Prevalence of ATTR-CA and high-risk features to guide testing in patients referred for TAVR.

PURPOSE: Transthyretin cardiac amyloidosis (ATTR-CA) is thought to be prevalent in patients with severe aortic stenosis (AS) who are referred for transcatheter aortic valve replacement (TAVR). However, prior studies were published when TAVR was only offered to elderly, inoperable, and high-risk patients. The aim of this study was to reevaluate the prevalence of ATTR-CA in a contemporary TAVR population and identify high-risk features to guide referral for technetium-99 pyrophosphate scan (99mTc-PyP scan) screening. METHODS: Patients seen in a multidisciplinary TAVR clinic for severe AS 70 years and older were referred for a 99mTc-PyP scan to evaluate for ATTR-CA. The primary outcome was the percent with a positive scan. The discriminatory ability of high-risk features was assessed to develop a more judicious screening system. RESULTS: Over the study period, 380 patients underwent screening, and 20 patients (5.3%) had a positive scan, with 17 patients having confirmed ATTR-CA, 1 patient deferring confirmatory testing (combined 4.7%), 1 having light chain amyloidosis, and 1 negative on biopsy. Compared to other patient and echocardiographic measures, elevated NT-pro BNP (> 1000 ng/L) was the best discriminator on who should be referred for 99mTc-PyP scan screening, with a sensitivity of 90% and a negative predictive value of 99%. CONCLUSION: The prevalence of ATTR-CA may be lower in a contemporary TAVR population due to its expanded indication for low-risk patients. NT-pro BNP is a simple test that can improve screening yield and more judiciously guide screening for ATTR-CA in this at-risk population. Comparison of the original versus the proposed algorithm.

Dobutamine stress PET/CT for assessment of hemodynamic significance of coronary myocardial bridges.

Myocardial bridges are common and often benign, but can cause hemodynamically significant obstruction of blood flow with stress. Dobutamine stress positron emission tomography/computed tomography (PET/CT) is a powerful tool for non-invasively assessing for ischemia. We present a case of using dobutamine stress PET/CT to determine the significance of a myocardial bridge.

Survey of Conventional and Complementary and Alternative Therapy in Patients With Low Back Pain.

UNLABELLED: Both conventional and alternative medical therapies are used by patients to treat low back pain, a condition that affects approximately 33% of the U.S. POPULATION: Little is known about patients' perceptions of conventional versus alternative therapies. Patients recruited from an orthopedic spine clinic completed surveys containing questions about their use of many conventional and alternative therapies. Patients rated perceived helpfulness, side effects, and their recommendation for each therapy. They also completed a questionnaire that detailed demographic information, stress, and pain. Questionnaires were completed by 166 patients. Conventional medications were used by 154 (95%) patients, most commonly acetaminophen and opioid derivatives. Alternative therapies were used by 159 (96%) patients, including therapeutic exercises, salves, supplements, and stress management techniques. Generally, patients reported that alternative therapies are more effective and have fewer side effects and would more likely recommend their use. These data can be used to counsel patients and guide future research.

Sex-Specific Prognosis of Left Ventricular Size and Function Following Repair of Degenerative Mitral Regurgitation.

BACKGROUND: Prior studies have demonstrated worse long-term outcomes for women after surgery for severe mitral regurgitation (MR). The current Class I indications for surgery for severe degenerative MR use cutoffs of left ventricular end-systolic dimension (LVESD) and left ventricular ejection fraction (EF) that do not account for known sex-related differences. OBJECTIVES: The primary objective of this study was to assess long-term mortality following mitral valve repair in women compared with men on the basis of preoperative left ventricular systolic dimensions and EF. METHODS: Consecutive patients who underwent isolated mitral valve repair for degenerative MR at a single institution between 1994 and 2016 were screened. Adjusted HRs for all-cause mortality were compared according to baseline LVESD, LVESD indexed to body surface area (LVESDi), and EF for men and women. RESULTS: Among 4,589 patients, 1,825 were women (40%), and after a median follow-up period of 7.2 years, 344 patients (7.5%) had died. The risk for mortality for women increased from the baseline hazard at an LVESD of 3.6 cm, whereas an inflection point for increased risk with LVESD was not evident in men. Regarding LVESDi, the risk for women increased at 1.8 cm/m2 compared with 2.1 cm/m2 in men. For EF, women and men had a similar inflection point (58%); however, mortality was higher for women as EF decreased. CONCLUSIONS: After mitral valve repair, women have a higher risk for all-cause mortality at lower LVESD and LVESDi and higher EF. These results support consideration of sex-specific thresholds for LVESDi in surgical decision making for patients with severe MR.

