Snoring Survivors: the impact of obstructive sleep apnoea and continuous positive airway pressure use on in-hospital mortality, length of stay and costs among patients hospitalised with acute cardiovascular disease - A retrospective analysis of 2016-2019 National Inpatient Sample Data.

BACKGROUND: The routine administration of supplemental oxygen to non-hypoxic patients with acute myocardial infarction (AMI) has been abandoned for lack of mortality benefit. However, the benefits of continuous positive airway pressure (CPAP) use in patients hospitalised with acute cardiovascular disease and concomitant obstructive sleep apnoea (OSA) remain to be elucidated. METHODS: In this retrospective case-control analysis, using 10th International Classification of Diseases, Clinical Modification (ICD-10) codes, we searched the 2016-2019 Nationwide Inpatient Sample for patients diagnosed with unstable angina (UA), AMI, acute decompensated heart failure (ADHF) and atrial fibrillation with rapid ventricular response (AFRVR), who also carried a diagnosis of OSA. We identified in-hospital CPAP use with ICD-10-Procedure Coding System codes. In-hospital death, length of stay (LOS) and hospital charges were compared between patients with and without OSA, and between OSA patients with and without CPAP use. RESULTS: Our sample included 2 959 991 patients, of which 1.5% were diagnosed with UA, 30.3% with AMI, 37.5% with ADHF and 45.8% with AFRVR. OSA was present in 12.3%. Patients with OSA were more likely to be younger, male, smokers, obese and have chronic obstructive pulmonary disease, renal failure and heart failure (p<0.001 for all). Patients with OSA had significantly lower in-hospital mortality (aOR 0.71, 95% CI (0.7 to 0.73)). Among patients with OSA, CPAP use significantly increased the odds of in-hospital death (aOR 1.51, 95% CI (1.44 to 1.60)), LOS (adjusted mean difference of 1.49 days, 95% CI (1.43 to 1.55)) and hospital charges (adjusted mean difference of US$1168, 95% CI (273 to 2062)). CONCLUSION: Our study showed that patients with recognised OSA hospitalised for AMI, ADHF and AFRVR had significantly lower mortality regardless of CPAP use, while CPAP treatment among these patients was associated with significantly higher in-hospital mortality and resource utilisation. The routine use of CPAP during acute cardiovascular encounters could neutralise the impact of chronic intermittent ischaemic preconditioning.

Outcomes of percutaneous coronary intervention (PCI) among patients with connective tissue disease: Propensity match analysis.

BACKGROUND: Inflammation is the hallmark of coronary artery disease (CAD) and CTD. There are reports of increased prevalence of CAD among patients with CTD such as Rheumatoid Arthritis. However, there is a paucity of data regarding the outcomes of PCI among patients with CTD. METHODS: Using the National Inpatient Database, patients that underwent PCI between 2007 and 2015 were identified using ICD-9-CM codes. Propensity match analysis with 1: 3 matching of patients with and without CTD was performed. Outcomes were acute kidney injury (AKI), access site complication (ASC), ventricular fibrillation (VF), cardiogenic shock (CS), Stroke, In-hospital mortality and hospital length of stay (LOS) compared between both groups. RESULT: We identified 17,422 patients with CTD and matched with 52, 266 patients without CTD. Patients were predominantly female (63.1%) and white (77.2%), with a mean age of 63 ± 12.1 years. AKI (8.3% vs. 6.6%, p < 0.001), ASC (3.2% vs. 2.7%, p = 0.01) and hospital stay (4.2 ± 4.8 vs. 3.8 ± 5.2, p < 0.001) were higher among patients with CTD. There was no statistically significant difference in rates of VF, CS, stroke, and In-hospital mortality among the two groups. However, in subgroup analysis, rates of VF were lower among patients with Systemic Lupus Erythematosus (SLE) (1.5% vs. 2.2%, p = 0.006). CONCLUSIONS: Patients with CTD undergoing PCI have a higher rate of AKI, Access site complications, and prolonged hospital stay.

Electrocardiographic Associations Seen with Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is a chronic respiratory disorder associated with repeated nocturnal partial or complete collapse that is often underdiagnosed and associated with multiple comorbidities. The association between specific features on an electrocardiogram and OSA has not been well studied. This retrospective study attempts to bridge this gap in knowledge. METHODS: A total of 265 patients' medical records were reviewed retrospectively. Specific features of their electrocardiograms and their association with the severity of OSA were studied from April 2014 to May 2016. 215 patients were included in the final analysis. Tests of group difference between OSA patients and controls were done using student's t-tests for continuous variables and using chi-square tests for categorical outcomes. Multivariate tests of differences between OSA and control patients were done using logistic regression to control for possible confounding factors. RESULTS: A total of 215 patients with diagnosed OSA and 41 controls in whom OSA was ruled out using polysomnography were compared. Males were more likely to present with OSA than females (93 % versus 76 %; p < 0.001). OSA patients were also significantly older: 52.18 ± 14.04 versus 44.55 ± 14.64; p = 0.002. Deep S waves in V5-6 (p=0.014) and RS pattern with Deep S waves in leads I and AVF (p=0.017) were both significantly associated with OSA based on univariate comparisons. These findings lost significance in the multivariate analysis. CONCLUSION: The idea of using an electrocardiogram in aiding in the assessment of OSA is attractive and feasible, as it is a safe, noninvasive, and cost-effective method. Our results can be used for early risk stratification in patients with OSA.

