Real-world performance and accuracy of stress echocardiography: the EVAREST observational multi-centre study.

AIMS: Stress echocardiography is widely used to identify obstructive coronary artery disease (CAD). High accuracy is reported in expert hands but is dependent on operator training and image quality. The EVAREST study provides UK-wide data to evaluate real-world performance and accuracy of stress echocardiography. METHODS AND RESULTS: Participants undergoing stress echocardiography for CAD were recruited from 31 hospitals. Participants were followed up through health records which underwent expert adjudication. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, medical management of ischaemia, acute coronary syndrome, or cardiac-related death within 6 months. A total of 5131 patients (55% male) participated with a median age of 65 years (interquartile range 57-74). 72.9% of studies used dobutamine and 68.5% were contrast studies. Inducible ischaemia was present in 19.3% of scans. Sensitivity and specificity for prediction of a cardiac outcome were 95.4% and 96.0%, respectively, with an accuracy of 95.9%. Sub-group analysis revealed high levels of predictive accuracy across a wide range of patient and protocol sub-groups, with the presence of a resting regional wall motion abnormalitiy significantly reducing the performance of both dobutamine (P < 0.01) and exercise (P < 0.05) stress echocardiography. Overall accuracy remained consistently high across all participating hospitals. CONCLUSION: Stress echocardiography has high accuracy across UK-based hospitals and thus indicates stress echocardiography is being delivered effectively in real-world practice, reinforcing its role as a first-line investigation in the assessment of patients with stable chest pain.

Clinical Presentations and Outcomes of Coronavirus Disease 2019 in Patients With Solid Tumors.

Background Coronavirus disease 2019 (COVID-19) is a global health crisis. The literature suggests that cancer patients are more prone to be affected by COVID-19 because cancer suppresses the immune system and such patients usually present poor results. The objective of this study is to present all clinical, laboratory, and demographic characteristics of COVID-19 patients with solid tumors. Methodology This study was conducted at the Dow University of Health Sciences for a period of six months from April 2020 to September 2020. In this study, we included a total of 1,519 confirmed patients diagnosed with solid tumors via polymerase chain reaction. The mortality timeline within 30 days of contracting the virus was considered, and the median age of the included individuals was 61 years, with a range of 20-95 years. Of the patients included in the study, 49.4% (750) were men; moreover, 3.15% of our study population had prostate cancer, 10.20% had colorectal cancer, 2.76% had breast cancer, and 10.46% had lung cancer. Of the patients, 25.93% presented with at least one comorbidity. For 73% of the patients, at least one direct therapy for COVID-19 was included in the treatment; 56.6% of the patients were hospitalized, and 11.32% were admitted to the intensive care unit. Results The mortality rate was 4.74% in the first 30 days after diagnosis, where 72 patients died. The findings of the first multi-variation model showed that males at older ages who were diabetic and going through cytotoxic therapy were prone to die within the first 30 days. However, the 30-day mortality rate was lower in patients diagnosed with prostate and breast cancer. The second set incorporated laboratory factors, where we found that higher values of leukocytosis, thrombocytopenia, and lymphocytopenia were correlated with higher rates of mortality within 30 days. Conclusions We conclude that there is a higher mortality rate of COVID-19 in patients with solid tumors than in the general population. However, it was found to be lower in the Pakistani population compared with the Chinese and Western populations. Intensive care can decrease mortality rates in COVID-19 and cancer patients.

Scoliosis and Gastroesophageal Reflux Disease in Adults.

