Reza Masoomi

Optimal Medical Management Reduces Risk of Disease Progression and Ischemic Events in Asymptomatic Carotid Stenosis Patients: A Long-Term Follow-Up Study.

Background and Purpose: To assess the effect of optimal medical management including atherosclerotic risk factor control on ischemic stroke (IS), transient ischemic attack (TIA), carotid revascularization (CRV), and progression of severity of carotid stenosis (PSCS) in patients with asymptomatic carotid artery stenosis (ACAS). Methods: We conducted a retrospective analysis of patients with ACAS (who had at least 3 serial carotid duplex ultrasounds) for incidence of IS, TIA, and PSCS. Results: Eight hundred sixty-four patients with a mean follow-up duration of 79 ± 36 months were included. IS/TIA and CRV occurred in 12.2% of the patients and PCSS was observed in 21.5% vessels. On univariate analysis it was found that low-density lipoprotein (LDL) levels >100 mg/dL, no statin or low-potency statins, average systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg and history of smoking were predictors of the combined endpoint of IS/TIA/CRV and PSCS. On multivariate analysis, it was found that LDL >100 mg/dL, no statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, and Hx of smoking were independent predictors of PSCS. Similarly no statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, Hx of atrial fibrillation/flutter, Hx of chronic kidney disease, and PSCS were independent predictors of IS/TIA. No statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, diabetes mellitus, baseline carotid artery stenosis ≥70%, and PSCS were found to be independent predictors of combined endpoint IS/TIA and CRV. Conclusion: Intensive medical therapy in the patients with ACAS results in lower incidence of IS/TIA, CRV, and PSCS with a significant incremental beneficial effect.

Progression of external and internal carotid artery stenosis is associated with a higher risk of ischemic neurologic events in patients with asymptomatic carotid artery stenosis

A small percentage of patients with asymptomatic carotid artery stenosis (ACAS) who are on optimal medical management do go on to develop ischemic stroke or transient ischemic attacks (IS/TIA). Several diagnostic tools have been studied to identify those patients who are at increased risk. However, most of these diagnostic tools are not available for routine clinical use or are resource intensive. We performed a retrospective study to assess the incremental value of external carotid artery stenosis progression (ECASP) along with internal carotid artery stenosis progression (ICASP) in predicting risk of ipsilateral IS/TIA in a cohort of patients with ACAS. We conducted a retrospective analysis of patients with ACAS who had at least two serial duplex ultrasounds (DUS) at our center. A total of 356 patients (712 carotid arteries) were included in the study (mean age 74.7±9 years, 49.2% male) with a mean follow-up of 60.7±32.7 months. In univariate analysis, concurrent progression of ICA and ECA stenosis on the same side arteries was associated with a very significant increased risk of ipsilateral IS/TIA (14.7% vs 4.6%, p<0.001). Also, multivariable regression analysis showed that concurrent ECA/ICA progression was an independent predictor of IS/TIA (OR=3.6, 95% CI 1.64–7.8; p=0.001). ECASP along with ICASP is significantly associated with increased risk of ipsilateral IS/TIA and provides incremental risk stratification over that provided by ICASP alone. The ECA is routinely evaluated in clinical practice, and it could serve as an additional marker for identifying higher risk patients with ACAS.

THE PREVALENCE AND ANATOMICAL PATTERNS OF INTRACAVITARY CORONARY ARTERIES: DETECTION BY CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY

Congenital coronary anomalies incidence have been reported up to 5.6% in the literature based on angiograms. However we are noticing increasing incidence of some coronary anomalies including intracavitary coronary arteries (ICCA) with use of the new diagnostic modalities like coronary computed

A nationwide analysis of 30-day readmissions related to critical limb ischemia:

