Prasad Gunasekaran

Left ventricular hypertrophy and risk reclassification for coronary events in multi-ethnic adults

Background Left ventricular hypertrophy (LVH) has not been evaluated for reclassification improvement in the intermediate Framingham risk category for incident hard coronary events in a large multi ethnic population free of cardiovascular disease at baseline. Design A post-hoc analysis on the Multi Ethnic Study of Atherosclerosis (MESA) dataset (n = 4921) was performed. Methods LVH was defined as the upper 95 th percentile of cardiac magnetic resonance imaging derived left ventricular mass (LVM) indexed based on body surface area (BSA) and height. Multivariate Cox proportional hazards models were used to assess the independent association between LVH and composite outcomes like all cardiovascular disease (CVDa) and hard coronary heart disease (CHDh) events over a mean follow-up period of 4.5 years. To assess the incremental value of LVH over traditional CV risk factors for CHDh prediction, we compared the discrimination, calibration and net reclassification index (NRI) of models comprising of traditional CV risk factors with and without LVH. Results LVH derived from LVM indexed by BSA (LVH-BSA) and height1.7(LVH-height) showed an independent association with CVDa (LVH-BSA: hazard ratio (HR) 1.52, 95% confidence interval (CI) 1.05–2.20, p = 0.03; LVH-height1.7: HR 1.58, 95% CI 1.14–2.18, p = 0.012) and CHDh (LVH-BSA: HR 2.36, 95% CI 1.37–4.04, p = 0.002; LVH-height1.7: HR: 1.95, 95% CI: 1.17–3.26, p = 0.01). Addition of LVH to the model based on traditional CV risk factors demonstrated no significant improvement in NRI for CHDh in either the entire cohort (LVH-BSA: NRI 1.7%, 95% CI: –8.3% to 11.7%, p = 0.74; LVH-height1.7: NRI 2.7%, 95% CI: –5.8% to 11.3%, p = 0.62) or the intermediate risk group (LVH-BSA: NRI 12.0%, 95% CI: –5.7% to 29.8%, p = 0.19; LVH-height1.7: NRI 14.5%, 0.1% to 28.8%, p = 0.05). Conclusions Although an independent predictor of cardiovascular events, LVH does not lead to clinically meaningful reclassification of the overall and intermediate risk population for CHDh.

Periprocedural Management of Non-Vitamin K Oral Anticoagulants in Chronic Kidney Disease: A Review of Existing Heterogeneity and Contemporary Evidence

Non vitamin-K oral anticoagulants (NOAC) have considerably enhanced anticoagulation practice for non-valvular atrial fibrillation with specific advantages of fixed dosing, non-fluctuant therapeutic levels and obviation of therapeutic level monitoring. NOAC pharmacology is remarkable for considerable renal excretion. Heterogeneity in the precise time cut-offs for discontinuation of NOACs prior to elective surgical or percutaneous procedures arise from the non-linear variations of drug excretion with different levels of creatinine clearances as in chronic kidney disease. Multiple authors have suggested cut-offs leading to ambiguity among practicing clinicians. Recent data pertaining to systemic thromboembolism, stroke and major bleeding derived from randomized controlled clinical trials have simplified the periprocedural management of NOACs. This review focusses on heterogeneity in the management of NOACs in patients with CKD in this peculiar scenario and highlights the contemporary evidence to support a unified approach towards perioperative management of NOACs. Multiple antidotes targeted towards binding of specific NOACs have been developed and are in the testing phase, thereby offering immense potential for rapid and complete reversal of NOAC activity in emergent procedures and major bleeding episodes. Targeted research on thromboembolism, stroke and major bleeding following temporary periprocedural interruption of NOACs using multicentric registries could further expand the clinical utility of these agents.

