Oluwaseyi Bolorunduro

Ivabradine: A Review of Labeled and Off-Label Uses

Ivabradine is a unique medication recently approved in the USA for the treatment of select heart failure patients. It was first approved for use in several countries around the world over a decade ago as an anti-anginal agent, with subsequent approval for use in heart failure patients. Since ivabradine has selective activity blocking the If currents in the sinus node, it can reduce heart rate without appreciable effects on blood pressure. Given this heart-rate-specific effect, it has been investigated in many off-label indications as an alternative to traditional heart-rate-reducing medications such as beta blockers and calcium channel blockers. We conducted searches of PubMed and Google Scholar for ivabradine, heart failure, HFrEF, HFpEF, angina, coronary artery disease, inappropriate sinus tachycardia, postural orthostatic hypotension, coronary computed tomography angiography and atrial fibrillation. We reviewed and included studies, case reports, and case series published between 1980 and June 2016 if they provided information relevant to the practicing clinician. In many cases, larger clinical trials are needed to solidify the benefit of ivabradine, although studies indicate benefit in most therapeutic areas explored to date. The purpose of this paper is to review the current labeled and off-label uses of ivabradine, with a focus on clinical trial data.

Simultaneous transcatheter aortic valve replacement and endovascular repair for critical aortic stenosis and large abdominal aortic aneurysm

A 75-year-old man with severe aortic stenosis, severe chronic obstructive pulmonary disease, NYHA class III heart failure and a large abdominal aortic aneurysm underwent concurrent transfemoral transcatheter aortic valve replacement (TF-TAVR) and endovascular aneurysm repair (EVAR). An Edwards Sapien device was implanted with resolution of hemodynamics. EVAR was performed using an Endurant bifurcated stent graft system. We describe the procedure technique, periprocedural management and one year outcome. To the authors best knowledge, this is the first case of simultaneous TF-TAVR and EVAR published in North America.

Racial Difference in Symptom Onset to Door Time in ST Elevation Myocardial Infarction

Background There are poorer outcomes following ST elevation myocardial infarction in blacks compared to white patients despite comparable door‐to‐reperfusion time. We hypothesized that delays to hospital presentation may be contributory. Methods and Results We conducted a retrospective analysis of the 1144 patients admitted for STEMI in our institution from 2008 to 2013. The door‐to‐balloon time (D2BT) and symptom‐onset‐to‐door time (SODT) were compared by race. Bivariate analysis was done comparing the median D2BT and SODT. Stratified analyses were done to evaluate the effect of race on D2BT and SODT, accounting for insurance status, age, sex and comorbidities. The mean age was 59±13 years; 56% of this population was black and 41% was white. Males accounted for 66% of this population. The median D2BT was 60 minutes (interquartile range [IQR] 42–82), and median SODT was 120 minutes (IQR 60–720). There was no significant difference in D2BT by race (P=0.86). Black patients presented to the emergency room (ER) later than whites (SODT=180 [IQR 60–1400] vs 120 [IQR 60–560] minutes, P<0.01) and were more likely to be uninsured (P<0.01). After controlling for comorbidities, insurance, and socioeconomic status, blacks were 60% more likely to present late after a STEMI (OR 1.6, P<0.01). A subset analysis excluding transferred patients showed similar results. Conclusions Black patients present later to the ER after STEMI with no difference in D2BT compared to whites. This difference in time to presentation may be one of the factors accounting for poor outcomes in this population.

Gaining a New Skill With the Risk of Losing One: The Effect of Radial Catheterization

The adoption of radial catheterization has been relatively slow in the United States. This study was conducted to assess the perceived comfort level of cardiology fellows with radial catheterizations and to predict the practice patterns in the United States in the near future. A 21-question survey on cardiology fellows preferred cardiac catheterization access site was conducted between April and June 2015. Data on access preference and perceived competency were analyzed based on the fellows level of training and type of training program (university vs community). A total of 101 responses were received from a total of 250 invitations; 85 (85%) of these respondents completed all questions. Data were collected from fellows of several programs nationwide. Of the 85 respondents with complete data, 22%, 29%, and 19% were first-, second-, and third-year interventional fellows respectively. Most respondents (82%) were from university-based programs, 46.3% of respondents considered that their programs provided a balance of both radial and femoral training. Irrespective of the training year, most fellows seemed to prefer radial over femoral access. Senior fellows appeared to be equally comfortable with a femoral access approach (P = 0.03). There was no difference by training site (university vs community programs) (P = 0.921). In 2015, US cardiology fellows appear to prefer radial over femoral access for cardiac catheterizations. Although it is good to see the shift toward better radial access skills, we need to stress the importance of the femoral skills that would be necessary to keep in the armamentarium of interventional cardiologists.

Resolution of complete heart block after revascularization of acute marginal branch of the right coronary artery

A patient presented with typical angina and a non-ST elevation myocardial infarction. Electrocardiogram showed complete heart block, and she was found to have a 90% acute marginal artery stenosis. The block resolved after balloon angioplasty of this artery that does not supply the atrioventricular node. We propose that increased vagal tone due to inferior wall ischemia from acute marginal artery stenosis has elicited the Bezold-Jarisch reflex. This is a likely mechanism for this uncommon etiology of complete heart block.

