Effect of cardiovascular drugs on cardiovascular events in 1599 patients followed in an academic outpatient cardiology practice.

This study investigated the effects of medical therapy on incidences of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG) in an academic outpatient cardiology practice. Chart reviews were performed in 1599 treated patients (1138 men and 461 women), mean age 72 years. Medications investigated included the use of statins, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and aspirin. The mean follow-up was 63 months during 1977-2009. Of 1599 patients, MI occurred in 100 patients (6%), PCI occurred in 296 patients (19%), and CABG occurred in 235 patients (15%). Stepwise logistic regression analysis showed that significant independent risk factors for MI were statins [odds ratio = 0.07; 95% confidence interval (CI), 0.05-0.11, P < 0.001], beta blockers (odds ratio = 0.15, 95% CI, 0.10-0.23, P < 0.001), ACE inhibitors (odds ratio = 0.27, 95% CI, 0.16-0.45, P < 0.001), ARBs (odds ratio = 0.09, 95% CI, 0.04-0.20, P < 0.001), and aspirin (odds ratio = 0.18, 95% CI, 0.12-0.29, P < 0.001). Significant independent risk factors for PCI were statins (odds ratio = 0.15, 95% CI, 0.11-0.20, P < 0.001), beta blockers (odds ratio = 0.26, 95% CI, 0.20-0.35, P < 0.001), ACE inhibitors (odds ratio = 0.25, 95% CI, 0.18-0.34, P < 0.001), and ARBs (odds ratio = 0.18, 95% CI, 0.11-0.28, P < 0.001). Significant independent risk factors for CABG were statins (odds ratio = 0.16, 95% CI, 0.12-0.22, P < 0.001), beta blockers (odds ratio = 0.43, 95% CI, 0.32-0.58, P < 0.001), ACE inhibitors (odds ratio = 0.38, 95% CI, 0.27-0.53, P < 0.001), ARBs (odds ratio = 0.19, 95% CI, 0.11-0.31, P < 0.001), and aspirin (odds ratio = 0.45, 95% CI, 0.33-0.61, P < 0.001).

Risk factor reduction in progression of angiographic coronary artery disease.

INTRODUCTION: To investigate differences between outpatients with progressive and nonprogressive coronary artery disease (CAD) measured by coronary angiography. MATERIAL AND METHODS: Chart reviews were performed in patients in an outpatient cardiology practice having ≥ 2 coronary angiographies ≥ 1 year apart. Progressive CAD was defined as 1) new non-obstructive or obstructive CAD in a previously disease-free vessel; or 2) new obstruction in a previously non-obstructive vessel. Coronary risk factors, comorbidities, cardiovascular events, medication use, serum low-density lipoprotein cholesterol (LDL-C), and blood pressure were used for analysis. RESULTS: The study included 183 patients, mean age 71 years. Mean follow-up duration was 11 years. Mean follow-up between coronary angiographies was 58 months. Of 183 patients, 108 (59%) had progressive CAD, and 75 (41%) had nonprogressive CAD. The use of statins, ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and aspirin was not significantly different in patient with progressive CAD or nonprogressive CAD Mean arterial pressure was higher in patients with progressive CAD than in patients with nonprogressive CAD (97±13 mm Hg vs. 92±12 mm Hg) (p<0.05). Serum LDL-C was insignificantly higher in patients with progressive CAD (94±40 mg/dl) than in patients with nonprogressive CAD (81±34 mg/dl) (p=0.09). CONCLUSIONS: Our data suggest that in addition to using appropriate medical therapy, control of blood pressure and serum LDL-C level may reduce progression of CAD.

The impact of statin therapy on long-term cardiovascular outcomes in an outpatient cardiology practice.

