Pulmonary Arterial Enlargement is Associated With Acute Chest Pain in Patients Without Obstructive Coronary Artery Disease.

BACKGROUND: Pulmonary hypertension (PH) is an underdiagnosed cause for chest pain in patients without significant coronary artery disease (CAD). Studies showed that enlarged pulmonary arterial (PA) and right ventricular chamber sizes correlate with the severity of PH. Therefore, we studied the association between chest pain, right ventricular dimensions (RVDs), and PA size on coronary coronary tomographic angiography (CCTA). METHODS: The CCTA of 87 patients presenting with chest pain without evidence of obstructive CAD was examined. The PA diameter (PAD), right atrial dimension (RAD), and RVD were measured. A comparative control cohort included 31 patients who presented without cardiopulmonary complaints and underwent thoracic CT. The risk for obstructive sleep apnea (OSA) was assessed using STOP-BANG questionnaires. RESULTS: Patients with chest pain without obstructive CAD showed markedly dilated right atrial and ventricular chambers compared with standard parameters (right atrium: 48 ± 6.4 mm; right ventricle long axis: 61 ± 9.5 mm). When comparing chest pain vs non-chest pain group, respectively, the mean PAD measured 25.92 ± 0.43 mm vs 22.89 ± 0.38 mm (P < .001), RAD2 measured 40.1423 ± 0.7108 mm vs 34.8800 ± 1.0245 mm (P = .0048), and RVD2 measured 31.7729 ± 0.7299 mm vs 27.6379 ± 1.6178 mm (P = .034). Chest pain was associated with higher PAD (odds ratio [OR]: 11.11, P < .05) after adjusting for age, sex, body mass index, history of hypertension, hyperlipidemia, congestive heart failure, chronic obstructive pulmonary disease, OSA, and smoking. The chest pain group had a mean STOP-BANG score of 3.9 ± 1.8 in all patients, and 3.62 ± 0.20 in patients without known history of OSA, representing an elevated risk index for the disease. CONCLUSIONS: In patients presenting with chest pain without obstructive CAD on CCTA, there is a strong association between the presence of chest pain and enlarged PAD. They also represent a high-risk group for OSA.

Is 30-Day Mortality after Admission for Heart Failure an Appropriate Metric for Quality?

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) model for publicly reporting national 30-day-risk-adjusted mortality rates for patients admitted with heart failure fails to include clinical variables known to impact total mortality or take into consideration the culture of end-of-life care. We sought to determine if those variables were related to the 30-day mortality of heart failure patients at Geisinger Medical Center. METHODS: Electronic records were searched for patients with a diagnosis of heart failure who died from any cause during hospitalization or within 30 days of admission. RESULTS: There were 646 heart-failure-related admissions among 530 patients (1.2 admissions/patient). Sixty-seven of the 530 (13%) patients died: 35 (52%) died during their hospitalization and 32 (48%) died after discharge but within 30 days of admission; of these, 27 (40%) had been transferred in for higher-acuity care. Fifty-one (76%) died from heart failure, and 16 (24%) from other causes. Fifty-five (82%) patients were classified as American Heart Association Stage D, 58 (87%) as New York Heart Association Class IV, and 30 (45%) had right-ventricular systolic dysfunction. None of the 32 patients who died after discharge met recommendations for beta-blockers. Criteria for prescribing angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor blockers were not met by 33 of the 34 patients (97%) with heart failure with reduced ejection fraction not on one of those drugs. Fifty-seven patients (85%) had a do-not-resuscitate (DNR) status. CONCLUSION: A majority of heart failure-related mortality was among patients who opted for a DNR status with end-stage heart failure, limiting the appropriateness of administering evidence-based therapies. No care gaps were identified that contributed to mortality at our institution. The CMS 30-day model fails to take important variables into consideration.

Limited Fibrosis Progression but Significant Mortality in Patients Ineligible for Interferon-Based Hepatitis C Therapy.

BACKGROUND: Individuals ineligible for interferon-based hepatitis C therapy may have a worse prognosis than patients who have failed or not received treatment. AIMS: To provide information about the limitations of medical treatment of hepatitis C in real-world patients. METHODS: We studied 969 treatment-ineligible patients and 403 treated patients enrolled between 1/1/01 and 6/30/06; data were collected until 3/31/13. Treatment barriers were grouped into five categories and classified as health-related or health-unrelated. Fibrosis stage was assessed initially and at the end of follow-up. Mortality was determined by search of the Social Security database. Death certificates of treatment-ineligible patients were reviewed. RESULTS: Initially, 288 individuals had advanced fibrosis and compensated disease; 87 untreated patients developed advanced fibrosis during follow-up. Health-related treatment barriers were more commonly associated with fibrosis progression and worse survival. During follow-up, 247 untreated patients died: 47% of liver-related and 53% of liver-unrelated causes. Patients with significant comorbid illness had the worst five- (70%) and ten-year (50.5%) survival. Despite high mortality (47%) in persons with decompensated liver disease, no treatment barrier was associated with a greater incidence of liver-related death. Only significant comorbid medical illness was an independent predictor of disease progression; however, it was not associated with a greater incidence of liver-related death. Furthermore, treated patients had better 10-year survival than untreated patients on Kaplan-Meier analysis (80.3% vs. 74.5%, P = 0.005). CONCLUSION: Many patients with hepatitis C will die of non-liver-related causes and may not be helped by anti-viral treatment.