Reassessing Risk Factors for High Defibrillation Threshold: The EF-SAGA Risk Score and Implications for Device Testing.

OBJECTIVES: To reevaluate risk factors for high defibrillation threshold (DFT) and propose a risk assessment tool. BACKGROUND: Controversy exists over routine DFT testing during implantable cardioverter defibrillator (ICD) placement. METHODS: We retrospectively analyzed 1,642 consecutive patients who received an ICD and underwent DFT testing. RESULTS: The incidence of high DFT requiring addition of a subcutaneous array was 2.3%. Five significant independent variables predictive of high DFT were identified, including younger age, male gender (hazard ratio 1.99), left ventricular (LV) dysfunction, secondary prevention (hazard ratio 2.33), and amiodarone use (hazard ratio 2.39). Each 10-year increase in age was indicative of a 0.35-times lower chance of high DFT. Each 10% increase of LV ejection fraction (EF) was indicative of a 0.52-times lower chance of high DFT. These five variables form the EF-SAGA risk score (LVEF < 20%, Secondary prevention ICD indication, Age < 60 years, male Gender, Amiodarone use). Cumulative risk of high DFT increased incrementally; patients with four or more variables had an 8.9% likelihood of high DFT. Importantly, primary prevention patients with LVEF > 20% had a negative predictive value for high DFT of 99.3%. CONCLUSION: We identified five independent predictors of high DFT. We propose the EF-SAGA risk score to help decision making. Primary prevention patients with an LVEF > 20% had an exceedingly low incidence of high DFT suggesting that testing could be avoided in these patients. Careful assessment of the risk-benefit ratio of testing is important in high-risk patients.

Medicolegal characteristics of aortic stenosis litigation: a review of the LexisNexis Academic database.

BACKGROUND AND AIM OF THE STUDY: Currently, few studies have been conducted to assess the outcome patterns of medicolegal cases involving patients with cardiovascular disease. Thus, the literature was reviewed for patterns of liability and medical outcomes in patients involved in aortic stenosis (AS) litigation. METHODS: Legal case opinions were obtained from LexisNexis Academic; case characteristics, litigation outcomes, and medical outcomes were identified. RESULTS: Of the 133 cases reviewed, 27% were disability claims, 23% workers' compensation cases, 14% medical malpractice cases, and 9% military service connection cases. Of the 133 cases, only 47% were judged in the patients' favor. The patients' mean age was 48.8 years, and 77% were male. The most common etiology of AS was calcific (38%), followed by rheumatic (31%), bicuspid/congenital (27%), and subaortic (4%). The most common presentation was precordial pain (38%), shortness of breath (35%), syncope/dizziness (18%), fatigue (11%) and death (9%). Aortic valve replacement (AVR) was the most common form of treatment (67%); disability was the most common medical outcome (42%). CONCLUSION: AS in litigation follows the standard pattern of AS disease. Only a minority of AS litigation cases are due to medical malpractice, while the majority of AS litigation cases are due to those seeking workers' or disability compensation. Cardiologists treating patients with AS should be cognizant of these litigation patterns and proactively document medical findings, since resulting court decisions profoundly affect the patients' financial means and quality of life.

Usefulness of Oximetry Paradoxus to Diagnose Cardiac Tamponade.

Although echocardiography is usually diagnostic of cardiac tamponade, it may not be readily available at the point-of-care. We sought to develop and validate a measurement of respirophasic variation in the amplitude of pulse oximetry plethysmographic waveforms as a diagnostic tool for cardiac tamponade. Pulse oximetry plethysmographic waveforms were recorded, and the ratio of maximum-to-minimum measured amplitude of these waveforms from one respiratory cycle was calculated by blinded observers. Ratios from 3 consecutive respiratory cycles were then averaged to derive an "oximetry paradoxus" ratio. Cardiac tamponade was independently confirmed or excluded according to a "blinded" objective interpretation of echocardiography or right heart catheterization. Seventy four subjects were enrolled (51% men; mean age 54 ± 15 years); 19 of whom had cardiac tamponade. Oximetry paradoxus area under the curve for diagnosis of cardiac tamponade was 0.90 (95% confidence interval, 0.84 to 0.97); its diagnostic performance was superior to sphygmomanometer-measured pulsus paradoxus (area under the curve difference = 0.16, p = 0.022). In a derivation cohort (n = 37; tamponade, 9 cases), 3 diagnostic oximetry paradoxus thresholds were identified and validated in an independent validation cohort (n = 37; tamponade, 10 cases): 1.2 (100% sensitivity, 44% specificity), 1.5 (80% sensitivity, 81% specificity), and 1.7 (80% sensitivity, 89% specificity). Furthermore, oximetry paradoxus was significantly reduced after draining pericardial fluid. In conclusion, we defined and validated oximetry paradoxus as a simple and ubiquitous point-of-care test to diagnose cardiac tamponade using respirophasic changes in pulse plethysmography waveforms. This test can aid in identifying patients with cardiac tamponade, thus expediting confirmatory testing and life-saving treatment.

A simple validated clinical tool to predict the absence of coronary artery disease in patients with systolic heart failure of unclear etiology.

