Wassef Karrowni

Statin Therapy Reduces Growth of Abdominal Aortic Aneurysms

Background The aim of this study was to evaluate the influence of statins on the growth of small abdominal aortic aneurysms (AAAs). Methods We retrospectively examined AAA diameter in 211 patients who had undergone serial imaging surveillance. Results Patients treated with and without statins were similar regarding age, initial aneurysm size, diagnosis of diabetes and hypertension, and smoking history. Patients receiving statins had a decreased aneurysm growth rate compared with those patients not receiving statins (0.9 mm/y [interquartile range, −1.0 to +1.0] vs 3.2 mm/y [interquartile range, 2.0–4.9], P < 0.0001). This difference in the rate of growth was maintained after adjusting for potential confounding factors. Conclusions To date, this is the one of the largest retrospective studies demonstrating an association between statin use and decreased growth rate of AAA.

Insulin Resistance Is Associated With Significant Clinical Atherosclerosis in Nondiabetic Patients With Acute Myocardial Infarction

Objective—The prevalence of insulin resistance (IR) is increasing worldwide because of increasing age, obesity, and physical inactivity. Emerging evidence supports a direct proatherogenic effect of IR on the coronary vasculature, but the relation between IR and angiographic atherosclerosis in a real-world clinical setting is uncertain. In this work, we assessed whether IR is independently associated with clinically significant angiographic atherosclerosis in nondiabetic individuals. Approach and Results—We examined the association between IR and the extent of coronary atherosclerosis determined by angiography in 1073 nondiabetic patients surviving acute myocardial infarction. Patients were divided into quartiles on the basis of the homeostasis model assessment grading of IR, and associations between IR and multivessel coronary artery disease, defined as ≥2 arteries with ≥70% stenosis (or ≥50% left main stenosis), were analyzed in bivariate and multivariable modeling. Overall, the cohort had a median age of 56 years; 28.9% women and 21.8% nonwhite. The crude prevalence of multivessel coronary artery disease was 37.8%, 42.3%, 47.2%, and 48.0% for homeostasis model assessment grading of IR quartiles 1, 2, 3, and 4, respectively (Ptrend=0.009). In multivariable modeling, compared with quartile 1, both quartile 3 (relative risk [95% confidence interval], 1.31 [1.07–1.60]) and quartile 4 (1.29 [1.03–1.60]) were independently associated with multivessel coronary artery disease. Covariates in the model included patient demographic and clinical characteristics and metabolic factors (low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, triglyceride, glycosylated hemoglobin, and high-sensitivity C-reactive protein). Conclusions—We demonstrate an independent association between IR and multivessel coronary artery disease in nondiabetic postmyocardial infarction patients. Our findings strengthen the experimental evidence for a direct atherogenic effect of IR independent of glucose control and other components of the metabolic syndrome.

Left Main Coronary Artery Compression by an Enlarged Pulmonary Artery

![Figure][1] [Online Video 1][2] Severe ostial stenosis of the left main coronary artery depicted in a caudal left anterior oblique view. ![Figure][1] [Online Video 2][3] A caudal right anterior oblique view demonstrating the close proximity of the enlarged pulmonary artery to the

Diastolic Heart Failure The Current Understanding and Approach for Management With Focus on Intensive Care Unit Patients

Multiple recent epidemiologic studies have highlighted the importance of diastolic heart failure (DHF) as a public health problem. Approximately half of patients presenting with symptomatic heart failure (HF) have DHF and they suffer from morbidity and mortality comparable to those with systolic HF. Our understanding of the pathophysiology of DHF has evolved rapidly over the last decade, and the associated echo-Doppler findings that assist with its diagnosis are greatly refined. Recently, there has been increased recognition of the role of diastolic dysfunction and DHF in the care of critically ill patients, including those admitted to noncardiac units. The purpose of this review is to provide an up-to-date summary of the concepts of the pathophysiology of DHF. In addition, we provide an overview of the diagnostic approaches, prognostic identifiers, and associated comorbidities that make DHF more resistant to manage with a focus of the patients admitted to the intensive care unit. The current approach to managing patients with DHF is also reviewed.

Meta-analysis of same versus different stent for drug-eluting stent restenosis.