INTRODUCTION: Statins reduce coronary events in patients with coronary artery disease. MATERIAL AND METHODS: Chart reviews were performed in 305 patients (217 men and 88 women, mean age 74 years) not treated with statins during the first year of being seen in an outpatient cardiology practice but subsequently treated with statins. Based on the starting date of statins use, the long-term outcomes of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABGs) before and after statin use were compared. RESULTS: Mean follow-up was 65 months before statins use and 66 months after statins use. Myocardial infarction occurred in 31 of 305 patients (10%) before statins, and in 13 of 305 patients (4%) after statins (p < 0.01). Percutaneous coronary intervention had been performed in 66 of 305 patients (22%) before statins and was performed in 41 of 305 patients (13%) after statins (p < 0.01). Coronary artery bypass graft surgery had been performed in 56 of 305 patients (18%) before statins and in 20 of 305 patients (7%) after statins (p < 0.001). Stepwise logistic regression showed statins use was an independent risk factor for MI (odds ratio = 0.0207, 95% CI, 0.0082-0.0522, p < 0.0001), PCI (odds ratio = 0.0109, 95% CI, 0.0038-0.0315, p < 0.0001) and CABGs (odds ratio = 0.0177, 95% CI = 0.0072-0.0431, p < 0.0001) CONCLUSIONS: Statins use in an outpatient cardiology practice reduces the incidence of MI, PCI, and CABGs.

Reduction in atherosclerotic events: a retrospective study in an outpatient cardiology practice.

INTRODUCTION: Although atherosclerotic disease cannot be cured, risk of recurrent events can be reduced by application of evidence-based treatment protocols involving aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statin medications. We studied atherosclerotic event rates in a patient population treated before and after the development of aggressive risk factor reduction treatment protocols. MATERIAL AND METHODS: We performed a retrospective chart review of patients presenting for follow-up treatment of coronary artery disease in a community cardiology practice, comparing atherosclerotic event rates and medication usage in a 2-year treatment period prior to 2002 and a 2-year period in 2005-2008. Care was provided in both the early and later eras by 7 board-certified cardiologists in a suburban cardiology practice. Medication usage was compared in both treatment eras. The primary outcome was a composite event rate of myocardial infarction, cerebrovascular events, and coronary interventions. RESULTS: Three hundred and fifty-seven patients were studied, with a follow-up duration of 12.1 (±3.5) years. There were 132 composite events in 104 patients (29.1%) in the early era compared to 40 events in 33 patients (9.2%) in the later era (p < 0.0001). From the early to the later eras, there was an increase in use of ß-blockers (66% to 83%, p < 0.0001), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (34% to 80%, p < 0.0001), and statins (40% to 90%, p < 0.0001). CONCLUSIONS: Application of aggressive evidence-based medication protocols for treatment of atherosclerosis is associated with a significant decrease in atherosclerotic events or need for coronary intervention.

Treatment of pulmonary hypertension.

Pulmonary arterial hypertension (PAH) is a chronic progressive disease of the pulmonary vasculature characterized by elevated pulmonary arterial pressure and secondary right ventricular failure. PAH is considered a life-threatening condition unless treated. This article provides a comprehensive review of controlled and uncontrolled trials to define the risk-benefit for different therapeutic options of this clinical disorder. Relevant published articles were identified through searches of the National Center for Biotechnology PubMed database. All therapeutic measures for PAH were discussed. Six drugs have been approved in the United States for the treatment of PAH. Extensive medical advancement has been achieved in treatment of PAH. However, none of the approved therapies have shown ability to cure the disease. New research should be performed to develop promising new therapies.

The impact of statin therapy on long-term cardiovascular outcomes in an outpatient cardiology practice.

