Sagar Mallikethi-Reddy

Myocardial fibrosis on cardiac magnetic resonance and cardiac outcomes in hypertrophic cardiomyopathy: a meta-analysis

Objective Late gadolinium enhancement (LGE) on cardiac MRI that indicates the extent of myocardial fibrosis in hypertrophic cardiomyopathy (HCM) is a potential risk factor of sudden cardiac death (SCD) in non-high-risk patients according to conventional clinical markers. Methods The present study was designed to systematically review prospective trials and assess the association between LGE and SCD in HCM. We systematically searched the electronic databases, MEDLINE, PubMed, Embase and Cochrane for prospective cohort studies of the effects of LGE on clinical outcomes (SCD/aborted SCD, all-cause mortality, cardiac and heart failure death) in HCM. Results We identified six clinical studies, examining 1414 patients without LGE and 1653 with LGE and an average follow-up of 3.05 years. The incidence of SCD/aborted SCD in patients with HCM and LGE was significantly increased as compared with patients without LGE (OR 2.52, 95% CI 1.44 to 4.4, p=0.001). The all-cause mortality and cardiac death rates were also significantly increased in patients with LGE. The extent of LGE was not significantly related to the risk of SCD. Conclusions LGE is significantly associated with SCD risk, cardiac mortality and all-cause mortality in patients with non-high-risk HCM according to conventional risk factors.

Meta-Analysis of Transcatheter Aortic Valve Replacement Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Valve Stenosis

Transcatheter aortic valve replacement (TAVR) is a viable option in the treatment of severe aortic stenosis in patients at high risk for surgery. We sought to further investigate outcomes in patients at low to intermediate risk with aortic stenosis who underwent surgical aortic valve replacement (SAVR) versus TAVR. We systematically searched the electronic databases, MEDLINE, PubMed, EMBASE, and Cochrane for prospective cohort studies of the effects of TAVR versus SAVR on clinical outcomes (30-day mortality, all-cause mortality, stroke and myocardial infarction, major vascular complications, paravalvular regurgitation, permanent pacemaker implantation, major bleeding, and acute kidney injury). We identified 5 clinical studies, examining 1,618 patients in the TAVR group and 1,581 patients in the SAVR group with an average follow-up of 1.05 years. No difference in all-cause mortality, stroke, and myocardial infarction between the 2 approaches was found. TAVR was associated with higher rates of vascular complications, permanent pacemaker implantation, and moderate or severe paravalvular regurgitation (p <0.001 for all), whereas more major bleeding events were seen in the SAVR group (p <0.001). In conclusion, TAVR was found to have similar survival and stroke rates and lower major bleeding rates as compared with SAVR in patients at low or intermediate surgical risk. However, SAVR was associated with less pacemaker placements and paravalvular regurgitation rates.

Uric acid and cardiovascular disease risk reclassification: Findings from NHANES III

Background The studied associations between serum uric acid (sUA) and cardiovascular disease (CVD) events have been controversial. We sought to evaluate the association between sUA and CVD mortality, including its ability to reclassify risk in a multiethnic nationally representative population free of clinical CVD and diabetes at baseline. Methods The study cohort included 11,009 adults enrolled as a part of the National Health and Nutrition Examination Survey (NHANES) III. Multivariate Cox proportional hazard analysis was performed to evaluate sUA as a predictor of CVD and coronary heart disease (CHD) mortality. Discriminative and recalibrative properties of sUA for CHD deaths were also assessed over traditional CVD risk factors. Net reclassification index (NRI) was calculated by comparing regression models incorporating traditional CVD risk factors with and without sUA. Results sUA was not predictive of either CVD mortality [model 4: hazards ratio (HR) 1.06, 95% confidence interval (CI) 0.96–1.16, p = 0.27] or CHD mortality (model 4: HR 1.06, 95% CI 0.94–1.19, p = 0.32). Addition of sUA to traditional CVD risk factors resulted in no significant increment in c-statistic, receiver-operating characteristics–area under curve, absolute NRI (0.5%, 95% CI –1.9 to 2.9%, p = 0.68), or intermediate NRI (2.5%, 95% CI –1.6 to 6.6%, p = 0.24) for prediction of hard CHD deaths. Conclusions sUA was not an independent predictor of both CVD and CHD mortality. Ethnicity did not influence the association of sUA with CVD mortality. Furthermore, sUA did not add to risk assessment beyond traditional CVD risk factors.

Incidence and survival after in-hospital cardiopulmonary resuscitation in nonelderly adults

Background— Survival trends after in-hospital cardiopulmonary resuscitation (ICPR) for cardiac arrest in nonelderly adults is not well known. Influence of cardiopulmonary resuscitation guidelines on nationwide survival after ICPR is yet to be well elucidated. Methods and Results— We examined survival trends and factors associated with survival after ICPR in nonelderly adults aged 18 to 64 years, using Healthcare Utilization Project Nationwide Inpatient Sample Database from 2007 through 2012 in the United States. Furthermore, we studied the impact of 2010 American Heart Association cardiopulmonary resuscitation guidelines on survival. We identified 235 959 patients who underwent ICPR after cardiac arrest. Overall, 30.4% patients survived to hospital discharge. Survival improved from 27.4% in 2007 to 32.8% in 2012 (Ptrend<0.001). Shockable arrest rhythms were noted in 23.3% of patients. Incidence of ICPR increased from 1.81 per 1000 hospitalizations in 2007 to 2.37 per 1000 hospitalizations in 2012 (Ptrend<0.001). There was no statistically significant change in survival trends before and after 2010 cardiopulmonary resuscitation guidelines. Female sex and shockable rhythms were associated with higher adjusted odds of survival, whereas black race, lack of health insurance, age, and weekend admission were associated with lower adjusted odds of survival. Conclusions— Among nonelderly adults, survival after ICPR improved significantly from 2007 through 2012, with an overall survival rate of 30.4%. Incidence of ICPR increased significantly during the study period. There was no statistically significant change in survival before and after 2010 cardiopulmonary resuscitation guidelines. Female sex and black race were associated with higher and lower odds of survival, respectively.