Drug-eluting stent (DES) in-stent restenosis (ISR) can be treated by restenting using the same DES as previously placed (same stent strategy), versus switching to a stent that elutes a different drug (different stent strategy). To compare the efficacy of these strategies, a meta-analysis of controlled trials and observational studies evaluating patients with DES ISR was performed. The primary outcome was target lesion revascularization or target vessel revascularization, and secondary outcomes were major adverse cardiovascular events, death, and myocardial infarction. Pooled odds ratios (ORs) were calculated with the generic inverse variance method using a random-effects model. The chi-square test was used to evaluate heterogeneity. Ten studies (1,680 patients) were included. There was no significant heterogeneity among the studies for any end point. The different stent strategy was found to reduce the odds of target lesion revascularization or target vessel revascularization (OR 0.73, 95% confidence interval [CI] 0.55 to 0.96) and major adverse cardiovascular events (OR 0.72, 95% CI 0.54 to 0.96). There was no difference between the 2 strategies in rates of death (OR 1.03, 95% CI 0.49 to 2.16) or myocardial infarction (OR 0.59, 95% CI 0.24 to 1.41). In conclusion, this study demonstrates that treatment of DES ISR by restenting with a different DES than previously placed may lead to improved outcomes compared with the use of the same DES. Further large-scale trials are needed to confirm this effect.

Coronary collateral circulation: Its relevance

The interest in coronary collateral circulation (CCC) as “natural bypasses” is growing, especially in patients in whom the extent of coronary atherosclerosis is too severe to allow for conventional revascularization. The anatomic foundation of CCC has been recognized for long time. Recently, reliable methods have become available for the assessment of the adequacy of collateral flow. However, the debate regarding the importance of CCC in the different clinical settings continues. In this article, we present the recent progress in the understanding of anatomy and physiology of the CCC and focus on the studies addressing their functional significance in acute, subacute, and chronic coronary artery disease. In addition, we provide a focused update on the essential role of collateral circulation in the management of coronary chronic total occlusions.

Outcome comparison of 600 mg versus 300 mg loading dose of clopidogrel for patients with ST-elevation myocardial infarction: a meta-analysis.

Abstract Background: A 600-mg loading dose (LD) of clopidogrel has been shown to be superior to a 300-mg LD in inhibiting platelet function. However, data for clinical superiority are limited, and there is a paucity of adequately powered randomized trials investigating this issue. This meta-analysis was performed to determine the optimal LD of clopidogrel in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Methods: A meta-analysis of controlled trials and observational studies was performed comparing 600-mg with 300-mg LDs of clopidogrel. The primary efficacy end point was a major adverse cardiac event (MACE), and the primary safety end point was major bleeding. Data were extracted on an intention to treat basis. The X2 test was used to evaluate heterogeneity. A random effects model was used, and odds ratios (OR) were calculated using the Mantel-Haenszel method. Results: Nine studies involving 18 623 patients were included in the efficacy analysis. Mean duration of follow-up was 8 months. Four studies were eligible for the safety analysis. The MACE risk was lower with a 600-mg LD (7.0% [650/9231]) than with a 300-mg LD (9.2% [867/9392]; OR, 0.75; 95% CI, 0.63-0.91). On the other hand, there was no significant difference in the major bleeding events between the 2 groups (2.5% [89/3551] with 600 mg vs 2.3% [63/2796] with 300 mg; OR, 0.84; 95% CI, (0.60-1.16). Conclusions: In ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention, administration of a 600-mg LD of clopidogrel is associated with a lower risk of MACE than is administration of a 300-mg LD, without increasing the risk of major bleeding.

OBESITY PARADOX AMONG SURVIVORS OF ACUTE MYOCARDIAL INFARCTION AND ITS INTERACTION WITH TIME

Obese patients are known to have a lower 1-year mortality after AMI compared to normal weight patients. However, it is unknown whether this obesity paradox persists over time. As metabolic abnormalities in the obese may take longer to display their effects, disparities in outcome may manifest later

A Meta-analysis of Ostial and Trunk versus Distal Lesions in Unprotected Left Main Coronary Artery Stenting.

Aims: To assess outcomes for percutaneous coronary intervention (PCI) in ostial and trunk versus distal unprotected left main coronary artery (LMCA) lesions in the drugeluted stent (DES) era. Study Design: A meta-analysis and systematic review. Methods: With the help of a librarian, we searched Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the Clinical Trials Registry from 2001 to July 2012.We included studies that enrolled ≥ 50 patients and had ≥6 months of follow-up. Our co-primary endpoints were the incidence of major adverse cardiac events (MACE) and target lesion/vessel revascularization

COMPARISON OF 600MG VERSUS 300MG LOADING DOSE OF CLOPIDOGREL FOR PATIENTS WITH STEMI: A META-ANALYSIS

The optimal loading dose (LD) of clopidogrel in ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI) is not well established. The current AHA/ACC STEMI guidelines recommend 300–600mg as LD. We undertook a meta-analysis of controlled