Vikas Bhalla

Correlation and Prognostic Utility of B-Type Natriuretic Peptide and Its Amino-Terminal Fragment in Patients With Chronic Kidney Disease

This study compared the correlation and prognostic utility of B-type natriuretic peptide (BNP) and the N-terminal fragment of proBNP (NT-proBNP) in 171 outpatients with renal dysfunction. The NT-proBNP correlated well with BNP in all cases (r = 0.911; P pound .01), regardless of degree of renal impairment or type of left ventricular dysfunction. BNP and NT-proBNP concentrations (P < .005) and their ratios (P pound .01) increased as the glomerular filtration rate (GFR) declined, indicating a greater effect of GFR on NT-proBNP levels. Both natriuretic peptide levels were higher in patients with systolic dysfunction (P < .05) compared with patients with normal echocardiograms. In contrast, BNP and NT-proBNP levels were below the diagnostic cutoffs for congestive heart failure exacerbations in patients with normal heart function or diastolic dysfunction, with no statistical difference between these groups (P = .99). Both peptides are useful prognostic tools for predicting mortality and cardiac hospitalization in renal patients.

Cardiac biomarkers: a contemporary status report

The field of cardiac biomarkers has grown by leaps and bounds in the past two decades. In this review we try to summarize the explosion of emerging knowledge and address the roles of some of the biomarkers that have either proven or potential utility. We detail some of the markers of ischemia, hemodynamic markers of heart failure, inflammatory markers, and the novel and innovative approach of combining these for a multimarker strategy. At the end of this review we highlight some of the biomarker-guided approaches and strategies that might lead to better and more-effective care of patients.

Oesophageal motor functions and its disorders

The function of the oesophagus is relatively straightforward—to transport the swallowed food into the stomach. In order to meet this functional need, the design of the oesophagus is simple; a relatively straight muscular tube that is guarded at it two ends by the upper and lower oesophageal sphincters. Following a voluntary act of a swallow, the two sphincters relax and open and a contraction wave or peristalsis sweeps behind the bolus autonomously. The contraction wave sweeps through the entire length of the oesophagus followed by closure of the two sphincters. Neuromuscular control mechanisms that bring about normal functioning of the two sphincters and oesophageal peristalsis are complex and require fine coordination of the muscles and nerves at the level of the central and peripheral nervous system. Disturbance of sphincters and peristalsis causes symptoms of dysphagia and oesophageal pain. The latter may manifest either as chest pain (pressure-like sensation) or heartburn (retrosternal burning). The nature of dysfunction in oesophageal motor disorders has been the subject of intense investigation for several decades. In this paper, we will review briefly the physiology of oesophageal peristalsis and lower oesophageal sphincter and then attempt to understand what may be wrong in motor disorders of the oesophagus. Novel pharmacological approaches to treat oesophageal motor disorders are also discussed. The anatomy of the oesophagus is unique; it is made up of skeletal muscle in the upper one third, a mixture of skeletal and smooth muscle in the middle one third, and smooth muscle only in the distal one third in humans. The upper oesophageal sphincter is composed of all skeletal muscle and the lower oesophageal sphincter of all smooth muscle. The muscularis propria of the oesophagus, similar to the rest of the gastrointestinal tract, is made of two distinct muscle layers that are arranged in a circular …

Oesophageal wall stress and muscle hypertrophy in high amplitude oesophageal contractions

Abstract  Excessive wall stress is a known stimulus for muscle growth. We recently reported a thickened muscularis propria in patients with high amplitude oesophageal contractions (HAEC). The goal of this study was to determine oesophageal wall stress in normal subjects and patients with HAEC. A manometry catheter equipped with a high frequency ultrasound (US) transducer was used to record pressure and US images simultaneously in 10 healthy subjects and 11 patients with HAEC. Recordings were obtained at 2 and 10 cm above the lower oesophageal sphincter during water swallows. The changes in circumferential wall stress during oesophageal contraction in both groups are relatively small because of an increase in the wall thickness‐to‐radius ratio during contraction. Patients show a greater muscle thickness than normal subjects at rest and at the peak of contraction. The wall stress in patients is elevated at the 2 cm but not at the 10‐cm level as compared to normal subjects. Wall strain is not different between the two groups. Increase in wall thickness during oesophageal contraction maintains low wall stress. A greater wall stress in patients with HAEC may be a stimulus for the increased wall thickness.