Objectives There is paucity of information regarding critical limb ischemia-related readmission rates in patients admitted with critical limb ischemia. We studied 30-day critical limb ischemia-related readmission rate, its predictors, and clinical outcomes using a nationwide real-world dataset. Methods We did a secondary analysis of the 2013 Nationwide Readmissions Database. We included all patients with a primary diagnosis of extremity rest pain, ulceration, and gangrene secondary to peripheral arterial disease. From this group, all patients readmitted with similar diagnosis within 30 days were recorded. Results Of the total 25,111 index hospitalization for critical limb ischemia, 1270 (5%) were readmitted with a primary diagnosis of critical limb ischemia within 30 days. The readmission rate was highest (9.5%) for the group that did not have any intervention (revascularization or major amputation) and was lowest for surgical revascularization and major amputation groups (2.6% and 1.3%, P value <0.001 for all groups). Severity of critical limb ischemia at index admission was associated with a significantly higher rate of 30-day readmission. Critical limb ischemia-related readmission was associated with a higher rate of major amputation (29.6% vs. 16.2%, P<0.001), a lower rate of any revascularization procedure (46% vs. 62.6%, P<0.001), and a higher likelihood of discharge to a skilled nursing facility (43.2% vs. 32.2%, P<0.001) compared to index hospitalization. Conclusions In patients with primary diagnosis of critical limb ischemia, 30-day critical limb ischemia-related readmission rate was affected by initial management strategy and the severity of critical limb ischemia. Readmission was associated with a significantly higher rate of amputation, increased length of stay, and a more frequent discharge to an alternate care facility than index admission and thus may serve as a useful quality of care metric in critical limb ischemia patients.

Peripartum cardiomyopathy: An epidemiologic study of early and late presentations

OBJECTIVE Peripartum cardiomyopathy (PPCM) can present during pregnancy and up to months post-delivery. Most large-scale epidemiologic studies have reported on cases occurring during pregnancy or the first few days postpartum (termPPCM). Limited information is available on PPCM in the later postpartum period (latePPCM). We studied the incidence, predictors, and hospital outcome of peripartum cardiomyopathy (PPCM) in the prepartum and immediate post delivery period versus up to 3 months post-delivery. METHODS We performed a secondary analysis of the 2013 Nationwide Readmissions Database, and compared the incidence, patient characteristics and in-hospital outcomes of PPCM during the peripartum and three-month postpartum period. All women with a discharge diagnosis of PPCM during a hospitalization for childbirth were included in the termPPCM group and those re-hospitalized within 3 month post-delivery with a new diagnosis of PPCM comprised the latePPCM group. RESULTS There were 568 cases of PPCM, indicating an incidence of 1 per 2187 deliveries. Two thirds of those were latePPCM, and 75% of latePPCM cases occurred within 10 days of discharge. LatePPCM incidence was 1 per 208 deliveries in the highest risk group (age > 35, gestation diabetes and preeclampsia). Patients with termPPCM were more likely to be co-diagnosed with preeclampsia, to be anemic, and to be delivered by C-section. CONCLUSIONS Most cases of PPCM were diagnosed during a readmission, rather than during pregnancy or childbirth-related index hospitalization. It may be possible to identify latePPCM cases by pre-discharge screening in high risk women and institute early management to potentially decrease morbidity/mortality.

A novel unembalmed human cadaveric limb model for assessing conformational changes in self-expanding nitinol stents in the popliteal artery

To develop an unembalmed human cadaveric lower limb model as a more realistic environment for testing self‐expanding nitinol stents. We studied conformational changes and strain induced by knee flexion in nitinol stents deployed in the popliteal artery (PA).

Cardiac tamponade causing severe reversible hyponatraemia

Severe hyponatraemia in setting of cardiac tamponade is very rare and only few case reports have been reported so far. This case report highlights pericardial tamponade as a rare but easily treatable cause of severe hyponatraemia. Pertinent literature is also reviewed. A 70-year-old woman presented to the emergency department with altered mental status. She was tachycardic and hypotensive with cardiomegaly on a chest X-ray. Serum sodium was severely low at 109 mmol/L and was identified as the likely cause for her abnormal mentation. She was also in acute renal failure with serum creatinine of 4.1 mg/dL. A transthoracic echocardiogram was done that showed a large pericardial effusion with evidence of tamponade physiology. She underwent emergent pericardiocentesis with rapid improvement in clinical picture and blood pressure. Her serum sodium level rapidly improved and was normal in 48 hours.

