A case of biventricular failure after pericardial window for large pericardial effusion.

Pericardial tamponade resulting in hemodynamic compromise requiring either pericardiocentesis [Vandyke 1983] or subxiphoid pericardial window has been reported in literature [Armstrong 1984]. There are no large case series, only scattered case reports. Cardiac tamponade is known to affect the diastolic function of the heart but rare reports have documented systolic impairment of the left and right ventricle in the setting of tamponade [Vandyke 1983; Armstrong 1984]. We report a case of a transient biventricular systolic dysfunction in a patient with early cardiac tamponade after surgical drainage of pericardia1 effusion.

Assessment of the American Society of Echocardiography-European Association of Echocardiography guidelines for diastolic function in patients with depressed ejection fraction: an echocardiographic and invasive haemodynamic study.

AIMS: There is controversy surrounding the accuracy of echo-Doppler variables, including early mitral inflow/mitral annular velocity (E/e'), for estimating left ventricular filling pressure (LVFP) in patients with depressed ejection fraction (EF < 50%). METHODS AND RESULTS: The American Society of Echocardiography-European Association of Echocardiography (ASE-EAE) algorithm for diastolic function in depressed LVEF was retrospectively applied to a database of patients who underwent echocardiography ≤20 min of cardiac catheterization. LV pre-atrial contraction pressure (pre-A) ≥15 mmHg was elevated. Of 62 patients studied, the mean age was 53.6 ± 10.6 years and the mean LVEF was 27.2 ± 11.8%. The correlations of E/e' (R = 0.43, P = 0.0005) and E (R = 0.39, P = 0.002) with LV pre-A were modest, compared with pulmonary artery pressure (PAP, R = 0.69, P = 0.0006), E/late mitral (A) velocity (R = 0.52, P < 0.0001), and mitral deceleration time (DT, R = -0.51, P < 0.0001). Using the ASE-ESE algorithm starting with E/A, E, and DT, 54 of 62 patients were accurately classified to predict LV pre-A >15 or <15 mmHg (sensitivity = 84%, specificity = 80%, area under the curve = 0.86, P < 0.001). The 6 of 6 patients with E/A < 1 and E < 50 and the 14 of 15 (93%) patients with E/A> 2 and DT < 150 were correctly classified as having normal and elevated LVFP, respectively, while 34 of 41 (83%) patients with E/A = 1-2 or E/A<1 and E>50 cm/s were correctly classified using the addition of E/e' and PAP. CONCLUSION: This retrospective study shows that in this population with depressed LVEF, no single echo-Doppler variable had high accuracy for predicting LV pre-A ≥15 mmHg. However, the ASE-EAE algorithm using multiple variables predicted LVFP with good accuracy, superior to any single echo-Doppler variable alone.

Hypertrophic obstructive cardiomyopathy-alcohol septal ablation vs. myectomy: a meta-analysis.

AIMS: Our purpose is to conduct a meta-analysis of all published studies comparing alcohol septal ablation (ASA) and myectomy (MM) for drug refractory hypertrophic obstructive cardiomyopathy (HOCM). Alcohol septal ablation is a less invasive alternative to MM for relief of symptoms in patients with drug refractory HOCM. METHODS AND RESULTS: An extensive search of PubMed identified five non-randomized studies comparing ASA and MM. Of 351 patients studied, 183 underwent ASA and 168 underwent MM. Patients undergoing ASA were older (mean age 54.4 +/- 6.3 vs. 45.0 +/- 4.4 years, P = 0.02). All patients were in New York Heart Association (NYHA) class II-IV. Baseline left ventricular outflow tract (LVOT) gradient was comparable (81.4 +/- 14.3 mmHg in ASA vs. 77.4 +/- 15.5 mmHg in MM, P = 0.2). Although resting LVOT gradient after septal reduction therapy in both groups was <20 mmHg at follow-up, patients undergoing MM had lower LVOT gradient (18.2 +/- 6.7 vs. 10.8 +/- 6.3 mmHg, P < 0.001). Patients in both groups had comparable improvement in NYHA class (1.5 +/- 0.3 in ASA vs. 1.3 +/- 0.2, P = 0.2) at follow-up. A higher percentage of patients undergoing ASA required permanent pacemaker (PPM) implantation for complete heart block (18.4 +/- 7.9 vs. 3.3 +/- 3.9%, P = 0.04). There was no significant in-hospital mortality difference between the two groups. CONCLUSION: Alcohol septal ablation and MM provide significant reduction in LVOT gradient and NYHA functional class on mid-term follow-up. A higher percentage of patients required PPM after ASA. Randomized trials are needed to confirm current findings.