BACKGROUND: Statins reduce coronary events in patients with coronary artery disease. MATERIAL/METHODS: Chart reviews were performed in 305 patients (217 men and 88 women, mean age 74 years) not treated with statins during the first year of being seen in an outpatient cardiology practice but subsequently treated with statins. Based on the starting date of statins use, the long-term outcomes of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABGS) before and after statin use were compared. RESULTS: Mean follow-up was 65 months before statins use and 66 months after statins use. MI occurred in 31 of 305 patients (10%) before statins, and in 13 of 305 patients (4%) after statins (p < 0.01). PCI had been performed in 66 of 305 patients (22%) before statins and was performed in 41 of 305 patients (13%) after statins (p < 0.01). CABGS had been performed in 56 of 305 patients (18%) before statins and was performed in 20 of 305 patients (7%) after statins (p < 0.001). Stepwise logistic regression showed statins use was an independent risk factor for MI (odds ratio = 0.0207, 95% CI, 0.0082-0.0522, p < 0.0001), PCI (odds ratio = 0.0109, 95% CI, 0.0038-0.0315, p < 0.0001), and CABGS (odds ratio = 0.0177, 95% CI = 0.0072-0.0431, p<0.0001.) CONCLUSIONS: Statins use in an outpatient cardiology practice reduces the incidence of MI, PCI, and CABGS.

T cell lymphoma presenting as esophageal obstruction and bronchoesophageal fistula.

BACKGROUND: The mediastinum is an uncommon location for presentation of peripheral T cell lymphoma. Esophageal involvement by non-Hodgkin's lymphoma is extremely unusual. Although staging can be performed with routine imaging studies, surgical intervention is often required to ensure accurate histologic diagnosis of these lymphomas. Peripheral T cell lymphomas not otherwise specified are among the most aggressive non-Hodgkin lymphomas with often a poor response to conventional chemotherapy. CASE REPORT: We report a case of a 63 year-old-man with an aggressive mediastinal T cell lymphoma presenting as esophageal obstruction and bronchoesophageal fistula. The patient was treated with a cyclophosphamide, vincristine, and prednisone (COP) regimen. Repeat computer tomography scan of the chest after chemotherapy noted a significant decrease in the cavitary lesion in the right paraesophageal region and right mediastinum. Bronchoscopy revealed a large opening in the posterior wall of the bronchus intermedius leading into the esophagus. A fistulogram was done which clearly demonstrated a fistulous tract between the lower esophagus and the right intermediate bronchus secondary to perforation from the lymphoma. The patient eventually underwent cervical esophagostomy and jejunostomy tube placement to correct the brochoesophageal fistula. CONCLUSIONS: The mediastinum is an uncommon location for presentation of peripheral T cell lymphomas, and surgical intervention is often required to ensure accurate histological diagnosis of these lymphomas. In our patient, aggressive mediastinal T cell lymphoma presented as esophageal obstruction and bronchoesophageal fistula.

Hyperthyroidism.

Hyperthyroidism is a pathological syndrome in which tissue is exposed to excessive amounts of circulating thyroid hormone. The most common cause of this syndrome is Graves' disease, followed by toxic multinodular goitre, and solitary hyperfunctioning nodules. Autoimmune postpartum and subacute thyroiditis, tumors that secrete thyrotropin, and drug-induced thyroid dysfunction, are also important causes.

RESPeRATE: nonpharmacological treatment of hypertension.

Systemic hypertension has been well documented as a major risk factor for premature cardiovascular morbidity and mortality. Reduction of high blood pressure (BP) by nonpharmacological means is widely recommended, either as a primary prevention therapy or as an adjunctive treatment with antihypertensive drugs. RESPeRATE is a commercially available electronic device that presents a novel nonpharmacological approach to the treatment of hypertension. RESPeRATE-guided slow-paced breathing aimed at achieving a respiratory frequency of <10 breaths per minute has been shown, in multiple studies, to reduce BP in hypertensive individuals by improving the autonomic balance through respiratory control. This article discusses RESPeRATE and the scientific evidence that supports the use of device-guided slow breathing to reduce BP.

Patients with ischemic stroke have a higher prevalence of a planar QRS-T angle >90° than patients with transient ischemic attack.

