Dynamic "spiked helmet sign": Further evidence for prolonged QT.

A 69-year-old woman was admitted after a cardiac arrest. She developed status epilepticus and was later found to have variable morphologies of a "spiked helmet sign" (SHS) on ECGs in the setting of prolonged QT interval, raising the question of whether this sign is a manifestation of QT prolongation.

Role of Gender in Dual Antiplatelet Therapy After Acute Coronary Syndrome.

PURPOSE OF REVIEW: The effect of gender on use of dual antiplatelet therapy (DAPT) in treatment of acute coronary syndrome (ACS) is not well established. The purpose of this review is to understand gender-based differences in response to DAPT, so that treatment of ACS can be optimized in women to prevent ischemic events while minimizing bleeding risk. RECENT FINDINGS: There are innate gender differences in platelet reactivity and response. However, it is unknown if this translates into differences in clinical outcomes. In all major studies evaluating the effect of DAPT in ACS, women are underrepresented. Hence, the results from the existing trials cannot be generalizable to women. There is a significant knowledge gap regarding how to balance the bleeding and ischemic risk profile among women with ACS. Currently, there is no recommendation to consider gender as covariate in choosing the type of antiplatelet drug or duration. The existing clinical evidence is limited by under representation of women in DAPT trials. The current literature does not strongly support considering gender in decision making regarding type or duration of DAPT after ACS. Future dedicated trial designs with adequate representation from women and gender specific analysis from large registry data are warranted to enhance our understanding of the interaction of gender with DAPT after ACS.

Feasibility, safety, and patient satisfaction of same-day discharge following peripheral arterial interventions: A randomized controlled study.

OBJECTIVE: To assess feasibility, safety, and patient satisfaction of same-day discharge (SD) following peripheral arterial interventions. BACKGROUND: Although diagnostic angiography is routinely performed as a same-day procedure, same-day percutaneous trans-luminal angioplasty is less common. Because there is very low incidence of peri-procedural complications after 4 hr, discharge after this window is possible provided the patient is able to ambulate and has necessary social support. To-date, safety and patient satisfaction related to SD has not been studied systematically in this population. METHOD: After providing informed consent, patients undergoing out-patient peripheral arterial interventions in a single institution between 2011 and 2015 were randomized to usual care (overnight stay, OS) or SD following successful interventions. Patient satisfaction, complications, and readmission status was ascertained by blinded telephone interviewers at 48-72 hr and 10 days post-procedure. RESULTS: A total of 24 patients consented. Of these, 5 (21.7%) failed screening, leaving 19 patients for randomization to control (n = 10) and experimental group (n = 9) conditions. The SD group experienced zero complications, however their Likert scale rating scores were significantly lower than OS for perceived level of safety (P = 0.02) and likelihood of having the procedure again (P = 0.004). CONCLUSION: This small, single-center randomized study found that among carefully selected peripheral arterial interventions, SD may be feasible and safe. However, patient satisfaction and perceived safety were significantly lower among SD compared to the OS condition. Larger prospective studies are warranted to confirm these findings.

Comparison of antithrombotic agents during urgent percutaneous coronary intervention following thrombolytic therapy: A retrospective cohort study.

