The Conundrum of "Warfarin Hypersensitivity": Prolonged Partial Thromboplastin Time From Factor IX Propeptide Mutation.

Carboxylation of glutamic acid residues of vitamin K dependent clotting factors (II, VII, IX, and X) is essential to their biological functioning. Binding of these factors to γ-glutamyl carboxylase enzyme for carboxylation reaction is mediated by wild-type propeptide, a small sequence of amino acids that precede the actual polypeptide. Missense mutations at certain residue severely decrease the affinity of mutated propeptide for the enzyme. Such mutations are reported to occur at codon-10 of factor IX propeptide, a clinically silent metabolic event in normal conditions. However in the presence of warfarin, such mutations and resultant decrease affinity of factor IX propeptide for the enzyme that causes severe selective decrease in factor IX activity. This can potentially leads to life-threatening bleeding complications and known as one of the causes of warfarin hypersensitivity. It is imperative to recognize such cases early on to avoid additional warfarin therapy. Recurrent bleeding episodes, subtherapeutic to therapeutic range international normalized ratio values with relatively prolong partial thromboplastin time should raise the suspicion of underlying factor IX propeptide mutations.

Gender Differences and Predictors of Mortality in Takotsubo Cardiomyopathy: Analysis from the National Inpatient Sample 2009-2010 Database.

OBJECTIVES: Takotsubo cardiomyopathy (TC) is characterized by left-ventricle apical ballooning with elevated cardiac biomarkers and electrocardiographic changes similar to an acute coronary syndrome. We studied the prevalence, in-hospital mortality, and predictors of mortality in TC. METHODS: All patients ≥18 years of age diagnosed with TC were identified in the Nationwide Inpatient Sample (NIS) 2009-2010 database using the 9th revision of the International Classification of Diseases (ICD) 429.83. Demographics, conventional risk factors (diabetes, hypertension, hyperlipidemia, and tobacco abuse), acute critical illnesses like sepsis, acute cerebrovascular disease (cerebrovascular accident; CVA), acute respiratory insufficiency, and acute renal failure, and chronic conditions (anxiety, depression, and malignancy) were studied. RESULTS: The prevalence of TC was 0.02% (n = 7,510). The total in-hospital mortality rate was 2.4%, with a higher mortality in men (4.8%) than in women (2.1%). Sepsis (9 vs. 4.2%; p < 0.01) was more prevalent in men with an increased prevalence of other critical illness, although this was not statistically significant. Age (OR 1.05; 95% CI 1.01-1.09), malignancy (OR 3.38; 95% CI 1.35-8.41), acute renal failure (OR 5.4; 95% CI 2.2-13.7), acute CVA (OR 9.4; 95% CI 2.96-29.8), and acute respiratory failure (OR 11.1; 95% CI 3.9-31.1) predicted mortality in fully adjusted models. CONCLUSION: A higher mortality was seen in men, likely related to the increased prevalence of acute critical illnesses, ventricular arrhythmia, and sudden cardiac arrest. Acute CVA and respiratory failure were the strongest predictors of mortality. © 2015 S. Karger AG, Basel.

Peripartum cardiomyopathy: definition, incidence, etiopathogenesis, diagnosis, and management.

Peripartum cardiomyopathy (PPCM) is a serious pregnancy-associated disorder of unknown etiology. The precise cellular and molecular mechanisms underlying PPCM are unclear. A heightened awareness among health care providers can result in early diagnosis of heart failure in late pregnancy and the early postpartum period. Though the symptoms of dyspnea and fatigue can result from normal physiologic changes during pregnancy, an electrocardiogram and brain natriuretic peptide level should be obtained in these patients, in addition to baseline laboratory tests such as a complete blood count, and basic metabolic and hepatic function panels. If the electrocardiogram and brain natriuretic peptide level are abnormal, an echocardiogram should be obtained. The role of endomyocardial biopsy for the diagnosis of PPCM is controversial. Patients should be started on diuretics if volume overloaded, and beta-blockers (preferably metoprolol) if no contraindications exist; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be avoided during pregnancy or lactation. There are no standard, universally accepted guidelines for the management of PPCM. Although experimental therapies like bromocriptine, pentoxifylline and immunoglobulins have shown promising results, large double-blind randomized trials are essential to confirm the results of smaller studies. In patients with persistent severe left ventricular (LV) dysfunction, advanced therapies like mechanical circulatory support and heart transplantation should be considered. Owing to recent data demonstrating deterioration of LV systolic function after initial recovery, it is essential to maintain long-term follow up of these patients regardless of initial recovery of LV function. We present a comprehensive review of the literature etiopathogenesis, diagnosis, and management of PPCM.