B-Type Natriuretic Peptide and Impedance Cardiography at the Time of Routine Echocardiography Predict Subsequent Heart Failure Events

BACKGROUND Detection of heart failure (HF) in stable outpatients can be difficult until an overt event occurs. This study sought to determine whether the combination of B-type natriuretic peptide (BNP) and impedance cardiography (ICG) could be used in a nonacute clinical setting to risk stratify and predict HF-related events in stable outpatients. METHODS AND RESULTS Patients undergoing routine outpatient echocardiography underwent ICG and BNP testing and were followed for one year for HF-related events (Emergency Department [ED] visit or hospitalization due to HF or all-cause death). A total of 524 patients were analyzed, resulting in 57 HF-related events; 16 ED visits, 17 hospitalizations, and 24 all-cause deaths. Using Cox regression analyses, BNP and systolic time ratio index (STRI) by ICG proved to be the strongest predictors of future HF-related events. Patients with a BNP >100 pg/ml and STRI >0.45 sec(-1) had a significantly lower event-free survival rate than those with a high BNP and low STRI (67% versus 89%, P=.001). In patients with LV dysfunction only, if both BNP and STRI values were high, the relative risk of a HF-related event increased by 12.5 (95 % C.I. 4.2-36.7), when compared with patients with a low BNP and low STRI (P<.001). CONCLUSIONS In a nonacute clinical setting, both BNP and ICG testing can provide unique predictive power of long-term HF-related events in a stable cohort of patients with and without LV dysfunction.

Evolution of B-type natriuretic peptide in evaluation of intensive care unit shock*

Congestive heart failure (CHF) is a major and increasing cause of death and disability in United States. Its prevalence is attributable to the drastic increase in cardiovascular risk factors such as obesity and diabetes and improved survival rate after acute myocardial infarction (and subsequent dev

Prognostic significance of abnormal P wave morphology and PR-segment displacement after ST-elevation myocardial infarction

INTRODUCTION Atrial infarction is uncommonly diagnosed and data on its significance are limited. Its incidence in ST-elevation myocardial infarction (STEMI) reportedly ranges from 0.7-42%. Certain atrial ECG changes, such as abnormal P wave morphology suggestive of atrial involvement have been associated with 90-day mortality after STEMI. However, whether atrial ECG changes are associated with short (30-day) or long-term (1-year) mortality have not been studied. METHODS We examined index ECG in 224 consecutive STEMI. Demographics, clinical variables, peak troponin I, ejection fraction, and angiographic data were collected. Atrial ECG patterns were examined and correlated with mortality. RESULTS Length of stay was longer with abnormal P waves (p=0.008) or PR displacement in any lead (p=0.003). Left main coronary disease was more prevalent with abnormal P wave (p=0.045). Abnormal P wave morphology in any lead was associated with higher 30-day (OR 3.09 (1.35-7.05)) and 1-year mortality (OR 5.33 (2.74-10.36)). PR displacement in any lead was also associated with increased 30-day (OR 2.33 (1.03-5.28)) and 1-year mortality (OR 6.56 (3.34-12.86)). Abnormal P wave, PR depression in II, III and AVF, and elevation in AVR or AVL were associated with increased 1-year mortality (OR 12.49 (5.2-30.0)) as was PR depression in the precordial leads (OR 21.65 (6.82-68.66)). After adjusting for age, ejection fraction, peak troponin I, and left main disease, PR displacement in any lead was associated with increased 1-year mortality (adjusted OR 6.22 (2.33-18.64)). CONCLUSION PR segment displacement in any lead, found in 31% of patients with STEMI, independently predicted 1-year mortality.

Mitral Annular Calcification as a Possible Nidus for Endocarditis: A Descriptive Series with Bacteriological Differences Noted.