BACKGROUND: The optimal antithrombotic regimen for urgent percutaneous coronary interventions (PCI) following thrombolytic therapy for ST segment myocardial infarction (STEMI) is currently unknown. METHODS: We performed a retrospective analysis of all patients referred to our institution from January 2005 to July 2014 who underwent urgent PCI within 24 hr after receiving thrombolytic therapy. The patients were divided into three cohorts based on the anticoagulation strategy during PCI-bivalirudin, heparin alone or heparin plus Glycoprotein IIb/IIIa inhibitor (GPI). The primary end point of major adverse cardiovascular events (MACE) was defined as a composite of inpatient death, myocardial infarction (MI) and stroke. Net adverse clinical events (NACE) were defined as a combination of MACE plus major bleeding complications. Univariable, multivariable and propensity-weighted modeling were used to compare MACE and NACE between the three treatment groups. RESULTS: A total of 695 patients met the inclusion criteria during the study period. In the univariable analysis, there was no significant difference treatment in MACE between the three groups (Bivalirudin: 1.2% vs. Heparin + GPI: 4.4%; Heparin alone: 2.7%, P = 0.11). In the reduced logistic regression model, compared to bivalirudin, the odds of NACE was significantly higher with heparin alone (OR: 3.58, 95% CI: 1.21, 10.54, P = 0.02) or with heparin plus GPI (OR: 9.0, 95% CI: 2.83, 28.64, P <0.001). CONCLUSION: In STEMI patients undergoing PCI within 24 hr after thrombolytic therapy, bivalirudin was associated with a strong trend toward reduced bleeding complications as compared to heparin alone or heparin plus GPI. The optimal antithrombotic regiment for urgent PCI following thrombolytic therapy is currently unknown. Our study demonstrated that use of bivalirudin during PCI following thrombolytic therapy is associated with a trend toward reduced bleeding complications compared to heparin alone or heparin plus GPI. Large randomized trials of adjunctive anticoagulation during PCI in this complex post-thrombolytic population are warranted. © 2017 Wiley Periodicals, Inc.

Long-term outcomes following fractional flow reserve-guided treatment of angiographically ambiguous left main coronary artery disease: A meta-analysis of prospective cohort studies.

OBJECTIVE: To define the long term outcomes of Fractional Flow Reserve (FFR) guided revascularization of ambiguous left main coronary artery (LMCA) lesions by performing a pooled meta-analysis of all available studies. BACKGROUND: Prospective studies evaluating the use of fractional flow reserve (FFR) for clinical decision-making in ambiguous unprotected left main coronary artery (LMCA) stenosis suggest the relative safety of that approach, but any final conclusions are limited by small sample size. We performed a pooled meta-analysis of studies to define the long-term outcomes in these patients. METHODS: Six prospective cohort studies involving 525 patients met the inclusion criteria. Patients underwent revascularization (revascularization group) or medical therapy (deferred group) based on FFR. The primary outcome was defined as rate of major cardiovascular events (a composite of death from all causes, nonfatal myocardial infarctions and subsequent revascularizations). The secondary outcomes included individual components of the primary end point. Pooled effect sizes were calculated using a fixed effects model. RESULTS: Based on the FFR results, 217 patients (41%) underwent revascularization. There was no statistically significant difference between the groups in the rates of primary end point (P = 0.15), all-cause mortality (P = 0.06) or nonfatal myocardial infarctions (P = 0.76). However, there was a significant increase in the rate of subsequent revascularizations in the deferred patients (P = 0.002). CONCLUSION: The long term clinical outcomes in patients with ambiguous LMCA stenosis for whom revascularization is deferred based on FFR are favorable and similar to the revascularized group in terms of overall mortality and subsequent myocardial infarctions.

Formative research to adapt a cardiac rehabilitation program to breast cancer survivors: the heart health after cancer treatment (HEART-ACT) study.

BACKGROUND: Breast cancer survivors are disproportionately at risk for cardiovascular disease; exercise-based interventions may improve cardiovascular health. The objective of this formative research is to better understand the needs of patients and barriers to participation in an adapted cardiac rehabilitation program for diverse breast cancer survivors in an urban safety net setting. METHODS: We recruited 30 participants (10 English-speaking, 10 Spanish-speaking, and 10 Cantonese-speaking) who had received treatment with curative intent for breast cancer from an urban safety net hospital between November 9, 2021, to August 30, 2022. Participants completed surveys and interviews about perspectives on health behaviors and participating in an adapted cardiac rehabilitation program. Interviews were qualitatively analyzed using rapid template analysis with pre-selected constructs from the Theory of Planned Behavior, Unified Theory of Acceptance and Use of Technology, and Consolidated Framework for Implementation Research, as well as emergent codes. We developed a Participant User Journey for a program based on responses and conducted human-centered design sessions with 8 participants to iteratively revise the Participant User Journey. RESULTS: Among 30 participants, mean age was 56.7 years (standard deviation [SD] 10.2) with 100% female sex assigned at birth; 1 participant withdrew before completing study procedures. Most participants had limited health literacy (18/29, 62%). Mean body mass index was 31.4 (SD 8.3), 21/29 (72%) had blood pressure below 140/90 mmHg, and 12/29 (41%) had blood pressure below 130/80. Mean 6-minute walk distance was 384.9 meters (SD 78.3). The desired benefits of a program included healthy living and prevention of cancer recurrence. Barriers to participation included motivation, social support, transportation, and concerns about exercise safety. Participants emphasized the need for practicality, such as fitting physical activity into daily life and nutrition support, including recipes and shopping lists. Trusted experts and cultural and language concordance were viewed as important aspects of the program. CONCLUSIONS: Through participant interviews and human-centered design sessions, we developed the HEART-ACT program, a 12-week multi-disciplinary program addressing physical activity, nutrition, emotional well-being, cardiovascular risk, survivorship, and other components if indicated (e.g., tobacco cessation). Future research will test the effects of this program on patient-centered outcomes.