Cardiac Involvement by Burkitt Lymphoma in a 49-Year-Old Man.

Malignant metastases are among the most common cardiac masses. We report a rare case of cardiac involvement by Burkitt lymphoma in a 49-year-old man who presented with a 2-month history of dyspnea and palpitations. A transthoracic echocardiogram revealed 2 intracardiac masses in the right atrium (one of which partially encased the tricuspid valve), myocardial infiltration, and pericardial disease. Results of pleural fluid cytology and flow cytometry confirmed involvement by Burkitt lymphoma. Subsequent chemotherapy markedly reduced the intracardiac tumor burden and resolved the patient's presenting symptoms. Our case highlights the importance of cardiac imaging in diagnosing systemic illness, initiating early and appropriate treatment, and monitoring disease progression in patients with intracardiac Burkitt lymphoma.

Reversible Cerebral Vasoconstriction Syndrome Associated with Coronary Artery Vasospasm.

Reversible cerebral vasoconstriction syndrome is a rare disorder associated with neurologic symptoms secondary to diffuse cerebral vasospasm. Cardiac involvement in this disease is exceedingly rare. A 50-year-old woman was admitted to our hospital for evaluation of chest pain. During a 3-year period, she had been admitted multiple times because of chest pain and elevated serum cardiac enzymes. Transthoracic echocardiograms showed transient wall-motion abnormalities; however, coronary angiograms revealed no coronary artery disease. At the current admission, she had a thunderclap headache, and cerebral angiograms revealed diffuse cerebral vasoconstriction that improved after verapamil infusion, confirming the diagnosis of reversible cerebral vasoconstriction syndrome. The patient was treated successfully with oral diltiazem and had no recurrence of symptoms. We describe what we think is the first reported case of coronary artery spasm in association with reversible cerebral vasoconstriction syndrome. Future research should be focused on identifying treatment options and defining the mechanisms by which the cerebral and coronary vasculature are affected.

Meta-analysis Comparing Multivessel Versus Culprit Coronary Arterial Revascularization for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes.

We present a systematic review and meta-analysis comparing efficacy and safety outcomes between single procedure multivessel revascularization (MVR) and culprit vessel only revascularization in patients presenting with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS is the most common form of acute coronary syndrome (ACS), and multivessel disease is common. There is no consensus on the most efficacious single procedure revascularization strategy for patients undergoing percutaneous coronary intervention not meeting coronary artery bypass grafting criteria. Studies in PubMed and EMBASE databases were systematically reviewed, and 15 studies met criteria for inclusion in the meta-analysis. Baseline characteristics between the groups were similar. A random effects model was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity of studies was assessed using Cochrane's Q and Higgins I2 tests. For short-term outcomes, patients who underwent MVR had higher rates of major adverse cardiac events (OR 1.14; 95% CI 1.01 to 1.29; p = 0.03); and stroke (OR 1.94; 95% CI 1.01 to 3.72; p = 0.05), but lower rates of urgent or emergent coronary artery bypass grafting (OR 0.35; 95% CI 0.29 to 0.43; p <0.00001). In the long-term, MVR patients had less frequent major adverse cardiac events (OR 0.76; 95% CI 0.61-0.93; p = 0.009), all-cause death (OR 0.83; 95% CI 0.71 to 0.97; p = 0.03), and repeat revascularization, (OR 0.62; 95% CI 0.42 to 0.90; p = 0.01). MVR following NSTE-ACS was associated with higher short-term risk, but long-term benefit. In conclusion, these results support the use of single procedure multivessel revascularization for NSTE-ACS patients who are suitable candidates at the time of percutaneous coronary intervention.

