Cardiovascular Outcomes Among Patients with Acute Coronary Syndromes and Diabetes: Results from ACS QUIK Trial in India.

Background: Despite cardiovascular disease being the leading cause of death in India, limited data exist regarding the factors associated with outcomes in patients with diabetes who suffer acute myocardial infarction (AMI). Methods: We examined 21,374 patients with AMI enrolled in the ACS QUIK trial. We compared in-hospital and 30-day major adverse cardiac events including death, re-infarction, stroke, or major bleeding in those with and without diabetes. The associations between diabetes and cardiac outcomes were adjusted for presentation and in-hospital management using logistic regression. Results: Mean ± SD age was 60.1 ± 12.0 years, 24.3% were females, and 44.4% had diabetes. Those with diabetes were more likely to be older, female, hypertensive, and have higher Killip class but less likely to present with STEMI. Patients with diabetes had longer symptoms onset-to-arrival (median 225 vs 290 min; P < 0.001) and, in case of STEMI, longer door-to-balloon times (median, 75 vs 91 min; P < 0.001). Diabetes was independently associated with higher in-hospital death (adjusted odds ratio [aOR], 1.46; 95% CI, 1.12-1.89), in-hospital reinfarction (aOR, 1.52; 95% CI, 1.15-2.02), 30-day MACE (aOR, 1.33; 95% CI, 1.14-1.55) and 30-day death (aOR, 1.40; 95%CI, 1.16-1.69) but not 30-day stroke or 30-day major bleeding. Conclusion: Among patients presenting with AMI in Kerala, India, a considerable proportion has diabetes and are at increased risk for in-hospital and 30-day adverse cardiovascular outcomes. Increased awareness of the increased cardiovascular risk and attention to the implementation of established cardiovascular therapies are indicated for patients with diabetes in lower-middle-income countries who develop AMI. Clinical Trial registration: ClinicalTrials.gov Unique identifier: NCT02256658.

Emergency department visits among patients with left ventricular assist devices.

Continuous-flow left ventricular assist devices (LVADs) are increasingly implanted to support patients with end-stage heart failure. These patients are at high risk for complications, many of which necessitate emergency care. While rehospitalization rates have been described, there is little data regarding emergency department (ED) visits. We hypothesize that ED visits are frequent and often require admission after LVAD implantation. We performed a retrospective review of patients in our health-care system followed by the advanced heart failure service for LVAD management after implantation between January 2011 and July 2015. We accounted for all ED visits in our system through February 2016, 7 months after the last implantation included. Clinically relevant demographic variables and ED visit details were recorded and analyzed to describe this population. We identified 81 patients with complete data, among whom there were 283 visits (3.49 visits/patient), occurring at a rate of approximately 7.3 ED visits per patient per year alive with LVAD. The most common reason for an ED visit is a complication related to bleeding (18% of visits), followed by chest pain (14%) and dizziness or syncope (13%). Thirty-six percent of patients were discharged from the ED without hospital admission. A growing populace with implanted LVADs represents an important population within emergency medicine. They are at risk for significant complications and frequently present to the ED. While many of these visits may be managed without hospital admission, this specialized patient group represents a potential area for improvement in provider education.

Low Cardiac Output After Orthotopic Heart Transplant Secondary to Large Inferior Vena Cava Thrombus After Prothrombin Complex: A Case Report.

Low cardiac output after orthotopic heart transplant (OHT) may be attributed to inadequate preload, vasodilation, and/or reduced inotropy. Inadequate preload because of an inferior vena cava (IVC) thrombus is a rare cause of low cardiac output and not frequently described in the literature. Although the use of prothrombin complex (PCC) has been associated with thrombus formation, its contribution to life-threatening IVC thrombosis has yet to be described. This case report describes the use of perioperative ultrasound in the diagnosis and management of a low cardiac output state induced by an IVC thrombus in an OHT recipient who received PCC.

Predictive factors of early spontaneous resolution in children with primary vesicoureteral reflux.

PURPOSE: Questions regarding the efficacy and safety of long-term prophylactic antibiotics and the option of minimally invasive therapy have increased clinical emphasis on predicting early resolution in patients with vesicoureteral reflux. We reviewed multiple potential prognostic factors in addition to grade to enhance predictive ability regarding early vesicoureteral reflux resolution. MATERIALS AND METHODS: Medical records and cystograms from 324 children (257 girls and 67 boys) with primary vesicoureteral reflux were reviewed. Multiple factors were analyzed with respect to outcome and multivariable dependent tables were constructed to enhance the prediction of vesicoureteral reflux resolution. RESULTS: Mean +/- SD age at diagnosis was 2.3 +/- 2.1 years and followup was 1.7 +/- 2.8 years. Reflux grade was significantly associated with resolution (p <0.001). Multivariate analysis stratifying by grade demonstrated that a bladder volume at reflux onset on the initial cystogram of greater than 50% of predicted bladder capacity (p <0.001), age younger than 2 years at diagnosis (p = 0.003) and history of prenatal hydronephrosis (p <0.001) were significant factors predicting resolution within 2 years. Multivariable tables using age, bladder volume at reflux onset and grade demonstrated that children younger than 2 years at diagnosis and volume at onset greater than 50% of predicted bladder capacity had a higher early resolution rate for grades 2 (p = 0.012) and 3 (p <0.001) reflux. CONCLUSIONS: Initial reflux grade, bladder volume at reflux onset, age at diagnosis and history of prenatal hydronephrosis were shown to be independent factors affecting the resolution rates of vesicoureteral reflux. The multivariable tables permit improved individualized prediction of resolution in patients with grades 2 and 3 reflux.

Bladder volume at onset of reflux on initial cystogram predicts spontaneous resolution.

PURPOSE: Reflux grade is the factor most commonly used to predict spontaneous reflux resolution. We evaluated other potential predictive factors aside from reflux grade relative to spontaneous resolution. MATERIALS AND METHODS: We reviewed the records of 20 males and 98 females who were diagnosed with primary vesicoureteral reflux between ages 0 and 7 years between 1990 and 2000. Age, sex, height, weight, reflux grade, bladder volume at onset of reflux and laterality were recorded for the first, second and most recent voiding cystourethrogram or nuclear cystogram before spontaneous resolution or operative intervention. RESULTS: Of 118 patients 75 (64%) had spontaneous resolution, 27 (23%) underwent corrective surgery and 16 (13%) are still being followed. Average age at diagnosis was 2.3 years (range 1 day to 7.7 years) and average followup was 4.3 years (range 0.2 to 14). Average time to spontaneous resolution was 2.2 years (range 0.5 to 10.3) vs a time to operative treatment of 3.6 years (range 0.2 to 11.2). There was a significantly higher spontaneous resolution rate for lower reflux grades (p = 0.0004). Reflux occurring at greater than 75% of predicted bladder capacity had a significantly higher resolution rate (p = 0.0005). The initial height and weight percentile was not significant for predicting spontaneous resolution. Breakthrough urinary tract infections were negative predictors of spontaneous resolution (p <0.0001). CONCLUSIONS: In addition to grade, bladder volume relative to predicted bladder capacity at the onset of reflux appears to provide additional prognostic information regarding the likelihood of spontaneous resolution of primary vesicoureteral reflux.