Decongestive treatment of acute decompensated heart failure: cardiorenal implications of ultrafiltration and diuretics.

In patients with acute decompensated heart failure (ADHF), treatment aimed at adequate decongestion of the volume overloaded state is essential. Despite diuretic therapy, many patients remain volume overloaded and symptomatic. In addition, adverse effects related to diuretic treatment are common, including worsening kidney function and electrolyte disturbances. The development of decreased kidney function during treatment affects the response to diuretic therapy and is associated with important clinical outcomes, including mortality. The occurrence of diuretic resistance and the morbidity and mortality associated with diuretic therapy has stimulated interest to develop effective and safe treatment strategies that maximize decongestion and minimize decreased kidney function. During the last few decades, extracorporeal ultrafiltration has been used to remove fluid from diuretic-refractory hypervolemic patients. Recent clinical studies using user-friendly machines have suggested that ultrafiltration may be highly effective for decongesting patients with ADHF. Many questions remain regarding the comparative impact of diuretics and ultrafiltration on important clinical outcomes and adverse effects, including decreased kidney function. This article serves as a summary of key clinical studies addressing these points. The overall goal is to assist practicing clinicians who are contemplating the use of ultrafiltration for a patient with ADHF.

Epidemiology of sudden cardiac death in rural South India - insights from the andhra pradesh rural health initiative.

BACKGROUND: Sudden cardiac death (SCD) is a common initial presentation of coronary artery disease (CAD). Despite the growing epidemic of CAD in India, the epidemiology of SCD is largely unknown. OBJECTIVE: The objective of the study was to define the prevalence and determinants of sudden cardiac deaths in rural South India. METHODS: Prospective mortality surveillance was conducted in 45 villages (180,162 subjects) in rural South India between January 2006 and October 2007. Trained multipurpose health workers sought to do verbal autopsies within 4 weeks of any death. Detailed questionnaires including comorbidities and circumstances surrounding death were recorded. SCD was adjudicated using the modified Hinkle-Thaler classification. RESULTS: A total of 1916 deaths occurred in the study population over the 22 month time period and verbal autopsy was obtained in 1827 (95%) subjects. Overall mean age of the deceased was 62 ± 20 years and 1007 (55%) were men. Cardiovascular and cerebrovascular diseases together accounted for 559 deaths (31%), followed by infectious disease (163 deaths, 9%), cancer (126 deaths, 7%) and suicide (93 deaths, 5%). Of the 1827 deaths, after excluding accidental deaths (89 deaths), 309 deaths (17%) met criteria for SCD. Cardiovascular disease was the underlying causes in the majority of the SCD events (231/309 (75%)). On multivariate analyses, previous MI/CAD (p < 0.001, OR 14.25), hypertension (p < 0.001, OR 1.84), and age groups between 40-60 yrs (p=0.029) were significantly associated with SCD. CONCLUSION: Sudden cardiac death accounted for up to half of the cardiovascular deaths in rural Southern India. Traditional cardiovascular risk factors were strongly associated with SCD.

Comparison of Clinical Outcomes: Bivalirudin With Transfemoral Access Versus Heparin With Transradial Access in Patients With ST segment Elevation Myocardial Infarction.