Meta-Analysis of Catheter Directed Ultrasound-Assisted Thrombolysis in Pulmonary Embolism.

Ultrasound-assisted catheter directed thrombolysis (USAT) has been shown to improve hemodynamic function and reduce bleeding complications in patients with acute massive or submassive pulmonary embolism. We performed a meta-analysis to better evaluate the efficacy and safety of USAT. We conducted an extensive literature search in PUBMED, MEDLINE, and EMBASE databases from January 1, 2008 to December 31, 2018. Efficacy outcomes of interest were pulmonary artery systolic pressure, mean pulmonary pressure, ratio of right ventricular to left ventricular diameter, cardiac index, tricuspid annular plane systolic excursion, Miller Index Score, and Qanadli Score. Safety outcomes were in-hospital mortality, long-term mortality, major and minor bleeding complications, and recurrent pulmonary embolism. Meta-analysis was performed using Cochrane Collaboration Review Manager (version 5.1). Effect size was estimated using random effects model, with 95% confidence intervals (CIs). Twenty-eight studies (n = 2,135) met inclusion criteria. Compared with pretreatment parameters, post-USAT was associated with a reduction in the mean Miller Index Score and Qanadli Score by 10.55 (95% CI -12.98 to -8.12) and 15.64 (95% CI -19.08 to -12.20), respectively. Cardiac index and tricuspid annular plane systolic excursion improved by 0.68 L/m2 (95% CI 0.49 to 0.87) and 3.68 mm (95% CI 2.43 to 4.93), respectively. Pulmonary artery systolic pressure and mean pulmonary pressure after therapy were reduced by a mean difference of 16.69 mm Hg (95% CI -19.73 to -13.65) and 12.13 mm Hg (95% CI -14.67 to -9.59) respectively. The right ventricular to left ventricular diameter dimension ratio decreased by 0.35 (95% CI -0.40 to -0.30) after therapy. In-hospital mortality in patients who underwent USAT was 2.9%, and total long-term mortality was 4.1%. Major and minor bleeding complications were seen in in 5.4% and 6.0% of patients, respectively. Recurrent events occurred in 0.2% of patients after USAT. In conclusion, USAT is a safe and effective procedure associated with significant hemodynamic and clinical improvement in patients with massive and submassive pulmonary embolism.

Usefulness of B-type natriuretic peptide levels to predict left ventricular filling pressures in patients with body mass index >35, 31 to 35, and < or =30 kg/m2.

Noninvasive left ventricular (LV) pressure estimation in obese patients has not been well described. Simultaneous B-type natriuretic peptide (BNP) and echocardiographic Doppler examinations were performed in patients with dyspnea undergoing cardiac catheterization. Patients were divided into body mass index (BMI) >35 (markedly obese), 31 to 35 (obese), and < or =30 kg/m2 (nonobese). BNP levels and mitral early diastolic/tissue Doppler annular velocity (E/Ea) were compared with invasively measured LV end-diastolic and pre-atrial (pre-A) pressures. Seventy-two patients were studied. Except for BMI, LV mass index, and LV diastolic dimension, there were no significant differences in baseline, echocardiographic Doppler, or hemodynamic characteristics among the groups. However, BNP was significantly lower in markedly obese compared with obese and nonobese patients (116 +/- 187 vs 241 +/- 674 and 277 +/- 352 pg/ml, respectively; p = 0.03). BNP did not correlate with LV pre-A pressure in markedly obese patients (R = 0.13, p = 0.47), whereas BNP significantly correlated with this variable in the obese (R = 0.64) and nonobese (R = 0.58) groups. Mitral E/Ea significantly correlated with LV pre-A and LV end-diastolic pressures in all BMI groups. In markedly obese patients with dyspnea, BNP did not correlate with invasively measured LV filling pressure, whereas this correlated in obese and nonobese patients. However, mitral E/Ea significantly correlated with LV filling pressures in all BMI groups. In conclusion, BNP is not recommended for LV filling pressure estimation in ambulatory patients with dyspnea with BMI >35 kg/m2.

Incremental predictive power of B-type natriuretic peptide and tissue Doppler echocardiography in the prognosis of patients with congestive heart failure.

