Sainath Gaddam

Usefulness of Neutrophil to Lymphocyte Ratio in Predicting Short- and Long-Term Mortality After Non–ST-Elevation Myocardial Infarction

Neutrophil/lymphocyte ratio (NLR) is the strongest white blood cell predictor of adverse outcomes in stable and unstable coronary artery syndromes. The aim of our study was to explore the utility of NLR in predicting long-term mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Consecutive patients with NSTEMI at Staten Island University Hospital were evaluated for study inclusion. Of the 1,345 patients with NSTEMI admitted from September 2004 to September 2006, 619 qualified for study inclusion. Survival analysis, stratified by NLR tertiles, was used to evaluate the predictive value of average inpatient NLR levels. Four-year vital status was accessed with electronic medical records and Social Security Death Index. Patients in the highest NLR tertile (NLR >4.7) had a higher 4-year mortality rate (29.8% vs 8.4%) compared to those in the lowest tertile (NLR <3, Wilcoxon chi-square 34.64, p <0.0001). After controlling for Global Registry of Acute Coronary Events risk profile scores, average NLR level remained a significant predictor of inpatient and 4-year mortality. Hazard ratios per unit increase of average NLR (log) increased by 1.06 (p = 0.0133) and 1.09 (p = 0.0006), respectively. In conclusion, NLR is an independent predictor of short-term and long-term mortalities in patients with NSTEMI with an average NLR >4.7. We strongly suggest the use of NLR rather than other leukocyte parameters (e.g., total white blood cell count) in risk stratification of the NSTEMI population.

Serum lipoprotein levels in takotsubo cardiomyopathy vs. myocardial infarction.

Background In the setting of myocardial infarction (MI) or acute coronary syndrome (ACS), current guidelines recommend early and aggressive lipid lowering therapy with statins, irrespective of the baseline lipoprotein levels. Takotsubo cardiomyopathy (TCM) patients have a clinical presentation similar to myocardial infarction and thus receive early and aggressive statin therapy during their initial hospitalization. However, the pathology of TCM is not atherosclerotic coronary artery disease and hence we assumed the lipid profiles in TCM would be healthier than coronary artery disease patients. Methods In this retrospective study, we assessed fasting serum lipoprotein levels of ten TCM patients and compared them with forty, age and sex-matched myocardial infarction (MI) patients. Results Comparing serum lipoprotein levels of TCM with MI group, there was no significant difference in mean total cholesterol between the two groups (174.5 mg/dL vs. 197.6 mg/dL, p = 0.12). However, in the TCM group, mean HDL-C was significantly higher (66.87 mg/dL vs. 36.5 mg/dL, p = 0.008), the mean LDL-C was significantly lower (89.7 mg/dL vs. 128.9 mg/dL, p = 0.0002), and mean triglycerides was also significantly lower (65.2 mg/dL vs. 166.8 mg/dL, p < 0.0001). Conclusions In this study, TCM patients in comparison to MI patients had significantly higher levels of HDL-C, lower levels of LDL-C levels and triglycerides. The lipid profiles in TCM were consistent with the underlying pathology of non-atherosclerotic, non-obstructive coronary artery disease. As lipoproteins in most TCM patients were within the optimal range, we recommend an individual assessment of lipid profiles along with their coronary heart disease risk factors for considering long term lipid-lowering therapy. A finding of hyperalphalipoproteinemia or hypotriglyceridemia in 40% of TCM patients is novel but this association needs to be confirmed in future studies with larger sample sizes. These findings may provide clues in understanding the pathogenesis of takotsubo cardiomyopathy.

Biodegradable polymer stents vs second generation drug eluting stents: A meta-analysis and systematic review of randomized controlled trials

AIM To evaluate the premise, that biodegradable polymer drug eluting stents (BD-DES) could improve clinical outcomes compared to second generation permanent polymer drug eluting stents (PP-DES), we pooled the data from all the available randomized control trials (RCT) comparing the clinical performance of both these stents. METHODS A systematic literature search of PubMed, Cochrane, Google scholar databases, EMBASE, MEDLINE and SCOPUS was performed during time period of January 2001 to April 2015 for RCT and comparing safety and efficacy of BD-DES vs second generation PP-DES. The primary outcomes of interest were definite stent thrombosis, target lesion revascularization, myocardial infarction, cardiac deaths and total deaths during the study period. RESULTS A total of 11 RCTs with a total of 12644 patients were included in the meta-analysis, with 6598 patients in BD-DES vs 6046 patients in second generation PP-DES. The mean follow up period was 16 mo. Pooled analysis showed non-inferiority of BD-DES, comparing events of stent thrombosis (OR = 1.42, 95%CI: 0.79-2.52, P = 0.24), target lesion revascularization (OR = 0.99, 95%CI: 0.84-1.17, P = 0.92), myocardial infarction (OR = 1.06, 95%CI: 0.86-1.29, P = 0.92), cardiac deaths (OR = 1.07, 95%CI 0.82-1.41, P = 0.94) and total deaths (OR = 0.96, 95%CI: 0.80-1.17, P = 0.71). CONCLUSION BD-DES, when compared to second generation PP-DES, showed no significant advantage and the outcomes were comparable between both the groups.