INTRODUCTION: The best combination of access site and anticoagulant used during primary percutaneous coronary intervention (PCI) in patients presenting with ST segment elevation myocardial infarction is not known. METHODS: We conducted a retrospective cohort study of all patients >18 years of age who underwent primary PCI in 2 large regional ST segment elevation myocardial infarction centers in Massachusetts between 2012 and 2014. The cohort was divided into 3 groups: bival/fem, hep/rad, or off-protocol, based on anticoagulation and access used. We used multiple logistic regression model to compare major cardiovascular events-major adverse cardiovascular events (MACE) and bleeding complications between the 2 on-protocol groups (bival/fem and hep/rad). RESULTS: Of the 1074 patients in this study, there were 443 (41%), 501 (47%), and 130 (12%) patients in bival/fem, hep/rad, and off-protocol groups, respectively. There were significantly higher number of cardiogenic shock patients in the bival/fem compared to the hep/rad group (6.5% vs. 3.0%, P < 0.001). There was a trend toward reduced MACE in the hep/rad group compared to bival/fem (2.8 % vs. 5.1%, P = 0.068). When cardiogenic shock patients are excluded, there is no significant difference in mortality rates (bival/fem: 2.7% vs. hep/rad: 1.0%, P = 0.07) or bleeding complications between the groups (hep/rad: 4.5% vs. bival/fem: 2.1%, P = 0.06). CONCLUSIONS: In patients undergoing primary PCI, there was a trend toward reduced inpatient MACE with the use of heparin and radial access compared with bivalirudin with femoral access. In patients without cardiogenic shock, there is no significant difference in mortality or bleeding rates between the 2 groups.

Incorrect Electrocardiogram Lead Placement in ST-Segment-Elevation Myocardial Infarction.

This case report describes a patient in their 70s with acute onset waxing and waning chest pressure, which radiated to both arms and was accompanied by shortness of breath.

Clinical Outcomes of Transferred Versus Onsite Primary Percutaneous Coronary Intervention for Patients With STEMI: Time to Look Beyond Door to Balloon Time.

BACKGROUND: It is currently unknown if the delay due to practical aspects associated with transfer of patients from a non-percutaneous coronary intervention (PCI) facility to a primary PCI facility is associated with adverse outcomes. METHODS: We conducted a retrospective cohort study of all patients who presented with ST-segment elevation myocardial infarction (STEMI) and underwent primary PCI in 2 large regional STEMI centers in Massachusetts between January 2005 and June 2009. The cohort was divided into onsite patients who presented directly to the primary PCI center and transferred patients referred from another facility. The primary outcome was a composite of in-hospital major cardiovascular events (death, myocardial infarction, and stroke). Secondary outcomes were the individual components of the composite endpoint and bleeding complications. RESULTS: The cohort included a total of 1236 patients. Among them, 426 (34%) patients were transferred patients and 810 (66%) were onsite patients. The median door to balloon time was significantly higher at for transferred patients (124 vs. 71 minutes). There was no significant difference in primary composite endpoint between the 2 groups (onsite 3.8% vs. transfer 5.3%, odds ratio 1.50, 95% confidence interval 0.79-2.84; P = 0.21). Adjusted risk estimates did not show a statistical difference in all-cause bleeding rates between the groups (onsite 10.1% vs. transfer 7.3%, odds ratio 0.68, 95% confidence interval 0.41-1.14; P = 0.14). CONCLUSIONS: This study confirms that well-established and integrated regional STEMI programs provide equivalent care to transferred patients and onsite patients. Parameters beyond door to balloon times should be investigated for their contributions to improve patient outcomes.

Fractional Flow Reserve for the Evaluation of Tandem and Bifurcation Lesions, Left Main, and Acute Coronary Syndromes.

Fractional flow reserve (FFR) is a well-established invasive tool to assess the physiologic significance of a coronary stenosis. Several randomized trials proved the safety of deferring revascularization based on FFR in subjects with stable coronary artery disease with single or multivessel disease. Subjects with tandem or bifurcations lesions, left main disease, and acute coronary syndromes were not included in these trials. Unique hemodynamic changes occur in each of these situations, making the measurement and interpretation of FFR challenging. This article reviews the technical aspects of assessing FFR and literature supporting FFR-guided revascularization in each of these situations.