OBJECTIVES: This study was designed to determine how novel indexes of left ventricular (LV) filling pressure-transmitral early diastolic velocity/tissue Doppler mitral annular early diastolic velocity (E/Ea) and B-type natriuretic peptide (BNP)-compare to conventional predictors of outcome in patients with congestive heart failure (CHF). BACKGROUND: It is known that E/Ea can predict LV filling pressure in patients with cardiac disease, including, in contrast to conventional Doppler indexes, in normal ejection fraction. B-type natriuretic peptide has also been correlated to LV filling pressure, but appears to provide more global cardiac information than E/Ea. It is unknown, however, how these novel indexes compare to conventional predictors of CHF patient outcome. METHODS: A total of 116 consecutive patients hospitalized with CHF underwent simultaneous clinical assessment, BNP, and comprehensive echo-Doppler study once ready for discharge. The ability of these variables to determine the primary end point (cardiac death or re-hospitalization for CHF) was determined. RESULTS: Follow-up was complete on 110 of 116 patients at a mean of 527 days after hospital discharge. There were 54 patients (50%) with the primary end point (37 re-hospitalizations for CHF and 17 cardiac deaths). On Cox univariate analysis, E/Ea (chi-square = 13.6, p = 0.0001) and BNP (chi-square = 17.0, p < 0.0001) were significant predictors of the primary end point. In stepwise analysis, BNP >/=250 pg/ml and mitral E/Ea >/=15 had incremental predictive power (chi-square = 23.1, p for increment = 0.02), to which conventional predictors did not add further prognostic information. CONCLUSIONS: In patients admitted to hospital with CHF, pre-discharge BNP and E/Ea are incremental predictors of outcome, to which conventional predictors do not significantly add.

The obesity paradox: fact or fiction?

Although the adverse health consequences of obesity in the general population have been well documented, recent evidence suggests that obesity is associated with better outcomes in patients with heart failure (HF). Studies of patients with HF that specifically examined the impact of body mass index (BMI) on outcomes have suggested the existence of an "obesity paradox." However, closer examination of these studies raises important questions on the validity of the paradox. First, the diagnosis of HF in obese patients, particularly when made using clinical variables, may not be accurate; the obese patients in these studies may actually be "healthier" than their nonobese comparators. Second, the deleterious effects of cachexia, rather than the salutary ones of obesity, are likely the main reason for the inverse correlation between BMI and HF outcome, especially once the underlying biologic mechanisms behind cachexia and obesity in patients with HF are considered. Furthermore, few studies have specifically examined the more severely obese population (BMI >35 kg/m(2)) when assessing outcomes, and those that have suggest that severely obese patients may have worse outcomes than patients with normal weights or those who are mildly obese. Therefore, a "U-shaped" outcome curve according to BMI for patients with HF may actually exist, in which mortality is greatest in cachectic patients; lower in normal, overweight, and mildly obese patients; but higher again in more severely obese patients. Further prospective studies assessing the impact of more marked degrees of obesity on outcomes in patients with HF are needed to more conclusively determine whether the obesity paradox truly exists.

Comparative cost-effectiveness of B-type natriuretic peptide and echocardiography for predicting outcome in patients with congestive heart failure.

Two-dimensional echocardiographic and Doppler variables and B-type natriuretic peptide (BNP) can predict outcomes in patients with congestive heart failure (CHF). However, there is a paucity of data on the relative cost-effectiveness of these modalities in predicting outcome. One hundred sixteen patients hospitalized with CHF underwent simultaneous BNP and Doppler echocardiographic examinations once ready for discharge. The ability of these variables to determine the primary end point (cardiac death or rehospitalization for CHF) was determined. The cost-effectiveness ratios (CER) of 2-dimensional variables, Doppler indexes, and BNP were calculated for prediction of the primary end point. Follow-up was completed in 110 of 116 patients at a mean of 527 days after hospital discharge. Fifty-four patients (50%) reached the primary end point (37 rehospitalizations for CHF and 17 cardiac deaths). When added to a history of admission to the hospital in the preceding year for CHF, a comprehensive Doppler echocardiographic study predicted 52 of 54 events, with a CER of 729.10 dollars, whereas BNP predicted 47 of 54 events (CER 49.98 dollars; p < 0.001 for CER comparison). In patients admitted to hospitals with CHF, predischarge BNP is more cost-effective than comprehensive Doppler echocardiographic examination for the prediction of future cardiac death or rehospitalization for CHF.

