Patrick Alexander

Subclinical and clinical contrast-induced acute kidney injury: data from a novel blood marker for determining the risk of developing contrast-induced nephropathy (ENCINO), a prospective study

Abstract Objective: Neutrophil gelatinase-associated lipocalin (NGAL) is produced in response to tubular injury. Contrast-induced acute kidney injury (CI-AKI) is associated with adverse outcomes in chronic kidney disease (CKD) patients. We sought to characterize blood NGAL level and the degree of kidney injury in CKD patients who underwent coronary angiography. Methods: This study was a prospective, blinded assessment of blood samples obtained from patients with estimated glomerular filtration rates (eGFRs) between 15 and 90 mL/min/1.73 m2 undergoing elective coronary angiography with iodinated contrast. Blood NGAL and serum creatinine were measured at baseline, 1, 2, 4, 6, 12, 24 and 48 h after contrast administration. Results: A total of 63 subjects with a mean eGFR of 48.17 ± 16.45 mL/min/1.73 m2 were enrolled. There was a graded increase in baseline NGAL levels across worsening stages of CKD (p = 0.0001). Post-procedure NGAL increased from baseline in each stage of CKD. Eight (12.7%) patients were diagnosed with CI-AKI by diagnostic criteria of 2012 KDIGO definition of CI-AKI, and seven (11.1%) patients developed subclinical CI-AKI defined by a twofold or greater rise in NGAL. There was no relationship between baseline eGFR and diabetes on the composite outcome of subclinical and clinical CI-AKI. Conclusions: Baseline and post-procedure NGAL are progressively elevated according to the baseline stage of CKD. Using a twofold rise in NGAL, 46.7% of composite CI-AKI is detected and complements the 53.3% of cases identified using KDIGO criteria. Traditional risk predictors were not independently associated with this composite outcome.

Cardiac Sarcoidosis Presenting as Constrictive Pericarditis

In patients with cardiac sarcoidosis, the sarcoid granulomas usually involve the myocardium or endocardium. The disease typically presents as heart failure with ventricular arrhythmias, conduction disturbances, or both. Constrictive pericarditis has rarely been described in patients with sarcoidosis: we found only 2 reports of this association. We report the case of a 57-year-old man who presented with clinical and hemodynamic features of constrictive pericarditis, of unclear cause. He was admitted for treatment of recurrent pleural effusion. After a complicated hospital course, he underwent pericardiectomy. His clinical and hemodynamic conditions improved substantially, and he was discharged from the hospital in good condition. The pathologic findings, the patients clinical course, and his response to pericardiectomy led to our diagnosis of cardiac sarcoidosis presenting as constrictive pericarditis. In addition to the patients case, we discuss the nature and diagnostic challenges of cardiac sarcoidosis. Increased awareness of this disease is necessary for its early detection, appropriate management, and potential cure.

Unloading of Right Ventricle and Clinical Improvement after Ultrasound-Accelerated Thrombolysis in Patients with Submassive Pulmonary Embolism

Acute pulmonary embolism (PE) can be devastating. It is classified into three categories based on clinical scenario, elevated biomarkers, radiographic or echocardiographic features of right ventricular strain, and hemodynamic instability. Submassive PE is diagnosed when a patient has elevated biomarkers, CT-scan, or echocardiogram showing right ventricular strain and no signs of hemodynamic compromise. Thromboemboli in the acute setting increase pulmonary vascular resistance by obstruction and vasoconstriction, resulting in pulmonary hypertension. This, further, deteriorates symptoms and hemodynamic status. Studies have shown that elevated biomarkers and right ventricular (RV) dysfunction have been associated with increased risk of mortality. Therefore, aggressive treatment is necessary to “unload” right ventricle. The treatment of submassive PE with thrombolysis is controversial, though recent data have favored thrombolysis over conventional anticoagulants in acute setting. The most feared complication of systemic thrombolysis is intracranial or major bleeding. To circumvent this problem, a newer and safer approach is sought. Ultrasound-accelerated thrombolysis is a relatively newer and safer approach that requires local administration of thrombolytic agents. Herein, we report a case series of five patients who underwent ultrasound-accelerated thrombolysis with notable improvement in symptoms and right ventricular function.

Register and Roll: A Novel Initiative to Improve First Door-to-Balloon Time in ST Elevation Myocardial Infarction.

