Vijayapraveena Paruchuri

Spontaneous baroreflex sensitivity: Prospective validation trial of a novel technique in survivors of acute myocardial infarction

BACKGROUND Low baroreflex sensitivity (BRS) indicates poor prognosis after acute myocardial infarction. Noninvasive BRS assessment is complicated by nonstationarities and noise in electrocardiogram and pressure signals. Phase-rectified signal averaging is a novel signal processing technology overcoming these problems. OBJECTIVE To prospectively validate a BRS measure (baroreflex sensitivity assessed by means of phase-rectified signal averaging [BRS(PRSA)]) based on this technology. METHODS Nine hundred forty-one consecutive acute myocardial infarction survivors aged 80 years or younger in sinus rhythm were prospectively enrolled at 2 German university hospitals. All patients underwent 30-minute recordings of electrocardiogram and arterial blood pressures (Portapres; TNO-TPD Biomedical Instrumentation, Amsterdam, Netherlands) within the first 2 weeks after myocardial infarction. BRS(PRSA) was prospectively dichotomized at 1.58 ms/mm Hg. Primary end point was all-cause mortality at 5 years. Multivariable analyses included Global Registry of Acute Coronary Events score (dichotomized at ≥120), sex, BRS(PRSA), left ventricular ejection fraction (dichotomized at ≤35%), and diabetes mellitus. BRS(PRSA) was compared with 3 standard noninvasive BRS measures, that is, the sequence method, the transfer function method, and the correlation method. RESULTS During follow-up, 72 patients (7.7%) died. BRS(PRSA) stratified the study population into a high-risk group of 405 patients (≤1.58 ms/mm Hg) with an estimated 5-year mortality of 14.2% and a low-risk group of 536 patients (>1.58 ms/mm Hg) with a 5-year mortality of 2.8% (P <.0001). On multivariable analysis, BRS(PRSA) ≤ 1.58 ms/mm Hg was associated with a hazard ratio of 3.1 (confidence interval 1.7-5.6; P = .001). Predictive power of BRS(PRSA) ≤ 1.58 ms/mm Hg was particularly strong in patients with a Global Registry of Acute Coronary Events score of ≥120 or with a left ventricular ejection fraction of ≤35%. CONCLUSION BRS(PRSA) is a powerful and independent predictor of mortality in postinfarction patients especially when assessed in patients with a Global Registry of Acute Coronary Events score of ≥120 or a left ventricular ejection fraction of ≤35%.

Indications and imaging for aortic surgery: size and other matters.

OBJECTIVES To review the current general concepts and understanding of the natural history of thoracic aortic aneurysm and their clinical implications. METHODS Data on the the normal thoracic aortas were derived from the database of the Multi-Ethnic Study of Atherosclerosis (n = 3573), representative of the general population. Data on diseased thoracic aorta were derived from the database of the Aortic Institute at Yale-New Haven Hospital (n = 3263), representative of patients with thoracic aortic aneurysm and dissection. RESULTS Our studies have shown that the normal aorta in the general population is small (3.2 cm for the ascending aorta). Aortas larger than 5 cm are rare in the real world. The aneurysmal aorta grows at a mean of 0.2 cm/y, and larger aneurysms grow faster than do smaller ones. The dissection size paradox (which shows some aortic dissections occurring at small aneurysm sizes) is explained by the huge number of patients with small aortas in the general population. Genetic testing of patients with thoracic aortic disease helps identify genes responsible for aortic aneurysm and dissection. New imaging techniques such as 4-dimensional magnetic resonance imaging may add engineering data to our decision making. CONCLUSIONS Size continues to be a strong predictor of natural complications and a suitable parameter for intervention. As we enter the era of personalized aneurysm care, it is likely that specific genetic mutations will facilitate the determination of the appropriate size criterion for surgical intervention in individual cases.

Is intra‐procedure three‐dimensional transesophageal echocardiogram an alternative to preprocedure multidetector computed tomography for the measurement of the aortic annulus in patients undergoing transcatheter aortic valve replacement?

The role of three‐dimensional transesophageal echocardiography (3DTEE) vs multidetector computed tomography (MDCT) in aortic annular sizing has been poorly defined in patients undergoing transcatheter aortic valve replacements (TAVR). We set to determine the correlation between 3DTEE and MDCT in measuring the aortic annulus prior to TAVR.

ASSESSMENT OF CHANGE IN CLINICAL PRACTICE USING THE UPDATED 2009 AMERICAN COLLEGE OF CARDIOLOGY/ AMERICAN SOCIETY OF NUCLEAR CARDIOLOGY FOR APPROPRIATENESS CRITERIA SINGLE-PHOTON EMISSION COMPUTED TOMOGRAPHY MYOCARDIAL PERFUSION IMAGING

In 2009 the American College of Cardiology/ American Society of Nuclear Cardiology (ACC/ASNC) updated the 2005 appropriateness criteria categorizing the various indications for the performance of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI). We sought to

IMPACT OF THE UPDATED 2009 AMERICAN COLLEGE OF CARDIOLOGY/ AMERICAN SOCIETY OF NUCLEAR CARDIOLOGY APPROPRIATENESS CRITERIA FOR SINGLE-PHOTON EMISSION COMPUTED TOMOGRAPHY MYOCARDIAL PERFUSION IMAGING

In 2009 the American College of Cardiology/ American Society of Nuclear Cardiology (ACC/ASNC) updated the 2005 appropriateness criteria categorizing the various indications for the performance of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI). We sought to

LATE GADOLINIUM ENHANCEMENT PREDICTS CARDIAC EVENTS IN NON-ISCHEMIC CARDIOMYOPATHY: A META-ANALYSIS

Presence of late gadolinium enhancement (LGE) on cardiac MRI (CMR) in non-ischemic cardiomyopathy (NICM) may predict adverse cardiac events. Current published studies are limited by sample size and varying outcomes. We sought to better evaluate the utility of LGE in NICM with a meta-analysis. A

EVALUATION OF GUIDELINE-BASED APPROPRIATE ICD PLACEMENT AND THERAPY AMONG HYPERTROPHIC CARDIOMYOPATHY PATIENTS REFERRED FOR QUARTERNARY CARE

Hypertrophic cardiomyopathy (HCM) is known to cause sudden cardiac death (SCD) in a proportion of affected patients. The most effective treatment for primary prevention of SCD is the placement of an implantable cardioverter defibrillator (ICD), though no treatment guidelines were in place until