Predictors of outcome after alcohol septal ablation therapy in patients with hypertrophic obstructive cardiomyopathy.

BACKGROUND: Alcohol septal ablation (ASA) therapy results in clinical and hemodynamic improvement in patients with hypertrophic obstructive cardiomyopathy. However, a subset remains symptomatic afterward, requiring additional procedures. We sought to examine the determinants of an unsatisfactory outcome, defined as unchanged symptoms with <50% reduction of baseline left ventricular outflow tract (LVOT) gradient. METHODS AND RESULTS: Of 173 consecutive hypertrophic obstructive cardiomyopathy patients who underwent ASA, 39 had an unsatisfactory outcome after the first procedure. Patients with an unsatisfactory outcome had a higher baseline LVOT gradient, fewer septal arteries injected with ethanol, lower peak creatine kinase (CK), smaller septal area opacified by contrast echocardiography, and higher residual gradient in the catheterization laboratory after ASA (all P<0.05). Symptoms, septal thickness, mitral regurgitation severity, and ventricular function were not determinants of outcome. On multiple logistic regression, LVOT gradient reduction after ASA in the catheterization laboratory to > or =25 mm Hg (OR, 5.5; P=0.01) and peak CK <1300 U/L (OR, 2.5; P=0.04) were the independent predictors of an unsatisfactory outcome. CONCLUSIONS: The residual LVOT gradient in the catheterization laboratory and peak CK leak after ASA are the independent predictors of ASA outcome.

Acute effect of nonsurgical septal reduction therapy on regional left ventricular asynchrony in patients with hypertrophic obstructive cardiomyopathy.

BACKGROUND: Patients with hypertrophic obstructive cardiomyopathy have left ventricular (LV) diastolic dysfunction due, in part, to temporal heterogeneity in regional function. The acute effect of the relief of LV outflow tract obstruction is unknown. Therefore, we investigated the effects of nonsurgical septal reduction therapy (NSRT) on regional function. METHODS AND RESULTS: Twenty-two patients (aged 56+/-17 years) underwent echocardiographic examination, including tissue Doppler imaging, simultaneously with left heart catheterization before and after NSRT. LV regional function was assessed in 12 segments from which myocardial strain was obtained. Asynchrony was calculated as the coefficient of variation of the time interval from the QRS complex to the onset of expansion and to early diastolic strain. After NSRT, a significant reduction in LV outflow tract obstruction (from 57+/-5 to 12+/-3 mm Hg) occurred with shortening of the time constant of LV relaxation (71+/-4 to 61+/-3 ms; both P<0.05). The coefficient of variation of the time interval to onset of regional expansion decreased significantly and related well to the changes in the time constant of LV relaxation (r=0.81, P<0.01). CONCLUSIONS: NSRT has a favorable effect on LV regional asynchrony, which accounts for the acute changes in LV relaxation.

Optimal noninvasive assessment of left ventricular filling pressures: a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters.