In-stent thrombosis after 68 months of implantation inspite of continuous dual antiplatelet therapy: a case report

Lately, there has been an increased incidence of late stent thrombosis; especially following Drug eluting stent (DES) implantation. Several factors are associated with an increased risk of stent thrombosis, including the procedure itself, patient and lesion characteristics, stent design, and premature cessation of anti-platelet drugs. We present a case of late stent thrombosis (LST) following DES implantation after a period of 68 months, making it the longest reported case of LST reported in the literature, despite the use of dual anti-platelet therapy.

Contrast media use in patients with chronic kidney disease undergoing coronary angiography: A systematic review and meta-analysis of randomized trials

BACKGROUND Patients with chronic kidney disease (CKD) undergoing coronary angiography (CA), adequate hydration and minimizing volume of contrast media (CM) are class 1b recommendations for preventing contrast induced nephropathy (CIN). Current data are insufficient to justify specific recommendations about isoosmolar vs. low-osmolar contrast media by the ACCF/AHA/SCAI guidelines. METHODS Randomized trials comparing IOCM to LOCM in CKD stage 3 and above patients undergoing CA, and reporting incidence of CIN (defined by a rise in creatinine of 25% from baseline) were included in the analysis. The secondary outcome of the study was the incidence of serum creatinine increase by >1mg/dl. RESULTS A total of 2839 patients were included in 10 trials, in which 1430 patients received IOCM and 1393 received LOCM. When compared to LOCM, IOCM was not associated with significant benefit in preventing CIN (OR=0.72, [CI: 0.50-1.04], P=0.08, I2=59%). Subgroup analysis revealed non-significant difference in incidence of CIN based on baseline use of N-acetylcystine (NAC), diabetes status, ejection fraction, and whether percutaneous coronary intervention vs coronary angiography alone was performed. The difference between IOCM and LOCM was further attenuated when restricted to studies with larger sample size (>250 patients) (OR=0.93; [CI: 0.66-1.30]) or when compared with non-ionic LOCM (OR=0.79, [CI: 0.52-1.21]). CONCLUSION In patients with CKD stage 3 and above undergoing coronary angiography, use of IOCM showed overall non-significant difference in incidence of CIN compared to LOCM. The difference was further attenuated when IOCM was compared with non-ionic LOCM.

Proximal atherosclerotic lesion as a cause of very late stent thrombosis

Very late stent thrombosis is defined as in-stent thrombosis occurring after 1 year of an intra-coronary artery stent placement. Drug eluting stents have lately been criticized for increased reports of very late stent thrombosis. The exact cause of these very late stent thromboses is not clearly understood. Virchows triad describes the three main factors of thrombus formation to be stasis of blood flow, endothelial injury and hypercoagulability. Based on Virchows triad, we propose the cause of very late stent thrombosis to be formation of a de novo atherosclerotic lesion in the proximal segment of a stented artery. The de novo atherosclerotic lesion narrows the vessel lumen and causes stasis of blood flow in the distal stent. The de novo lesion can also cause myocardial ischemia creating a prothrombotic environment in the stented region. Stasis of blood flow and prothrombotic environment in the stented region can lead to the formation of very late stent thrombosis. Since atherosclerosis is a dynamic aging process in humans, we propose de novo proximal lesions in the coronary arteries can predispose to very late stent thrombosis.

New-onset lone atrial fibrillation in pregnancy.

Incidence of tachyarrhythmias may increase during pregnancy, possibly due to the physiological changes associated with pregnancy. Though atrial fibrillation is the most common arrhythmia, its incidence in pregnancy is rare and if present it usually occurs in patients with congenital heart disease, rheumatic heart disease and other noncardiac conditions such as thyroid and electrolyte abnormalities, medication effects (such as tocolytics) and pulmonary embolism [Walsh et al. 2008]. New-onset lone atrial fibrillation in pregnancy is extremely rare and here we report a case of a young pregnant female presented with lone atrial fibrillation without hemodynamic compromise who responded well to intravenous diltiazem.