Predictors of in-hospital mortality in coronary artery dissection: Findings from the National Inpatient Sample 2009-2010.

BACKGROUND: The pathophysiology of coronary artery dissection (CD) remains poorly under-stood and little is known about the factors predicting mortality in these patients. We aimed to study the epidemiology of CD and predictors of mortality in these patients. METHODS: All patients diagnosed with CD in the Nationwide Inpatient Sample 2009-2010 database using International Classification of Diseases ninth revision 414.12 were included in the study. Chronic conditions included in the analysis were diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease (CAD), obesity, alcohol use, smoking, heart failure and ventricular arrhythmias. Non-cardiovascular conditions were connective tissue disorders, fibromuscular dysplasia, Ehlers-Danlos syndrome, Marfan's syndrome, sarcoidosis, Crohn's disease, polycystic kidney disease, rheumatoid arthritis, vasculitis including giant cell arteritis, polyarteritis nodosa and Takayasu's disease, cocaine use, early or premature labor. RESULTS: The prevalence of CD in the United States was 0.02% (n = 11,255), based on the hospital admissions reviewed in the database. The mean age was 63.25 years with women (64.62 years) being older than men (62.25 years) (p < 0.001). In-hospital mortality rate was 4.2%, with women (5.5%) having higher mortality than men (3.2%) (p = 0.009). Ventricular arrhythmias (OR 5.86, p < 0.001) predicted higher mortality, while hyperlipidemia (OR 0.26, p < 0.001) and CAD (OR 0.31, p = 0.001) predicted lower mortality in multivariate analysis. CONCLUSIONS: Our study demonstrated that CD was more prevalent in men but women had higher mortality than men. Age, heart failure and ventricular arrhythmias were independent predictors of increased mortality but hyperlipidemia CAD predicted lower mortality in patients with CD.

Prevalence and predictors of coronary artery disease in adults with Kawasaki disease.

BACKGROUND: Accelerated coronary atherosclerosis in patients with Kawasaki disease, in conjunction with coronary artery aneurysm and stenosis that characterise this disease, are potential risk factors for developing coronary artery disease in young adults. We aimed to determine the prevalence and predictors of coronary artery disease in adult patients with Kawasaki disease. METHODS: All patients aged 18-55 years of age diagnosed with Kawasaki disease were sampled from Nationwide Inpatient Sample database using International Classification of Diseases 9th revision (ICD 9 code 446.1) from 2009 to 2010. Demographics, prevalence of coronary artery disease, and other traditional risk factors in adult patients with Kawasaki disease were analysed using ICD 9 codes. RESULTS: The prevalence of Kawasaki disease among adults was 0.0005% (n=215) of all in-hospital admissions in United States. The mean age was 27.3 years with women (27.6 years) older than men (27.1 years). Traditional risk factors were hypertension (21%), hyperlipidaemia (15.6%), diabetes (11.5%), tobacco use (8.8%), and obesity (8.8%), with no significant difference between men and women. Coronary artery disease (32.4%), however, was more prevalent in men (44.7%) than in women (12.1%; p=0.03). In multivariate regression analysis, after adjusting for demographics and traditional risk factors, hypertension (OR=13.2, p=0.03) was an independent risk factor of coronary artery disease. CONCLUSION: There was increased preponderance of coronary artery disease in men with Kawasaki disease. On multivariate analysis, hypertension was found to be the only independent predictor of coronary artery disease in this population after adjusting for other risk factors.

Predictors of coronary artery disease in patients with Behçet's disease.

BACKGROUND: Behçet's disease (BD) is a multisystem vasculitis of unknown etiology. We aimed to determine the prevalence and predictors of coronary artery disease (CAD) in patients with BD. METHODS: All adult patients diagnosed with BD from the National Inpatient Sample database using the International Classification of Diseases 9th revision (ICD-9 code 136.1) during 2009-2010 were included in the analysis. We analyzed the demographics, traditional risk factors, prevalence, and predictors of CAD in patients with BD using ICD-9 codes. RESULTS: The prevalence of BD among adults was 0.006% (n = 2,540) of all in-hospital admissions in the USA. The mean age was 43.9 years, with women (45 years) being older than men (40 years) (p < 0.001). Traditional risk factors prevalent in our study were hypertension (35%), hyperlipidemia (17.4%), diabetes mellitus (13.8%), smoking (13.1%), and obesity (7.2%). The prevalence of CAD was 12.1%. Hypertension (OR = 2.20, p = 0.03) and hyperlipidemia (OR = 2.34, p = 0.02) were found to be independent predictors of CAD in a multimodel regression analysis. CONCLUSION: In patients with BD, traditional risk factors associated with CAD were similar to what is expected in the overall population. However, the young age of patients with CAD in this population suggests an accelerated course of atherosclerosis in BD.

