The Evolving Trends in Infective Endocarditis and Determinants of Mortality: a 10-year Experience From a Tertiary Care Epicenter.

The epidemiology of infective endocarditis (IE) continues to evolve in areas affected by the opioid epidemic. Understanding the demographics of the disease allows us to better tailor therapy towards this at-risk population. This was an observational study of adults (age ≥ 18) admitted to the University of Kentucky hospital with IE between January 2009 and December 2018. 1,255 patients were included in the final analysis. The mean age was 42 years, 45% were female and injection drug use was seen in 66% of patients. On multivariable analysis, higher Charlson comorbidity indices, left sided, and multivalve involvement were associated with increased mortality, whereas surgical intervention demonstrated a trend towards lower mortality. Our results highlight the alarming increase in injection drug use related IE and the high mortality rates despite therapeutic advances. Patients with left sided IE, multivalve involvement and a higher Charlson comorbidity index had decreased survival.

Interoperator reliability of an on-site machine learning-based prototype to estimate CT angiography-derived fractional flow reserve.

BACKGROUND: Advances in CT and machine learning have enabled on-site non-invasive assessment of fractional flow reserve (FFRCT). PURPOSE: To assess the interoperator and intraoperator variability of coronary CT angiography-derived FFRCT using a machine learning-based postprocessing prototype. MATERIALS AND METHODS: We included 60 symptomatic patients who underwent coronary CT angiography. FFRCT was calculated by two independent operators after training using a machine learning-based on-site prototype. FFRCT was measured 1 cm distal to the coronary plaque or in the middle of the segments if no coronary lesions were present. Intraclass correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate interoperator variability effect in FFRCT estimates. Sensitivity analysis was done by cardiac risk factors, degree of stenosis and image quality. RESULTS: A total of 535 coronary segments in 60 patients were assessed. The overall ICC was 0.986 per patient (95% CI 0.977 to 0.992) and 0.972 per segment (95% CI 0.967 to 0.977). The absolute mean difference in FFRCT estimates was 0.012 per patient (95% CI for limits of agreement: -0.035 to 0.039) and 0.02 per segment (95% CI for limits of agreement: -0.077 to 0.080). Tight limits of agreement were seen on Bland-Altman analysis. Distal segments had greater variability compared with proximal/mid segments (absolute mean difference 0.011 vs 0.025, p<0.001). Results were similar on sensitivity analysis. CONCLUSION: A high degree of interoperator and intraoperator reproducibility can be achieved by on-site machine learning-based FFRCT assessment. Future research is required to evaluate the physiological relevance and prognostic value of FFRCT.

Diagnosis of cardiac sarcoidosis: a primer for non-imagers.

Sarcoidosis is a multisystem granulomatous disorder that can potentially involve any organ. Cardiac involvement in sarcoidosis has been reported in up to 25% of patients based on autopsy and imaging studies. The gold standard for diagnosing cardiac sarcoidosis is endomyocardial biopsy demonstrating non-caseating granulomas; however, this technique lacks sensitivity due to the patchy nature of myocardial involvement. This, along with the non-specific clinical presentation, renders the diagnosis of cardiac sarcoidosis extremely challenging. Difficulties in obtaining histopathologic diagnosis and the advances in imaging modalities have led to a paradigm shift toward non-invasive imaging in the diagnosis of cardiac sarcoidosis. Advances in cardiac imaging modalities have also allowed unprecedented insights into the prevalence and natural history of cardiac sarcoidosis. This review discusses the role of non-invasive imaging for diagnosis, risk stratification, and monitoring the response to therapies in cardiac sarcoidosis. Echocardiography remains the first-line modality due to widespread availability and affordability. Cardiac magnetic resonance imaging (CMR) can be used to study cardiac structure, function, and most importantly tissue characterization to detect inflammation and fibrosis. Fluoro-deoxy glucose positron emission tomography (FDG PET) is the gold standard for non-invasive detection of cardiac inflammation, and it offers the unique ability to assess response to therapeutic interventions. Hybrid imaging is a promising technique that allows us to combine the unique strengths of CMR and FDG PET. Understanding the advantages and disadvantages of each of these imaging modalities is crucial in order to tailor the diagnostic algorithm and utilize the most appropriate modality for each patient.

