Xiushui Ren

Detection of Paroxysmal Atrial Fibrillation by 30-Day Event Monitoring in Cryptogenic Ischemic Stroke The Stroke and Monitoring for PAF in Real Time (SMART) Registry

Background and Purpose— Patients with cryptogenic ischemic stroke may have undetected paroxysmal atrial fibrillation (PAF). We established the Stroke and Monitoring for PAF in Real Time (SMART) Registry to determine the yield of 30-day outpatient PAF monitoring in cryptogenic ischemic stroke. Methods— The SMART Registry was a 3-year, prospective multicenter registry of 239 patients with cryptogenic ischemic stroke undergoing 30-day outpatient autotriggered PAF detection in Kaiser Permanente Northern California. Results— In intention-to-monitor analysis, PAF was detected in 29 of 239 patients (12.1%; 95% CI, 8.6%–16.9%). After retrospective chart review was performed, a new diagnosis of PAF was confirmed in 26 of 236 patients (11.0%; 95% CI, 7.6%–15.7%). The majority of detected PAF events were asymptomatic; only 6 of 98 recorded PAF events (6.1%) were patient-triggered or associated with symptoms. Conclusions— -Approximately 1 in every 9 patients with cryptogenic ischemic stroke was found to have new PAF within 30 days. Routine monitoring in this population should be strongly considered.

Comparison of Outcomes Using Bare Metal Versus Drug-Eluting Stents in Coronary Artery Disease Patients With and Without Human Immunodeficiency Virus Infection

Patients with human immunodeficiency virus (HIV) who undergo percutaneous coronary intervention have a substantial risk of subsequent cardiovascular events. However, outcome data from HIV-infected patients who receive drug-eluting stents (DESs) are limited. We hypothesized that HIV-infected patients treated with DESs would have fewer recurrent cardiac events compared with those who receive bare metal stents (BMSs). We evaluated 97 HIV-infected patients and 97 non-HIV control patients who had undergone percutaneous coronary intervention between January 2000 and July 2007. Clinical, laboratory, and angiographic data were obtained by chart review. Major adverse cardiovascular events (MACE), defined as clinically driven coronary revascularization, nonfatal myocardial infarction, and cardiovascular death, were adjudicated by 2 independent physicians. The mean age of the HIV cohort was 53 years, and all patients were men. Compared with non-HIV patients, HIV-infected patients were less likely to have hypertension, diabetes mellitus, and previous coronary artery disease and were more likely to have been treated with longer stent length and more stents. During a mean follow-up of 3.1 years, patients who received a DES had a lower rate of MACE compared with those who had received a BMS, regardless of HIV status. After multivariate adjustment for baseline characteristic differences, non-HIV-DES patients had 65% fewer MACE and HIV-DES patients had 60% fewer MACE compared with non-HIV-BMS patients. In conclusion, these data suggest that treatment with DESs in the HIV population is safe and efficacious.

Usefulness of Diastolic Dominant Pulmonary Vein Flow to Predict Hospitalization for Heart Failure and Mortality in Ambulatory Patients With Coronary Heart Disease (from the Heart and Soul Study)

Diastolic dysfunction is usually identified by the combination of characteristic mitral and pulmonary vein flow patterns. However, obtaining a complete set of echocardiographic parameters can be technically difficult and data may conflict. We hypothesized that as a stand-alone variable, (ventricular) diastolic dominant pulmonary vein flow would predict heart failure (HF) hospitalizations and cardiovascular death. Standard transthoracic echocardiograms were obtained in 906 subjects from the Heart and Soul Study, a prospective study of the effects of depression on coronary heart disease. Pulmonary vein flow pattern was determined using the dominant velocity-time integral. Cardiac events were determined by 2 independent adjudicators, and Cox proportional hazards models were used. Systolic dominant pulmonary vein flow was present in 89% of subjects, and diastolic dominant, in the remaining 11%. During an average 4.1 years of follow-up, subjects with diastolic dominant pulmonary vein flow had a 25% rate of HF hospitalization and 9% rate of cardiovascular death. After multivariate adjustment including left ventricular ejection fraction, diastolic pulmonary vein flow was associated with a 3-fold risk of HF hospitalization (p = 0.001) and a 2-fold risk of HF hospitalization or death (p = 0.004). In conclusion, diastolic dominant pulmonary vein flow pattern was a stand-alone predictor of adverse cardiac events, and its presence was associated with significantly higher rates of HF hospitalizations and cardiovascular death.