Peripheral venoarterial extracorporeal membrane oxygenation in combination with intra-aortic balloon counterpulsation in patients with cardiovascular compromise.

OBJECTIVES: Patients with profound cardiovascular compromise have poor prognosis despite inotropic and intra-aortic balloon pump (IABP) support. Peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) offers these patients temporary support as a bridge to various options including the 'bridge to recovery'. METHODS: We studied the outcomes of 135 patients who underwent peripheral V-A ECMO and concomitant IABP implantation in our hospital from 2007 to 2012 for various clinical indications. The ECMO circuit consisted of a centrifugal pump and an oxygenator. RESULTS: V-A ECMO was implanted in the cardiac catheterization laboratory in 51 patients (37.8%), at the bedside in 5 (3.7%) and in the operating room in 79 (58.5%). Mean duration of support was 8.5 ± 7.1 days. Median length of stay was 28 days (interquartile range 14-62). Complications included bleeding at the access site in 14.1%, stroke in 11.1% and vascular complications requiring intervention in 16.3%. Overall inhospital survival was 57.8% with outcomes including heart transplantation (3%), implantable left ventricular assist device (8.1% as bridge to transplantation and 6.7% as destination therapy), surgery (7.4%) and myocardial recovery (40.7%). Prior IABP use and axillary cannulation were independent predictors of reduced inhospital mortality, stroke or vascular injury. CONCLUSIONS: Peripheral V-A ECMO with IABP is an effective therapy for patients with severely compromised cardiovascular function. It offers reasonable survival and a spectrum of definitive options from 'bridge to recovery' to heart transplantation for the management of this critically ill population.

Percutaneous mitral heart valve repair--MitraClip.

Mitral regurgitation (MR) is the most common cardiac valvular disease in the United States. Approximately 4 million people have severe MR and roughly 250,000 new diagnoses of MR are made each year. Mitral valve surgery is the only treatment that prevents progression of heart failure and provides sustained symptomatic relief. Mitral valve repair is preferred over replacement for the treatment of MR because of freedom from anticoagulation, reduced long-term morbidity, reduced perioperative mortality, improved survival, and better preservation of left ventricular function compared with valve replacement. A large proportion of patients in need of valve repair or replacement do not undergo such procedures because of a perceived unacceptable perioperative risk. Percutaneous catheter-based methods for valvular pathology that parallel surgical principles for valve repair have been developed over the last few years and have been proposed as an alternate measure in high-risk patients. The MitraClip (Abbott Labs) device is one such therapy and is the subject of this review.

Non-ST-elevation myocardial infarction in the United States: contemporary trends in incidence, utilization of the early invasive strategy, and in-hospital outcomes.

BACKGROUND: There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non-ST-elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in-hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in-hospital outcomes of NSTEMI in the United States. METHODS AND RESULTS: We analyzed the 2002-2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age-, sex-, and race/ethnicity-stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age-, sex-, and race/ethnicity-stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (Ptrend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (Ptrend<0.001). Risk-adjusted in-hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978). CONCLUSIONS: There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in-hospital mortality and length of stay.

Relation of smoking status to outcomes after cardiopulmonary resuscitation for in-hospital cardiac arrest.