Background: Mitral annular calcification (MAC) is a chronic inflammatory process with similarities to atherosclerosis. It is common in elderly patients and those with renal dysfunction. Although MAC is associated with cardiovascular morbidity, its relationship to infective endocarditis is unclear. The aim of this study was to test the hypothesis that MAC would be prevalent in patients with mitral valve vegetations and that vegetations would frequently occur on calcific nodules. A secondary aim was to look for possible bacteriological differences between vegetations attached to the calcified annulus versus leaflet vegetations. Methods: We retrospectively reviewed all echocardiographic studies of patients with native mitral valve vegetations from January 2007 to August 2015 (N = 56). We searched for (1) presence of MAC, (2) location of MAC, and (3) vegetation location (on calcium deposits or distant). MAC was defined as focal echo brightness in a nodular or band‐like pattern. The modified Duke criteria were used to confirm the diagnosis of infective endocarditis. Transthoracic, transesophageal, and three‐dimensional echocardiograms (when available) at the time of infection were evaluated by a single reader. Results: Twenty‐eight subjects were infected with Staphylococcus aureus, 17 with a streptococcal species, and five with other organisms; blood cultures were sterile in 6. Thirty‐four (61%) subjects had some degree of MAC, while 22 (39%) had none. Among those with MAC, the vegetation was located on the calcium deposits in 22 (65%), versus in 12 (35%) where it was not. Among all 56 subjects, when S. aureus was the infecting organism it was present on MAC in 16/28 (57%) versus 6/28 (21%; P = .01) for other bacterial species. By contrast, streptococcal infections more frequently involved the leaflets (16/17 [94%]) versus nonstreptococcal infections (18/39 [46%]; P = .0008). Conclusions: MAC may act as a nidus for infection especially with S. aureus. Differences in mechanism of attachment between S. aureus and streptococci may account for the observed difference in frequency of attachment of vegetations to MAC. HighlightsMitral annular calcification is an inflammatory process that can serve as a nidus for infective endocarditisVegetations arising from the calcified annulus are frequently due to S. aureus.Infections involving the calcified annulus sometimes produce large, speckled vegetations; these possibly represent destruction of annular tissue resulting in distribution of flecks of calcium throughout the vegetation.

QRS duration and left ventricular ejection fraction (LVEF) in non-ST segment elevation myocardial infarction (NSTEMI).

BACKGROUND Non-traditional EKG parameters such as QRS pattern and QRS duration (QRSd) are being investigated in acute coronary syndrome as prognostic markers. Following an infarction, the heart attempts to compensate for myocardial loss through remodeling which eventually lowers the ejection fraction (LVEF). Our objective is to evaluate the relationship between the QRSd at the time of NSTEMI and extent of coronary artery disease (CAD) and changes in LVEF. METHODS AND RESULTS Patients admitted with NSTEMI between 08/01/2006 and 9/30/2012 were included. Patients were classified into high or low QRSd at cutoff value of 90ms noted on initial EKG after excluding bundle-branch block. A total of 536 patients with mean age of 66±14years were included. 49% were male and majority were African American (73%). Patients within the higher QRSd group had a lower LVEF at the time of the NSTEMI compared to those with QRSd <90ms (47±15% vs. 50±13%; p<0.038). The LVEF remained lower in the high QRS group on follow up to 12months (47±15% vs. 52±11%; p<0.001). The high QRSd group had a higher incidence of severe LV dysfunction at baseline (27% vs. 18%; p<0.045). Logistic regression analysis revealed that a QRSd ≥90ms was also independently associated with a severely reduced LVEF on follow-up (OR=2.7; CI 1.55-4.69; p<0.001). CONCLUSION QRSd ≥90ms at the time of NSTEMI is predictive of three-vessel/left main coronary artery involvement and a lower LVEF. This depression in LVEF is maintained for up to 12months. Thus, the QRSd at time of NSTEMI has additional prognostic significance.

Validation of digital ankle-brachial index as a screening tool in symptomatic patients with peripheral arterial disease

INTRODUCTION There is scarcity of data validating portable digital ankle-brachial index (ABI) with contrast angiography in peripheral arterial disease (PAD). Our aim was to provide an objective analysis of the relationship between digital ABI (dABI) and peripheral angiographic data. METHODS Consecutive patients with symptoms of PAD between May 2014 to May 2015 at Einstein Medical Center, Philadelphia, who were undergoing simultaneous dABI and peripheral angiography, were evaluated. Measurements were made using the FloChec™ Digital ABI system (Bard) prior to the scheduled peripheral angiogram. RESULTS The final cohort consisted of 51 patients. Mean age was 68.8 ± 9.5 years with 55% being male. Aorto-iliac disease accounted for 13% of the total lesions, while femoro-popliteal lesions comprised 55%. The FloChec™ digital ABI had a sensitivity of 84% and a positive predictive value of 84%. The area under the receiver operating characteristic curve was 0.74 (p = 0.007). On multivariate analysis, FloChec™ digital ABI was still an independent predictor of PAD, Odds ratio 6.8 (2.3-20.6, p = 0.001). CONCLUSION A portable, point-of-care digital ABI system can be used as a valuable, simple, cost-effective and reliable screening tool with high sensitivity and accuracy. To date, ours is the first study validating FloChec™ digital ABI with the gold standard angiographic data.