Shafik Khoury

Discriminating Circulatory Problems From Deconditioning: Echocardiographic and Cardiopulmonary Exercise Test Analysis

Background: Discriminating circulatory problems with reduced stroke volume (SV) from deconditioning, in which the muscles cannot consume oxygen normally, by gas exchange parameters is difficult. Methods: We performed combined stress echocardiography (SE) and cardiopulmonary exercise tests (CPET) in 110 patients (20 with normal effort capacity, 54 with attenuated SV response, and 36 with deconditioning) to evaluate multiple hemodynamic parameters and oxygen content difference (A‐Symbolo2 Diff) in four predefined activity levels to assess which of the gas measures may help in the discrimination. Symbol. No caption available. Results: Reduced anaerobic threshold (AT), low unchanging peak oxygen pulse, periodic breathing, shallow &Dgr; peak oxygen consumption (Symbolo2)/&Dgr;work rate (WR) ratio, and high expired volume per unit time/carbon dioxide production (Symbole/Symbolco2) slope were all associated with abnormal SV response (P < .05 for all). The best discriminator was Symbole/Symbolco2 slope to Symbolo2 ratio (≥ 2.7; area under the curve [AUC], 0.79; P < .0001). The optimal gas exchange model included &Dgr;Symbolo2/&Dgr;WR < 8.6; Symbole/Symbolco2 slope to peak Symbolo2 ratio ≥ 2.7, and periodic breathing (AUC of 0.84; P < .0001). Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Conclusions: The best single gas exchange parameter to discriminate between circulatory problems and deconditioning is Symbole/Symbolco2 slope to peak SymbolO2 ratio. Combining it with &Dgr;Symbolo2/&Dgr;WR and periodic breathing improves the discriminative ability. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available. Symbol. No caption available.

Relation of subclinical serum creatinine elevation to adverse in-hospital outcomes among myocardial infarction patients

Background: Acute kidney injury is associated with adverse outcomes after acute ST elevation myocardial infarction (STEMI). It remains unclear, however, whether subclinical increase in serum creatinine that does not reach the consensus criteria for acute kidney injury is also related to adverse outcomes in STEMI patients undergoing primary percutaneous coronary intervention. Methods: We conducted a retrospective study of 1897 consecutive STEMI patients between January 2008 and May 2016 who underwent primary percutaneous coronary intervention, and in whom acute kidney injury was not diagnosed throughout hospitalization. We investigated the incidence of subclinical acute kidney injury (defined as serum creatinine increase of ≥ 0.1 and < 0.3 mg/dl) and its relation to a composite end point of adverse in hospital outcomes. Results: Subclinical acute kidney injury was detected in 321 patients (17%). Patients with subclinical acute kidney injury had increased rate of the composite end point of adverse in-hospital events (20.3% vs. 9.7%, p<0.001), a finding which was independent of baseline renal function. Individual components of this end point (occurrence of heart failure, atrial fibrillation, need for mechanical ventilation and in-hospital mortality) were all significantly higher among patients with subclinical acute kidney injury (p< 0.05 for all). In a multivariable regression model subclinical acute kidney injury was independently associated with higher risk for adverse in-hospital events (odds ratio 1.92.6, 95% confidence interval: 1.23–2.97, p=0.004). Conclusions: Among STEMI patients treated with primary percutaneous coronary intervention, small, subclinical elevations of serum creatinine, while not fulfilling the consensus criteria for acute kidney injury, may serve as a significant biomarker for adverse outcomes.

Prognostic Implications of Chronic Kidney Disease on Patients Presenting with ST-Segment Elevation Myocardial Infarction with versus without Stent Thrombosis

Background: Limited data is present regarding long-term outcomes in chronic kidney disease (CKD) patients presenting with stent thrombosis (ST). We evaluated the possible implications of CKD on long-term mortality in patients presenting with ST-segment elevation myocardial infarction (STEMI) and treated with primary percutaneous coronary intervention (PCI), and its interaction with the presence of ST. Methods: We retrospectively studied 1,722 STEMI patients treated with primary PCI. Baseline CKD was categorized as an estimated glomerular filtration rate <60 mL/min/1.73 m2 at presentation. The presence of ST was determined using the Academic Research Consortium definitions. Patients were evaluated for the presence of CKD and ST, as well as for long-term mortality. Results: A total of 448/1,722 (26%) patients had baseline CKD. Patients with CKD were older and had more comorbidities and a higher rate of ST (4 vs. 7%, respectively, p < 0.001). In a univariate analysis, long-term mortality was significantly higher among those with CKD compared to those without CKD (17.6 vs. 2.7%, p < 0.001). The presence of ST did not alter long-term mortality in both CKD and no-CKD patients. In a Cox regression model, CKD was an independent predictor of long-term mortality (hazard ratio 2.04, 95% confidence interval 1.17-3.56, p = 0.01), while ST as a covariate was not significantly associated with long-term mortality. Conclusion: Among STEMI patients, CKD, but not ST, is a predictor of long-term mortality.

INCIDENCE AND OUTCOMES OF EARLY LEFT VENTRICULAR THROMBUS FORMATION FOLLOWING ST-ELEVATION MYOCARDIAL INFARCTION TREATED WITH PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Background: Since the advent of primary percutaneous coronary intervention (PCI) for the treatment of ST-elevation myocardial infarction (STEMI), studies have reported a declining incidence of left ventricular thrombus (LVT) following STEMI. The majority of LVT were found prior to hospital discharge