Severe Pulmonary Hypertension Due to Adult-Onset Still's Disease.

A 29-year-old female with adult-onset Still's disease (AOSD) presented with progressive shortness of breath both on rest and on exertion, increased abdominal girth, and swelling in both legs. She was on oral prednisone and was recently started on canakinumab (interleukin-1 antagonist) for joint pain and rash of AOSD. Echocardiogram showed severely dilated right ventricle, dilated pulmonary artery, moderately reduced right ventricular systolic function, but with normal left ventricular systolic function. Computed tomography with contrast ruled out pulmonary embolism. Blood tests ruled out other rheumatologic diseases. The patient was diagnosed with right-sided heart failure likely secondary to AOSD. Right heart catheterization was needed but could not be performed because of severely dilated pulmonary artery. The patient was transferred to a higher center for further management and possible cardiopulmonary transplant.

Unusual Sign from an Unusual Cause: Wellens' Syndrome due to Myocardial Bridging.

It is vital to recognize correctly, chest pain of cardiac etiology. Most commonly, it is because of blood supply-demand inequity in the myocardium. However, the phenomenon of myocardial bridging as a cause of cardiac chest pain has come to attention reasonably recently. Herein, a coronary artery with a normal epicardial orientation develops a transient myocardial course. If the cardiac muscle burden is substantial, the respective artery gets compressed during each cycle of systole, thereby impeding blood flow in the artery. Hence, myocardial bridging has been attributed to as a rare cause of angina. In this case report, the authors discuss a patient in whom myocardial bridging turned out to be an elusive cause of angina. We wish to underscore the importance of being clinically mindful of myocardial bridging when assessing a patient with angina.

Duration of Dual Antiplatelet Therapy Following Drug-Eluting Stent Implantation in Diabetic and Non-Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Diabetic patients account for an increasing number of patients undergoing percutaneous coronary intervention (PCI). However, diabetes mellitus (DM) is associated with increased residual platelet activity during dual antiplatelet treatment (DAPT) and DM patients have worse clinical outcomes after PCI as compared to non-DM. OBJECTIVE: To evaluate efficacy and safety of short duration DAPT (S-DAPT) and long duration DAPT (L-DAPT) after drug eluting stent (DES) implantation in DM and non-DM patients. METHODS: We searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials (RCTs) assessing the effect of S-DAPT versus L-DAPT after DES implantation in DM and non-DM patients. Efficacy endpoints were all-cause mortality, cardiac mortality, myocardial infarction (MI), stent thrombosis (ST), target vessel revascularization (TVR), and composite end point of net adverse clinical events (NACE) (all-cause mortality, cardiac mortality, MI, ST, TVR, stroke, major bleeding). Safety endpoints were major bleeding and stroke. Event rates were compared using a forest plot of relative risk using a random effects model. RESULTS: We included eight RCTs that randomized 28,318 patients to S-DAPT versus L-DAPT (8234 DM and 20,084 non-DM). S-DAPT was associated with an increased rate of ST in non-DM patients [3.67 (2.04, 6.59)]. There was no significant difference in the rate of all-cause mortality, cardiac mortality, ST, MI, TVR, major bleeding, stroke and NACE with S-DAPT and L-DAPT in DM patients [1.19 (0.72-1.95); 1.25 (0.69, 2.25); 1.52 (0.70, 3.29); 1.33 (0.88, 2.01); 1.39 (0.89, 2.17); 0.92 (0.19, 4.42); 0.98 (0.29, 3.28); and 0.94 (0.57, 1.54) respectively]. Further, there was no significant difference in the rate of all-cause mortality, cardiac mortality, MI, TVR, major bleeding, stroke and NACE with S-DAPT and L-DAPT in non-DM patients [0.93 (0.58, 1.48); 0.75 (0.42, 1.35); 1.52 (0.81, 2.83); 0.99 (0.71, 1.39); 0.72 (0.28, 1.84); 1.01 (0.40, 2.56); and 1.01 (0.77, 1.32) respectively]. CONCLUSION: Compared to L-DAPT, S-DAPT was associated with significant increase in rate of ST in non-DM patients. Duration of DAPT had no significant impact on rates of all-cause mortality, cardiac mortality, MI, ST and TVR among DM patients.