Incremental Value of Two Dimensional Speckle Tracking Echocardiography in the Functional Assessment and Characterization of Subclinical Left Ventricular Dysfunction

Subclinical left ventricular (LV) dysfunction refers to subtle abnormalities in LV function which typically precede a reduction in the left ventricular ejection fraction (LVEF). The assessment of myocardial function using LVEF, a radial metric of systolic function, is subject to load dependence, intra-observer and inter-observer variability. Reductions in LVEF typically manifest late in the disease process thus compromising the ability to intervene before irreversible impairment of systolic perfor-mance sets in. 2-Dimensional speckle tracking echocardiography (2D-STE), a novel strain imaging modality has shown promise as a sensitive indicator of myocardial contractility. It arms the clinician with a powerful and practical tool to rapidly quantify cardiac mechanics, circumventing several inherent limitations of conventional echocardiography. This article highlights the incremental utility of 2D-STE in the detection of subclinical LV dysfunction.

Association of Helicobacter pylori seropositivity with all-cause mortality: fact or fiction?

We read the article by Chen et al with great interest and would like to congratulate them on their findings. Their analysis of the data from the National Health and Nutrition Examination Survey (NHANES III) have shown a lack of association between Helicobacter pylori seropositivity and all-cause mortality in patients more than 40 years of age.1 As there is an existing controversy2–4 in this area, evaluation of other large databases is clinically relevant, particularly if the analyses provides congruent data as in this instance, replicating findings that help consolidate the evidence base in the literature. The …

INDEPENDENT ASSOCIATION OF SYMPTOMATIC PERIPHERAL ARTERIAL DISEASE FOR ADVERSE OUTCOMES, POOR GRAFT SURVIVAL AND LENGTH OF HOSPITAL STAY FOLLOWING HEART TRANSPLANTATION: AN ANALYSIS OF 22,820 HEART TRANSPLANTS FROM THE UNOS DATABASE

Background: Peripheral arterial disease (PAD) is a risk factor for increased long term mortality following heart transplantation (HT). However, data on the incidence of adverse events, length of hospitalization immediately following HT and long term graft survival time in patients with PAD is

THE IMPACT OF TRANSAORTIC GRADIENT AND TRANSAORTIC FLOW ON THE DISCREPANCY BETWEEN ECHOCARDIOGRAPHIC AND CARDIAC CATHETERIZATION EVALUATION OF SEVERE AORTIC STENOSIS WITH PRESERVED EJECTION FRACTION

Background: Current guidelines discourage aortic stenosis (AS) evaluation by direct pressure measurement if echocardiography (echo) is adequate. However several studies show sizable discrepancies between echo and catheterization (cath) lab measurements. We wanted to investigate the impact of both

SAFETY AND EFFICACY OF USING PRESSURE WIRE WITH DOBUTAMIN INFUSION IN THEMOYNAMIC ASSESSMENT OF LOW FLOW LOW GRADIENT AORTIC STENOSIS

Background: Current guidelines discourage aortic stenosis (AS) evaluation by direct pressure measurement if echocardiography (echo) is adequate. However several studies show sizable differences between echo and catheterization (cath) lab measurements. Dobutamine Challenge is recommended for

CLINICAL PRESENTATION, NATURAL HISTORY AND MANAGEMENT OF CORONARY ARTERY ECTASIA

Background: Clinical presentation, natural history of coronary artery ectasia (CAE) and prognostic implications of its anatomic classification of are not well known. Methods: We retrospectively analyzed 376 consecutive cases of CAE and angiographically categorized them using the Markis

USE OF MECHANICAL CIRCULATORY SUPPORT LEADING TO HEART TRANSPLANT IS ASSOCIATED WITH STROKES IN THE IMMEDIATE POST-TRANSPLANT PERIOD: ANALYSIS OF 59,170 HEART TRANSPLANTS FROM THE UNOS DATABASE

Data pertaining to the incidence of perioperative stroke in patients placed on mechanical circulatory support (MCS) leading to heart transplantation (HT) is limited. We sought to determine the association between the use of different types of pre-HT MCS and the incidence of stroke following HT. We

EFFECT OF AGGRESSIVE LIPID THERAPY ON PROGRESSION OF CAROTID ARTERY STENOSIS: A LONGTERM FOLLOW UP STUDY

The relationship of serum lipid levels, aggressive statin use and progression of carotid stenosis (CS) severity has not been well studied. We assessed the correlation between aggressive risk modification, statin use, and lipid levels with progression of carotid artery stenosis and incidence of