Sumeet Gandhi

Hypertonic saline with furosemide for the treatment of acute congestive heart failure: a systematic review and meta-analysis.

BACKGROUND Advanced congestive heart failure (CHF) therapies include intravenous inotropic agents, change in class of diuretics, and venous ultrafiltration or hemodialysis. These modalities have not been associated with improved prognosis and are limited by availability and cost. Compared to high-dose furosemide alone, concomitant hypertonic saline solution (HSS) administration has demonstrated improved clinical outcomes with good safety profile. METHODS A literature search was conducted for randomized controlled trials that investigated the use of HSS in patients admitted to hospital with acute CHF. RESULTS 1032 patients treated with HSS and 1032 controls, demonstrated decreased all-cause mortality in patients treat with HSS with RR of 0.56 (95% CI 0.41-0.76,p=0.0003). 1012 patients treated with HSS and 1020 controls, demonstrated decreased heart failure hospital readmission with RR of 0.50 (95% CI 0.33-0.76,p=0.001). Patients treated with HSS also demonstrated decreased hospital length of stay (p=0.0002), greater weight loss (p<0.00001), and preservation of renal function (p<0.00001). CONCLUSION The results of this meta-analysis demonstrate that in patients with advanced CHF concomitant hypertonic saline administration improved weight loss, preserved renal function, and decreased length of hospitalization, mortality and heart failure rehospitalization. A future adequately powered, multi-centre, placebo controlled, randomized, double dummy, blinded trial is needed to assess the benefit of hypertonic saline in patients with renal dysfunction, in diverse patient populations, as well using a patient population on optimal current heart failure treatment. Pending further validation, there is promise for hypertonic saline as an advanced therapy for the management of acute advanced CHF.

Increased Uptake of Guideline-Recommended Oral Antiplatelet Therapy: Insights from the Canadian Acute Coronary Syndrome Reflective

Current guideline-based recommendations for oral dual-antiplatelet therapy in an acute coronary syndrome (ACS) include the use of newer adenosine diphosphate receptor inhibitor (ADPri) regimens and agents. The Canadian ACS Reflective Program is a multicenter observational quality-enhancement project that compared the use of ADPri therapy in 2 phases (November 2011-March 2013 and April 2013-November 2013) and also compared ADPri use with previous national data from the Canadian Global Registry of Acute Coronary Events (2000-2008). Of 3099 patients with ACS, 30.6% had ST-segment elevation myocardial infarction (STEMI), 52.3% had non-STEMI, and 17% had unstable angina. There was high use of dual-antiplatelet therapy for ≤ 24 hours, with important increases noted when compared with previous national experience (P for trend, < 0.0001). Clopidogrel was the most commonly used ADPri (82.2%), with lower use of the newer agents ticagrelor (9.0%) and prasugrel (3.1%). Ticagrelor and prasugrel use was most frequent in patients with STEMI undergoing percutaneous coronary intervention PCI (34.3%). There was relatively lower use of ADPri therapy at discharge; it was given mainly to patients who did not undergo PCI (68.2%) and to those with non-ST-elevation ACS (82%). When comparing the 2 consecutive phases of data collection in the ACS Reflective, there was an approximate 3- and 2-fold increase in the early and discharge use of the newer ADPri agents, respectively. In conclusion, there has been a temporal increase in ADPri use compared with previous national experience and an increased uptake of newer ADPri agents. Additional work is needed to identify and address barriers limiting optimal implementation of these newer guideline-recommended agents into routine Canadian practice.

Double Trouble: A Case of Valvular Disease in Pregnancy.

Patient presentation: A 29-year-old woman born in Canada, gravida 3, para 2 at 12 weeks gestation, presented to the cardiac pregnancy clinic with a 1-month history of progressive shortness of breath on exertion and chest discomfort. Her medical history was significant for stenosis of a congenital bicuspid aortic valve for which she underwent surgical aortic valve replacement with a #23 Carpentier-Edwards Perimount Magna ease porcine bioprosthetic valve 5 years earlier at the age of 24. There was a questionable history of rheumatic fever at the age of 21; investigations revealed positive antistreptolysin and Sjögren-specific antibody A titers. She was treated with valproic acid for an irregular tremor thought to be Syndenham chorea. The pathology from her surgery did not reveal any evidence of rheumatic disease. She went on to have 2 successful pregnancies at the age of 26 and 27 years without complications. Her last formal review was 1 year before, during her second pregnancy at 34 weeks gestation. Echocardiography showed mild prosthetic valve aortic stenosis with a peak/mean gradient of 41/27 mm Hg, normal ejection fraction, with increased gradients across the prosthetic valve thought to be secondary to a high-output state. She became pregnant unexpectedly 9 months after her second pregnancy and now had progressive shortness of breath and typical angina on exertion; she was unable to climb 1 flight of stairs or push her baby’s stroller without having to stop for prolonged periods. Her medications included aspirin, monthly intramuscular penicillin, and maternal vitamins. On physical examination, her blood pressure was 105/66 mm Hg, heart rate 101 beats/min regular, and normal respiratory rate; oxygen saturation was 98% on room air. She was comfortable and in no acute distress. Jugular venous pressure was 5 cm above the sternal angle with a negative abdominojugular reflex. Carotid pulse was of normal volume and contour, with no audible bruits. There was a midline sternotomy scar and the apical impulse was sustained. Auscultation revealed a normal S1, grade 2 late-peaking systolic ejection murmur best heard at the base with radiation to the carotid base, soft S2, and no S3 or S4. Lungs were clear to auscultation bilaterally. There was no pedal edema, all peripheral pulses were palpable, and the abdomen was soft, nontender. A 12-lead ECG revealed sinus tachycardia, with normal axis, normal intervals, and borderline left ventricular hypertrophy by voltage criteria (Figure 1).