Introduction Degenerative scoliosis most commonly presents with lower back pain. Literature suggests that adults who have degenerative scoliosis are at greater risk of both hiatal hernia and gastroesophageal reflux disease (GERD). The objective of this study was to evaluate scoliosis as being the risk factor of GERD in adults. Materials and methods This prospective study was conducted at Dow University of Health Sciences over a period of two years (May 2018 to April 2020). The investigation included 210 participants with spinal disorders. The mean age was 71.6±9.6 years. The X-rays of the participants' whole spine were taken in a standing position, in the sagittal and coronal planes. Symptoms of GERD were measured through the quality of life and utility evaluation survey technology (QUEST) score, taking six points as cutoff values. The evaluation was done using radiographs to determine any relationship between spinal disorders and GERD. Negative values were analyzed in a right-sided convex curve while positive values in the left-sided convex curve were viewed in the coronal plane. Degenerative scoliosis was explained as a lumbar/thoracolumbar Cobb angle of more than 10 degrees. Univariate and multivariate logistic regression analyses were done to assess the risk factors related to GERD. Results Out of 210 patients, 146 were found to have degenerative scoliosis at the level of the lumbar and thoracolumbar spine. Fifty-two patients had a right convex curve, and 94 had a left convex curve. Sixty-nine patients had GERD. According to the analysis of the multivariate logistic regression, the Cobb angle was highly related to GERD (p-value <0.05 and odds ratio of 1.031). The participants were grouped according to the Cobb angle of curve at the lumbar spine (less than 30 degrees with a large right-sided convex curve, 30 and more with a small curve, and more than 30+ degrees with a large left-sided convex curve). The study revealed that a large left-sided convex curve was highly related to GERD, with a p-value <0.05 and odds ratio of 10.935. Conclusions The left-sided large convex curve at the thoracolumbar or lumbar spine, especially when the Cobb angle was more than 30 degrees, was highly associated with GERD. Therefore, the symptoms of GERD should be monitored in the elderly population with degenerative scoliosis.

Corrigendum to "Gender and Ethnicity Based Differences in Clinical and Laboratory Features of Myasthenia Gravis".

[This corrects the article DOI: 10.1155/2015/197893.].

Short and long terms clinical outcomes of Paclitaxel drug-eluting balloons applied for de-novo coronary artery lesions in the context of acute coronary syndrome: A real world experience.

A single-centre retrospective observational study aimed at observing the outcomes of using DEB in ACS patients. All-comer ninety patients were included with a follow-up of 12-36 months. DEBs were deployed successfully yielding TIMI 3 without significant coronary dissection. MACE was 1.1% and 3.3% for 30 days and 12-36 months respectively.

Acute coronary syndrome: which age group tends to delay call for help?

BACKGROUND: Early diagnosis and treatment of ACS can reduce the risk of complications and death. Delay calling for help can increase morbidity and mortality. It is unclear which age group among patients with acute coronary syndrome tend to delay their call for help. RESULTS: Our observational retrospective study showed that men and women in their 50s and 40s respectively tend to delay their call for help from symptoms onset. For the former, the mean time delays (590 ± 71.1 min), whereas for the latter it was (1084 ± 120.1 min). Moreover, these groups tend to have a longer time delay between symptoms onset and arrival at the hospital. Among deaths, we observed that the death rate was proportional to the time delay, which is not unexpected. Next step, we plan to perform a qualitative study in the form of questionnaires to target the individuals with a high risk of CVD within these age groups. CONCLUSION: Middle age group of both genders tend to delay their call for help when they experience symptoms of ACS; moreover, regardless of the age, the longer the delay, the higher the mortality rate. The results of this study gave us a better understanding of our local population and will pave the road for a well-structured teaching programme for them to minimise the time delay for calling for help.

Cobalt-related cardiomyopathy: A real concern! A review of published evidence.

BACKGROUND: Cobalt (Co) toxicity-related cardiomyopathy (CMP) in hip arthroplasty has recently been reported in the literature. The purpose of this review was to identify and assess available published evidence of CMP in hip arthroplasty patients and to derive recommendations for management. METHODS: We evaluated 23 cases reported till October 2018 and stratified into three categories, based on pre-existing risk factors for CMP, histological confirmation and evidence of systemic signs of Co toxicity. RESULTS: Co toxicity was considered to be the definite cause of CMP in 8 cases and probably contributory in 13 cases. Two cases were considered to have developed CMP secondary to pre-existing risk factors. Majority of the patients had good recovery of cardiac function after hip revision and cardiac management, but five cases deteriorated and died. CONCLUSION: Although Co-related CMP has been reported in a small number of cases of hip arthroplasty, a delay or missed diagnosis may lead to significant morbidity and mortality. Timely diagnosis, removal of causative implant and avoidance of metal articulations in revision for fractured ceramic implants may help in effective management.