Acute Coronary Syndromes in Heart Transplant Recipients (From A National Database Analysis)

With an expanding and aging heart transplant population, the incidence of acute coronary syndromes (ACS) is expected to increase. Our study aims to report current trends in in-hospital management and outcomes in heart transplant recipients presenting with ACS. We conducted an analysis of the National Inpatient Sample (2007 to 2014) to study the trends in hospitalization, in-hospital management, and outcomes in heart transplant recipients with a primary diagnosis of ACS. We included patients with ST elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and those with unstable angina pectoris (UAP). A total of 1,621 ACS (NSTEMI/UAP-76% vs STEMI-24%) hospitalizations were identified. Despite 1,327 (81%) of patients who underwent left heart catheterization, coronary revascularization was performed in only 576 patients (36%). Mortality was significantly higher in patients presenting with STEMI versus NSTEMI/UAP (28% vs 11%, respectively; p <0.05) and those who did not undergo revascularization (19% vs 7%; p <0.05). Cardiogenic shock (CS) was diagnosed in 14.5% patients. Mechanical circulatory support utilization was higher in CS group compared with non-CS group (69% vs 2.8%; p <0.05), as was in-hospital mortality (39% vs 10%; p <0.05). Repeat transplantation during the index hospitalization was done in 4.5% of ACS patients. In conclusion, in heart transplant recipients, ACS is associated with a high incidence of CS and in-hospital mortality. Aggressive treatment strategy that includes revascularization, mechanical circulatory support use (in those developing CS), and urgent retransplantation in suitable candidates seems to lead to better results than a more conservative strategy.

Inverse Correlation of Venous Brain Natriuretic Peptide Levels with Body Mass Index Is due to Decreased Production

Objective: The aim of this paper was to study the association between body mass index (BMI) and coronary sinus (CS) brain natriuretic peptide (BNP) levels in patients with heart failure and reduced systolic function (HFrEF). Background: There is an inverse relationship between systemic venous BNP (V-BNP) levels and BMI in patients with HFrEF. It is unclear whether this finding is due to decreased production or due to an increased metabolism of BNP. Since CS-BNP levels reflect BNP production, we hypothesized that assessing the correlation of CS-BNP levels with BMI would provide insight into the mechanism of this inverse relationship of V-BNP and BMI. Methods: We prospectively enrolled 54 subjects with HFrEF who were to undergo cardiac resynchronization device implantation. CS-BNP, V-BNP, and arterial BNP (A-BNP) levels were measured during the implant procedure. Subjects were divided into 2 groups based on their BMI (group 1: BMI <30 and group 2: BMI ≥30). Results: The mean age of the overall study group was 64 ± 10 years. Average BMI for group 1 was 25.8 ± 2.8 and 36.8 ± 4.6 for group 2 (p < 0.03). A history of hypertension was present in 55% (n = 26) of the subjects, while diabetes was reported in 31% (n = 15). Serum creatinine was 1.0 ± 0.2 mg/dL and TSH 2.1 ± 1.4 mIU/L. 79% of the subjects were receiving β-blockers, while 94% were receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The mean CS-BNP, V-BNP, and A-BNP levels in group 2 were significantly lower than in group 1 (286.2 ± 170.5 vs. 417.5 ± 247.5 pg/mL, p = 0.04; 126.6 ± 32.5 vs. 228 ± 96.4 pg/mL, p = 0.01; and 151.9 ± 28.6 vs. 242 ± 88.8 pg/mL, p = 0.04, respectively). Univariate analysis and multivariate regression adjusted for age, diabetes mellitus, sex, glomerular filtration rate, and left atrial size confirmed BMI as an independent predictor of CS-BNP levels (β = -0.372, p = 0. 03) in our study. Conclusions: In this study, we demonstrate an inverse relationship between CS-BNP levels and BMI in patients with HFrEF. These findings suggest that the previously established inverse relationship between V-BNP and BMI is due to a decreased cardiac production of BNP in obese patients rather than from increased peripheral metabolism.

TIMELY USE OF RIGHT HEART CATHETERIZATION IS ASSOCIATED WITH REDUCED IN-HOSPITAL MORTALITY IN PATIENTS WITH CONGESTIVE HEART FAILURE: INSIGHT FROM THE UNITED STATES NATIONAL INPATIENT SAMPLE DATABASE

Background: In patients with congestive heart failure (CHF), right heart catheterization (RHC) is recommended in certain situations. However, there remains uncertainty of its impact on mortality and other clinical outcomes. Methods: A secondary analysis of the United States National Inpatient