Novel Oral Anticoagulants in Atrial Fibrillation: Update on Apixaban.

Almost 800,000 new or recurrent strokes occur every year. Atrial fibrillation, the most common cardiac arrhythmia, is a major risk factor for stroke, accounting for 15-20% of ischemic strokes. Apixaban is a direct inhibitor of Factor Xa that was approved in December 2012 by the US Food and Drug Administration (FDA) for the prevention of stroke in patients with non-valvular atrial fibrillation. It is part of a family of novel oral anticoagulants (NOACs) which has advantage over warfarin of less dosing variability, rapid onset of action and no INR monitoring required. Apixaban showed superiority to warfarin in both primary efficacy and primary safety outcomes by simultaneously showing both significantly lower rates of strokes and systemic embolism and a reduced risk of major clinical bleeding in clinical trials. Warfarin remains the anticoagulant of choice for patients with prosthetic heart valves and significant mitral stenosis. There are currently no head-to-head studies that directly compare the different NOACs with one another, but it is expected that there will be more trials in the future that will explore this comparison. Dabigatran is the only NOAC with an FDA approved reversal agent. However, a reversal agent for apixaban is being developed and was successful in recent clinical trials. This review summarizes the clinical trial data on apixaban for atrial fibrillation, compares apixaban to other NOACs and discusses apixaban use in clinical practice.

Nanomedicine in coronary artery disease.

Nanomedicine is one of the most promising therapeutic modalities researchers are working on. It involves development of drugs and devices that work at the nanoscale (10-9m). Coronary artery disease (CAD) is responsible for more than a third of all deaths in age group >35 years. With such a huge burden of mortality, CAD is one of the diseases where nanomedicine is being employed for preventive and therapeutic interventions. Nanomedicine can effectively deliver focused drug payload at sites of local plaque formation. Non-invasive strategies include thwarting angiogenesis, intra-arterial thrombosis and local inflammation. Invasive strategies following percutaneous coronary intervention (PCI) include anti-restenosis and healing enhancement. However, before practical application becomes widespread, many challenges need to be dealt with. These include manufacturing at the nanoscale, direct nanomaterial cellular toxicity and visualization.

Role of Vasodilator Testing in Pulmonary Hypertension.

Pulmonary hypertension is clinically defined by a mean pulmonary artery (PA) pressure of 25mm Hg or more at rest, as measured by right heart catheterization. To identify patients who are likely to have a beneficial response to calcium channel blockers (CCBs) and therefore a better prognosis, acute vasodilator testing should be performed in patients in certain subsets of pulmonary arterial hypertension (PAH). A near normalization of pulmonary hemodynamics is needed before patients can be considered for therapy with CCBs. Intravenous adenosine, intravenous epoprostenol, inhaled nitric oxide, or inhaled iloprost are the standard agents used for vasoreactivity testing in patients with idiopathic PAH. In this review we describe the various aspects of vasodilator testing including the rationale, pathophysiology and agents used in the procedure.

Acute pulmonary edema secondary to hyperbaric oxygen therapy.

Hyperbaric oxygen therapy (HBOT) has been shown to be effective in the treatment of diabetic ulcers, air embolism, carbon monoxide poisoning and gas gangrene with minimal adverse effects. Very few cases of HBOT causing acute pulmonary edema (PE) has been described; with a study on dogs suggesting that a complication of this therapy could be PE. We describe the case of an 80-year-old man with a history of stable systolic heart failure and diabetes mellitus presenting with acute PE following treatment with HBOT for diabetic foot.

Correlation of echocardiographic left atrial abnormality with myocardial ischemia during myocardial perfusion assessment in patients with left bundle branch block.

Left atrial (LA) abnormality, an easily quantifiable parameter of left ventricular (LV) diastolic dysfunction, has been associated with cardiovascular risk. Because during myocardial perfusion study (MPS), the abnormal LV activation pattern in patients with left bundle branch block (LBBB) frequently induces perfusion defects, a clinical correlate of early myocardial ischemia such as LA enlargement could alleviate some of these inherent challenges. We prospectively studied 144 consecutive patients with LBBB who underwent MPS after screening for electrocardiographic and echocardiographic LA enlargement over a 6-month period. Of those, 114 had a positive MPS result. We found that LA size (p <0.0001) and P-wave duration (p = 0.001) were significantly increased in patients as the severity of the defects increased on MPS, whereas LV ejection fraction was decrementally reduced (p = 0.001). Importantly, LA size (≥43.5 mm; sensitivity 70%, specificity 89%) and P-wave duration (≥135 milliseconds; sensitivity 63%, specificity 90%) were greatest when the MPS defect was severe. In conclusion, the presence of LA enlargement appears significantly correlated with myocardial ischemia among patients with LBBB and could therefore assist during MPS interpretation among patients in whom MPS interpretation could be challenging.