Cobalt cardiomyopathy in hip arthroplasty.

BACKGROUND: Cobalt toxicity-related cardiomyopathy in hip arthroplasty has recently been reported in the literature. The purpose of this review is to identify and assess available published evidence of cardiomyopathy in hip arthroplasty patients and to derive recommendations for management. METHODS: We evaluated 23 cases reported until October 2018 and stratified them into 3 categories, based upon pre-existing risk factors for cardiomyopathy, histological confirmation, and evidence of systemic signs of cobalt toxicity. RESULTS: Cobalt toxicity was considered to be the definite cause of cardiomyopathy in 8 cases, and probably contributory in 13 cases. Two cases were considered to have developed cardiomyopathy secondary to pre-existing risk factors. Majority of the patients had a good recovery of cardiac function after hip revision and cardiac management, but 5 cases deteriorated and died. CONCLUSIONS: Although cobalt-related cardiomyopathy has been reported in a small number of cases of hip arthroplasty, a delay or missed diagnosis may lead to significant morbidity and mortality. Timely diagnosis, removal of causative implant, and avoidance of metal articulations in revision for fractured ceramic implants may help in an effective management.

A retrospective cohort study of the association between smoking and mortality after acute ST-segment elevation myocardial infarction.

BACKGROUND: Several studies have shown a 'smoker's paradox', where following an acute myocardial infarction, smokers have a paradoxically lower mortality than non-smokers. To date, no large study has investigated this paradox in unselected patients with acute ST-segment elevation myocardial infarction (STEMI) managed by primary percutaneous coronary intervention (PCI) alone. OBJECTIVES: We aimed to examine the association of smoking status and 1-year mortality in patients who had STEMI managed by primary PCI. METHODS: This retrospective study included all patients admitted with acute STEMI undergoing primary PCI in a single UK centre from January 2009 to April 2012. The survival status for all patients post-STEMI was obtained. Differences in survival by smoking status were assessed using a Kaplan-Meier curve, and after adjustment for age, gender and additional cardiovascular risk factors using a Cox regression analysis. RESULTS: The 1-year mortality for patients with STEMI was 149/1796 (8.3%). There were 846/1796 (47.1%) current smokers, 476/1796 (26.5%) ex-smokers and 417/1796 (23.2%) never smokers. Current smokers were approximately 10 years younger than ex-smokers and never smokers (p=0.001). A multivariate Cox proportional hazards model found no evidence of an association between mortality and smoking status after adjustment; p=0.23. Compared with never smokers, the HR (95% CI) for 1-year mortality for current smokers was 1.47 (0.90 to 2.39) and 1.08 (0.66 to 1.77) for ex-smokers. CONCLUSIONS: In this retrospective cohort study, we found no evidence of an association between mortality and smoking status in patients with acute STEMI treated with PCI, and thus no evidence of a 'smoker's paradox'.

Pronounced increase in risk of acute ST-segment elevation myocardial infarction in younger smokers.