Coronary artery disease (CAD) is a major cause of systolic heart failure (HF). Identifying CAD as a cause of systolic HF has prognostic and treatment implications. Whether all patients with systolic HF of unclear etiology should undergo coronary angiography has been controversial. We sought to derive and validate a clinical prediction rule to exclude CAD as a cause of systolic HF. A derivation cohort was formed of consecutive patients who had undergone coronary angiography with a primary diagnosis of systolic HF of unclear etiology (ejection fraction <50%). Using multivariate logistic regression analysis, we derived a prediction rule for severe CAD (≥50% diameter stenosis in the left main, 3-vessel CAD, and 2-vessel CAD involving the proximal left anterior descending artery). The diagnostic performance of the defined prediction rule was prospectively validated in a separate cohort recruited from 2 institutions. Of the 124 patients in the derivation cohort, 27% had CAD, including 15% with severe CAD. The independent predictors of severe CAD included diabetes (odds ratio 5.1, p = 0.005), electrocardiographic Q waves or left bundle branch block (odds ratio 3.8, p = 0.02), and ≥2 nondiabetes risk factors: age (men ≥55 or women ≥65 years), dyslipidemia, hypertension, and tobacco use (odds ratio 4.8, p = 0.02). A prediction rule of having ≥1 independent predictor identified 97% of the patients with CAD and 100% of the patients with severe CAD. In the prospective validation cohort of 143 patients, the prediction rule had 98% sensitivity and 18% specificity for CAD but 100% sensitivity for severe CAD. In conclusion, a simple clinical prediction rule can accurately identify patients with CAD and eliminate the need for angiography in a substantial proportion of patients with systolic HF, with potentially significant cost savings and risk avoidance.

Innate immune collectin surfactant protein D enhances the clearance of DNA by macrophages and minimizes anti-DNA antibody generation.

Dying microbes and necrotic cells release highly viscous DNA that induces inflammation and septic shock, and apoptotic cells display DNA, a potential autoantigen, on their surfaces. However, innate immune proteins that mediate the clearance of free DNA and surface DNA-containing cells are not clearly established. Pulmonary surfactant proteins (SP-) A and D are innate immune pattern recognition collectins that contain fibrillar collagen-like regions and globular carbohydrate recognition domains (CRDs). We have recently shown that collectins SP-A, SP-D, and mannose binding lectin recognize DNA and RNA via their collagen-like regions and CRDs. Here we show that SP-D enhances the uptake of Cy3-labeled fragments of DNA and DNA-coated beads by U937 human monocytic cells, in vitro. Analysis of DNA uptake by freshly isolated mouse alveolar macrophages shows that SP-D, but not SP-A, deficiency results in reduced clearance of DNA, ex vivo. Analysis of bronchoalveolar lavage fluid shows that SP-D- but not SP-A-deficient mice are defective in clearing free DNA from the lung. Additionally, both SP-A- and SP-D-deficient mice accumulate anti-DNA Abs in sera in an age-dependent manner. Thus, we conclude that collectins such as SP-A and SP-D reduce the generation of anti-DNA autoantibody, which may be explained in part by the defective clearance of DNA from the lungs in the absence of these proteins. Our findings establish two new roles for these innate immune proteins and that SP-D enhances efficient pinocytosis and phagocytosis of DNA by macrophages and minimizes anti-DNA Ab generation.

Nucleic acid is a novel ligand for innate, immune pattern recognition collectins surfactant proteins A and D and mannose-binding lectin.

Collectins are a family of innate immune proteins that contain fibrillar collagen-like regions and globular carbohydrate recognition domains (CRDs). The CRDs of these proteins recognize various microbial surface-specific carbohydrate patterns, particularly hexoses. We hypothesized that collectins, such as pulmonary surfactant proteins (SPs) SP-A and SP-D and serum protein mannose-binding lectin, could recognize nucleic acids, pentose-based anionic phosphate polymers. Here we show that collectins bind DNA from a variety of origins, including bacteria, mice, and synthetic oligonucleotides. Pentoses, such as arabinose, ribose, and deoxyribose, inhibit the interaction between SP-D and mannan, one of the well-studied hexose ligands for SP-D, and biologically relevant d-forms of the pentoses are better competitors than the l-forms. In addition, DNA and RNA polymer-related compounds, such as nucleotide diphosphates and triphosphates, also inhibit the carbohydrate binding ability of SP-D, or approximately 60 kDa trimeric recombinant fragments of SP-D that are composed of the alpha-helical coiled-coil neck region and three CRDs (SP-D(n/CRD)) or SP-D(n/CRD) with eight GXY repeats (SPD(GXY)(8)(n/CRD)). Direct binding and competition studies suggest that collectins bind nucleic acid via their CRDs as well as by their collagen-like regions, and that SP-D binds DNA more effectively than do SP-A and mannose-binding lectin at physiological salt conditions. Furthermore, the SP-D(GXY)(8)(n/CRD) fragments co-localize with DNA, and the protein competes the interaction between propidium iodide, a DNA-binding dye, and apoptotic cells. In conclusion, we show that collectins are a new class of proteins that bind free DNA and the DNA present on apoptotic cells by both their globular CRDs and collagen-like regions. Collectins may therefore play an important role in decreasing the inflammation caused by DNA in lungs and other tissues.