Salman Bandeali

High-density lipoprotein and atherosclerosis: the role of antioxidant activity.

Levels of high-density lipoprotein (HDL) cholesterol are generally inversely associated with the risk for the development of atherosclerosis. The mechanism by which HDL imparts protection from the initiation and progression of occlusive vascular disease is complex and multifactorial. The major anti-atherosclerotic effect of HDL is felt to be reverse cholesterol transport. HDL has been demonstrated to scavenge cholesterol from the peripheral vasculature with transport to the liver, where is it excreted in the biliary system. However, HDL exhibits multiple other physiologic effects that may play a role in the reduced risk for atherosclerosis. HDL has been demonstrated to exhibit beneficial effects on platelet function, endothelial function, coagulation parameters, inflammation, and interactions with triglyceride-rich lipoproteins. Increasing amounts of clinical and experimental data have shown that HDL cholesterol has significant antioxidant effect that may significantly contribute to protection from atherosclerosis.

Diastolic Dysfunction in Rheumatoid Arthritis: A Meta-Analysis and Systematic Review

To determine if the prevalence of diastolic dysfunction is increased in rheumatoid arthritis (RA) patients.

Comparison by Meta-Analysis of Mortality After Isolated Coronary Artery Bypass Grafting in Women Versus Men

Short- and long-term mortality in women who undergo coronary artery bypass grafting (CABG) has been evaluated in multiple studies with conflicting results. The investigators conducted a meta-analysis of all existing studies to evaluate the impact of female gender on mortality in patients who undergo isolated CABG. A comprehensive search of studies published through May 31, 2012 identified 20 studies comparing men and women who underwent isolated CABG. All-cause mortality was evaluated at short-term (postoperative period and/or at 30 days), midterm (1-year), and long-term (5-year) follow-up. Odds ratios (ORs) and 95% confidence interval (CIs) were calculated using a random-effects model. A total of 966,492 patients (688,709 men [71%], 277,783 women [29%]) were included in this meta-analysis. Women were more likely to be older; had significantly greater co-morbidities, including hypertension, diabetes mellitus, hyperlipidemia, unstable angina, congestive heart failure, and peripheral vascular disease; and were more likely to undergo urgent CABG (51% vs 44%, p <0.01). Short-term mortality (OR 1.77, 95% CI 1.67 to 1.88) was significantly higher in women. At midterm and long-term follow-up, mortality remained high in women compared with men. Women remained at increased risk for short-term mortality in 2 subgroup analyses including prospective studies (n = 41,500, OR 1.83, 95% CI 1.59 to 2.12) and propensity score-matched studies (n = 11,522, OR 1.36, 95% CI 1.04 to 1.78). In conclusion, women who underwent isolated CABG experienced higher mortality at short-term, midterm, and long-term follow-up compared with men. Mortality remained independently associated with female gender despite propensity score-matched analysis of outcomes.

Outcomes of Preoperative Angiotensin-Converting Enzyme Inhibitor Therapy in Patients Undergoing Isolated Coronary Artery Bypass Grafting

The association between preoperative use of angiotensin-converting enzyme (ACE) inhibitors and outcomes after coronary artery bypass grafting (CABG) remain controversial. Our aim was to study in-hospital outcomes after isolated CABG in patients on preoperative ACE inhibitors. A retrospective analysis of 8,889 patients who underwent isolated CABG from 2000 through 2011 was conducted. The primary outcome of interest was the incidence of major adverse events (MAEs) defined as a composite of mortality, postoperative renal dysfunction, myocardial infarction, stroke, and atrial fibrillation during index hospitalization. The secondary outcome was the incidence of individual outcomes included in MAEs. Logistic regression analyses were performed. Of 8,889 patients, 3,983 (45%) were on preoperative ACE inhibitors and 4,906 (55%) were not. Overall incidence of MAEs was 38.1% (n = 1,518) in the ACE inhibitor group compared to 33.6% (n = 1,649) in the no-ACE inhibitor group. Preoperative use of ACE inhibitors was independently associated with MAEs (odds ratio 1.13, 95% confidence interval 1.03 to 1.24), most of which was driven by a statistically significant increase in postoperative renal dysfunction (odds ratio 1.18, 95% confidence interval 1.03 to 1.36) and atrial fibrillation (odds ratio 1.15, 95% confidence interval 1.05 to 1.27). In-hospital mortality, postoperative myocardial infarction, and stroke were not significantly associated with preoperative ACE inhibitor use. Analyses performed after excluding patients with low ejection fractions yielded similar results. In conclusion, preoperative ACE inhibitor use was associated with an increased risk of MAEs after CABG, in particular postoperative renal dysfunction and atrial fibrillation.