The effect of inpatient stress testing on subsequent emergency department visits, readmissions, and costs.

BACKGROUND: Patients with low-risk chest pain are frequently readmitted for evaluation of recurrent chest pain. It is unknown whether stress testing during the first admission for chest pain is a cost-effective means of reducing readmissions. METHODS: Using a hospital administrative database, we conducted a retrospective cohort study of patients aged ≥18 years admitted under "observation status" to Baystate Medical Center between January 2007 and July 2009 for chest pain without acute coronary syndrome. We compared subsequent emergency department (ED) visits, readmissions, and costs within 1 year for patients who had a stress test at index admission to those who did not, adjusting for age, gender, race, insurance, and comorbidities. RESULTS: The cohort included 3315 patients. Most (n = 2376, 71.7%) had a stress test during the index admission. Within 1 year, 256 (7.7%) patients returned to the ED at least once with chest pain. Of these, 112 (43.8%) were admitted during their first return visit. In the multivariable model, return visits for chest pain were negatively associated with previous stress testing (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.5 to 0.9). Once in the ED, however, the risk of admission did not vary by stress test during index admission (OR: 0.8, 95% CI: 0.4 to 1.4). Overall costs, including index admission and follow-up visits for chest pain, were higher for patients with stress testing at index admission. CONCLUSION: Inpatient stress testing reduced subsequent resource utilization in terms of ED visits and resultant readmissions, but the savings were not enough to offset the cost of initial testing.

Primary testicular lymphoma with cardiac involvement in an immunocompetent patient: case report and a concise review of literature.

Primary testicular lymphoma (PTL) is a rare testicular tumor representing less than 9% of all testicular cancers. PTL usually tends to spread to or relapse at nodal structures or extra-nodal sites such as contralateral testes, central nervous system, skin, lung, pleura, waldeyer's ring and soft tissues. We present a case of PTL with huge left atrial mass, an extremely unusual site of involvement. Early disease usually carries a good prognosis, whereas advanced stage carries an extremely poor prognosis. Herein, we report the complete remission to date in a patient with advanced stage PTL with huge left atrial mass, treated with systemic rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone and intrathecal methotrexate. A brief review of literature focusing on various aspects of management of primary testicular lymphoma and lymphomatous involvement of heart is also discussed.

Outcomes of patients admitted for observation of chest pain.

BACKGROUND: Low-risk chest pain is a common cause of hospital admission; however, to our knowledge, there are no guidelines regarding the appropriate use of stress testing in such cases. METHODS: We performed a retrospective cohort study of patients 21 years and older who were admitted to our tertiary care center with chest pain in 2007 and 2008. Using electronic records and chart review, we sought (1) to identify differences in the use of stress testing based on patient demographics and comorbidities, pretest probability of coronary artery disease, and house staff coverage and (2) to describe the results of stress testing and patient outcomes, including revascularization procedures and 30-day readmissions for myocardial infarction. RESULTS: Of 2107 patients, 1474 (69.9%) underwent stress tests, and the results were abnormal in 184 patients (12.5%). Within 30 days, 22 patients (11.6%) with abnormal test results underwent cardiac catheterization, 9 (4.7%) underwent revascularization, and 2 (1.1%) were readmitted for myocardial infarction. In a multivariable model, stress test ordering was positively associated with age younger than 70 years (RR [relative risk], 1.12; 95% CI, 1.02-1.23), private insurance (vs Medicare/Medicaid: RR, 1.19; 95% CI, 1.11-1.27), and no house staff coverage (RR, 1.39; 95% CI, 1.28-1.50). Of patients with low (<10%) pretest probability, 68.0% underwent stress testing, but only 4.5% of these had abnormal test results. CONCLUSIONS: Most patients who are admitted with low-risk chest pain undergo stress testing, regardless of pretest probability, but abnormal test results are uncommon and rarely acted on. Ordering stress tests based on pretest probability could improve efficiency without endangering patients.