BACKGROUND: The aim of the study was to investigate the prevalence of a planar QRS-T angle >90° in patients with ischemic stroke versus transient ischemic attack (TIA). MATERIAL/METHODS: In a prospective study of 279 consecutive patients who had ischemic stroke (197 patients) or TIA (82 patients), the planar QRS-T angle was measured from a 12-lead electrocardiogram taken at the time of the stroke or TIA. All QRS-T angle measurements were made by 3 authors who agreed on the measurements and who were blinded to the clinical findings. A QRS-T angle >90° was considered abnormal. RESULTS: The mean age was 66±6 years in patients with ischemic stroke versus 62±6 years in patients with TIA (p=0.04). The mean body mass index and the prevalence of gender, smoking, hypertension, diabetes mellitus, dyslipidemia, and coronary artery disease were not significantly different between patients with ischemic stroke versus TIA. A QRS-T angle >90° was present in 55 of 197 patients (28%) with ischemic stroke and in 10 of 82 patients (12%) with TIA (p=0.004). CONCLUSIONS: The prevalence of a planar QRS-T angle >90° was higher in patients with ischemic stroke than in patients with TIA (p=0.004).

Association of warfarin use with CHADS(2) score in 441 patients with nonvalvular atrial fibrillation and no contraindications to warfarin.

The authors investigated the use of warfarin at hospital discharge in 557 consecutive patients, mean age 76 years, with nonvalvular atrial fibrillation (AF) at a university hospital. Of 557 patients with AF, 116 (21%) had contraindications to warfarin. Of patients eligible for warfarin, warfarin was used in 8 of 30 patients (27%) with a CHADS(2) score of 0, in 82 of 132 patients (62%) with a CHADS(2) score of 1, in 121 of 175 patients (70%) with a CHADS(2) score of 2, in 72 of 77 patients (94%) with a CHADS(2) score of 3, and in 27 of 27 patients (100%) with a CHADS(2) score of 4 to 6. Warfarin was used in 123 of 168 patients (73%) older than 75 years, in 74 of 79 patients (94%) aged 65 to 75 years, and in 23 of 32 patients (72%) younger than 65 years. Warfarin was used in 80 of 116 patients (69%) with a glomerular filtration rate < 60 mL/min/1.73 m(2) and in 140 of 163 patients (86%) with a glomerular filtration rate ≥ 60 mL/min/1.73 m(2) . There was no significant difference in use of warfarin between men and women and between whites and nonwhites.

A case of explosive progression of hepatocellular carcinoma in a patient with common variable immunodeficiency (CVID).

OBJECTIVE: While it is well known that patients with common variable immunodeficiency (CVID) are predisposed to various malignancies, primarily non-Hodgkin's lymphoma and gastric carcinomas, to our knowledge no cases of hepatocellular carcinoma have been reported in the absence of preexisting liver disease. METHOD AND RESULTS: We report a 50-year-old male patient with CVID with a B- and T-cell deficiency. The patient was on prophylactic intravenous gammaglobulin and had received several years earlier a course of rituximab for an autoimmune disorder. He had no history of hepatitis. The patient developed a rapidly progressing hepatocellular carcinoma within 3 to 4 weeks. CONCLUSIONS: Although patients with CVID are predisposed to malignancies such as lymphoma and adenocarcinoma of the stomach, rapidly progressive hepatocellular carcinoma in the absence of any preexisting liver disease has not been described.

Cardiovascular manifestations in patients with thrombotic thrombocytopenic purpura: a single-center experience.