Comparison of radial to femoral PCI in acute myocardial infarction and cardiogenic shock: a systematic review

In randomized control trials and meta-analyses in patients with acute MI undergoing PCI, the radial artery (RA) approach compared to the femoral artery (FA) approach has shown to safely reduce access site related bleeding, length of hospitalization, and major adverse cardiac event (MACE) rates. However, these studies have excluded patients with cardiogenic shock. A systematic search was conducted to retrieve studies that investigated the safety of RA to FA PCI in patients with AMI and cardiogenic shock. Primary outcomes of interest was the pooled relative risk ratio (RR) of access site related bleeding. Secondary outcomes included (i) 30-day all cause mortality, (ii) major bleeding, (iii) final TIMI 3 flow, (iv) fluoroscopy time, and (v) amount of contrast volume administered. 6 observational studies with 7,753 patients met inclusion; 5,347 (69 %) with STEMI, 2,406 (31 %) with non-STEMI. In comparison of RA to FA PCI, there was less access site related bleeding (relative risk (RR) 0.11, p = 0.001), less 30-day mortality (RR 0.65, p = 0.0 < 0.001), and less major bleeding (RR of 0.46 p < 0.0001). There was no significant difference in final TIMI 3 flow (p = 0.27), fluoroscopy time (p = 0.95), and contrast volume administered (p = 0.59). In conclution, despite its limitations, our analysis demonstrates an association towards lower adverse events in the RA PCI group. Although we believe that the choice of access site in a high-risk setting should be at the operator discretion, if technically feasible, the RA appears to be a reasonable vascular access approach in high-risk patients in cardiogenic shock.

Automation, machine learning, and artificial intelligence in echocardiography: A brave new world

Automation, machine learning, and artificial intelligence (AI) are changing the landscape of echocardiography providing complimentary tools to physicians to enhance patient care. Multiple vendor software programs have incorporated automation to improve accuracy and efficiency of manual tracings. Automation with longitudinal strain and 3D echocardiography has shown great accuracy and reproducibility allowing the incorporation of these techniques into daily workflow. This will give further experience to nonexpert readers and allow the integration of these essential tools into more echocardiography laboratories. The potential for machine learning in cardiovascular imaging is still being discovered as algorithms are being created, with training on large data sets beyond what traditional statistical reasoning can handle. Deep learning when applied to large image repositories will recognize complex relationships and patterns integrating all properties of the image, which will unlock further connections about the natural history and prognosis of cardiac disease states. The purpose of this review article was to describe the role and current use of automation, machine learning, and AI in echocardiography and discuss potential limitations and challenges of in the future.

Elevated end-diastolic wall stress after acute myocardial infarction predicts adverse cardiovascular outcomes and longer hospital length of stay

Acute myocardial infarction (MI) leads to ventricular remodeling in response to oxygen demand. Such changes include left ventricular (LV) dilatation and increased myocardial wall stress. Prior studies showed that wall stress is a vital parameter of cardiac remodeling. However, outcome data are lacking. We aim to investigate wall stress post‐MI in relation to biomarkers of cardiac remodeling and cardiovascular outcomes.

MitraClip and Transcatheter Aortic Valve Replacement in a Patient With Recurrent Heart Failure

An 85-year-old man presented to the emergency department with a 3-week history of progressive dyspnea, orthopnea, and mild ankle edema without chest discomfort. His past medical history was significant for coronary artery disease with a non–ST-segment–elevation myocardial infarction 8 years prior with percutaneous coronary intervention to the distal right coronary artery, with mild residual nonobstructive disease in the left anterior descending artery and circumflex artery. Cardiovascular risk factors included hypertension, dyslipidemia, and chronic kidney disease stage 3. His remaining medical history was significant for cecal adenocarcinoma with a right hemicolectomy 20 years prior, and pulmonary sarcoidoisis that was quiescent without any history of steroid use or immunosuppression. The most recent pulmonary function tests revealed normal spirometry and diffusion capacity. He was a nonsmoker, and before the onset of symptoms he was functionally independent only using a cane for mobility. Initial vital signs revealed a regular heart rate of 81 bpm, and blood pressure of 121/78 mm Hg. He was afebrile, and his oxygen saturation was 95% on 2-L nasal prongs. Jugular venous pressure was elevated at 7 cm above the sternal angle with a normal waveform; the hepatojugular reflex was positive. The carotid pulse was of decreased volume but normal contour, without audible bruits. Auscultation revealed a normal S1 and S2, a holosystolic murmur at the apex, and a grade 2 midpeaking systolic ejection murmur at the base, with radiation to the carotids. Respiratory examination revealed clear and equal breath sounds bilaterally with the presence of bibasilar crackles at the lung bases. Peripheral pulses were present, with bilateral pitting edema at the ankles. Abdominal examination was unremarkable. Initial investigations revealed hemoglobin of 103 g/dL, and electrolytes within the normal range with a creatinine of 121 mmol/L (estimated glomerular filtration rate 50 mL/min). Troponin I (high sensitivity) was elevated with peak of …

SUCCESSFUL VALVE-IN-VALVE TAVI IN PREGNANCY FOR SEVERE DEGENERATIVE BIOPROSTHETIC AORTIC VALVE STENOSIS

Patients with prosthetic valves are at high risk for complications in pregnancy. 29-year-old female at 12 weeks gestation presented with dyspnea and exertional chest pain. Her medical history included congenital bicuspid aortic valve stenosis, at the age of 24 she underwent aortic valve replacement