Rajat Kalra

Left ventricular strain and untwist in hypertrophic cardiomyopathy: Relation to exercise capacity

Background Nonobstructive hypertrophic cardiomyopathy (nHCM) is often associated with reduced exercise capacity despite hyperdynamic systolic function as measured by left ventricular ejection fraction. We sought to examine the importance of left ventricular strain, twist, and untwist as predictors of exercise capacity in nHCM patients. Methods Fifty-six nHCM patients (31 male and mean age of 52 years) and 43 age- and gender-matched controls were enrolled. We measured peak oxygen consumption (peak Vo2) and acquired standard echocardiographic images in all participants. Two-dimensional speckle tracking was applied to measure rotation, twist, untwist rate, strain, and strain rate. Results The nHCM patients exhibited marked exercise limitation compared with controls (peak Vo2 23.28 ± 6.31 vs 37.70 ± 7.99 mL/[kg min], P < .0001). Left ventricular ejection fraction in nHCM patients and controls was similar (62.76% ± 9.05% vs 62.48% ± 5.82%, P = .86). Longitudinal, radial, and circumferential strain and strain rate were all significantly reduced in nHCM patients compared with controls. There was a significant delay in 25% of untwist in nHCM compared with controls. Both systolic and diastolic apical rotation rates were lower in nHCM patients. Longitudinal systolic and diastolic strain rate correlated significantly with peak Vo2 (r = −0.34, P = .01 and r = 0.36, P = .006, respectively). Twenty-five percent untwist correlated significantly with peak Vo2 (r = 0.36, P = .006). Conclusions In nHCM patients, there are widespread abnormalities of both systolic and diastolic function. Reduced strain and delayed untwist contribute significantly to exercise limitation in nHCM patients.

Comparison of Approaches to Revascularization in Patients With Multivessel Coronary Artery Disease Presenting With ST-Segment Elevation Myocardial Infarction: Meta-analyses of Randomized Control Trials.

Background Significant controversy exists regarding the best approach for nonculprit vessel revascularization in patients with multivessel coronary artery disease presenting with ST‐segment elevation myocardial infarction. We conducted a systematic investigation to pool data from current randomized controlled trials (RCTs) to assess optimal treatment strategies in this patient population. Methods and Results A comprehensive search of SCOPUS from inception through May 2015 was performed using predefined criteria. We compared efficacy and safety outcomes of different approaches by categorizing the studies into 3 groups: (1) complete revascularization (CR) versus culprit lesion revascularization (CL) at index hospitalization, (2) CR at index hospitalization versus staged revascularization (SR) of nonculprit vessels at a separate hospitalization, and (3) comparison of SR versus CL. Eight eligible RCTs met the inclusion criteria: (1) CR versus CL (6 RCTs, n=1727) (2) CR versus SR (3 RCTs, n=311), and (3) SR versus CL (1 RCT, n=149). We observed significantly lower rates of major adverse cardiovascular events, revascularization, and repeat percutaneous coronary interventions among patients treated with CR and SR compared with a CL approach (P<0.05). The rates of all‐cause mortality, cause‐specific mortality, major bleeding, reinfarction, stroke, and contrast‐induced nephropathy did not differ in the CR arm compared with the CL arm. The rates of these outcomes were similar in the CR and SR arms. Conclusion Results suggest that CR and SR compared with CL reduce major adverse cardiovascular event and revascularization rates primarily by lowering repeated percutaneous coronary intervention rates. We did not observe any increase in the rate of adverse events while using a CR or SR strategy compared with a CL approach. Current guidelines discouraging CR need to be reevaluated, and clinical judgment should prevail in treating multivessel coronary artery disease patients with ST‐segment elevation myocardial infarction as data from larger RCTs accumulate.