3-hydroxy-3-methylglutaryl-CoA reductase enzyme inhibitors for prevention of contrast-induced nephropathy: A meta-analysis of prospective randomized controlled studies

Contrast-induced nephropathy (CIN) is a possible complication of interventional procedures that require administration of an iodinated contrast. Previous observational and small prospective randomized trials suggested that 3-hydroxy-3-methylglutaryl-CoA reductase enzyme inhibitors may reduce the incidence of CIN. We performed a meta-analysis of the effect of statins on CIN including prospective randomized, controlled trials of statin therapy. We conducted an EMBASE and MEDLINE search for studies in which patients were randomized to treatment with a statin plus standard treatment (or placebo) versus standard treatment (or placebo). We included studies that provided data on creatinine clearance, and incidence of CIN before the initiation of the treatment and at the end of the follow-up period. We identified 9 prospective randomized studies of high-dose statin treatment compared with placebo treatment for CIN prevention with 2504 controls and 2480 patients that received statins. A significant reduction in CIN was observed when pharmacologic intervention with statins was used (odds ratio, 0.45; 95% confidence interval, 0.34–0.58; P < 0.0001). In this meta-analysis of prospective controlled studies, we found a statistically significant reduction of CIN incidence in patients pretreated with high-dose statins before the procedure.

Transcatheter aortic valve implantation in the United States: Predictors of early hospital discharge

BACKGROUND There is a concerted push for adopting a minimalist strategy with emphasis on early hospital discharge for patients undergoing Transcatheter aortic valve implantation (TAVI). However, studies on discharge patterns and predictors of early discharge (≤3 days post-TAVI) are sparse, in the United States. METHODS We analyzed using Healthcare Utilization Project, Nationwide Inpatient Sample database, 2011-2012. A total of 7321 TAVI procedures were identified. We compared in-hospital outcomes between early and late discharge cohorts, and determined the predictors of early discharge. Correlation of costs and post-TAVI length of stay was also performed. RESULTS Early discharge rate post-TAVI was about 21% in the United States, in 2011-2012. Overall mean age was 81 years. In-hospital adverse outcomes post-TAVI were higher in late discharge cohort (P < 0.001). Mean length of stay post-TAVI (7.7 days vs 2.6 days) and costs (

Novel biomarkers with potential for cardiovascular risk reclassification.

208 752 vs

Coronary artery calcium in hypertension: A review

157 663) were significantly higher in late discharge than early discharge cohort. Females, bleeding, blood transfusions, stroke, permanent pacemakers, mechanical circulatory support, acute kidney injury were associated with significantly lower adjusted odds for early discharge. Transfemoral TAVI approach, prior aortic valvuloplasty, and procedure year 2012 were associated with significantly higher odds for early discharge. We observed positive correlation between costs of hospitalization and post-TAVI length of stay (R = 0.58; P < 0.001). CONCLUSIONS Females, bleeding, blood transfusions, stroke, permanent pacemakers, mechanical circulatory support devices, renal failure were associated with lower odds for early discharge. Transfemoral approach and prior aortic valvuloplasty increased the likelihood for early discharge. Post-TAVI length of stay was associated with significantly higher hospitalization costs.

Burden of arrhythmias in peripartum cardiomyopathy: Analysis of 9841 hospitalizations

Abstract Precise estimation of the absolute risk for CVD events is necessary when making treatment recommendations for patients. A number of multivariate risk models have been developed for estimation of cardiovascular risk in asymptomatic individuals based upon assessment of multiple variables. Due to the inherent limitation of risk models, several novel risk markers including serum biomarkers have been studied in an attempt to improve the cardiovascular risk prediction above and beyond the established risk factors. In this review, we discuss the role of underappreciated biomarkers such as red cell distribution width (RDW), cystatin C (cysC), and homocysteine (Hcy) as well as imaging biomarkers in cardiovascular risk reclassification, and highlight their utility as additional source of information in patients with intermediate risk.

MicroRNAs in Atrial Fibrillation

Coronary artery calcium (CAC) is a powerful independent predictor of future cardiovascular events. However, the clinical utility of calcium score testing specifically among patients with hypertension is not well defined. We performed a review of studies involving both high blood pressure (BP) and CAC to assess several aspects of the interrelationship. Among four specific topics evaluated, the main objective was to assess the independent association of CAC with cardiovascular risk among patients with hypertension. From 6822 identified publications, 21 studies met criteria for inclusion. All studies (n = 14) that reported the relationship between BP values and the presence or extent of coronary calcium found positive associations. The results from two studies linking coronary calcium with the risk for developing hypertension were mixed. Each of the five studies that evaluated the relationships between CAC score in regard to future cardiovascular events and/or all-cause mortality in patients with high BP reported independent positive associations. The inclusion of calcium score results into prediction models improved risk stratification when statistically evaluated. The findings of this review demonstrate that CAC testing is likely to be of clinical utility for tailoring the medical management of patients with high BP, particularly among individuals with mild or prehypertension. Future trials testing the clinical effectiveness of a calcium score-based treatment algorithm should be considered.