Pre-test Prediction of Non-ischemic Cardiomyopathies using Time-Series EHR Data.

Clinical imaging is an important diagnostic test to diagnose non-ischemic cardiomyopathies (NICM). However, accurate interpretation of imaging studies often requires readers to review patient histories, a time consuming and tedious task. We propose to use time-series analysis to predict the most likely NICMs using longitudinal electronic health records (EHR) as a pseudo-summary of EHR records. Time-series formatted EHR data can provide temporality information important towards accurate prediction of disease. Specifically, we leverage ICD-10 codes and various recurrent neural network architectures for predictive modeling. We trained our models on a large cohort of NICM patients who underwent cardiac magnetic resonance imaging (CMR) and a smaller cohort undergoing echocardiogram. The performance of the proposed technique achieved good micro-area under the curve (0.8357), F1 score (0.5708) and precision at 3 (0.8078) across all models for cardiac magnetic resonance imaging (CMR) but only moderate performance for transthoracic echocardiogram (TTE) of 0.6938, 0.4399 and 0.5864 respectively. We show that our model has the potential to provide accurate pre-test differential diagnosis, thereby potentially reducing clerical burden on physicians.

Frequency of screening for cardiac allograft vasculopathy: warranty period of initial low risk positron emission tomography.

AIMS: The short-term risk of moderate-severe cardiac allograft vasculopathy (CAV) after a low-risk positron emission tomography/computed tomography (PET/CT) is unknown, and therefore, there is no guidance on how frequently to perform screening. The aim of this study was to assess the rate of progression to moderate-severe CAV as part of an annual screening programme. METHODS AND RESULTS: Patients with no history of CAV 2/3 and a low-risk result on initial screening PET/CT (CAV 0/1) were enrolled in the study. The primary outcome was the progression to CAV 2/3 as part of an annual screening programme (within 6-18 months of initial scan). PET CAV results were graded according to a published and externally validated diagnostic criterion for CAV. Over the study period, 231 patients underwent an initial PET/CT and had a subsequent evaluation for CAV. In this cohort, 4.3% of patients progressed to CAV 2/3 at a median of 374 days (interquartile range 363-433). Initial PET CAV grade was the most significant patient characteristic associated with the progression of CAV, with 17% of patients with PET CAV 1 progressing to CAV 2/3 compared with 1.6% with PET CAV 0 (odds ratio 12.4, 95% confidence interval 3.06-50.3). CONCLUSION: The rate of progression to moderate-severe CAV at 1 year after the lowest-risk PET/CT is low, but approximately 1/6 patients with PET CAV 1 progress to CAV 2/3. Annual screening with PET/CT for select patients with PET CAV 0 may not be warranted. The optimal screening interval awaits confirmation of our findings in multi-centre registries.

Negative Predictive Value and Prognostic Associations of Rb-82 PET/CT with Myocardial Blood Flow in CAV.

BACKGROUND: Invasive coronary angiography (ICA) is the traditional screening modality for cardiac allograft vasculopathy (CAV). Positron emission tomography/computed tomography (PET/CT) scan with myocardial blood flow (MBF) quantification has emerged as a potential noninvasive alternative. OBJECTIVES: The aim of the study was to validate the diagnostic and prognostic value of a previously published algorithm for diagnosing CAV via PET/CT scans with MBF in a larger population. The study also sought to assess the downstream use of ICA when using PET/CT scanning as a screening modality. METHODS: Patients with heart transplantation without prior revascularization who underwent PET/CT scans with MBF were identified retrospectively. The accuracy of the algorithm was assessed in patients who underwent PET/CT scanning within 1 year of ICA. The prognostic value was assessed via a composite outcome of heart failure hospitalization, myocardial infarction, retransplantation, and all-cause mortality. RESULTS: A total of 88 patients for the diagnostic portion and 401 patients for the prognostic portion were included. PET CAV 0 had high negative predictive value for moderate to severe CAV (97%) and PET CAV 2/3 had a high positive predictive value for moderate to severe CAV (68%) by ICA. The cohort was followed for a median of 1.2 (IQR: 1.0-1.8) years with 46 patients having an adverse event. The annualized event rates were 6.9%, 9.3%, and 30.8% for PET CAV 0, 1, and 2/3, respectively (P < 0.001). CONCLUSIONS: An algorithm using PET/CT scanning with MBF demonstrates high a negative predictive value for CAV. PET CAV 2/3 is associated with a higher risk of adverse events and need for revascularization. PET/CT scanning with MBF is a reasonable alternative to ICA for screening for CAV.