In-hospital cardiac arrest (IHCA) is common and is associated with poor prognosis. Data on the effect of smoking on outcomes after IHCA are limited. We analyzed the Nationwide Inpatient Sample databases from 2003 to 2011 for all patients aged≥18 years who underwent cardiopulmonary resuscitation (CPR) for IHCA to examine the differences in survival to hospital discharge and neurologic status between smokers and nonsmokers. Of the 838,464 patients with CPR for IHCA, 116,569 patients (13.9%) were smokers. Smokers were more likely to be younger, Caucasian, and male. They had a greater prevalence of dyslipidemia, coronary artery disease, hypertension, chronic pulmonary disease, obesity, and peripheral vascular disease. Atrial fibrillation, heart failure, and diabetes mellitus with complications were less prevalent in smokers. Smokers were more likely to have a primary diagnosis of acute myocardial infarction (14.8% vs 9.1%, p<0.001) and ventricular tachycardia or ventricular fibrillation as the initial cardiac arrest rhythm (24.3% vs 20.5%, p<0.001). Smokers had a higher rate of survival to hospital discharge compared with nonsmokers (28.2% vs 24.1%, adjusted odds ratio 1.06, 95% confidence interval 1.05 to 1.08, p<0.001). Smokers were less likely to have a poor neurologic status after IHCA compared with nonsmokers (3.5% vs 3.9%, adjusted odds ratio 0.92, 95% confidence interval 0.89 to 0.95, p<0.001). In conclusion, among patients aged ≥18 years who underwent CPR for IHCA, we observed a higher rate of survival in smokers than nonsmokers-consistent with the "smoker's paradox." Smokers were also less likely to have a poor neurologic status after IHCA.

Cardiac involvement in hemochromatosis.

Cardiac hemochromatosis or primary iron-overload cardiomyopathy is an important and potentially preventable cause of heart failure. This is initially characterized by diastolic dysfunction and arrhythmias and in later stages by dilated cardiomyopathy. Diagnosis of iron overload is established by elevated transferrin saturation (>55%) and elevated serum ferritin (>300 ng/mL). Genetic testing for mutations in the HFE (high iron) gene and other proteins, such as hemojuvelin, transferrin receptor, and ferroportin, should be performed if secondary causes of iron overload are ruled out. Patients should undergo comprehensive 2D and Doppler echocardiography to evaluate their systolic and diastolic function. Newer modalities like strain imaging and speckle-tracking echocardiography hold promise for earlier detection of cardiac involvement. Cardiac magnetic resonance imaging with measurement of T2* relaxation times can help quantify myocardial iron overload. In addition to its value in diagnosis of cardiac iron overload, response to iron reduction therapy can be assessed by serial imaging. Therapeutic phlebotomy and iron chelation are the cornerstones of therapy. The average survival is less than a year in untreated patients with severe cardiac impairment. However, if treated early and aggressively, the survival rate approaches that of the regular heart failure population.

Warfarin use and prevalence of coronary artery calcification assessed by multislice computed tomography.

Warfarin inhibits the synthesis and function of matrix Gla protein, a vitamin K-dependent protein, which is a potent inhibitor of tissue calcification. We had earlier reported the association of warfarin use with valvular calcification in patients with nonvalvular atrial fibrillation. The aim of our present study was to investigate the association of warfarin use with the presence and severity of coronary artery calcification. A total of 233 patients underwent computed tomography scan (CT) at our institution for the assessment of coronary artery calcium score (CACS). Of 233 patients, the mean age was 63 years, 28 patients (12%) were treated with warfarin, and 205 patients (88%) were not on warfarin. Based on their total CACS, the patients were subsequently stratified into 59 with no coronary calcium (CACS = 0), 63 with low CACS (1-100), 49 with moderate CACS (101-400), 33 with severe CACS (410-1000), and 29 with very severe CACS (>1000). The χ test and Student t-test were used for the comparison of categorical and continuous variables, respectively, between warfarin users and nonusers. Using the variables age, gender, race, smoking, hypertension, diabetes, dyslipidemia, glomerular filtration rate, calcium-phosphorus product, alkaline phosphatase, use of aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins, stepwise logistic regression analysis did not show any association of coronary calcification with use of warfarin. In our study, warfarin use was not associated with a higher prevalence or severity of CACS assessed by coronary computed tomography.

Early invasive versus initial conservative treatment strategies in octogenarians with UA/NSTEMI.