Hospitalization Rates, Prevalence of Cardiovascular Manifestations, and Outcomes Associated With Sarcoidosis in the United States

Background Recent trends of hospitalizations and in‐hospital mortality are not well defined in sarcoidosis. We examined aforementioned trends and prevalence of cardiovascular manifestations and explored rates of implantable cardioverter‐defibrillator implantation in hospitalizations with sarcoidosis. Methods and Results Using data from the National Inpatient Sample, a retrospective population cohort from 2005 to 2014 was studied. To identify sarcoidosis, an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) diagnosis code was used. We excluded hospitalizations with myocardial infarction, coronary artery disease, and ischemic cardiomyopathy. Cardiovascular manifestations were defined by the presence of diagnosis codes for conduction disorders, arrhythmias, heart failure, nonischemic cardiomyopathy, and pulmonary hypertension. A total of 609 051 sarcoidosis hospitalizations were identified, with an age of 55±14 years, 67% women, and 50% black. The number of sarcoidosis hospitalizations increased from 2005 through 2014 (138 versus 175 per 100 000, P trend<0.001). We observed declining trends of unadjusted in‐hospital mortality (6.5 to 4.9 per 100 sarcoidosis hospitalizations, P trend<0.001). Overall ≈31% (n=188 438) of sarcoidosis hospitalizations had coexistent cardiovascular manifestations of one or more type. Heart failure (≈16%) and arrhythmias (≈15%) were the most prevalent cardiovascular manifestations. Rates of implantable cardioverter‐defibrillator placement were ≈7.5 per 1000 sarcoidosis hospitalizations (P trend=0.95) during the study period. Black race was associated with 21% increased risk of in‐hospital mortality (odds ratio, 1.21; 95% confidence interval, 1.16–1.27 [P<0.001]). Conclusions Sarcoidosis hospitalizations have increased over the past decade with a myriad of coexistent cardiovascular manifestations. Black race is a significant predictor of in‐hospital mortality, which is declining. Further efforts are needed to improve care in view of low implantable cardioverter‐defibrillator rates in sarcoidosis.

Surgical Embolectomy for Acute Pulmonary Embolism: Systematic Review and Comprehensive Meta-Analyses

Surgical pulmonary embolectomy (SPE) is a viable treatment approach for subsets of patients with acute pulmonary embolism. However, outcomes data are limited. We sought to characterize mortality and safety outcomes for this population. Studies reporting inhospital mortality for patients undergoing SPE for acute pulmonary embolism were included. In 56 eligible studies, we found 1,579 patients who underwent 1,590 SPE operations. The pooled inhospital all-cause mortality rate was 26.3% (95% confidence interval: 22.5% to 30.5%). Surgical site complications occurred in 7.0% of operations (95% confidence interval: 4.9% to 9.8%). More investigation is required to define the patient population that would benefit the most from SPE.

Conducting and interpreting high-quality systematic reviews and meta-analyses

Systematic reviews and meta-analyses are powerful tools for summarizing existing literature and combining evidence from multiple studies. These methods employ complex searches, statistical techniques, and presentation techniques with which the clinical audience may not be very familiar. This review article aims to familiarize the clinical audience with the various techniques employed to conduct a high-quality systematic review and meta-analysis.

Catheter-directed treatment for acute pulmonary embolism: Systematic review and single-arm meta-analyses ☆

BACKGROUND We sought to estimate the efficacy and safety outcomes of catheter-directed treatment (CDT) for patients with acute pulmonary embolism (PE). METHODS We searched SCOPUS for studies reporting outcomes after CDT for acute PE. Studies were categorized in three groups for analyses due to heterogeneity in the classification of acute PE: 1) patients with PE causing right ventricular dysfunction and haemodynamic instability: unstable haemodynamic status, 2) patients with PE causing right ventricular dysfunction where study outcomes were not stratified by haemodynamic status: stable and unstable haemodynamic status, and 3) patients with PE causing right ventricular dysfunction who remained haemodynamically stable: stable haemodynamic status. Efficacy and safety outcomes were estimated and presented as point estimates with 95% confidence intervals. RESULTS In 35 studies with 1253 patients, 1277 CDTs were performed. The in-hospital mortality rates for the unstable haemodynamic status, stable and unstable haemodynamic status, and stable haemodynamic status groups were 18.1% (7.3-38.2%), 7.1% (5.0-10.1%), and 2.6% (0.8-7.3%), respectively. The major bleeding rates across the groups were estimated to be 4.5, 8.5 and 3.9 per 100 CDTs, respectively. Minor bleeding occurred in 6.2, 11.9 and 9.1 per 100 CDTs, respectively. After CDT, all groups had improvements in mean pulmonary artery pressure and right ventricular function. CONCLUSIONS We provide descriptive measures of efficacy and safety for patients who underwent CDT for acute PE.