Relation of Concentric Remodeling to Adverse Outcomes in Patients With Stable Coronary Artery Disease (from the Heart and Soul Study)

Concentric remodeling (CR) is defined as increased left ventricular (LV) wall thickness with normal total LV mass. When encountered in populations with hypertension or patients undergoing aortic valve replacement, some studies have shown that CR predicts cardiovascular (CV) events and stroke. To expand our understanding of the prognostic implications of this common echocardiographic finding, we examined the association of CR and adverse CV events in ambulatory patients with coronary artery disease (CAD). We tested the hypothesis that finding CR on echocardiogram in ambulatory CAD independently predicts heart failure hospitalizations and CV death. Transthoracic echocardiograms were recorded in 973 participants from the Heart and Soul Study. Participants were divided into 4 groups: normal, CR, concentric LV hypertrophy, and eccentric LV hypertrophy. CV events were determined by 2 independent adjudicators and these were analyzed by Cox proportional hazards models. After mean 4.9 ± 1.5 years of follow-up, adverse outcomes occurred more frequently in those with concentric and eccentric LV hypertrophy but not in those with CR. After multivariate adjustment, concentric and eccentric LV hypertrophies were associated with increased risk of death and heart failure hospitalization, whereas CR was not. In conclusion, our hypothesis was not supported because CR was not associated with adverse CV events in our cohort of patients with stable CAD.

Aortic Dissection Manifesting as ST-Segment–Elevation Myocardial Infarction

An 80-year-old man presented to the emergency department with acute chest discomfort. An ECG showed sinus rhythm with 1-mm ST-segment elevation in the inferior limb leads. He was brought to the cardiac catheterization laboratory for primary percutaneous coronary intervention. Selective angiography of the left coronary system showed no obstructive disease. The initial attempt to selectively engage the right coronary artery (RCA) was unsuccessful, and contrast injection through the JR-4 catheter showed aortic regurgitation (Figure 1 and Movie I in the online-only Data Supplement). After …

Electrical alternans and pulsus paradoxus

A 65-year-old man with chronic obstructive pulmonary disease and right lung nodule presented with dyspnea. Physical examination revealed a pulse of 130 beats per minute, respiratory rate of 28 times per minute, blood pressure of 100/ 60 mm Hg, estimated jugular venous pressure of greater than 15 cm above the right atrium at a 45-degree semirecumbent position, and distant heart sounds. He subsequently developed hypotension and an arterial line was placed. A single-channel electrocardiogram (Figure 1A; upper tracing) demonstrated electrical alternans. Simultaneous arterial line (Figure 1A; lower tracing) showed decreased systolic blood pressure from 136 mm Hg (Figure 1A; arrow) to 96 mm Hg (Figure 1A; arrowhead) with inspiration, consistent with exaggerated pulsus paradoxus. A transthoracic echocardiogram confirmed a large pericardial effusion with the heart oscillating from side (Figure 1B) to side (Figure 1C) within the pericardial sac. Pericardiocentesis was performed and 1100 mL of bloody pericardial fluid was removed with prompt resolution of hypotension, tachycardia, electrical alternans, and abnormal pulsus paradoxus.

Doppler‐Detected Valve Movement in Aortic Stenosis: A Predictor of Adverse Outcome

The absence of auscultatory aortic valve closure sound is associated with severe aortic stenosis. The absence of Doppler‐derived aortic opening (Aop) or closing (Acl) may be a sign of advanced severe aortic stenosis.

Classic Hemodynamic Findings of Severe Aortic Regurgitation

A 46-year-old woman was hospitalized for acute heart failure. Transthoracic echocardiogram showed a left ventricular (LV) end-diastolic dimension of 5.6 cm, normal LV systolic function, and malcoaptation of the aortic leaflets (Movie I in the online-only data supplement). M-mode showed type A early closure of the mitral valve (Figure …

Water doesn't run uphill (by itself).

Pulmonary artery (PA) pressure, raised in excess of normal levels, is commonly encountered when performing hemodynamic evaluation in left ventricular (LV) diseases. The incidence of adverse outcomes is proportional to the presence and severity of pulmonary pressure elevation ([1,2][1]), making the