Interleukin-1 Antagonists for the Treatment of Recurrent Pericarditis.

Although most patients with acute pericarditis will recover, a minority will have recurrent, debilitating episodes. In these patients, refractory symptoms result in high morbidity, and typically require a prolonged duration of anti-inflammatory treatment. Initially, the efficacy of colchicine in both recurrent pericarditis and periodic fever syndromes suggested the central role of the inflammasome in pericarditis. Subsequently, the success of interleukin-1 antagonists in autoinflammatory diseases prompted further investigation in recurrent pericarditis. In current clinical practice, interleukin-1 antagonists include canakinumab, anakinra, and rilonacept. Both anakinra and rilonacept have demonstrated efficacy in randomized trials of patients with recurrent pericarditis. The aim of the current review is to explain the biological rationale for interleukin-1 antagonists in recurrent pericarditis, highlight supporting clinical evidence, and emphasizing future areas of investigation.

Novel Oral Anticoagulants Following Percutaneous Coronary Intervention.

Antiplatelet and anticoagulant medications are the cornerstone of therapy for patients with acute coronary syndrome and have also been shown to reduce recurrent cardiovascular events in patients with stable coronary disease. Whereas antiplatelet medications have been the preferred therapy for long-term secondary prevention, the development of novel oral anticoagulants has renewed interest in the use of anticoagulation to prevent atherosclerotic events. In patients with atrial fibrillation or other indications for anticoagulation, recent clinical trials have shown the benefit of double therapy with full-dose novel oral anticoagulants and P2Y12 inhibitors compared with regimens with vitamin K antagonists. In patients without an indication for anticoagulation, the use of low doses of the factor Xa inhibitor, rivaroxaban, has shown benefit. Clinicians have many pharmacological options when treating patients following percutaneous coronary intervention. This review discusses the evidence for the use of novel oral anticoagulants, with an emphasis on patient selection, choice of therapy, and appropriate dosing of anticoagulant and antiplatelet agents, in secondary prevention strategies for atherosclerosis following coronary revascularization for patients with and without a traditional indication for anticoagulation.

An Atrial Fibrillation Transitions of Care Clinic Improves Atrial Fibrillation Quality Metrics.

OBJECTIVES: This study sought to assess whether an atrial fibrillation (AF)-specific clinic is associated with improved adherence to American College of Cardiology (ACC)/American Heart Association (AHA) clinical performance and quality measures for adults with AF or atrial flutter. BACKGROUND: There are significant gaps in care of patients with AF, including underprescription of anticoagulation and treatment of AF risk factors. An AF specialized clinic was developed to reduce admissions for AF but may also be associated with improved quality of care. METHODS: This retrospective study compared adherence to ACC/AHA measures for patients who presented to the emergency department for AF between those discharged to a typical outpatient appointment and those discharged to a specialized AF transitions clinic run by an advanced practice provider and supervised by a cardiologist. Screening and treatment for common AF risk factors was also assessed. RESULTS: The study enrolled 78 patients into the control group and 160 patients into the intervention group. Patients referred to the specialized clinic were more likely to have stroke risk assessed and documented (99% vs. 26%; p < 0.01); be prescribed appropriate anticoagulation (97% vs. 88%; p = 0.03); and be screened for comorbidities such as tobacco use (100% vs. 14%; p < 0.01), alcohol use (92% vs. 60%; p < 0.01), and obstructive sleep apnea (90% vs. 13%; p < 0.01) and less likely to be prescribed an inappropriate combination of anticoagulant and antiplatelet medications (1% vs. 9%; p < 0.01). CONCLUSIONS: An AF specialized clinic was associated with improved adherence to ACC/AHA clinical performance and quality measures for adult patients with AF.