Objective. We examined the cause of transfer delay in patients with an acute ST-segment myocardial infarction (STEMI) from non percutaneous coronary intervention (PCI) capable to PCI capable hospitals. We then implemented a novel, simple, and reliable initiative to improve the transfer process. Background. Guidelines established by the ACC/AHA call for door-to-balloon times of ≤90 minutes for patients with STEMI. When hospital transfer is necessary, this is only met in 8.6% of cases. Methods. All patients presenting with STEMI to a non-PCI capable hospital from April 2006 to February 2009 were analyzed retrospectively. After identifying causes of transfer delay the “Register and Roll” initiative was developed. An analysis of effect was conducted from March 2009 to July 2011. Results. 144 patients were included, 74 pre-initiative and 70 post- initiative. Time to EMS activation was a major delay in patient transfer. After implementation, the EMS activation time has significantly decreased and time to reperfusion approaches recommended goal (Median 114 min versus 90 min, P < 0.001), with 55% in <90 minutes. Conclusion. “Register and Roll” streamlines the triage process and improves hospital transfer times. This initiative is easily instituted and reliable in a community hospital setting where resources are limited.

Erythropoietin Levels in Cardiac Resynchronization Patients

Cardiac resynchronization therapy (CRT) is indicated in patients with advanced heart failure secondary to severe systolic impairment and refractory symptoms despite optimized medical treatment and evidence of electro- mechanical dyssynchrony with a QRS complex greater than 120 milliseconds (msec). Approximately 20%-30% of patients who receive CRT fail to respond with little improvement in subjective symptoms, functional capacity, and left ventricular indices. To date, there fails to be a serologic marker to adequately assess the degree of ventricular dyssynchrony and electro-mechanical dissociation. Increased levels of erythropoietin (EPO), a hematopoietic cytokine, has been demonstrated in patients with more advanced stages of heart failure and is associated with an increase in mortality and hospital re-admission. A recent study demonstrated a significant response to CRT in patients with higher baseline EPO levels (> 25mU/mL) with improvements in cardiac function and reduced heart failure symptoms. The presence of elevated EPO levels in addition to traditional determinants of cardiac dyssynchrony may effectively predict those that will benefit from CRT. LETTER TO THE EDITOR Cardiac resynchronization therapy (CRT) is indicated in patients with advanced heart failure secondary to severe systolic impairment and refractory symptoms despite optimized medical treatment and evidence of electro- mechanical dyssynchrony with an ECG QRS complex greater than 120 msec. Simultaneous pacing of both the right and left ventricle (BiV pacing) has been shown to restore electro-mechanical synchrony, improve overall cardiac function, reduce hospitalizations, and confer a mortality benefit (1). Despite the cardiovascular benefits of BiV pacing demonstrated in recent trials, approximately 20%- 30% of patients who receive CRT fail to respond with little improvement in subjective symptoms, functional capacity, and left ventricular functional indices (2). Absence of electro-mechanical dyssynchrony despite prolonged QRS duration (>120ms), pre-existing right bundle branch block (RBBB), inappropriate lead placement and continued disease progression have been shown as causes for non-response to CRT. To date, there fails to be a serologic marker to adequately assess the degree of ventricular dyssynchrony and electro-mechanical dissociation. Erythropoietin (EPO), a hematopoietic cytokine, has traditionally been associated with erythropoiesis in response to anemic stress. Several studies have indicated the positive effects of EPO treatment in heart failure patients with concomitant anemia resulting in reductions in hospital re- admission, improved cardiac and renal function, as well as

Large vegetation associated with implantable cardioverter‐defibrillator lead

A 79‐year‐old‐male presented with a 2‐month history of recurrent septic shock and bacteremia. His history is relevant for hypertension and ischemic cardiomyopathy with an ejection fraction of 20%, with an implantable cardioverter‐defibrillator (ICD) placement one month prior to presentation. A transesophageal echocardiogram (TEE) was performed due to persistent S. Aureus bacteremia despite antimicrobial therapy, demonstrating an attached vegetation to the ICD lead (Figure Figure 1). The patient underwent successful surgical extraction of intracardiac leads, and his condition improved and has remained afebrile with negative blood cultures. Figure 1 Transesophageal echocardiogram demonstrating 1.5×1.3 cm vegetation attached to the ICD lead (arrow). RA, right atrium. LA, left atrium. ICD related endocarditis is an uncommon but serious complication. Incidence rate ranging from 0.5–0.8% and mortality rates close to 35% have been reported 1, 2, with a projected increase in incidence secondary to the expanded indications for ICD use in sudden death prevention. High clinical suspicion in this patient results in a prompt diagnosis considering the intracardiac leads a foreign body equivalent to prosthetic valves. TEE is the preferred method of evaluation with reported sensitivity around 95% 3. Surgical extraction is favored over conservative therapy with demonstrated decrease in mortality rates 2. Percutaneous retrieval of devices is associated with a high risk of dislodgment and embolization of vegetation and, therefore, is not routinely recommended 2.