-vessel/left main coronary artery involvement and a lower LVEF. This depression in LVEF is maintained for up to 12months. Thus, the QRSd at time of NSTEMI has additional prognostic significance.

Trans-Catheter Aortic Valve Replacement Thrombus in Patient on Xarelto and Aspirin Resolved Three Months After Warfarin

Trans-catheter aortic valve replacement has been gaining ground since it was performed in 2002. Indications for the procedure are also expanding and are expected to include patients with intermediate risk for perioperative mortality. There are no guidelines on the use of anticoagulation in patients who have undergone trans-catheter aortic valve replacement. We present an interesting case of an 82-year-old gentleman with past medical history of paroxysmal atrial fibrillation with CHA2DS2-VASc (a clinical prediction tool for estimating risk of stroke in patients with atrial fibrillation) score of 3, coronary artery disease, pernicious anemia, and severe symptomatic aortic stenosis who had trans-catheter aortic valve replacement. He was on Xarelto and aspirin, and still developed thrombus on the aortic valve many months after the procedure. The thrombus resolved after few months of anti-coagulation with Coumadin. This case shows that thrombus on the valve can still occur post-procedure even in patients who are on direct oral anticoagulant and aspirin. This calls into question if there is need to anti-coagulate all patients after TAVR procedure with Coumadin for at least 3 - 6 months. As our knowledge of the post-TAVR complications and outcomes continues to grow, we may be able to answer this question in the future, especially with large scale research studies. J Med Cases. 2018;9(8):278-280 doi: https://doi.org/10.14740/jmc3084w

An Unusual Case of Constrictive Pericarditis in a Young Patient With Childhood History of Successfully Treated Kawasaki Disease

Kawasaki disease, also known as mucocutaneous lymph node syndrome, is a disease in which blood vessels in the body become inflamed. It occurs usually in childhood and one of the well-known cardiac complications is coronary artery aneurysm which occurs usually after 1 - 2 years. Constrictive pericarditis is not a known sequela of Kawasaki disease. We present a case of a 21-year-old white male referred to the emergency department by his gastroenterologist after an outpatient abdominal ultrasound obtained for elevated liver enzymes revealed ascites and bilateral pleural effusion. He has background history of Kawasaki disease at the age of 8 years that was treated with aspirin and intravenous immunoglobulin (IVIG) without any cardiac complications based on echocardiogram obtained after treatment. Autoimmune screen was negative. He had echocardiogram which revealed evidence of constrictive pericarditis. J Med Cases. 2018;9(7):211-214 doi: https://doi.org/10.14740/jmc3071w

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

Appropriate triage of patients with chest pain can be challenging. HEART score was proposed by Six et al in Netherlands to facilitate quick triage in emergency room. It is not validated in US. This pilot study was initiated to determine utility of HEART score in patients presenting with chest pain

STAGED AND SINGLE PERCUTANEOUS CORONARY INTERVENTIONS ARE EQUIVALENT IN RENAL OUTCOMES

While there is no survival benefit, staged PCI is often chosen over single PCI to minimize renal damage in high-risk patients. To date, there is no study that examines the renal impact of each procedure. Patients undergoing staged PCI at Einstein Hospital between 2012 and 2014 were matched by age,

QRS DURATION AND LEFT VENTRICULAR EJECTION FRACTION IN NON ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Non-traditional EKG parameters as pattern of QRS or its duration (QRSd) have been investigated in acute coronary syndrome. Following an infarction, the heart attempts to compensate for myocardial loss through remodeling which alters the ejection fraction over time. Our objective is to evaluate the