Likelihood of Spontaneous Cardioversion of Atrial Fibrillation Using a Conservative Management Strategy Among Patients Presenting to the Emergency Department.

Numerous emergency department (ED) atrial fibrillation (AF) protocols have been developed to reduce hospitalizations, focusing on the use of cardioversion in the ED. An alternative strategy of rate control with early specialty follow-up may be more widely applicable. The likelihood of spontaneous cardioversion with such a protocol is unknown. Between 2015 and 2018, 157 patients who presented to the ED with a primary diagnosis of AF and were hemodynamically stable and with low to moderate symptom severity were discharged with early follow-up at an AF specialty clinic. Rhythm at short-term (within 72 hours), within 30-day follow-up, and need for electrical cardioversion was tabulated. Various demographic and co-morbidity variables were assessed to determine their association with likelihood of spontaneous cardioversion. At an average of 2.3 days, 63% and within 30 days, 83% had spontaneous cardioversion. By 90 days, only 6.3% required electrical cardioversion. Diabetes (38% vs 69%, p <0.01), coronary artery disease (39% vs 66%, p = 0.02), reduced ejection fraction (40% vs 72%, p <0.01), dilated right atrium (43% vs 73%, p <0.01) and moderate-to-severely dilated left atrium (38% vs 78%, p <0.01) predicted those who were less likely to convert to sinus rhythm. Most patients who present to the ED with AF will spontaneously convert to sinus rhythm by short-term (2 to 3 days) follow-up with a rate control strategy. In conclusion, aggressive use of electrical cardioversion in the ED may be unnecessary in hemodynamically stable patients without severe symptoms.

Rogue one: a story of tophaceous gout in the spine.

A 26-year-old man with history of extensive tophaceous gout presented to the referring facility with decreased bilateral lower extremity sensation and motor function that began acutely 1 week prior to admission and had progressed to urinary incontinence. The patient was admitted to the intensive care unit due to concern for sepsis secondary to epidural abscess. The patient was started on empiric vancomycin and cefepime. Neurosurgery did not recommend acute neurosurgical intervention given the lack of a compressive lesion. Aspiration of the paraspinal collection by interventional radiology subsequently showed crystals consistent with tophaceous gout. Given the high initial suspicion for gout and results of the paraspinal aspiration, the patient was started on prolonged steroid taper as well as allopurinol and colchicine. The patient eventually had partial neurological recovery with discharge to an inpatient rehabilitation facility for further physical therapy rehabilitation.

Does Screw Configuration or Fibular Osteotomy Decrease Healing Time in Exchange Tibial Nailing?

OBJECTIVES: This multicenter study was designed to evaluate whether tibia fracture nonunions treated with exchange nailing proceed to union faster with dynamically- versus statically-locked nails, or with fibular osteotomy versus no fibular osteotomy. DESIGN: Retrospective, chart-review, multicenter study. SETTING: Multicenter review of 6 level 1 trauma centers. PATIENTS/PARTICIPANTS: Patients who had a tibia fracture treated with an intramedullary nail that progressed to nonunion, and were subsequently treated with exchange nailing, were identified. All patients that met inclusion criteria and subsequently progressed to union were included in the study. INTERVENTION: Patients underwent tibial exchange nailing to repair nonunions, with screws in either a dynamically- or statically-locked configuration with or without fibular osteotomy. MAIN OUTCOME MEASURES: The primary outcome measure was a comparison of time to healing of tibial nonunion comparing different screw configurations and fibular osteotomy. RESULTS: Fifty-two patients underwent an exchange nail procedure and their outcomes were used for the primary analysis. Patients with dynamically-locked nails proceeded to union 7.9 months after revision surgery compared with 7.3 months for those with statically-locked nails, but this was not statistically significant (P = 0.68). Patients with fibular osteotomy proceeded to union 2.9 months faster than those without fibular osteotomy, and this trended toward significance (P = 0.067). Obese patients healed on average 8.8 months after surgery compared with 6.8 months for nonobese patients (P = 0.27). Closed fractures healed after 6.4 months compared with 7.7 months for open fractures (P = 0.40). CONCLUSIONS: There was no significant difference in time to union between patients who had a dynamic screw configuration compared with a static screw configuration for their exchange nail. Patients who underwent fibular osteotomy proceeded to union faster than those without an osteotomy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.