Vamsi Kodumuri

Outcomes of nonemergent percutaneous coronary intervention with and without on-site surgical backup: a meta-analysis.

Despite major advances in percutaneous coronary intervention (PCI) techniques, the current guidelines recommend against elective PCI at hospitals without on-site cardiac surgery backup. Nonetheless, an increasing number of hospitals without on-site cardiac surgery in the United States have developed programs for elective PCI. Studies evaluating outcome in this setting have yielded mixed results, leaving the question unanswered. Hence, a meta-analysis comparing outcomes of nonemergent PCI in hospitals with and without on-site surgical backup was performed. A systematic review of literature identified four studies involving 6817 patients. Three clinical end points were extracted from each study and included in-hospital death, myocardial infarction, and the need for emergency coronary artery bypass grafting. The studies were homogenous for each outcome studied. Therefore, the combined relative risks (RRs) across all the studies and the 95% confidence intervals (CIs) were computed using the Mantel-Haenszel fixed-effect model. A two-sided alpha error less than 0.05 was considered to be statistically significant. Compared with facilities with on-site surgical backup, the risk of in-hospital death (RR, 2.7; CI, 0.6-12.9; P = 0.18), nonfatal myocardial infarction (RR, 1.3; CI, 0.7- 2.2; P = 0.29), and need of emergent coronary artery bypass grafting (RR, 0.46; CI, 0.06- 3.1; P = 0.43) was similar in those lacking on-site surgical backup. The present meta-analysis suggests that there is no difference in the outcome with regard to risk of nonfatal myocardial infarction, need for emergency coronary artery bypass grafting, and the risk of death in patients undergoing elective PCI in hospitals with and without on-site cardiac surgery backup.

A COMPARISON OF SIMPLE VERUS COMPLEX STRATEGY FOR CATHETER BASED TREATMENT OF CORONARY BIFURCATION LESIONS: META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

The optimal approach to catheter-based treatment of coronary bifurcation lesions is unknown. Clinical trials in this group of patients have yielded mixed results. We performed a comprehensive meta-analysis to compare the clinical outcomes for simple (provisional T-stenting) versus complex (routine T

Fixing the "broken heart": pharmacologic implications.

Broken-heart syndrome also known as Left ventricular apical ballooning syndrome or Stress-induced cardiomyopathy or Takotsubo cardiomyopathy is an important clinical entity, which presents clinically, similar to acute coronary syndrome with an acute onset of chest pain, ST-T changes in electrocardiogram, and moderate cardiac enzyme elevation. Recent studies have shown that it accounts for 1%–2% of cases of ST-elevation infarction. An episode of intense emotional or physiologic stress has been reported before its presentation and is presumed to be the triggering factor in the pathogenesis. The pathophysiology of this syndrome still remains unclear, and management is mostly empiric and supportive. In this review, we have discussed various pathophysiologic mechanisms underlying this cardiomyopathy and their pharmacological implications and role of medications such as aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and statins for patients presenting with this syndrome in treatment and prevention.

Comparison of low molecular weight heparin with unfractionated heparin during percutaneous coronary interventions: a meta-analysis

To conduct a meta-analysis of the current evidence to evaluate the safety and efficacy of low molecular weight heparin (LMWH) as compared to unfractionated heparin (UFH). Several studies have demonstrated the therapeutic advantage of LMWH over UFH in the medical management of acute coronary syndromes. However, evidence comparing the 2 in percutaneous coronary interventions (PCI) is inconclusive. Previously published meta-analysis did not include some large-scale trials. We performed a systematic literature search for randomized clinical trials that compared LMWH and UFH in urgent or elective PCI. Studies that evaluated efficacy end points [composite of nonfatal myocardial infarction (MI) and death with or without target vessel revascularization] and bleeding end points were included. Studies were excluded if they involved coadministration of thrombolytics. Data were extracted on an intention-to-treat basis. Heterogeneity of the studies was analyzed by Cochran Q statistics. The Mantel-Haenszel fixed-effect model was used to calculate combined relative risks for outcomes where studies were homogenous and the random effect model when the studies were heterogenic. Fourteen studies involving 12,394 patients were included. The efficacy and bleeding risk of LMWH in patients undergoing PCI were comparable with UFH. A subgroup analysis of studies using intravenous or intraarterial administration of LMWH, demonstrated them to be safer than UFH with comparable efficacy. LMWH is at least as efficacious and safe as UFH in patients undergoing PCI. Additionally, evidence suggests that LMWH, when used intravenously, is associated with lower bleeding risks when compared with UFH.

Rare Presentation of Lupus Myocarditis With Acute Heart Failure-A Case Report.

Systemic lupus erythematosus is an autoimmune disease with diffuse organ involvement. The cardiac complications include pericarditis, myocarditis, pulmonary hypertension, coronary vasculitis, and Libman-Sacks endocarditis. Symptomatic lupus myocarditis presenting with left ventricular dysfunction, acute heart failure, and pulmonary edema, although rare, is a life-threatening complication. We report the occurrence of acute lupus myocarditis in a 38-year-old postpartum female who had a cesarean section a week before presentation for preeclampsia. Initially she was managed for pneumonia but later found to have acute pericarditis and myocarditis related to systemic lupus erythematosus. She had a complicated hospital course including acute respiratory failure and cardiogenic shock. She was started on pulse dose steroids besides the treatment for heart failure and had a dramatic improvement within days.