OBJECTIVES: Previous studies have shown that smokers presented with ST-segment elevation myocardial infarction (STEMI) a decade earlier than non-smokers. However, no account has been made for population smoking trends, an important deficit addressed by this study. METHODS: The combination of admission data on patients with acute STEMI undergoing percutaneous coronary intervention and demographic data supplied by the Office for National Statistics for the South Yorkshire population between 2009-2012 were analysed to generate incidence rates and rate ratios (RR) to quantify the relative risk of STEMI from smoking, overall and by age group. RESULTS: There were 1795 STEMI patients included of which 72.9% were male. 68 patients were excluded as they had no smoking status recorded, leaving 48.5% of the remaining population as current smokers, 27.2% ex-smokers and 24.3% never smokers. Smokers were over-represented with overall smoking prevalence in South Yorkshire calculated at 22.4%. The incidence of STEMI in smokers aged under 50, 50-65 and over 65 years was 59.7, 316.9 and 331.0 per 100 000 patient years at risk compared to 7.0, 60.9 and 106.8 for the combined group of ex- and never smokers. This gave smokers under the age of 50 years an 8.47 (95% CI 6.80 to 10.54) increase in rate compared to non-smokers of the same age, with the 50-65 and over 65 age groups having RRs of 5.20 (95% CI 4.76 to 5.69) and 3.10 (95% CI 2.67 to 3.60), respectively. CONCLUSIONS: Smoking was associated with an eightfold increased risk of acute STEMI in younger smokers, when compared to ex- and never smokers. Further efforts to reduce smoking in the youngest are needed.

Association of endothelial dysfunction and no-reflow during primary percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Coronary no-reflow during primary percutaneous coronary intervention (PPCI) is a predictor of poorer cardiovascular outcome. Both endothelial dysfunction and no-reflow involves abnormal vascular function and hemostasis. Our aim was to assess the association between endothelial dysfunction and no reflow during primary PCI. METHODS: Thirty consecutive patients with ST elevation myocardial infarction (STEMI) and normal flow during primary PCI were compared to 19 consecutive patients who had no reflow. All subjects underwent assessment of peripheral endothelial function by reactive hyperemia index (RHI) 48-72h post PCI using the EndoPAT device. RESULTS: Age, sex and hypertension were similar in both groups. Smokers were less likely to have no-reflow. Post PPCI there was less ST segment resolution in the no-reflow group (48%±7 vs. 81%±6; p=0.001). Patients who had no reflow had subsequently lower ejection fraction (39%±10 vs. 47%±10; p=0.015). There was no difference in vascular function (RHI), between the no-reflow and normal flow groups (1.91±0.3 vs. 2.09±0.11; p=0.24). CONCLUSIONS: Systemic peripheral endothelial function does not differ between STEMI patients with and without no reflow during primary PCI.

Impact of frailty on outcomes after percutaneous coronary intervention: a prospective cohort study.

BACKGROUND: Average life expectancy is rising, resulting in increasing numbers of elderly, frail individuals presenting with coronary artery disease and requiring percutaneous coronary intervention (PCI). PCI can be of value for this population, but little is known about the balance of benefit versus risk, particularly in the frail. OBJECTIVE: To determine the relationship between frailty and clinical outcomes in patients undergoing PCI. METHODS: Patients undergoing PCI, for either stable angina or acute coronary syndrome, were prospectively assessed for frailty using the Canadian Study of Health and Ageing Clinical Frailty Scale. Demographics, clinical and angiographic data were extracted from the hospital database. Mortality was obtained from the Office of National Statistics. RESULTS: Frailty was assessed in 745 patients undergoing PCI. The mean age of patients was 62±12 years and 70% were males. The median frailty score was 3 (IQR 2-4). A frailty score ≥5, indicating significant frailty, was present in 81 (11%) patients. Frail patients required longer hospitalisation after PCI. Frailty was also associated with increased 30-day (HR 4.8, 95% CI 1.4 to 16.3, p=0.013) and 1 year mortality (HR 5.9, 95% CI 2.5 to 13.8, p<0.001). Frailty was a predictor of length of hospital stay and mortality, independent of age, gender and comorbidities. CONCLUSIONS: A simple assessment of frailty can help predict mortality and the length of hospital stay, and may therefore guide healthcare providers to plan PCI and appropriate resources for frail patients.