BACKGROUND: Cardiovascular manifestation in patients with thrombotic thrombocytopenic purpura. HYPOTHESIS: The aim of this study was to investigate the incidence of acute myocardial infarction (AMI), arrhythmias, congestive heart failure, and mortality in patients hospitalized for thrombotic thrombocytopenic purpura (TTP). METHODS: Thirty-eight patients (27 women and 11 men), mean age 44 years, were hospitalized with the diagnosis of TTP confirmed by a hematologist. We investigated the incidence of AMI which developed during hospitalization for TTP. AMI was diagnosed by new electrocardiographic changes, increased serum cardiac troponin I levels, and clinical symptomatology. The patients with AMI were also monitored for development of arrhythmias during hospitalization. RESULTS: Of the 38 patients, 8 (21%) developed new Q-wave AMI. There was no significant difference in baseline characteristics between patients who developed AMI and those who did not develop AMI. Of the 8 patients with AMI, 2 (25%) developed atrial fibrillation, 1 (13%) developed atrial flutter, 1 (13%) developed supraventricular tachycardia, and 2 (25%) developed congestive heart failure. Death occurred in 3 of 8 patients (38%) with AMI and in 1 of 30 patients (3%) without AMI (P < 0.01). CONCLUSIONS: New Q-wave AMI developed in 21% of 38 patients hospitalized with TTP. Supraventricular tachyarrhythmias developed in 50% of 8 patients with TTP who developed AMI. Patients hospitalized for TTP should be monitored for adverse cardiac events due to the high incidence of new AMI, supraventricular tachyarrhythmias, and mortality.

Risk factors for appropriate cardioverter-defibrillator shocks, inappropriate cardioverter-defibrillator shocks, and time to mortality in 549 patients with heart failure.

We investigated the risk factors for appropriate and inappropriate implantable cardioverter-defibrillator (ICD) shocks and mortality in 549 patients (mean age 74 years) with heart failure and ICDs. During a mean follow-up of 1,243 + or - 655 days, of the 549 patients, 163 (30%) had appropriate ICD shocks, 71 (13%) had inappropriate ICD shocks, and 63 (12%) died. Stepwise logistic regression analysis showed that significant independent prognostic factors for appropriate ICD shocks were smoking (odds ratio 3.7) and statins (odds ratio 0.54). The significant independent prognostic factors for inappropriate ICD shocks were atrial fibrillation (odds ratio 6.2) and statins (odds ratio 0.52). Finally, those for the interval to mortality were age (hazard ratio 1.08/1-year increase), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (hazard ratio 0.25), atrial fibrillation (hazard ratio 4.1), right ventricular pacing (hazard ratio 3.6), digoxin (hazard ratio 2.9), hypertension (hazard ratio 5.3), and statins (hazard ratio 0.32). In conclusion, in patients with heart failure and ICDs, smoking increased and statins reduced appropriate ICD shocks, atrial fibrillation increased and statins reduced inappropriate ICD shocks, and the interval to mortality was increased by age, atrial fibrillation, right ventricular pacing, hypertension, and digoxin and reduced by angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and statins.

Thiazide-induced severe hypercalcemia: a case report and review of literature.

Most common causes of hypercalcemia are hyperparathyroidism, malignancy, vitamin D-mediated conditions such as sarcoidosis, and vitamin D toxicity. Less commonly, hypercalcemia can be caused by drugs such as thiazide diuretics and lithium. Mild hypercalcemia is usually asymptomatic but severe hypercalcemia is associated with nausea, vomiting, abdominal pain, excessive thirst, muscle weakness, lethargy, confusion, and fatigue. We are reporting a case of abdominal pain and altered mental status caused by thiazide-induced severe hypercalcemia of 19.8 mg/dL. This is the most severe case of thiazide-induced hypercalcemia that we have seen reported. Patients on thiazide diuretics should have their electrolytes frequently checked, especially patients on calcium supplements. Management usually includes hydration and discontinuation of drugs causing hypercalcemia.

Prevalence of transthoracic echocardiographic abnormalities in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage.