Real-life global survey evaluating patients with atrial fibrillation (REALISE-AF): results of an international observational registry

Despite being one of the most studied arrhythmias, there is paucity of information regarding atrial fibrillation (AF) control in the general population and the treatment strategies utilized by healthcare providers. REALISE-AF is an ongoing international registry investigating the management of AF and its control in nonhospitalized subjects. The registry has enrolled patients in 26 countries worldwide with the primary aim to determine the control of AF. This article presents a review of the initial results from the REALISE-AF registry and compares it to major practice-changing clinical trials conducted in the past. It also gives an overview of the current management strategies, recent updates in treatment and what further developments portend in the future.

Clinical Outcomes of Percutaneous Interventions in Saphenous Vein Grafts Using Drug‐Eluting Stents Compared to Bare‐Metal Stents: A Comprehensive Meta‐Analysisof All Randomized Clinical Trials

Clinical outcomes of percutaneous coronary intervention (PCI) in patients with saphenous vein grafts (SVGs) remain poor despite the use of drug‐eluting stents (DES). There is a disparity in clinical outcomes in SVG PCI based on various registries, and randomized clinical data remain scant. We conducted a meta‐analysis of all existing randomized controlled trials (RCTS) comparing bare‐metal stents (BMS) and DES in SVGPCIs.

Prevalence of acute myocardial infarction in patients with presumably new left bundle-branch block

OBJECTIVES We assessed the prevalence of true acute myocardial infarction and the need for emergent revascularization among patients with new or presumably new left bundle branch block (nLBBB) for whom the primary percutaneous coronary intervention protocol was activated. METHODS AND RESULTS Among 802 patients, 69 (8.6%) had nLBBB. The chief presenting symptom was chest pain or cardiac arrest in 36 patients (52.2%) and shortness of breath in 15 (21.7%). Less than 30% of the patients had elevated cardiac troponin-I, and less than 10% had elevated creatine kinase-MB. Only 11.6% of the patients underwent emergent revascularization; the rate was higher for patients who presented with chest pain or cardiac arrest or shortness of breath than for patients who presented with other symptoms. CONCLUSIONS Acute myocardial infarction and the need for emergent revascularization are relatively uncommon among patients who present with nLBBB, especially when symptoms are atypical. Current guidelines for primary percutaneous coronary intervention protocol activation for nLBBB should be reconsidered.

Association between statins and infections after coronary artery bypass grafting

BACKGROUND We determined whether pre-operative statin therapy is associated with a decrease in the incidence of infections after coronary artery bypass grafting (CABG). METHODS A retrospective cohort study of 6253 patients undergoing isolated CABG, from the Texas Heart Institute Database from January 1, 2000 to December 31, 2010 (3869 receiving statins and 2384 not receiving statins) was conducted. Primary outcome was the development of any postoperative infection (composite of deep-sternal wound infection, leg harvest-site infection, pneumonia, or sepsis) after CABG. Secondary outcome was the association between pre-operative statin use and individual incidence of each aforementioned infection. Logistic regression analyses were performed. RESULTS Incidence of any postoperative infection in patients who received statins pre-operatively was 6.5% compared to 8.3% in patients who did not receive statins. Pre-operative statin therapy was associated with a significant reduction in the primary outcome (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.60-0.90) in adjusted models. Among individual secondary outcomes, pre-operative statin therapy was associated with a reduced incidence of sternal wound infections (2.5% vs. 3.2%, OR 0.6, 95% CI 0.5-0.8) and leg harvest site infections (0.6% vs. 1.3%, OR 0.46, 95% CI 0.2-0.8). Pre-operative statin therapy was not associated with a reduced incidence of pneumonia or sepsis. CONCLUSION Pre-operative statin use is associated with a decrease in overall incidence of post-operative infections after CABG. We propose immunomodulatory effects of statins leading to a dampening of inflammatory cascade as the cause of our findings.