A retrospective cross-sectional study on the association between tobacco smoking and incidence of ST-segment elevation myocardial infarction and cardiovascular risk factors.

BACKGROUND: Cigarette smoking is a well-established risk factor for the development of coronary heart disease. However, the relationship between smoking and acute ST-segment elevation myocardial infarction (STEMI) is less well described. OBJECTIVE: To determine the relative risk of acute STEMI in smokers and ex-smokers, compared with individuals who had never smoked. METHODS: This observational study studied all patients with STEMI undergoing percutaneous coronary intervention (PCI) in South Yorkshire, UK from 1 January 2009 to 6 April 2012. Additional contemporary demographical data for the South Yorkshire population, supplied by the Office for National Statistics, allowed derivation of the incidence rate of STEMI in South Yorkshire-both overall and stratified by smoking status. Incidence rate ratios and population attributable risk (PAR) were calculated to quantify STEMI risk. RESULTS: There were 1715 STEMIs in 1680 patients during the study period. Smoking status was obtained in 96.2% patients. The prevalence of smoking was 47.3% in patients with STEMI and 22.0% in the general population. In patients with STEMI, smokers were ∼10 years younger, mean (SD) 57.2 (11.1) years, than never-smokers, 66.4 (12.1) years, and ex-smokers, 67.9 (11.9) years. The age-standardised incident rate ratio of STEMI was 5.2 (4.5-6.1) for current smokers and 1.1 (1.0-1.3) for ex-smokers, with the reference group being never-smokers for both. Almost 50% of STEMIs were attributable to smoking (PAR=48.3%). CONCLUSION: Cigarette smoking is associated with a fivefold increased risk of STEMI. Smoking cessation reduced this risk to a level similar to never-smokers.

Short-term outcomes in patients with acute coronary syndrome treated with direct bioresorbable scaffold deployment.

BACKGROUND: Direct coronary stenting is a validated therapeutic option for coronary lesions. We studied the feasibility of direct deployment with a bioresorbable vascular scaffold (BVS) in acute coronary syndrome (ACS). METHODS: Demographic, procedural, and survival data were obtained for patients who had direct scaffold deployment with BVS from 1 May 2013 to 1 April 2014. RESULTS: We performed a retrospective review of nine patients which included eight patients having ST-elevation myocardial infarction. There were no cases of worsening coronary flow, scaffold thrombosis, target lesion revascularization or death up to 30 days post intervention. CONCLUSION: Direct BVS deployment in ACS appears safe and feasible.

Multimodality imaging for assessment of coronary embolus.

Caseous mitral annulus calcification involving aortomitral curtain is a rare occurrence. We report a case of a 64-year-old woman with end-stage renal failure and a candidate for renal transplant who presented with late ST-elevation myocardial infarction. Intracoronary imaging, computed tomography cardiac imaging, and histopathology confirmed coronary embolus into the left main stem artery from an extensive caseous mitral annulus calcification.

Role of frailty assessment in patients undergoing cardiac interventions.

Average life expectancy is increasing in the western world resulting in a growing number of frail individuals with coronary heart disease, often associated with comorbidities. Decisions to proceed to invasive interventions in elderly frail patients is challenging because they may gain benefit, but are also at risk of procedure-related complications. Current risk scores designed to predict mortality in cardiac procedures are mainly based on clinical and angiographic factors, with limitations in the elderly because they are mainly derived from a middle-aged population, do not account for frailty and do not predict the impact of the procedure on quality of life which often matters more to elderly patients than mortality. Frailty assessment has emerged as a measure of biological age that correlates well with quality of life, hospital admissions and mortality. Potentially, the incorporation of frailty into current risk assessment models will cause a shift towards more appropriate care. The need for a more accurate method of risk stratification incorporating frailty, particularly for elderly patients is pressing. This article reviews the association between frailty and cardiovascular disease, the impact of frailty on outcomes of cardiac interventions and suggests ways in which frailty assessment could be incorporated into cardiology clinical practice.