Comparison of approaches for stroke prophylaxis in patients with non-valvular atrial fibrillation: Network meta-analyses of randomized controlled trials

Background Multiple novel oral anticoagulants and left atrial appendage closure devices (WATCHMAN) have been tested against dose-adjusted vitamin K antagonists in randomized controlled trials for stroke prophylaxis in non-valvular atrial fibrillation. No direct comparisons of these strategies are available from randomized controlled trials. We conducted the current analyses by combining efficacy and safety characteristics of all FDA approved stroke prophylaxis treatment strategies for patients with non-valvular atrial fibrillation. Materials and Methods We searched SCOPUS from 1945 till October 2015 for randomized controlled trials comparing these strategies and reporting efficacy and safety outcomes. Six randomized controlled trials were identified and included in the final analyses and review. We followed PRISMA guidelines for network meta-analyses while reporting the current analyses. We collected data on ischemic stroke, major bleeding, and the composite primary safety endpoint as defined by various randomized controlled trials. Network meta-analyses were conducted using consistency and inconsistency models for efficacy and safety outcomes. Surface under the cumulative ranking curve were then utilized to cluster rank these treatments for safety and efficacy. Results Six randomized controlled trials with 59,627 patients comparing six treatment strategies were eligible for the analyses. All prophylaxis strategies had comparable rates of ischemic stroke. Apixaban was associated with the least number of primary safety endpoint events as compared with all other treatments. In the cluster analyses assessing safety and efficacy, apixaban, edoxaban and dabigatran ranked best followed by vitamin K antagonists and rivaroxaban, whereas the WATCHMAN left atrial appendage closure device ranked last. Conclusions Dose-adjusted vitamin K antagonists, novel oral anticoagulants, and the WATCHMAN left atrial appendage closure devices are equally efficacious for ischemic stroke prevention but these treatments have different safety profiles. More randomized controlled trials are needed to directly compare these strategies.

MORTALITY OUTCOMES FOR SURGICAL PULMONARY EMBOLECTOMY FOR HIGH-RISK PULMONARY EMBOLISM: A COMPREHENSIVE META-ANALYSIS

Untreated high-risk pulmonary embolism (PE) is associated with a mortality rate as high as 60%. Surgical pulmonary embolectomy (SPE) is an efficacious treatment but outcomes data regarding this approach are limited. We sought to characterize mortality outcomes for patients with high-risk PE

Urinary Catheterization—When Good Intentions Go Awry: A Teachable Moment

Story From the Front Lines A man in his 80s with a history of mild dementia and peripheral vascular disease with left below the knee amputation presented to our general medicine service with several weeks of fatigue and worsening lower extremity edema. He was found to have acute kidney injury and nephrotic range proteinuria. He did not have his prosthesis in the hospital and was unable to ambulate to the bathroom without it. A urinary catheter was placed to monitor urinary output while he received diuretics. After several days of diuresis, his symptoms were much improved, and he was discharged home. Five days after discharge, the patient was readmitted to the medical intensive care unit with severe sepsis due to a lower urinary tract infection (UTI). His sepsis was almost certainly due to the urinary catheter our medical team had inserted during his prior admission. With treatment, he recovered and was discharged home, but the hospitalization and its risks could probably have been avoided had he not been catheterized.

Costs of Transcatheter Aortic Valve Replacement: Implications of Proposed Medicare Cuts

Severe aortic stenosis (AS) is a progressive life threatening “surgical” illness. Previous studies have shown a substantial improvement in quality of life as well as survival after valve replacement in patients with severe AS [(1)][1]. Transcatheter aortic valve replacement (TAVR) is recommended