Diabetes is not associated with an increased peri-operative mortality or non-infectious morbidity following lower extremity arterial reconstruction

BACKGROUNDnThe aim of this study was to determine if, at a national level, diabetes mellitus is associated with worse perioperative outcomes after open lower extremity arterial reconstruction.nnnMETHODSnUsing Current Procedural Terminology codes, the National Surgical Quality Improvement Program database was queried to identify diabetic and nondiabetic patients who underwent open lower extremity arterial reconstruction from January 1, 2005, to December 31, 2007. These 2 groups were then compared using bivariate and multivariate analyses.nnnRESULTSnThere was no difference in mortality between the 2 groups (3.3% in diabetics and 3.5% in nondiabetics, P = .618). On multivariate analysis, there was no difference in the incidence of cardiac, pulmonary, or renal complications between the 2 groups. Diabetics, though, were more likely to develop infectious complications postoperatively.nnnCONCLUSIONSnAfter lower extremity arterial reconstruction, diabetes is not associated with an increased risk for mortality or an increased rate of major postoperative complications. Diabetics, however, have an increased rate of certain perioperative infections.

Case reportMissing grafts and the potential for inappropriate revascularizationFalta de enxertos e o potencial de uma revascularização inapropriada

The best outcome for coronary intervention in coronary artery bypass graft patients requires knowledge of prior coronary anatomy. This information is not always available as many cases present acutely, especially in ST-elevation myocardial infarction. We present three cases in which bypass grafts were documented as occluded but follow-up angiograms for other reasons revealed that the grafts were still patent. This presents the potential for inappropriate revascularizations.

Missing grafts and the potential for inappropriate revascularization

The best outcome for coronary intervention in coronary artery bypass graft patients requires knowledge of prior coronary anatomy. This information is not always available as many cases present acutely, especially in ST-elevation myocardial infarction. We present three cases in which bypass grafts were documented as occluded but follow-up angiograms for other reasons revealed that the grafts were still patent. This presents the potential for inappropriate revascularizations.

Impact of Pre-existing Kidney Dysfunction on Outcomes Following Transcatheter Aortic Valve Replacement

Background: Pre-existing chronic kidney disease (CKD) portends adverse outcomes following heart valve surgery. However, only limited and conflicting evidence is available on the impact of CKD on outcomes following transcatheter aortic valve replacement (TAVR). The objective of this review was to evaluate the effect of pre-existing CKD on TAVR outcomes. Methods: We performed a systematic electronic search using the PRISMA statement to identify all randomized controlled trials and observational studies investigating the effect of pre-existing CKD on outcomes following TAVR. 30-day and long-term outcomes were measured comparing patients with Glomerular filtration rate (GFR) ≥60 to those with GFR <60. Results: Ten studies were analyzed comprising of 8688 patients. Compared to patients with GFR ≥60, those with GFR < 60 had worse 30-day all cause mortality (OR 1.40, 95% CI: 1.13-1.73), cardiovascular mortality (OR 1.66, 95% CI: 1.04-2.67), strokes (OR 1.39, 95% CI: 1.05-1.85), acute kidney injury (OR 1.42, 95% CI: 1.21-1.66) and the risk for dialysis (OR 2.13, 95% CI: 1.07-4.22). There was no difference in device success (p=0.873), major or life threatening bleeds (p = 0.302), major vascular complications (p=0.525), need for pacemaker implantation (p = 0.393) or paravalvular leaks (p = 0.630). All-cause mortality at 1 year was also significantly higher in patients with GFR <60 (OR 1.80, 95% CI: 1.26-2.56). Conclusion: Pre-existing CKD defined as GFR <60 is a strong predictor of worse short and long-term outcomes following TAVR. Active measures should be taken to mitigate the postprocedure risk in these group of patients.

Disparities in Revascularization After ST Elevation Myocardial Infarction (STEMI) Before and After the 2002 IOM Report

OBJECTIVESnTo examine nationwide trends for racial disparities in Percutaneous Coronary Intervention after ST elevated Myocardial Infarction (STEMI).nnnBACKGROUNDnThe Institute of Medicine (IOM) report published in 2002 showed that African Americans were less likely to receive coronary revascularization such as CABG and stents even after controlling for socioeconomics. It recommended increased awareness of these disparities among health professionals to reduce this. We hypothesized that increased awareness of disparities since this report would have translated to reduction in racial disparities in percutaneous coronary intervention.nnnMETHODSnA retrospective analysis was conducted using data from the Agency of Healthcare Research and Qualitys (AHRQ) National Inpatient Sample (NIS) 1998-2007. All patients with STEMI during this period were identified. The proportion that received Percutaneous Coronary Intervention (PCI) during the incident admission was compared by different ethnicities over the time period. Multivariable regression for each year was conducted using Poisson regression with robust variances. The analysis controlled for gender, insurance status, co-morbidities, hospital bed size, location and teaching status.nnnRESULTSnBased on the database, about 2.04 million patients were managed for acute Myocardial Infarction from 1998 to 2007, of these 938,176 had STEMI. The primary PCI rate after STEMI among Caucasians was 29.1%, African Americans-23.3% and Hispanics-28.3% [Pxa0<xa00.001] On multivariate regression, compared to Caucasians, African Americans and Hispanics respectively were 26% (IRRxa0=xa00.74) and 16% (IRRxa0=xa00.84) less likely to receive PCI (both with Pxa0<xa00.001) during the entire study period.nnnCONCLUSIONnEthnic disparities in primary PCI after STEMI persist despite the 2002 IOM report.