BACKGROUND: Previous studies have demonstrated improved outcomes with an early invasive strategy in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI). However, there are limited data for patients ≥80 years of age in these studies. METHODS: We used the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥80 years of age (octogenarians) with UA/NSTEMI. Multivariable logistic regression was used to compare in-hospital outcomes in octogenarians with UA/NSTEMI undergoing early invasive (coronary angiography within 48 hours of admission, with or without revascularization) versus initial conservative treatment. RESULTS: Among 968,542 octogenarians with UA/NSTEMI, 806,902 (83.3%) were managed using an initial conservative approach and 161,640 (16.7%) using an early invasive strategy. Patients in the early invasive group were more likely to be younger, men, white, and had a higher prevalence of smoking, dyslipidemia, obesity, hypertension, known coronary artery disease, carotid artery disease, and peripheral vascular disease. In-hospital mortality was significantly lower in octogenarians in the early invasive group (adjusted odds ratio [OR] 0.76; 95% confidence interval [CI], 0.74-0.78). Early invasive strategy was associated with lower rates of acute ischemic stroke (adjusted OR 0.63; 95% CI, 0.60-0.66), intracranial hemorrhage (adjusted OR 0.60; 95% CI, 0.510.70), gastrointestinal bleeding (adjusted OR 0.63; 95% CI, 0.60-0.65), and shorter average length of stay (5.3 vs 5.8 days, P <.001), but higher cardiogenic shock (adjusted OR 2.14; 95% CI, 2.06-2.23) and total hospital cost (23,584 vs 13,278 USD). CONCLUSION: Compared with an initial conservative approach, an early invasive strategy in octogenarians with UA/NSTEMI was associated with lower in-hospital mortality, acute ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and shorter length of stay, but higher cardiogenic shock and total hospital cost.

Predictors of in-hospital mortality and acute myocardial infarction in thrombotic thrombocytopenic purpura.

BACKGROUND: Despite the widespread availability of plasmapheresis as a therapy, thrombotic thrombocytopenic purpura is associated with significant morbidity and mortality. There is a paucity of data on the predictors of poor clinical outcome in this population. Acute myocardial infarction is a recognized complication of thrombotic thrombocytopenic purpura. Little is known about the magnitude of this problem, its risk factors, and its influence on mortality in patients hospitalized with thrombotic thrombocytopenic purpura. METHODS: We used the 2001-2010 Nationwide Inpatient Sample database to identify patients aged ≥18 years with the diagnosis of thrombotic thrombocytopenic purpura (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 446.6) who also received therapeutic plasmapheresis (ICD-9-CM code 99.71) during the hospitalization. Patients with acute myocardial infarction were identified using the Healthcare Cost and Utilization Project Clinical Classification Software code 100. Stepwise logistic regression was used to determine independent predictors of in-hospital mortality and acute myocardial infarction in thrombotic thrombocytopenic purpura patients. RESULTS: Among the 4032 patients (mean age 47.5 years, 67.7% women, and 36.9% white) with thrombotic thrombocytopenic purpura who also underwent plasmapheresis, in-hospital mortality was 11.1%. Independent predictors of increased in-hospital mortality were older age (odds ratio [OR] 1.03; 95% confidence interval [CI], 1.02-1.04; P <.001), acute myocardial infarction (OR 1.89; 95% CI, 1.24-2.88; P = .003), acute renal failure (OR 2.75; 95% CI, 2.11-3.58; P <.001), congestive heart failure (OR 1.66; 95% CI, 1.17-2.34; P = .004), acute cerebrovascular disease (OR 2.68; 95% CI, 1.87-3.85; P <.001), cancer (OR 2.49; 95% CI, 1.83-3.40; P <.001), and sepsis (OR 2.59; 95% CI, 1.88-3.59; P <.001). Independent predictors of acute myocardial infarction were older age (OR 1.03; 95% CI, 1.02-1.04; P <.001), smoking (OR 1.60; 95% CI, 1.14-2.24; P = .007), known coronary artery disease (OR 2.59; 95% CI, 1.76-3.81; P <.001), and congestive heart failure (OR 2.40; 95% CI, 1.71-3.37; P <.001). CONCLUSION: In this large national database, patients with thrombotic thrombocytopenic purpura had an in-hospital mortality rate of 11.1% and an acute myocardial infarction rate of 5.7%. Predictors of in-hospital mortality were older age, acute myocardial infarction, acute renal failure, congestive heart failure, acute cerebrovascular disease, cancer, and sepsis. Predictors of acute myocardial infarction were older age, smoking, known coronary artery disease, and congestive heart failure.

Predictors of mortality, rehospitalization for syncope, and cardiac syncope in 352 consecutive elderly patients with syncope.