BACKGROUND: Early transmitral velocity/tissue Doppler mitral annular early diastolic velocity (E/Ea) and B-type natriuretic peptide (BNP) have been correlated with left ventricular filling pressures, yet there are no data on how these 2 estimates of left ventricular filling pressures compare. METHODS AND RESULTS: Patients admitted to intensive care underwent simultaneous tissue Doppler echocardiography, BNP measurement, and pulmonary capillary wedge pressure (PCWP) determination. The ability of mitral E/Ea and BNP to predict PCWP >15 mm Hg was assessed. Fifty patients were studied. Ln BNP had a correlation of r=0.32 (P=0.02) with PCWP compared with r=0.69 (P<0.001) between E/Ea and PCWP. E/Ea >15 was the optimal cutoff to predict PCWP >15 mm Hg (sensitivity, 86%; specificity, 88%), whereas the optimal BNP cutoff was >300 pg/mL (sensitivity, 91%; specificity, 56%). The correlation between change in PCWP and change in E/Ea at 48 hours was r=0.87 (P=0.003) compared with r=-0.59 (P=0.39) for BNP. In the 36 patients with cardiac disease, E/Ea >15 (sensitivity, 92%; specificity, 91%) appeared more accurate than BNP >400 pg/mL (sensitivity, 92%; specificity, 51%), whereas in patients without cardiac disease, BNP (sensitivity, 81%; specificity, 83%) appeared more accurate than E/Ea >15 (sensitivity, 74%; specificity, 72%) for PCWP >15 mm Hg. CONCLUSIONS: In intensive care unit patients, mitral E/Ea has a better correlation than BNP with PCWP. Both BNP and mitral E/Ea have high sensitivity for PCWP >15 mm Hg; however, E/Ea appears more specific in this patient population. In patients without cardiac disease, BNP appears more accurate than E/Ea for PCWP >15 mm Hg, whereas E/Ea appears more accurate in patients with cardiac disease.

Complete heart block: determinants and clinical impact in patients with hypertrophic obstructive cardiomyopathy undergoing nonsurgical septal reduction therapy.

OBJECTIVES: The purpose of this paper is to examine the incidence and determinants of permanent complete heart block (CHB) after nonsurgical septal reduction therapy (NSRT), and to evaluate the clinical impact of permanent pacemaker (PPM) placement. BACKGROUND: Nonsurgical septal reduction therapy with ethanol improves the clinical and hemodynamic parameters in patients with symptomatic hypertrophic obstructive cardiomyopathy. Complete heart block is a common complication after NSRT. METHODS: The database of 261 consecutive patients who underwent NSRT at Baylor College of Medicine was reviewed. Clinical variables that were considered as possible determinants for CHB after NSRT were: age, gender, New York Heart Association (NYHA) functional class, left ventricular outflow tract (LVOT) gradient at rest or with provocation, septal thickness, and baseline exercise duration. For electrocardiographic (ECG) variables, the presence of first-degree atrioventricular (AV) block, bifascicular block, left bundle branch block, atrial fibrillation, and left ventricular hypertrophy were analyzed. In addition, the volume of ethanol injected, the method of administration of ethanol (i.e., bolus vs. slow injection [over 30 to 60 s]), number of septal arteries occluded, use of myocardial echocardiography, and infarct size as determined by peak creatine kinase level. RESULTS: Of 261 consecutive patients, 37 had PPM or automatic implantable cardiac defibrillator placed before NSRT. Of the remaining 224 patients, 31 (14%) developed CHB after the procedure. Multivariate logistic regression analysis showed that female gender (odds ratio [OR] 4.3; P = 0.02), bolus injection of ethanol (OR 51; P = 0.004), injecting more than one septal artery (OR 4.6; P = 0.016), the presence of left bundle branch block (OR 39; P = 0.002), and first-degree AV block (OR 14; P = 0.001) on the baseline ECG are independent predictors of CHB after NSRT. Patients requiring PPM placement had a similar improvement in their NYHA functional class, septal thickness reduction, LVOT gradient reduction, and improvement of exercise capacity when compared with patients who did not require pacing. CONCLUSIONS: Multiple demographic, electrocardiographic, and technical factors seem to increase the risk of CHB after NSRT. Patients with CHB after NSRT derive similar clinical and hemodynamic benefit to patients who did not require permanent pacing.

Effectiveness of percutaneous intervention for patients with obstructive hypertrophic cardiomyopathy and coronary artery disease.

Seven patients with obstructive hypertrophic cardiomyopathy and single-vessel coronary artery disease underwent percutaneous revascularization of the coronary lesion in addition to alcohol septal ablation therapy for dynamic outflow tract obstruction. One year later, there was a significant reduction of dynamic left ventricular outflow tract obstruction and no clinical evidence of restenosis.

Comparative accuracy of B-type natriuretic peptide and tissue Doppler echocardiography in the diagnosis of congestive heart failure.