INTRODUCTION: This study investigated the prevalence of transthoracic echocardiographic abnormalities in patients with ischemic stroke (IS), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH) in sinus rhythm. MATERIAL AND METHODS: The patients included 120 with IS, 30 with SAH, and 41 with ICH. All diagnoses were confirmed by magnetic resonance imaging or brain computed tomography. Two-dimensional echocardiograms were taken at the time stroke was diagnosed. All echocardiograms were interpreted by an experienced echocardiographer. RESULTS: Of 120 IS patients, 1 (1%) had a left ventricular (LV) thrombus, 1 (1%) had mitral valve vegetations, 30 (25%) had LV hypertrophy, 26 (22%) had abnormal LV ejection fraction, 4 (3%) had mitral valve prolapse, 33 (28%) had mitral annular calcium (MAC), 40 (33%) had aortic valve calcium (AVC), 3 (3%) had a bioprosthetic aortic valve, 10 (8%) had aortic stenosis (AS), 6 (5%) had atrial septal aneurysm, 2 (2%) had patent foramen ovale, and 40 (33%) had no abnormalities. Of 30 SAH patients, 5 (17%) had LV hypertrophy, 1 (3%) had abnormal LV ejection fraction, 1 (3%) had AS, 4 (13%) had MAC, 5 (17%) had AVC, and 20 (67%) had no abnormalities. Of 41 ICH patients, 9 (22%) had LVH, 1 (2%) had abnormal LV ejection fraction, 1 (3%) had AS, 6 (15%) had MAC, 8 (20%) had AVC, and 22 (54%) had no abnormalities. CONCLUSIONS: Transthoracic echocardiographic abnormalities are more prevalent in patients with IS than in patients with SAH or ICH.

Incidence of appropriate cardioverter-defibrillator shocks and mortality in patients with implantable cardioverter-defibrillators with ischemic cardiomyopathy versus nonischemic cardiomyopathy at 33-month follow-up.

INTRODUCTION: The aim of the study was to investigate at long-term follow-up the incidence of appropriate implantable cardioverter-defibrillator (ICD) shocks and of all-cause mortality in patients with ICDs with ischemic cardiomyopathy versus nonischemic cardiomyopathy. MATERIAL AND METHODS: ICDs were implanted in 485 patients with ischemic cardiomyopathy and in 299 patients with nonischemic cardiomyopathy, all of whom had coronary angiography. Baseline characteristics were not significantly different between the 2 groups. Follow-up was 965 days in patients with ischemic cardiomyopathy versus 1039 days in patients with nonischemic cardiomyopathy (p not significant). The ICDs were interrogated every 3 months to see if shocks occurred. RESULTS: Appropriate ICD shocks occurred in 179 of 485 patients (37%) with ischemic cardiomyopathy and in 93 of 299 patients (31%) with nonischemic cardiomyopathy (p not significant). All-cause mortality occurred in 162 of 485 patients (33%) with ischemic cardiomyopathy and in 70 of 299 patients (23%) with nonischemic cardiomyopathy (p = 0.002). CONCLUSIONS: The incidence of appropriate ICD shocks was not significantly different at 33-month follow-up in patients with ischemic cardiomyopathy versus nonischemic cardiomyopathy. However, patients with ischemic cardiomyopathy had a significantly higher incidence of all-cause mortality than patients with nonischemic cardiomyopathy (p = 0.002).

Incidence of appropriate cardioverter-defibrillator shocks and mortality in patients with heart failure treated with combined cardiac resynchronization plus implantable cardioverter-defibrillator therapy versus implantable cardioverter-defibrillator therapy.

Of 529 patients with heart failure and a mean left ventricular ejection fraction of 29%, 209 (40%) were treated with cardiac resynchronization therapy (CRT) plus an implantable cardioverter-defibrillator (ICD) and 320 (60%) with an ICD. Mean follow-up was 34 months for both groups. Stepwise logistic regression analysis showed that significant independent variables for appropriate ICD shocks were statins (risk ratio = 0.35, P < .0001), smoking (risk ratio = 2.52, P < .0001), and digoxin (risk ratio = 1.92, P = .0001). Significant independent variables for time to deaths were use of CRT (risk ratio = 0.32, P = .0006), statins (risk ratio = 0.18, P < .0001), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (risk ratio = 0.10, P < .0001), hypertension (risk ratio = 24.15, P < .0001), diabetes (risk ratio = 2.54, P = .0005), and age (risk ratio = 1.06, P < .0001). In conclusion, statins reduced and smoking and digoxin increased appropriate ICD shocks. Use of CRT, statins, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers reduced mortality and hypertension, diabetes, and older age increased mortality.