Are electrocardiographic changes in patients with acute subarachnoid hemorrhage associated with takotsubo cardiomyopathy

elevated catecholamine levels [4] ; however, the exact quantification of these hormones has not been well established. The ECG manifestations in SAH and TC are similar. QT prolongation can be found in both SAH and TC. In SAH, ECG changes are mostly seen in the acute phase and are generally transient [5] . In this study, 61% of patients had ECG changes. The most common findings included QT prolongation (33%) and T wave inversion (11%). Similarly, in a study on TC by Wittstein et al. [4] , all patients with TC had QT prolongation (100%) and in most of these patients the QT interval normalized within 1–2 days. In this study, troponin T was elevated in 2 patients (4.8%) of which only 1 patient demonstrated left ventricular regional wall motion abnormality (RWMA). In comparison, in the Parekh et al. [6] study on SAH, 20% of patients had elevated troponin I levels, and a higher incidence of myocardial dysfunction. The variation in cardiac marker elevation between studies may be secondary to their small sample size and sampling bias. In contrast, most patients with TC in the Wittstein study [4] had mildly elevated levels of cardiac biomarkers and all had wall motion abnormalities. The degree of elevation of cardiac biomarkers did not correlate with the severity of cardiac dysfunction. The diagnosis of Takotsubo cardiomyopathy (TC), or stress-induced cardiomyopathy, has become increasingly common due to a heightened awareness of the condition. However, the pathogenesis remains uncertain. Emotional stress followed by a subsequent surge in catecholamine that causes myocardial stunning is the most widely accepted mechanism for TC. Scientists have also proposed that since the ECG manifestations of subarachnoid hemorrhage (SAH) are similar to those of TC, that the pathogenesis of both conditions may be similar. That is, patients with SAH may also demonstrate a catecholamine elevation and present clinically with regional wall motion abnormalities. In Cardiology , Jung et al. [1] evaluated the parallels between these 2 conditions. A variety of emotional stressors can cause TC, for example sudden loss of family members, motor vehicle accidents, seizures, surgeries and major environmental disasters [2, 3] . The diagnosis is based on the characteristic clinical presentation of ‘ischemic’ ECG changes including ST elevations or deep T wave inversions anteriorly, mild-to-moderate elevation of cardiac biomarkers, normal coronaries on cardiac catheterization, and typical apical ballooning seen on left ventriculogram. Patients with TC will usually experience a complete resolution of left ventricular dysfunction within weeks to months following the acute event. Most patients with TC manifest Received: November 27, 2009 Accepted: December 1, 2009 Published online: February 4, 2010

NATIONAL TRENDS OF PCI AND CONCURRENT MORTALITY IN PATIENTS ≥75 YEARS AGE HOSPITALIZED DUE TO ACUTE MYOCARDIAL INFARCTION

The national epidemiology and temporal trends of percutaneous coronary intervention (PCI) and concurrent mortality in patients ≥75 years hospitalized with acute myocardial infarction (AMI) is unknown. We sought to characterize the trend and outcome of this life saving procedure in this population

Smoke trails of a dying gut: portal and mesenteric vein gas

DESCRIPTION A 49-year-old male, status postresection of melanoma 2 years ago, presented with constipation, abdominal pain and abdominal distension for the last 1 week. CT abdomen with contrast showed small bowel obstruction and a transition point was identified in the central abdomen (figure 1). Also noted were innumerable hepatic and splenic metastases (figure 2), and innumerable abdominal lymph nodes, largest one measuring 6.9 cm. After 3 h, a repeat CT abdomen was performed to look for delayed passage of contrast beyond the transition point. In this interim, the patient developed small bowel pneumatosis, with new mesenteric and portal venous gas (figures 3 and 4). An emergency laparotomy was performed. The entire mid small bowel was covered with fibrinous exudate with evidence of ischaemia and perforation. Ischaemia and obstruction was from strangulation of the small bowel due to lymph node adhesions and external compression by massively enlarged lymph nodes. A wide mesenteric resection was carried out incorporating all the large lymph nodes in the area of perforation. A primary anastomosis was performed between the ileum and the mid jejunum. Postsurgery, the patient remained mechanically ventilated with pressure support, but the family decided to withdraw all the supportive measures and the patient expired in 2 days. This rare radiological sign was first described by Wolfe and Evans 1 in neonates secondary to necrotising enterocolitis. It is believed that air leaks through the obstructed gut into capillary veins due to perforation of ischaemic intestinal wall. The treatment and prognosis of portal venous gas depends on the underlying cause. 2 In adults, it is mostly seen secondary to bowel ischaemia, hence requires emergency laparotomy and carries a high mortality. 3 This sign is also reported in some benign conditions requiring only conservative management. 4