B-type natriuretic peptide (BNP) and early diastolic transmitral velocity/tissue Doppler mitral annular velocity (E/Ea) both estimate left ventricular filling pressure, but have not been compared in the diagnosis of congestive heart failure (CHF). One hundred twenty-two hospital inpatients with suspected CHF underwent simultaneous clinical examination, BNP measurement, and comprehensive echo-Doppler examination. The accuracy of BNP and echocardiography was compared with the Framingham criteria diagnosis of CHF. Seventy patients (57%) had clinical CHF, whereas 52 (43%) did not. In all patients, the optimal BNP cutoff was >250 pg/ml (sensitivity 86%, specificity 77%). E/Ea >15 had 83% sensitivity and 82% specificity, whereas comprehensive echo-Doppler had 95% sensitivity and 88% specificity for CHF. In patients with normal ejection fraction, the optimal BNP cutoff was >150 pg/ml (sensitivity 79%, specificity 85%). E/Ea >15 had 79% sensitivity and 93% specificity, whereas comprehensive echo-Doppler had 85% sensitivity and 96% specificity for CHF. In patients with reduced ejection fraction, the optimal BNP cutoff was >300 pg/ml (sensitivity 88%, specificity 60%). E/Ea >15 had 92% sensitivity and 72% specificity, whereas comprehensive echo-Doppler had 96% sensitivity and 80% specificity (p = 0.08 compared with BNP) for CHF. Overall, BNP and E/Ea have similar diagnostic accuracy for CHF in this patient population. In patients with reduced ejection fraction, comprehensive echo-Doppler trended toward higher specificity than BNP for clinical CHF.

Comparison by meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting in patients with a mean age of ≥70 years.

A paucity of published data evaluating the outcomes of older patients (age ≥70 years) undergoing revascularization for unprotected left main coronary artery disease is available. We performed aggregate data meta-analyses of the clinical outcomes (all-cause mortality, nonfatal myocardial infarction, stroke, repeat revascularization, and major adverse cardiac and cerebrovascular events at 30 days and 12 and 22 months) in studies comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with a mean age of ≥70 years and unprotected left main coronary artery disease. A comprehensive, time-unlimited literature search to January 31, 2013 identified 10 studies with a total of 2,386 patients (PCI, n = 909; CABG, n = 1,477). Summary odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using the random-effects model. The patients in the PCI group were more likely than those in the CABG group to present with acute coronary syndrome (59.6% vs 44.8%, p <0.001). PCI was associated with a shorter hospital stay (4.2 ± 0.8 vs 8.3 ± 0.01 days, p <0.001). No significant differences were found between PCI and CABG for all cause-mortality, nonfatal myocardial infarction, and major adverse cardiac and cerebrovascular events at 30 days and 12 and 22 months. However, PCI was associated with lower rates of stroke at 30 days (OR 0.14, 95% CI 0.02 to 0.76) and 12 months (OR 0.14, 95% CI 0.03 to 0.60) and higher rates of repeat revascularization at 22 months (OR 4.34, 95% CI 2.69 to 7.01). These findings were consistent with the findings from a subgroup analysis of patients aged ≥75 years. In conclusion, older patients (age ≥70 years) with unprotected left main coronary artery disease had comparable rates of all-cause mortality, nonfatal myocardial infarction, and major adverse cardiac and cerebrovascular events after PCI or CABG. The patients undergoing PCI had a shorter hospital stay and lower rates of early stroke; however, they experienced higher repeat revascularization rates at longer term follow-up.

Safety and efficacy of antiplatelet and antithrombotic therapy in acute coronary syndrome patients with chronic kidney disease.

Chronic kidney disease (CKD) is prevalent and affects an ever-increasing proportion of patients presenting with acute coronary syndrome (ACS). Patients with CKD have a higher risk of ACS and significantly higher mortality, and are also predisposed to increased bleeding complications. Antiplatelet and antithrombotic drugs form the bedrock of management of patients with ACS. Most randomized trials of these drugs exclude patients with CKD, and current guidelines for management of these patients are largely based on these trials. We aim to review the safety and efficacy of these drugs in patients with CKD presenting with ACS.