Avoidance of ST-Segment-Elevation Myocardial Infarction Treatment for >1 Week Due to COVID-19 Fears.

During the coronavirus disease 2019 (COVID-19) pandemic, social distancing guidelines have negatively affected the care-seeking behavior of patients with chronic medical conditions, including those with cardiovascular disease. We report the case of a 60-year-old man with vague gastrointestinal symptoms who waited more than 1 week to seek treatment for fear of COVID-19 infection. On presentation at another hospital, he was found to have had an anterior myocardial infarction, and he underwent percutaneous coronary intervention to stent an occluded proximal left anterior descending coronary artery. Subsequently, the patient experienced refractory cardiogenic shock and, during his transfer to our hospital, refractory ventricular tachycardia, which ultimately proved fatal.

Passive antipyretic therapy is not as effective as invasive hypothermia for maintaining normothermia after cardiac arrest.

AIM OF THE STUDY: Targeted temperature management is a class I indication in comatose patients after a cardiac arrest. While the literature has primarily focused on innovative methods to achieve target temperatures, pharmacologic therapy has received little attention. We sought to examine whether pharmacologic therapy using antipyretics is effective in maintaining normothermia in post cardiac arrest patients. MATERIALS AND METHODS: Patients ≥18 years who were resuscitated after an in-hospital or out-of-hospital cardiac arrest and admitted at our institution from January 2012 to September 2015 were retrospectively included. Patients were divided into groups based on the method of temperature control that was utilized. The primary outcome was temperature control <38 °C during the first 48 h after the cardiac arrest. RESULTS: 671 patients were identified in Group 1 (no hypothermia), 647 in Group 2 (antipyretics), 44 in Group 3 (invasive hypothermia), and 51 in Group 4 (invasive hypothermia and antipyretics). Mean patient age was 59 (SD ±15.7) years with 40.6% being female. Using Group 1 as the control arm, 57.7% of patients maintained target temperature with antipyretics alone (p < 0.001), compared to 69.3% in the control group and 82.1% in the combined hypothermia groups 3&4 (p = 0.01). Patients receiving both invasive hypothermia and antipyretics (Group 4), had the greatest mean temperature decrease of 5.2 °C. CONCLUSIONS: Among patients undergoing targeted temperature management, relying solely on as needed use of antipyretics is not sufficient to maintain temperatures <38 °C. However, antipyretics could be used as an initial strategy if given regularly and/or in conjunction with more aggressive cooling techniques.

Infective endocarditis in pregnancy from 2009 to 2019: the consequences of injection drug use.

BACKGROUND: Endocarditis during pregnancy carries a maternal mortality of up to 30%, but prior publications do not reflect the current opioid epidemic. CASE PRESENTATIONS: We reviewed our institution's infective endocarditis registry from 2009 to 2019 and identified 19 females with endocarditis during pregnancy in order to compare our contemporary outcomes with historical reports. In our cohort, intravenous drug use was reported in all cases, and the most common pathogen was Staphylococcus (74%) followed by Serratia (13%). The tricuspid valve was involved in 18 (95%) patients, and contrary to prior reports, all but two patients were managed conservatively with antibiotics alone. Maternal and infant mortality (5% and 0%, respectively) were lower in our cohort compared to all previous reviews. CONCLUSION: We conclude that the better outcomes seen in this report are likely due to the younger age of the patients and the more frequent right-sided valvular involvement. SUMMARY: This review highlights contemporary outcomes in endocarditis during pregnancy. We review historical case reports in light of the opioid epidemic. We observed more Staphylococcus, more right-sided valvular involvement, and more conservative management as well as improved maternal and foetal mortality.

Cardiovascular Risk After Sepsis: Understanding the Role of Statin Indications and the Impact of Clinical Inertia on Prescribing Patterns.