Fatal Paraneoplastic Systemic Leukocytoclastic Vasculitis as a Presenting Feature of Chronic Lymphocytic Leukemia

BACKGROUND The most common paraneoplastic vasculitis is leukocytoclastic vasculitis (LCV),(1) 75% of which are caused by hematological malignancies. Chronic lymphocytic leukemia (CLL) is associated with a multitude of auto-immune paraneoplastic syndromes. Data on LCV in association with CLL is restricted to isolated case reports,(3,4) none of which had systemic LCV. We present a unique case of fatal paraneoplastic, systemic LCV as an initial presentation of CLL in an elderly male with multiple co-morbidities. CASE A 71-year-old man presented with a palpable, symmetric, purpuric rash on the lower extremities and an absolute lymphocytosis (white blood cell count 26.9; 23% lymphocytes). His co-morbidities included coronary artery disease, congestive heart failure, and new critical aortic stenosis. Flow cytometry of peripheral blood demonstrated an abnormal population of B-cells, positive for CD5, CD19, and CD23, consistent with CLL. The skin biopsy specimen revealed neutrophilic inflammation in vessel walls indicative of LCV. Acute renal failure (creatinine 2 mg/dL), urinary red cell casts, and hypocomplementemia were concerning for a systemic vasculitis. The antinuclear antibody, cryoglobulin titer, antineutrophil cytoplasmic antibody, serum protein electrophoresis, viral serologies were negative. On hospital day 6, he developed acute hepatocellular injury and acute respiratory failure. Continuous veno-venous hemodialysis was begun for worsening acidemia and hyperkalemia. Two days later he became obtunded on hospital day 8 and had an elevated lactic acid level with generalized abdominal tenderness worrisome for bowel ischemia. The same day he needed intubation with cardiopulmonary resuscitation for a brief episode of asystole. Despite aggressive treatment with high-dose steroids and plasmapheresis, he suffered worsening renal failure and shock. His family sought withdrawal of care on hospital day 11. Autopsy revealed diffuse LCV of the stomach, distal ileum, integument and alveoli with petechial hemorrhages, fibrin thrombi, and gangrenous patchy necrosis. CONCLUSION Paraneoplastic LCV is a rare syndrome and seldom occurs in association with CLL. This is the first reported case of fatal systemic paraneoplastic LCV from B-cell CLL. Dermatologic involvement is universal with LCV, and may portend systemic disease. More data on its pathogenesis in CLL is warranted.

Sustained Complete Remission of Metastatic Hepatocellular Carcinoma with Single Agent Sorafenib

Hepatocellular carcinoma (HCC) is the third highest cause of cancer-related death, with 626,000 deaths worldwide annually [1]. Additionally, the incidence rate in the developed world is increasing, with an estimated incidence of 81,000 new cases per year [1]. The standard treatment regimen for HCC is dependent on whether the patient has local or metastatic disease. Local disease is treated with radio-ablation, resection, trans-arterial chemo-embolization, and/or orthotopic liver transplant. These treatments can produce 5-year survival rates up to 60–70 % [2]. However, the average survival for patients with metastatic disease is 7.9 months [3]. Sorafenib is a small molecule serine/threonine/tyrosine kinase inhibitor that, in the 2008 landmark Sorafenib Hepatocellular Carcinoma Assessment Randomized Protocol (SHARP) trial, demonstrated an approximately 3-month increase in survival rate in the setting of metastatic HCC [3]. To date, only three published studies have demonstrated complete remission in the setting of advanced or metastatic HCC [4, 5, 6].We present a case of a patient with metastatic HCC who achieved sustained, complete biochemical remission and near-complete radiological remission for 42 months while on sorafenib.