OBJECTIVES: To investigate the etiologies of syncope and predictors of all-cause mortality, rehospitalization, and cardiac syncope in consecutive elderly patients presenting with syncope to our emergency department. PARTICIPANTS: Participants were 352 consecutive patients aged 65 years or older with syncope admitted to hospital from the emergency department. DESIGN: Observational retrospective study. MEASUREMENTS: Review of medical records for history, physical examination, medications, and tests to determine causes of syncope. Cox stepwise logistic regression analysis was performed to identify significant independent prognostic factors for rehospitalization with syncope, all-cause mortality, and cardiac syncope. RESULTS: Of 352 patients, mean age 78 years, the etiology of syncope was diagnosed in 243 patients (69%). Vasovagal syncope was diagnosed in 12%, volume depletion in 14%, orthostatic hypotension in 5%, cardiac syncope in 29%, carotid sinus hypersensitivity in 2%, and drug overdose/others in 7% of patients. During a mean follow-up of 24 months, 10 patients (3%) were readmitted to the hospital for syncope and 39 (11%) died. Stepwise logistic regression analysis identified history of congestive heart failure (OR 5.18; 95% CI 1.23-21.84, P = .0257) and acute coronary syndrome (OR 5.95; 95% CI 1.11-31.79, P = .037) as independent risk factors for rehospitalization. Significant independent prognostic factors for mortality were diabetes mellitus (OR 2.08; 95% CI 1.09-3.99, P = .0263), history of smoking (OR 2.23; 95% CI 1.10-4.49, P = .0255), and use of statins (OR 0.37; 95% CI 0.19-0.72, P = .0036). Independent risk factors for predicting a cardiac cause of syncope were an abnormal electrocardiogram (OR 2.58; 95% CI 1.46-4.57, P = .0012) and reduced ejection fraction (OR 2.92; 95% CI 1.70-5.02, P < .001). The San Francisco Syncope Rule and Osservatorio Epidemiologico sulla Sincope nel Lazio scores did not predict mortality or rehospitalization in our study population. CONCLUSIONS: Significant independent risk factors for rehospitalization for syncope were congestive heart failure and acute coronary syndrome. Significant independent risk factors for mortality were diabetes mellitus, history of smoking, and use of statins (inverse association).

Association of corrected QT interval with long-term mortality in patients with syncope.

INTRODUCTION: The electrocardiographic parameters QRS duration, QRS-T angle and QTc can predict mortality in patients with cardiovascular disease. The prgnostic value of these parameters in hospitalized patients with syncope needs investigation. MATERIAL AND METHODS: We retrospectively studied 590 consecutive patients hospitalized with syncope. After excluding patients with baseline abnormal rhythm, QT- prolonging medications, and missing data, 459 patients were analyzed. Baseline demographic characteristics, co-morbidities, medication use, San Francisco Syncope Rule (SFSR) and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score and data on mortality were collected. The categorical variables and continuous variables of the 2 groups of patients with prolonged QTc and normal QTc interval were analyzed by Fischer's exact test and Mann-Whitney Test. A stepwise Cox regression model was used for time to death analysis. RESULTS: Of 459 patients, prolonged QTc interval was observed in 122 (27%). Mean follow-up was 41 months. Patients with prolonged QTc interval had higher prevalence of cardiovascular disease, OESIL score, high risk SFSR, hypertension, dyslipidemia, coronary artery disease, congestive heart failure, and increased mortality. Stepwise Cox regression analysis showed that significant independent prognostic factors for time to death were prolonged QTc interval (p = 0.005), age (p = 0.001), diabetes mellitus (p = 0.001) and history of malignancy (p = 0.006). QRS duration and QRS-T angle were not independent predictors of mortality. CONCLUSIONS: A prolonged QTc interval is an independent predictor of long-term mortality in hospitalized patients with syncope.

Rheumatoid arthritis: cardiovascular manifestations, pathogenesis, and therapy.

Rheumatoid Arthritis (RA) is a chronic progressive inflammatory joint disorder that affects 0.5% - 1% of the general population. This review article discusses cardiovascular manifestations of rheumatoid arthritis, pathogenesis of these manifestations, and therapy. This disease not only affects the joints, but it also involves other organ systems. The majority of these patients suffer significant morbidity and mortality from cardiovascular disease. Cardiovascular manifestations of RA include predilection for accelerated atherosclerosis and endothelial dysfunction resulting in coronary artery disease (CAD), stroke, congestive heart failure, and peripheral arterial disease. Some studies have shown that the risk of developing CAD in RA patients is the same as for patients with diabetes mellitus. These patients should be treated with aggressive medical therapy such as disease modifying antirheumatic drugs, tumor necrosis factor alpha inhibitors, and corticosteroids and with appropriate control of risk factors such as smoking, dyslipidemia, hypertension, and obesity. Other manifestations include pericarditis, myocarditis, and vasculitis.