INTRODUCTION: Patients with sepsis have high rates of major adverse cardiovascular events (MACE) in the literature, but the stratification of those at risk has been limited. Statin indicated groups provides clear criteria for therapy, but the risk of MACE after sepsis based on these groups has never been assessed. MATERIALS AND METHODS: This was a retrospective cohort analysis conducted on adult patients admitted from January 1, 2013, to December 31, 2013, with suspected or confirmed sepsis and data available on statin use. Patients' past medical history; statin use prior, during, or at time of discharge; and occurrence of MACE were recorded from electronic health records. RESULT: A total of 321 patients were screened and 265 were found to have data available on statin use. The mean age of the patients was 59 ± 15 years and 47% were female. Overall, 9% were observed to have a MACE at 1 year, with significantly higher rates in those in a statin indicated group (12.2%). On admission, 174 patients were not taking a statin out of whom 52% were in a statin indicated group. Among those in a statin indicated group who survived to hospital discharge, only 10% not on a statin on admission received a statin on discharge, whereas 89% on a statin on admission received a statin on discharge. CONCLUSION: There is a high risk of MACE after sepsis especially among those in statin indicated groups with significant clinical inertia in prescribing practices.

Usefulness of Findings by Multimodality Imaging to Stratify Risk of Major Adverse Cardiac Events After Sepsis at 1 and 12 months.

Cardiovascular complications are reported in up to 30% of sepsis survivors. Currently, there is limited evidence to guide cardiovascular risk stratification of septic patients. We propose the use of left ventricular ejection fraction (LVEF) and coronary artery calcification (CAC) on nongated computed tomography (CT) scans to identify septic patients at highest risk for major adverse cardiovascular events (MACE). We retrospectively reviewed 517 adult patients with sepsis, elevated troponin levels, nongated CT scans that visualized the coronaries, and an echocardiogram. Patients were stratified into 4 groups based on the LVEF and presence or absence of CAC. Using the CAC negative/LVEF ≥ 50% as a control, we compared MACE and all-cause mortality outcomes across the patient groups. At 30 days, 39 patients (7.5%) experienced MACE and 166 patients (32%) died. Patients with no CAC and LVEF ≥ 50% experienced no MACE at 30 days or 1 year. Among patients with EF < 50%, CAC positive or negative patients were statistically more likely to experience a MACE event at 30 days (p < 0.001 for both groups). After 30 days, a further 6 patients (1.2%) experienced MACE and 66 (12.7%) patients died within the first year. Patients with CAC positive/LVEF < 50% experienced the highest rates of MACE at 1 year (p < 0.001). In conclusion, the combination of LVEF on echocardiography and CAC on nongated CT scans provides a powerful risk stratification tool for predicting cardiovascular events in septic patients.

Relation Between Epicardial Adipose and Aortic Valve and Mitral Annular Calcium Determined by Computed Tomography in Subjects Aged ≥65 Years.

Epicardial adipose tissue (EAT) has been linked to coronary artery calcium deposits and atherosclerotic disease. Mitral annular (MAC) and aortic valve calcium (AVC) have also been associated with atherosclerosis. This study examined the possible relation between EAT thickness and valvular calcium deposits. We included 294 patients aged ≥65 years who had noncontrast computed tomography scans of the chest. Mean age was 76 ± 7 years; 47% were men. Using reconstructed images, EAT thickness was measured at various locations. MAC and AVC were quantified by Agatston technique. The sum of AVC and MAC was reported as the grand total score (GTS). Subjects were divided into 2 groups based on the value of GTS; GTS = 0, no cardiac calcification and GTS ≥1, cardiac calcification group. Epicardial fat (left and right atrioventricular grooves and superior interventricular groove) was significantly greater in the cardiac calcification group compared with the no cardiac calcification (all values, p <0.05). After adjusting for clinical variables including BMI, EAT at the superior interventricular groove remained significantly associated with total calcium. Left atrioventricular groove EAT demonstrated a trend toward an association with total calcium, but this did not reach statistical significance. In conclusion, epicardial fat is associated with calcium deposits of the mitral annulus and aortic valve.